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									Dear Residents of Synergy Medical,

On behalf of the Board of Trustees, Faculty and Staff of Synergy Medical Education Alliance, I want to
welcome you to our organization and community. I believe you will find your time with us
educationally stimulating and personally rewarding.

We intend to provide you with outstanding educational opportunities in the real world of medicine. The
Saginaw medical community offers a progressive healthcare environment and receives referrals from
throughout East Central Michigan for a broad scope of specialty services. We know that you will learn
much from the professionalism, cooperation and dedication of the physicians and healthcare
professionals of our community.

Synergy Medical has a long history of preparing individuals like yourself for a successful career in
medicine. We take our work seriously and consider you to be an important member of the Synergy
Medical institution. While you are training in your area of expertise with the volunteer and full time
faculty, we expect that you will participate in the ongoing educational efforts of the physicians, other
residents and medical students. You will likely be asked to serve on the various committees
representing your colleagues, and we hope that you will look forward to these opportunities.

Again, we welcome you to Synergy Medical. Should there be anything that we can do to enhance your
training, please do not hesitate to let us know.

Sincerely,



Terrance E. Lerash                                         Christine Rohr, D.O.
Chief Executive Officer                                    Senior VP of Medical & Academic Affairs
WELCOME TO SYNERGY MEDICAL EDUCATION ALLIANCE

Synergy Medical Education Alliance and its employees strive to continue the tradition of
providing a work environment with dignity and respect while meeting our goal of excellence in
medical education. With a spirit of cooperation Synergy Medical will successfully assist in the
professional development of all those who have chosen to matriculate here. Formal and
experiential training is made possible through the combined efforts and resources of Covenant
HealthCare and Saint Mary’s Medical Center, as well as Synergy Medical. Our employed and
community physicians, nurses and support staff are dedicated to providing residents the
opportunity to enhance their medical knowledge through their commitment of time, expertise
and professionalism.

For most residents the transition from medical school to residency completion will be
challenging, but smooth. This manual and the policies provided herein provide a framework in
which resident must function to maintain a smooth transition, defining acceptable standards of
conduct, procedures and benefits.

While every effort has been made to provide concise and accurate policy descriptions, this
manual is not exhaustive, and Synergy Medical reserves the option of amending policies at
any time with reasonable notice.
                                                    Resident Policy Manual Table of Contents

1.0   Introduction, Overview, & General Policies           5.0    Employee Relations (Continued)
      1.1     Mission and Vision                                  5.4    Evaluation
      1.2     Statement of Commitment                             5.5    Faculty and Program Evaluation
      1.3     Disclaimer                                          5.6    Corrective Action
      1.4     Code of Ethics                                      5.7    Resident Termination
      1.5     Confidentiality                                     5.8    Hearing and Review
      1.5(a) Social Security Number Privacy                       5.9    Criteria for Resident Review
      1.6     Corporate Property and Personal Effects             5.10   Employment of Relatives
      1.7     Personal Appearance
      1.7(a) Personal Appearance for Faculty & Resident    6.0    Benefits
              Physician                                           6.1      Benefits Continuation
      1.8     Parking                                             6.2      Health Insurance Portability and
      1.9     Force Majeure                                                Accountability Act (HIPPA)
      1.10    Assigning a Substitute DIO                          6.3      Benefits Enrollment
                                                                  6.4      Resident Fringe Benefit Schedule
2.0   Communications                                              6.4(a) Employee Patient Care Discount
      2.1  Internal Communications                                6.5      Jury Duty Pay
      2.2  External Communications                                6.6      Bereavement Pay
      2.3  Whistle Blower Protection                              6.7      Travel
      2.4  Solicitation                                           6.8      Religious Observations
      2.5  Acceptable Use of Resources                            6.9      Educational Assistance
      2.6  Electronic Data Use                                    6.10     Resident Time Off
      2.7  Electronic Data Security and Breach
           Reporting                                       7.0    Clinical Policies
      2.8  Electronic Mail Use and Monitoring                     7.1      Amendments to Protected Health
      2.9  Freeware and Shareware, Software                                Information (PHI) by Patients
           Copyright                                              7.2      Authorizations For Use of PHI
      2.10 Internet Access Privileges, Use and                    7.3      Minimum Necessary Use of PHI
           Monitoring                                             7.4      Minors: Consent and Treatment; Informing
      2.11 Passwords                                                       Parents
      2.12 Personal Digital Assistants (PDAs)                     7.5      Obtaining Consent or Acknowledgement for
                                                                           Routine, TPO – Based use of PHI
3.0   Employment                                                  7.6      Patient Photography
      3.1    Employment At Will                                   7.7      PHI Privacy Complaints or Breaches
      3.2    Employment Classifications                           7.8      Revocation, Restriction or Modification of
      3.3    Resident Selection                                            use or Disclosure of PHI
      3.4    Resident Duty Hours, Supervision                     7.9      Sending PHI Electronically
      3.5    Program Closure or Reduction                         7.10     Use of PHI in Marketing
      3.6    Residents Changing Programs                          7.11     Termination of Physician-Patient
      3.7    Away Electives                                                Relationship
      3.7(a) Elective and Required Out of System                  7.12     Patient Collection and Termination
             Rotations                                            7.13     Missed or Cancelled Appointment
      3.8    Resident DEA Numbers                                 7.14     Second Opinions, Referrals, and
      3.9    Licensure of Residents                                        Consultations Policy
      3.10   Promotion                                            7.15     Quality Improvement
      3.11   Human Resources Records
      3.12   Family Medical Leave Act                      8.0    Academics
                                                                  8.1   Medical Records Responsibilities
4.0   Compensation                                                8.2   Resident Teaching Responsibilities
      4.1   Compensation Philosophy                               8.3   Resident Scholarly Requirements
      4.2   Paycheck Distribution                                 8.4   Academic Standards
      4.3   Payroll Deductions
                                                           9.0    General Information
5.0   Employee Relations                                          Corporate Profile
      5.1    Anti-Harassment                                      Information Resources
      5.2    Fair Treatment                                       Research and Educational Programs
      5.3    Substance Abuse                                      Institutional Review Board
      5.3(a) Drug and Alcohol Testing
      5.3(b) Substance Abuse Drug and Alcohol              10.0   Safety Manual
             Testing Procedure
POLICY NUMBER:          1.1                      REVISION DATE:           04/2005
POLICY NAME:            Mission and Vision       APPROVAL DATE:           04/2005
EFFECTIVE DATE:         07/01/01                 RESPONSIBLE              All Employees
                                                 PARTY:

MISSION:

Advance the medical education environment to increase the quality of care provided by the
Saginaw Valley medical community;

Educate individuals to excel as skilled, contemporary and compassionate physicians;

Support the physician staffing needs of East Central Michigan with our graduates.

VISION (Preferred Future Statement):

Synergy Medical Education Alliance: A magnet organization for students, residents, and
patients.

Strategic Domains

Academic Enhancement. Synergy Medical will deliver an innovative, credible, and
contemporary educational portfolio providing quality intellectual and experiential preparation for
physicians and students, motivating them to reach their full personal and professional
potential.

Physician-Centered. Synergy Medical understands the central role physicians fulfill in the
accomplishment of our educational mission. The organization relies on effective physician
leaders having an active voice in organizational planning and decision-making. Synergy
medical utilizes processes to organize systems that optimize the physicians' time in both
academic and clinical roles.

Quality Achievement. The organization will create and sustain a culture and environment
that fosters a commitment to continuous improvement efforts. Quality achievement at Synergy
Medical will be measured by meaningful academic, clinical, and service outcomes.

Organizational Health. Empowered employees, cohesive leadership and financial strength
will provide Synergy Medical the organizational health necessary to invest in a successful
future.
POLICY NUMBER:          1.2                     REVISION DATE:          06/12/06
POLICY NAME:            Statement of            APPROVAL DATE:          06/12/06
                        Commitment
EFFECTIVE DATE:         04/09/01                RESPONSIBLE             Board of Trustees
                                                PARTY:

                              STATEMENT OF COMMITMENT

            APPROVED BY THE SAGINAW COOPERATIVE HOSPITALS, INC.
                    BOARD OF TRUSTEES ON JUNE 12, 2006

Synergy Medical was established in 1969 as an organization committed to graduate and
undergraduate medical education with the expectation of improved patient care in mid-
Michigan: specifically in Saginaw and the surrounding communities. To this end, an affiliation
was formed among Michigan State University College of Human Medicine, Covenant
HealthCare and Saint Mary’s Medical Center, forming a separate and sovereign entity now
known as Synergy Medical Education Alliance (formerly Saginaw Cooperative Hospitals, Inc.
(SCHI))

Synergy Medical is governed by a Board of Trustees comprised of members from each
founding organization plus members of the community. The Board is ultimately responsible for
assuring program quality consistent with or exceeding ACGME accreditation standards for
both graduate and undergraduate medical education and providing financial and human
resource necessary to achieve these quality outcomes.

The medical staff at the member hospitals and within the larger community have embraced this
educational corporation. Evidence of commitment and support is demonstrated readily by the
participation of the medical staff members in graduate and undergraduate training programs,
through hospital commitment in the form of ongoing financial support and through the College
of Human Medicine’s innovative development of community based collaborative medical
education and training programs.

Despite the many financial and administrative challenges facing medical education today,
Synergy Medical continues to flourish. Synergy Medical programs graduate both primary care
and specialty physicians, many of whom establish professional practices in Saginaw, raising
the overall quality of patient care in the region. For these reasons, the Board of Trustees
pledges commitment to the continued support of Synergy Medical Education Alliance medical
education programs.
POLICY NUMBER:          1.3                    REVISION DATE:         07/01/01
POLICY NAME:           Disclaimer              APPROVAL DATE:         07/01/01
EFFECTIVE DATE:        07/01/01                RESPONSIBLE            Human Resources/
                                               PARTY:                 Leadership


PURPOSE:

To provide guidance on the significance of Synergy Medical’s Corporate Policy Manual.

POLICY:

The contents of this manual summarize the current company programs and policies in place at
Synergy Medical. The information herein is intended to be used as a guideline and can be
amended by the company at any time. Receiving this manual and its contents do not
constitute the terms of a contract and should not be construed as a guarantee of continued
employment. Employment with Synergy Medical is AT WILL, meaning the employment
relationship can be terminated by either the corporation or the employee at any time and for
any reason (not expressly prohibited by law) with or without cause or notice. The contents of
this manual supercede any oral or written representation to the contrary.
POLICY NUMBER:            1.4                     REVISION DATE:
POLICY NAME:             Code of Ethics           APPROVAL DATE:
EFFECTIVE DATE:          07/01/01                 RESPONSIBLE               Human Resources/
                                                  PARTY:                    Leadership


PURPOSE:

To communicate Synergy Medical’s support for the principle of Equal Employment
Opportunity.

POLICY:

Synergy Medical shall recruit, promote, and administer any and all personnel actions without
regards to race, color, religion, age, gender, national origin or ancestry, marital status,
disability, height, weight, familial status, or veteran’s status in accordance with applicable state
and federal laws. Equal employment opportunities will be provided to all employees on the
basis of demonstrated ability and competence. Synergy Medical will not tolerate any unlawful
discrimination and prohibits harassment in the aforementioned basis. Any knowledge of
discrimination, harassment, fraud, or non-compliance with applicable state and federal
regulations, must be reported to one’s supervisor.
POLICY NUMBER:            1.5                     REVISION DATE:            04/14/03
POLICY NAME:             Confidentiality          APPROVAL DATE:            02/25/03
EFFECTIVE DATE:          07/01/01                 RESPONSIBLE               All Employees
                                                  PARTY:

PURPOSE:

To protect the confidentiality of identifiable health information (or protected health information)
which includes patient information and medical records, all information pertinent to employees
and their employee records, business information, financial information and security records,
reports and information.

POLICY:

Information regarding all of the above shall be kept strictly confidential. Information shall be
shared only on a need-to-know basis among professionals within the corporation. No
information about any patient shall be released to any party except as permitted by state or
federal law without the expressed written permission of the patient and in accordance with
respective departmental guidelines.

The Department of Human Resources maintains all employee information with additional
access being limited to an employee’s supervisor. The Human Resources Department will
release information regarding verification of employment only upon receipt of authorization
from the employee. See also Policy 3.11 – Human Resources Records.

Unauthorized use or disclosure of protected health information (PHI) will result in disciplinary
action, up to and including the termination of employment or association with Synergy Medical
Education Alliance. See also applicable Communications (Section 2.0) and Clinical Policies
(Section 8.0) for further information.

All employees are required to read and sign Synergy Medical’s Employee Confidentiality
Agreement (see attached).
EMPLOYEE CONFIDENTIALITY AGREEMENT


       I, _________________________________, have read and understand Synergy Medical
Education Alliance policies regarding the privacy of individually identifiable health information (or
protected health information (PHI), as mandated by the Health Insurance Portability and Accountability
Act of 1996 (HIPAA). In addition, I acknowledge that I have received training in Synergy Medical
Education Alliance policies concerning PHI use, disclosure, storage and destruction as required by
HIPAA.

        In consideration of my employment or compensation from Synergy Medical Education Alliance,
I hereby agree that I will not at any time - either during my employment or association with Synergy
Medical Education Alliance or after my employment or association ends - use, access or disclose PHI to
any person or entity, internally or externally, except as is required and permitted in the course of my
duties and responsibilities with Synergy Medical Education Alliance, as set forth in Synergy Medical
Education Alliance privacy policies and procedures or as permitted under HIPAA. I understand that this
obligation extends to any PHI that I may acquire during the course of my employment or association
with Synergy Medical Education Alliance, whether in oral, written or electronic form and regardless of
the manner in which access was obtained.

        I understand and acknowledge my responsibility to apply Synergy Medical Education Alliance
policies and procedures during the course of my employment. I also understand that unauthorized use or
disclosure of PHI will result in disciplinary action, up to and including the termination of employment
and the imposition of civil penalties and criminal penalties under applicable federal and state law, as
well as professional disciplinary action as appropriate.

       I understand that this obligation will survive the termination of my employment or end of my
association with Synergy Medical Education Alliance, regardless of the reason for such termination.



Signed ___________________________________                 Date __________________________
POLICY NUMBER:          1.5 (a)                 REVISION DATE:
POLICY NAME:            Social Security         APPROVAL DATE:          03/11/2008
                        Number Privacy
                        Policy
EFFECTIVE DATE:         01/01/2007              RESPONSIBLE             Human Resources
                                                PARTY:

PURPOSE:

To properly secure and protect employee Social Security number/identification information,
holds all employees that use or have access to any employee's Social Security number and
information to the highest degree of confidentiality.

POLICY:

In addition to this company's normal security and confidentiality policy/practices, employees
are prohibited from accessing, viewing or using other employee's Social Security information.
No employee is permitted to access or use Social Security numbers without express
permission of Synergy Medical.

Only authorized personnel may access records and documents both internal and external that
contain employee Social Security number and identification information.

Any employee or individual without authorization that accesses Social Security data without
authorization or for illegal purposes shall be disciplined up to and including
discharge and if illegal intent is determined referred to authorities for possible criminal
prosecution.

All documents and records containing Social Security numbers and information will be kept in
a secure environment with need to know access by authorized personnel only. When
necessary documents containing this and other confidential information will be properly
destroyed through shredding or other means before disposal.
POLICY NUMBER:           1.6                     REVISION DATE:           01/28/03
POLICY NAME:            Corporate Property       APPROVAL DATE:           01/28/03
                        and Personal
                        Effects
EFFECTIVE DATE:         07/01/01                 RESPONSIBLE              Human Resources/
                                                 PARTY:                   Leadership/
                                                                          Information Resources

PURPOSE:

Preserve and share the resources of Synergy Medical.

POLICY:

Employees are expected to exercise due care, responsible, and acceptable use of company
property. Company property is not to be used for purposes outside the scope of its intended
use without supervisory permission. Employees shall request supervisory clarification as
necessary to ensure compliance with this standard.

All users of Synergy Medical property are personally responsible for its safe return. Users will
reimburse Synergy Medical for any loss or damage of materials. Unauthorized removal of
materials from Synergy Medical and/or refusal to return, replace or pay for lost materials and
equipment amounts to theft. Theft of Synergy Medical property can result in discipline up to
and including discharge.

Synergy Medical is not responsible for employee’s personal effects.

PROCEDURE:

Users of Synergy Medical property will sign an acknowledgment of their responsibility for any
Synergy Medical property they use. The department lending or issuing the equipment is
responsible for obtaining these signatures and educating users.

Commonly loaned materials include library materials (books, journals, videos, audiotapes,
CD’s), pagers, digital cameras, laptops, videoprojectors, and other a-v equipment. Synergy
Medical reserves the right to charge a processing fee for costs associated with reordering
materials; this will be standard practice for all lost library materials.

Any items not returned, replaced or paid for will result in loss of borrowing privileges,
notification of the user’s supervisor and ultimately could result in termination under Synergy
Medical’s Termination Policy.
POLICY NUMBER:          1.7                    REVISION DATE:
POLICY NAME:           Personal                APPROVAL DATE:
                       Appearance
EFFECTIVE DATE:        07/01/01                RESPONSIBLE             Leadership
                                               PARTY:

PURPOSE:

To provide guidance on appropriate professional appearance while working for Synergy
Medical

POLICY:

Staff are expected to present themselves in a professional manner which is congruent with
industry standards for their respective work areas. When in question, an employee’s
supervisor will determine appropriate standards of appearance.

Photo identification badges must be worn at all times while working for Synergy Medical on its
premises or at any of Synergy Medical’s affiliated hospitals. Lost badges must be replaced. A
replacement fee will be assessed and is the responsibility of the affected employee.
POLICY NUMBER:            1.7(a)                   REVISION DATE:           August 12, 2004
POLICY NAME:             Personal                  APPROVAL DATE:
                         Appearance for
                         Faculty & Resident
                         Physicians
EFFECTIVE DATE:          September 23, 2002        RESPONSIBLE              Clinical Department
                                                   PARTY:                   Leaders


PURPOSE:

In order to promote excellence in clinical staff at Synergy Medical, it is the expectation that all
clinical staff exhibit professional appearance.

SCOPE:

All clinical faculty and resident physicians of Synergy Medical irrespective of work-site.

POLICY:

Clinical employee attire shall be evaluated at the discretion of the Manager or Director. In
order to promote a professional appearance that lends credibility and respect, the following
criteria shall be used:

1.     Employee identification badge to be worn at all times. If lost or misplaced, temporary
       replacement is a must.
2.     Business casual clothing and/or scrubs should be neat, clean, pressed, and fit
       appropriately.
       a.     A clean white lab coat is encouraged during any clinical encounters if wearing
              business casual clothing.
       b.     No blue jeans should be worn.
       c.     No color restrictions specified.
       d.     Prints/patterns are allowed but should be in good taste.
       e.     Clothing with holiday theme shall be allowed for one week prior to a respective
              holiday (e.g., Halloween, Fourth of July, etc.); Christmas will be for two weeks.
       f.     Synergy Medical sweatshirt (or other Synergy Medical logo-wear) may be worn
              with slacks.
3.     Shoes need to be clean and have closed toes.
4.     No mid-abdominal exposure is allowed.
5.     Hair should be clean, neat, off the shoulder and pulled back as necessary in patient
       care settings.
6.     Nails should be neat in length, clean and professional in appearance.
POLICY NUMBER:           1.8                     REVISION DATE:
POLICY NAME:            Parking                  APPROVAL DATE:          06/13/06
EFFECTIVE DATE:         07/01/06                 RESPONSIBLE             Management
                                                 PARTY:

PURPOSE:

To provide safe and sufficient parking for patients, visitors and employees.

POLICY:

All employees are responsible for parking in their assigned areas. Employees must not park in
patient and visitor lots. Employees attending meetings from another campus does not meet
the criteria for parking in visitor lots.

IDENTIFICATION OF VEHICLES

During the course of their orientation, all employees and students will be required to register
their vehicle(s) with Human Resources within one week in order to park in a Synergy Medical
parking lot. Parking stickers with identification numbers will be assigned to each vehicle and
must be displayed in the lower left-hand corner of the windshield (driver side) so it may be read
from outside the vehicle.

PARKING ASSIGNMENT

•   Main Campus (1000 Houghton Ave)

    Synergy Medical Staff & Faculty Parking (Black Sticker)
    The north end of the lot directly west of our main campus on 1000 Houghton
    (approximately 60 spaces). These spaces are available on a first come, first serve basis.
    This lot is likely to be filled to capacity each day. Overflow parking is NOT IN THE
    PATIENT LOT. The parking lot near Irving and Stone will be designated as employee
    overflow parking.

    Physician Parking (Orange Sticker)
     Resident Physicians are to park in designated physician lost near Covenant Harrison and
    Cooper. Faculty & Staff Physicians may park in Synergy Medical Staff Parking Lost (see
    above or designated physician lots near Covenant Harrison and Cooper.

    Student Parking (Pink Sticker)
    Student Parking is located near the corner of Irving Avenue and Stone Street. The
    entrance is off of Stone St.
    The map below indicates proper Main campus parking assignments for Synergy Medical
    staff, physicians, and students.




•   North Campus (1575 Tittabawassee Road)

    The patient parking lot is located north of the building with the western and northwest
    portions reserved for patients and visitors. The employee parking lot is located east of the
    employee entrance. Employees and students are also allowed to park in the northeastern
    portion of the patient lot and in the limited number of service drive spaces east and south of
    the building.

PARKING VIOLATIONS

Parking violations normally occur when employees and students park in areas other than their
assigned lot. Other violations include but are not limited too: failing to register vehicle or
display parking sticker, parking where there is no parking space (e.g., at the end of an isle),
and double parking.

PARKING ENFORCEMENT
Each employee and student is responsible for knowing where to park. Management is
responsible for ensuring all employees park in their designated areas. This includes educating
employees about proper parking and instituting Corrective Action when necessary.

Covenant HealthCare Security will enforce this parking policy for Synergy Medical's Main
Campus by issuing tickets and applying vehicle disabling boots to those that violate this policy.
Security will also track and report violations to Human Resources, who will also notify the
employee’s manager.

•   Parking Fines

    First parking ticket           =       Warning (no fine)
    Each ticket thereafter         =       $10 fine
    Unpaid Fines
       -      Over fifteen (15) days - increase fine to $20.
       -      Over thirty (30) days - increase fine to $30.
       -      Over 45 days - vehicle will be disabled (booted), increase fine to $30 plus $25
           boot removal fee.

•   Registration Failure

    Continued failure to register vehicle or display parking sticker after three (3) weeks will
    result in applying a vehicle-disabling boot. A $25 boot removal fee will be assessed.

FEE COLLECTION

•   Employees are to pay parking fines at Covenant HealthCare's cashier's office.
•   Employees may pay boot removal fees by check at Covenant's Cooper Campus security
    office when the cashier's office is closed (NO CASH PAYMENTS WILL BE ACCEPTED).

CORRECTIVE ACTION

Unpaid parking fines, failure to register a vehicle, and excessive parking violations may result
in corrective action up to and including termination.
POLICY NUMBER:           1.9                     REVISION DATE:
POLICY NAME:            Force Majeure            APPROVAL DATE:           8/03/07
EFFECTIVE DATE:         10/01/07                  RESPONSIBLE             Administration
                                                 PARTY:

Policy:

Synergy Medical Education Alliance shall not be liable to any resident for any loss of training or
any other damage caused by or resulting from the failure of Synergy Medical to provide the
training or an interruption of the educational program when such failure or interruption is due to
an act of war or terrorism, an act of God, riots, strikes, labor stoppages, lockouts or labor
disputes or the inability to recruit and employ Program Staff, or the act of any governmental
agency department or entity, or due to any statute, order, rule or regulation or other causes
beyond the reasonable control of Synergy Medical.

In the event of such acts, Synergy Medical will make reasonable efforts to assist the resident in
finding appropriate regional training sites for program interruptions of a brief nature or
nationally for program interruptions of an indefinite nature. Should Synergy Medical be able to
remedy any programs interruption, the resident will be invited to resume his/her training
program. Rotations completed at temporary training sites approved by the respective program
director will be accepted in lieu of training at Synergy Medical if that site is approved by the
ACGME.

If during the time of program interruption the resident chooses to enroll in another residency
training program, the resident will be allowed to do so only with the consent of the DIO or
program director of their designee.
POLICY NUMBER:           1.10                    REVISION DATE:
POLICY NAME:            Institutional            APPROVAL DATE:           08/03/2007
                        Procedure for
                        Assigning a
                        Subsitute DIO
EFFECTIVE DATE:         10/01/2007                RESPONSIBLE             Senior VP of Medical
                                                 PARTY:                   & Academic Affairs

Procedure:

The Designated Institutional Official (DIO) is responsible for reviewing and countersigning all
documents and correspondence submitted by Program Directors to the ACGME.

In the absence of the DIO, any member of the Executive Leadership Team (ELT) will be
responsible for program oversight until the DIO returns or in the event of a prolonged absence,
termination or resignation, a suitable replacement is found. The institution will inform the
ACGME if the designee is required to assume the role for an extended period of time.
POLICY NUMBER:           1.11                     REVISION DATE:
POLICY NAME:             Tobacco Free             APPROVAL DATE:           04/22/2010
                         Campus
EFFECTIVE DATE:          05/01/2010               RESPONSIBLE              Leadership
                                                  PARTY:

PURPOSE:

To provide patients, visitors, students, and employees with an environment free from tobacco
use in order to reduce health risk, enhance the appearance of our facilities, and comply with
Michigan State Law.

POLICY:

The use of tobacco using any delivery method is prohibited:

   •   In any building and on the grounds of all Synergy Medical facilities and its affiliates;
   •   On sidewalks bordering these areas;
   •   All parking lots; and
   •   In personal vehicles while on the grounds of Synergy Medical facilities and its affiliates.

Violations are subject to corporate corrective action (See Policy 5.2 – Corrective Action) and
citations/fines issued by the County Health Department.
POLICY NUMBER:         2.1                    REVISION DATE:
POLICY NAME:           Internal               APPROVAL DATE:
                       Communications
EFFECTIVE DATE:        07/01/01               RESPONSIBLE            LEADERSHIP
                                              PARTY:

PURPOSE:

To identify the organization’s commitment to provide prompt communications with
employees about the organization as a whole as well as providing information for the
successful performance of job accountabilities.

POLICY:

The mission, vision and goals of Synergy Medical Education Alliance can only be successfully
achieved with effective communication. A conversation needs to be established for concerns
to be expressed and for the employment relationship to be efficient. Employees are therefore
encouraged to express their concerns through their supervisor, appropriate department head
or workgroup, or department of Human Resources in an appropriate and timely manner.
Otherwise, Leaders should maintain an “open door” philosophy by making themselves
available to meet with staff from both within and outside their department.
POLICY NUMBER:            2.2                      REVISION DATE:
POLICY NAME:             External                  APPROVAL DATE:
                         Communications
EFFECTIVE DATE:          07/01/01                  RESPONSIBLE              Administration/
                                                   PARTY:                   Leadership


POLICY:

Requests for external communication (e.g. by local news media, organizations, etc.) must be
directed to the Office of Administration. External communications (e.g., press releases,
advertisements, etc.) may be generated at the department level if known or approved
(expressly or implied) through one’s supervisor, relative to a project, function, or activity related
to an employee’s position or role in the corporation.
POLICY NUMBER:           2.3                     REVISION DATE:
POLICY NAME:            Whistle Blower           APPROVAL DATE:
                        Protection
EFFECTIVE DATE:         07/01/01                 RESPONSIBLE             Human
                                                 PARTY:                  Resources/Leadership

PURPOSE:

To ensure adherence with the Whistle Blowers Protection Act, which protects employees who
report state and federal violations or other wrongdoings.

POLICY:

Synergy Medical will make a reasonable effort to protect employees who report in good faith
what they reasonably believe to be a violation of compliance with state or federal laws or
conditions and practices which put the corporation’s or its employees health, safety, reputation,
or wellbeing at risk.

Employees or contractors must immediately report the violation, condition, or practice to a
person with supervisory authority over the employee or to an administrator and give the
company reasonable time to investigate the situation.

If this method is not effective, or proves to be uncomfortable due to the parties involved in the
violation, the employee should notify the Human Resource Office. Synergy Medical Education
Alliance prohibits any threats, discrimination, or retaliation in any manner against those
reporting perceived wrongdoings.
POLICY NUMBER:          2.4                    REVISION DATE:          05/12/05
POLICY NAME:           Solicitation            APPROVAL DATE:          04/26/05
EFFECTIVE DATE:        07/01/01                RESPONSIBLE             Administration
                                               PARTY:

POLICY:

Having access to solicit Synergy Medical Education Alliance employees shall be granted as a
privilege, not a right. Synergy Medical will accommodate those solicitors who respect
established departmental guidelines and, through their presence, contribute to the betterment
of the work environment. To ensure a work environment free of distractions, solicitations from
vendors must be approved through the Office of Administration. Employees must direct all
vendors to the Office of Administration if they suspect that solicitation rights have not been
granted. Likewise, employees should notify their supervisor if vendors do not respect
departmental solicitation guidelines.

Employees are expected to be tactful, discrete, and non-disruptive in their efforts to promote
activities which sponsor charitable causes. Solicitations by employees during work time for
personal gain is unacceptable.

The posting* of materials on designated bulletin boards is permitted with approval from Human
Resources. Solicitations through e-mail messages are not acceptable.

*Postings are normally limited to areas having bulletin boards, generally near copy machines
throughout Synergy Medical's facilities.
POLICY NUMBER:           2.5                     REVISION DATE:
POLICY NAME:            Acceptable Use of        APPROVAL DATE:
                        Resources
EFFECTIVE DATE:         07/01/01                 RESPONSIBLE              ALL DEPARTMENT
                                                 PARTY:                   SUPERVISORS


PURPOSE:

To ensure proper usage of equipment, technology, and resources for use in their respective
functions at Synergy Medical.

POLICY:

Personal use of equipment, technology, and resources must be limited to a minimum and must
not interfere with an employee’s ability to accomplish their position responsibilities. A standard
of appropriate use may be established by a departmental leader. Under no circumstances
should an employee’s use of equipment, technology, or resources violate generally accepted
moral or ethical codes of conduct (e.g., use for personal gain, theft, violation of others rights,
etc.).
POLICY NUMBER:           2.6                    REVISION DATE:
POLICY NAME:            Electronic Data Use     APPROVAL DATE:           02/25/03
EFFECTIVE DATE:         04/14/03                RESPONSIBLE              Information Resources
                                                PARTY:

PURPOSE:

To protect corporate information and computer assets while allowing: 1) e-mail communication,
2) information transfer, 3) access to corporate information resources for corporate users; 4)
ensuring compliance with local, state and federal law.

DEFINITIONS: “Employees” includes staff, residents, paid faculty, contracted staff,
consultants, rotating residents, and full-time or visiting students.

SEE RELATED POLICIES: Electronic Data Security and Breaches, Internet Use, Email Use,
Passwords, Corporate Data Security, PDA’s

GENERAL POLICY

1. There is NO user right of privacy in information stored on Synergy Medical facilities.
   Systems operators, supervisors, and other Synergy Medical staff may need to review such
   information in order to locate information, maintain the system, or administer this or other
   Synergy Medical policies. This applies to electronic data in the workplace in any form: email
   voicemail, web use, web-based email use, PDA’s, pagers, etc.
2. Users will keep use of technology for personal reasons to a minimum. An individual’s
   supervisor will determine the acceptable amount of personal use of Synergy Medical
   technology resources. Information Resources sets policies on type of use (ex.: Yahoo
   Instant Messaging, Internet Relay Chat, live radio, etc.) based on risk factors, bandwidth
   use, etc. Abuse of personal use privileges may lead to removal of system privileges or
   other disciplinary action.
3. Supervisors will determine access rights and permissions for individuals for corporate
   information sources. Information Resources is responsible for enabling or disabling such
   access. Information Resources staff is the liaison to Covenant and Saint Mary’s IS
   departments for Synergy Medical employee and student access to their systems.
4. All computing devices and users must use network file services to store corporate data, not
   local “My Documents” or “My Palm” files. Users must not store essential information on
   their local computer. Information Resources staff will configure all devices to use network
   servers to store corporate data, but some software defaults to local drives. Users are
   responsible for understanding where their information is being saved and for requesting
   network file services storage.
5. Employees who use external agencies’ computer systems for their work or education must
   abide by those systems’ policies as well as Synergy Medical policy.
6. Databases and documents will be backed up using best practices’ standards. However,
   backing up personal desktops (icons, shortcuts), standard office software and users’
   customized settings of same would require huge storage capacity and network bandwidth.
   Personal desktops and desktop software settings will not be backed up unless there
   is a significant business need.
7. If a user’s employment, affiliation or privileges with Synergy Medical should terminate for
   any reason, they are required to have all Synergy Medical software and data from their
   home and office computing devices removed. Users must contact Information Resources to
   ensure this is done properly. Human Resources will maintain a sign-out process wherein
   both the user and Information Resources staff will verify that this has been done.
USER RESPONSIBILITIES

1. Users must comply with the corporate policy and make best efforts to protect data and not
   indulge in activities that compromise data.
2. Users may not use any electronic communications to engage in any communication or
   action that is threatening, discriminatory, defamatory slanderous, obscene, or harassing.
3. Users may not use the company's computers, software and networks adversely in any way
   that affects the ability of others to use them.
4. Users are expected to attend group classes offered by Information Resources to learn the
   basics for computer use in their job. Supervisors are expected to arrange for their
   attendance.
5. Users must notify Information Resources of important data that is not stored on the
   corporate file servers. Information Resources is not responsible for important data
   that is not kept on file servers. Users are responsible for understanding how and where
   their computer stores data.
6. Users will use copyrighted software in accordance with the software license.
7. Users may not copy or use Synergy Medical software except for Synergy Medical business
   and then only when the license allows such use (example: for use on a home PC or
   personal PDA). Users who violate either the license or the copyright of Synergy Medical
   software are answerable to Synergy Medical and are legally liable to the license issuer or
   copyright holder.
8. No one but the Information Resources staff may change the hardware configuration of a
   desktop workstation.
9. Users may not knowingly create, execute, forward, or introduce any computer code
   designed to self-replicate, damage, or otherwise impede the performance of any
   computer's memory, storage, operating system, or software.
10. Synergy Medical will provide security software for all Synergy Medical-owned equipment.
    The user must cooperate fully in keeping that software up to date through regular
    connection to the Synergy Medical network and reporting of error messages.
11. Users are strictly forbidden from putting any confidential Synergy Medical information,
    including but not limited to protected health information, on their home or other non-
    Synergy Medical PC’s or PDA’s or computing devices without the written approval of the
    department of Information Resources (see: Use Of Protected Health Information (PHI) On
    Laptops, PDA’s And Personal Equipment Policy). In general, users needing home or
    mobile use of Synergy Medical information will be required to install and maintain firewalls,
    antivirus, and backup and security software.
12. Synergy Medical strongly discourages the storage of large number of email messages for a
    number of reasons including assuring confidentiality and the cost of storing and searching
    unneeded information.
13. Users with access to external agencies’ electronic resources (Covenant, Saint Mary’s,
    MSU, and Michnet) must understand and comply with those agencies’ policies for it, as well
    as Synergy Medical’s policy.
ENFORCEMENT

1. Information Resources will audit resources periodically to ensure that software and
   computer configurations comply with policy.
2. Information Resources will report to managers on unusual use patterns or flagrant misuse
   of computer resources in their areas.
3. A single visit to an objectionable Internet site is unlikely to spark an inquiry. Patterns of
   misuse or questionable use will trigger an investigation.
4. If Synergy Medical policy has been violated, then the user’s privileges may be restricted or
   other action taken as decided by the Director of Information Resources or the user’s
   supervisor.
5. Information Resources may act to enforce policy without notice by canceling an account or
   service but will inform the person’s supervisor after the network is safe.
6. Information Resources will submit automatic reports to managers and directors on their
   department’s use of computers, servers and the Internet upon their request.
7. The Director of Information Resources will maintain a log of all known or suspected policy
   breaches and actions taken in each case.
8. Violations to this policy will result in counseling, verbal warnings, written warnings,
   up to and including termination.
POLICY NUMBER:            2.7                      REVISION DATE:
POLICY NAME:             Electronic Data and       APPROVAL DATE:           02/25/03
                         Breach Reporting
EFFECTIVE DATE:          04/14/03                  RESPONSIBLE              Information Resources
                                                   PARTY:                   /Privacy and Security
                                                                            Committee


1. Corporate servers must be located in a secure physical location with access only by
   authorized personnel.
2. A firewall must separate all corporate computers and servers from the Internet. This
   firewall will be kept up-to-date, and access rights or ports changes logged and sealed when
   no longer needed. Openings in the firewall will be made only for business reasons.
3. The administrator and alternate administrator will be the only people with access to all files
   on a server.
4. All systems must have anti-virus software active and updated that scans all disks, floppy
   drives, and macros. This includes all laptops and PDA’s that connect to Synergy
   Medical systems, whether owned by Synergy Medical or individuals.
5. Server hardware, server software, and network printer cards must have their default access
   changed immediately after installation.
6. Modem connections to servers and personal computers must be approved by Information
   Resources, have a significant business use that cannot be met otherwise, and be secured
   to meet industry standards, including HIPAA requirements.
7. Synergy Medical will require the use of forced time-outs, locked screensavers or
   logouts on accounts with access to protected health information (e.g., a billing or
   EMR system) after a given time with no activity.
8. The corporate network will be protected by intrusion detection software at all times.
9. Encryption and authentication must be used whenever possible at the highest level
   possible for all protected health information or sensitive corporate information in any form:
   files, data transfers, email, etc.
10. The Synergy Medical Administrator on call will notify the Director of Information
    Resources of any situation involving Information Resources equipment (ex.: power outage,
    lightening strikes, HVAC failures, fire, flood, etc.). If the Director is unavailable, they will
    contact the Manager of Technical Services.
11. Information Resources staff must approve all new software for use on Synergy Medical
    equipment before its purchase. (This does not include books on CD or PDF files on CD
    meant for documentation, display and informational purposes only, but users are
    responsible for verifying that these can run on the system planned.) “Software” is a
    program that does work for users.
12. Human Resources will immediately report all changes in employment or affiliation status
    of any Synergy Medical employee or student to Information Resources.
13. Information Resources will make appropriate changes for access control privileges of these
    workers and notify our business associates’ IS departments as well (e.g., Covenant
    and St. Mary’s) ASAP.
14. No confidential information may be left on ‘loaner’ laptops. Information Resources will
    routinely erase all data left on laptops.
15. The Director of Information Resources and Corporate Compliance Officer will establish and
    maintain a procedure and schedule for data security auditing.

Breaches

1. Any reported breaches of this policy must be reported immediately to the employee’s
   supervisor, the Director of Information Resources and the corporate Security Officer.
2. The Director of Information Resources and Security Officer will investigate breaches in a
   timely fashion.
3. During the investigation, Synergy Medical may access any and all electronic files of the
   user or student.
4. The Director of Information Resources will report security incidents in writing to the
   appropriate parties, including the Corporate Compliance Officer, the director and manager
   of the area involved, or the CEO.
5. The Director of Information Resources is responsible for ensuring that all breaches are
   rectified speedily and similar occurrences prevented and a log of all such events
   maintained.
6. Violations of this policy will lead to discipline up to and including dismissal.


COMMON THREATS

1. Viruses introduced by e-mail, web browsing, floppy, CD, tape, or downloads.
2. Unauthorized login into computers by learned or hacked usernames and passwords for the
   purpose of reading, deleting, removing, or altering data.
3. Unauthorized physical access to corporate servers that may result in inadvertent or
   malicious shutoff, damage, or login access to the server.
4. Unauthorized access to data because of lack of file protection or errors in system
   configurations (e.g., hacking, accidental availability of sensitive info on the network or web).
5. ‘Denial of service’ or ‘zombie’ attacks from the Internet to corporate servers where hackers
   flood servers with useless traffic or use them to attack others.
6. Misdirection or loss of confidential corporate data during transfers (i.e., billing files or
   confidential files sent to unverified source).
7. Loss of data integrity (i.e., data tampered with during transmission) of confidential corporate
   data during network transfer.
8. Theft or loss of PDA’s, computers, disks and tapes and the data thereon.
9. Unauthorized tampering with network resources that can lead to damage to the network.
10. Illness or unavailability of staff members that may lead to users bypassing information
    security for the sake of convenience.
11. Loss of power, lightening strike, fire, flood or other environmental disasters.
POLICY NUMBER:            2.8                    REVISION DATE:
POLICY NAME:             Electronic Mail Use     APPROVAL DATE:           02/25/03
                         and Monitoring
EFFECTIVE DATE:          04/14/03                RESPONSIBLE              Information Resources
                                                 PARTY:

PURPOSE:
To ensure appropriate use of electronic mail; protect Synergy Medical and its resources from
risk associated with misuse.

POLICY:
1. An employee’s corporate electronic mail address and identification shall be hosted only
   through Synergy Medical’s server.
2. Synergy Medical requires users to check their Synergy Medical email regularly.
3. There is no expectation of privacy of email messages. Electronic mail sent, received,
   viewed or stored on computers owned or administered by Synergy Medical is not private.
   Electronic mail content may be accessed by Information Resources or supervisors at any
   time.
4. Synergy Medical can only protect email that resides within the network. Synergy Medical
   will not automatically forward corporate email to another address (such as a “Hotmail”
   account) because email in these accounts cannot be protected.
5. Users may not send protected health information (PHI) or sensitive corporate information
   over email without encryption and authentication of the sender and receiver. As of the date
   of the enacting of this policy, Synergy Medical does not yet have these capabilities.
6. Information Resources will determine the retention times for email. Information Resources
   may change the allowed size of messages or saved email files at any time. Staff will notify
   users before implementing such changes.
7. Users may not send unsolicited messages to large groups except as required for business.
8. Users should follow reasonable general precautions for email and Internet use, such as:
▪   Do not open messages from unknown senders.
    ▪   Do not send a reply to a junk email sender: it just confirms they have a working email
        address. Do use “opt out” features from known sources.
    ▪   Create an alternate free e-mail address (via Hotmail, Yahoo, etc.) for personal use.
    ▪   Assume that widely broadcast messages about viruses are probable hoaxes. Forward
        such messages only to Information Resources staff.
9. Synergy Medical does not require use of a disclaimer line or signature file. Employees
   should use their best judgement about when to use a disclaimer (“this opinion does not
   represent that of Synergy Medical”) or contents of a signature file (job title, contact
   information).
POLICY NUMBER:          2.9                    REVISION DATE:
POLICY NAME:           Freeware and            APPROVAL DATE:          02/25/03
                       Shareware,
                       Software Copyright
EFFECTIVE DATE:        04/14/03                RESPONSIBLE             Information Resources
                                               PARTY:

PURPOSE:

Software that may be marked as "free," "public domain," and "public use" may be free for
personal use, but not corporate use. Such software may also cause system problems and
often has no technical support available for solving those problems. Synergy Medical wishes to
limit liabilities and technical support time associated with the use of such software.

POLICY:

1. Information Resources must approve any software purchased by Synergy Medical for use
   on Synergy Medical equipment. (Exception: see PDA policy)
2. Software that Synergy Medical purchases and installs will receive full support. Second
   priority is software that Synergy Medical Information Resources has tested and found
   reliable but which Synergy Medical doesn’t purchase or install (example: Acrobat Reader,
   Internet plug-ins), also known as “endorsed” software.
3. Synergy Medical’s Information Resources department keeps a list of unacceptable
   software. This includes all software that causes conflicts with vital functions such as
   printing and web browsing, inordinate and unnecessary use of network bandwidth and
   resources, installs "spyware", causes conflicts with work-related software, makes
   unnecessary and inordinate use of system resources (memory, CPU), causes the computer
   to crash often, causes computer to boot and/or operate slowly, violates privacy by sending
   user information to 3rd parties or poses a potential security risk by opening unnecessary
   TCP/IP ports.
4. The current Unacceptable Software list will be kept on the Synergy Medical intranet. Some
   examples of Unacceptable Software include:

    AfterDark                            AOL Client
    BigCats                              Bonzi Buddy
    Comet Cursor                         Drive By Downloads
    Felix                                Firewalls, such as Zone Alarm, Black
                                         Ice Defender, Norton or McAfee
                                         Personal
    Gator                                GoZilla
    Hotbar                               KaZaA
    Spinner                              Weatherbug
    Webshots

5. Users may not install software that originally came from a home computer or elsewhere
   unless they can demonstrate from a written license that such use is permitted.
6. Users must not use copyrighted images or other material from the Internet without the
   owner’s written permission. For more information on copyright, contact Information
   Resources staff.
Users who violate this policy are personally responsible for violation of copyright laws or
   software licenses, including monetary damages that software or image publishers may be
   awarded.
POLICY NUMBER:           2.10                   REVISION DATE:           02/01/07
POLICY NAME:            Internet Access         APPROVAL DATE:           2/13/07
                        Privileges, Use and
                        Monitoring
EFFECTIVE DATE:         04/14/03                RESPONSIBLE              Information
                                                PARTY:                   Technology


PURPOSE: To ensure appropriate use of Internet and Intranet resources, protect Synergy
Medical and its staff and resources while ensuring an environment that supports academic
freedom and learning.

POLICY:

1. Synergy Medical provides Internet access to its workforce for Synergy Medical-related work
   and education. Internet usage may be monitored and/or restricted.
2. The leadership group will form an “IT Policy Group” and will work with Employees’
   supervisors to determine their need for Internet access, and the services and sites to which
   access is allowed. Directors, managers, physicians, residents, medical students and staff
   will have different levels of restriction on Internet access based on their work role.
3. No minors are allowed to use Synergy Medical computers without parental supervision.
4. Employees may briefly visit non-sensitive Internet sites during non-work time, such as
   breaks, lunch, or off-hours with the approval of their supervisor. Examples of acceptable
   sites are those dealing with travel, weather, news, and community activities.
5. Internet use must not jeopardize the operation of Synergy Medical’s network or the
   reputation and integrity of Synergy Medical. Employees will use this privilege in compliance
   with Synergy Medical policy and will not place an excessive burden on Synergy Medical’s
   resources.
6. MERIT, Inc. is Synergy Medical’s Internet Service Provider. Violations of Michnet policy
   jeopardize all of Synergy Medical’s access to the Internet. Synergy Medical staff will not
   violate Merit/Michnet use policy as provided on their website (www.merit.edu).
7. Employees may not use Synergy Medical Internet access to conduct a business concern
   outside of Synergy Medical or for personal financial gain. When using the Internet for
   personal purposes, you may not use Synergy Medical’s name or otherwise indicate, in any
   way, that you are speaking on behalf of Synergy Medical.
8. Downloading, displaying or disseminating materials of an obscene, pornographic, “harmful
   to minors” (consistent with any applicable state or local law), racist, sexist, or otherwise
   offensive nature is STRICTLY PROHIBITED. All such actions place Synergy Medical at
   risk of sexual or racial harassment accusations, among many other possibilities. Violation
   of this policy is grounds for disciplinary action up to and including immediate dismissal.
9. Information Technology will manage all Internet and Intranet site development. Employees
   may not create websites for Synergy Medical work or education without the approval of
   Information Technology.
10. There is no expectation of privacy of Internet use of any kind, including but not limited
    to instant messaging, Internet-based email, chat room use, sites visited, etc. Information
    Technology staff or corporate supervisors may access logs at any time.
11. Synergy Medical reserves the right to change, suspend, or cancel this privilege at any time
   for any reason.
POLICY NUMBER:           2.11                    REVISION DATE:
POLICY NAME:            Passwords                APPROVAL DATE:          02/25/03

EFFECTIVE DATE:         04/14/03                 RESPONSIBLE             Information Resources
                                                 PARTY:

PURPOSE:

The purpose of this policy is to establish a standard for creation of strong passwords, the
protection of those passwords, and the frequency of change.

POLICY:

Passwords are the front line of protection for user accounts. A poorly chosen password may
result in the compromise of Synergy Medical’s entire corporate network. As such, all Synergy
Medical employees (including contractors and vendors with access to Synergy Medical
systems) are responsible for taking the appropriate steps, as outlined below, to select and
secure their passwords.

SCOPE:

This policy includes all personnel who have any form of access that supports or requires a
password on any system that resides at any Synergy Medical facility, has access to the
Synergy Medical network, or stores any non-public Synergy Medical information.

GENERAL

   •   All Windows network passwords (e.g., Outlook Web Access, desktop computer, etc.)
       must be changed at least every six months. The recommended change interval is every
       four months.
   •   All Windows network passwords must conform to the guidelines described below. Some
       of the guidelines will be enforced by the system.
   •   All user accounts with access to protected health information (PHI), confidential or
       sensitive information will use password-protected screen savers as determined by
       Information Resources.
   •   Users may not access another user’s password or network access for any
       reason.


GUIDELINES

A. General Password Construction Guidelines
Passwords are used for various purposes at Synergy Medical. Some of the more common
uses include Windows network accounts, email accounts, screen saver protection, and
voicemail. All staff must be aware of how to select strong passwords.

Poor, weak passwords have the following characteristics:

    •   The password contains less than eight characters
    •   The password is a word found in a dictionary (English or foreign)
    •   The password is a common usage word such as:
           o Names of family, pets, friends, co-workers, fantasy characters, etc.
           o Computer terms and names, commands, sites, companies, hardware, software.
           o The words "Synergy Medical", "Saginaw", "Patient", “password” or any derivation.

           o Birthdays and other personal information such as addresses and phone
             numbers.
           o Word or number patterns like aaabbb, qwerty, zyxwvuts, 123321, etc.
           o Any of the above spelled backwards.
           o Any of the above preceded or followed by a digit (e.g., secret1, 1secret)

Strong passwords have the following characteristics:

    •   Contain both upper and lower case characters (e.g., a-z, A-Z)
    •   Have digits and punctuation characters as well as letters e.g., 0-9, !@#$%^&*()_+|~-
        =\`{}[]:";'<>?,./)
    •   Are at least eight alphanumeric characters long.
    •   Are not a word in any language, slang, dialect, jargon, etc.
    •   Are not based on personal information, names of family, etc.
    •   Passwords should never be written down or stored on-line. Try to create passwords that
        can be easily remembered. One way to do this is create a password based on a song
        title, affirmation, or other phrase. For example, the phrase might be: "This May Be One
        Way To Remember" and the password could be: "TmB1w2R!" or "Tmb1W>r~" or some
        other variation.

        NOTE: Do not use any of these examples as passwords!

HELPFUL HINT: Create a sentence and use the first letters/numbers, i.e.:
     − “We drove to Orlando on March 30” becomes the password “WdtOoM30”
        − “Lady Baltimore cakes require 6 eggs and 4 cups flour” becomes “LBcr6ea4cf”

B. Synergy Medical’s Password Requirements are as follows (enforced when you change
your password)

•   Passwords must be at least six characters long.
•   Passwords may not contain your user name or any part of your full name.
• Passwords must contain characters from at least three of the following four classes:
                Description                                 Examples
English upper case letters                 A, B, C, ... Z
English lower case letters                 a, b, c, ... z
Westernized Arabic numerals                0, 1, 2, ... 9
Non-alphanumeric ("special characters")    Punctuation marks and other symbols

C. Password Protection Standards
1. Passwords must not be inserted into email messages or other forms of electronic
    communication.
2. Do not use the same password for Synergy Medical accounts as for other non-Synergy
    Medical access (e.g., personal Internet account, option trading, benefits, etc.). Where
    possible, don't use the same password for various Synergy Medical access needs. For
    example, select one password for the Windows login and a separate password for the
    billing system. Different systems may have different password requirements.
3. Do not share Synergy Medical passwords with anyone, including administrative assistants
    or secretaries. All passwords are to be treated as sensitive, confidential Synergy Medical
    information.
4. If someone demands a password, refer him or her to this document or have them call
    someone in the Information Resources department.
5. Do not use the "Remember Password" feature of applications (e.g., Internet Explorer,
    OutLook, Netscape Messenger). They can be easily hacked. Users must not record
    passwords for systems with personal health information or sensitive corporate data either
    manually or digitally or by using password-caching software.
6. Again, do not write passwords down and store them anywhere in your office. Do not store
    passwords in a file on ANY computer system (including Palm Pilots or similar devices)
    without encryption.
7. Change passwords at least once every six months. The recommended change interval is
    every four months. The system will prompt you to change your password when it expires.
    Synergy Medical maximum password age is 6 months.

If you suspect an account or password to have been compromised, report the incident to
Information Resources and change all passwords.

Information Resources or its delegates may perform password cracking or guessing on a
periodic or random basis. If a password is guessed or cracked during one of these scans, the
user will be required to change it.

D. Password Recovery
   Information Resources staff are not able to see a user’s password. If a user loses a
   password, they may be required to appear in person at Information Resources for a reset
   password. The user must immediately change this reset password to an acceptable
   password.

ENFORCEMENT. Any employee found to have violated this policy may be subject todisciplinary
action, up to and including termination of employment.
POLICY NUMBER:           2.12                   REVISION DATE:
POLICY NAME:            Personal Digital        APPROVAL DATE:           02/25/03
                        Assistants (PDAs)
EFFECTIVE DATE:         04/14/03                RESPONSIBLE              Information Resources
                                                PARTY:

PURPOSE:

Synergy medical purchases PDA’s for approved employees to support their work and
education. This policy is to clarify purchasing, use, maintenance and support issues.

DEFINITIONS:

“PDA’s” includes all digital personal assistants, regardless of operating system or
manufacturer (i.e., Palm, WindowsCE devices or other PDA’s)

POLICY:

A. Purchasing and upgrading

1. Information Resources will set annual standards for PDA brands and models.
2. Students and residents will receive only one PDA from Synergy Medical funds during their
   training.
3. Finance will determine an annual limit for PDA costs.
4. Information Resources and Finance will collaborate to set an annual policy and procedure
   as to whether Synergy Medical will purchase the PDA’s or allow students and residents to
   select their own model from an approved list and receive reimbursement. Synergy Medical
   will not pay for unsupported models or PDA’s purchased before employment at Synergy
   Medical.
5. Students and residents, if allowed to purchase their own PDA’s or upgrades, must supply
   the original receipts for reimbursement.
6. The PDA must be kept in working order throughout the resident’s stay at SCHI. Resident is
   responsible for any repairs necessary.
7. Residents may use “Book Funds” to pay the remainder of their initial PDA purchase (for a
   model with more features than the standard) or for later upgrades (memory cards, book
   modules) with the approval of their program director.
B. Syncing, support security

1. Synergy Medical supplies security and synchronizing software for Synergy Medical PDA’s.
   Users are required to ‘sync’ their PDA regularly to keep Synergy Medical-provided data and
   security up to date.
2. Users may not store any protected health information on PDA’s or confidential corporate
   information unless they use Synergy Medical’s PDA security software according to
   instructions (see also: Password and HIPAA policies) or purchase and maintain their own
   PDA security software in compliance with current industry standards.
3. Users should use care in downloading and installing non-approved applications from the
   web to avoid the possibility of accidentally installing malicious software
4. Users are responsible for backing up any software they install outside that provided by
   Synergy Medical or the manufacturer of the PDA at time of purchase. This will require
   separate synchronizing with a home computer.
5. PDA information on PC’s is easily hacked. Users must also have passwords and other
   security measures on any PC’s other than SCHI’s that they sync to, including home PC’s.
   Information Resources can give recommendations of free or low cost software.
6. Information Resources does not support non-Synergy Medical PDA software and may
   remove such software from Synergy Medical-provided PDA’s without notice during
   troubleshooting or updates.
7. Users may not share your PDA with others, including family members.
8. Users must use care with regard to infrared beaming. It would be advisable to turn off the
   beam-receive option and enable it only when one is intentionally receiving data from
   another user. Even then, users should be wary of what data is being sent to them and
   guard against the possibility of receiving malicious code.
9. Users should safeguard the PDA against theft or loss as they would their own credit cards
   or car keys.
POLICY NUMBER:           3.1                     REVISION DATE:
POLICY NAME:            Employment At Will       APPROVAL DATE:
EFFECTIVE DATE:         07/01/01                 RESPONSIBLE             Human Resources
                                                 PARTY:

PURPOSE:

To provide a clear understanding of the concept of “AT WILL” employment.

POLICY:

Those employed by Synergy Medical are employed AT WILL for an indefinite period of time.
Under this policy, the employment relationship can be terminated by the employee or Synergy
Medical at any time without prior notice and without cause shown by either party. This policy
supersedes all prior oral or written representation to the contrary, unless the written statement
has been signed by the President of the corporation.
POLICY NUMBER:            3.2                     REVISION DATE:            07/01/03
POLICY NAME:             Employment               APPROVAL DATE:            05/27/03
                         Classifications
EFFECTIVE DATE:          07/01/01                 RESPONSIBLE               Human Resources
                                                  PARTY:

PURPOSE:

Employees are classified (part time, full time, salaried, hourly, etc.) for legal, budgetary, and
benefit distributing reasons.

POLICY:

CATEGORIES OF EMPLOYMENT

Synergy Medical recognizes two categories of employment:

*Full-time Employees who regularly work at least 32 hours per week.

*Part-time Employees who work less than 32 hours per week.

Fringe Benefits are assigned to employees based upon an employee’s scheduled hours per
week. Please refer to Section 8.0 – Benefits, for more information.

EXEMPT AND NON-EXEMPT EMPLOYMENT

Employees are classified as either exempt or non-exempt from minimum wage and overtime
provisions of the federal Fair Labor Standards Act. All aspects of compensation are managed
in accord with that law and its regulations.

Non-exempt/Hourly Employees. Pursuant to the Fair Labor Standards Act (FLSA) and
applicable state laws, “non-exempt employees” (i.e. most hourly staff) are entitled to overtime
pay for all hours worked in excess of 40 hours per week.

Exempt Employees/Salaried. Pursuant to the Fair Labor Standards Act (FLSA) and applicable
state laws, exempt employees are those who perform administrative, professional, or
managerial responsibilities, and those exempt employees are not entitled to overtime pay.
  POLICY NUMBER:        3.3                    REVISION DATE:
  POLICY NAME:         Resident Selection      APPROVAL DATE:
  EFFECTIVE DATE:                              RESPONSIBLE              Department Program
                                               PARTY:                   Directors


  POLICY:

I. ELIGIBILITY FOR APPOINTMENT TO A SYNERGY MEDICAL RESIDENCY PROGRAM

  A.   Applicants meeting the following minimum requirements are eligible for appointment:

             1.     A (pending) graduate of a medical school in the United States or Canada
                    accredited by the Liaison Committee on Medical Education (LCME); or
             2.     Graduate of a medical school in the United States, Canada, or accredited by
                    the American Osteopathic Association (AOA) or be enrolled in or completed
                    an AOA accredited internship; or
             3.     Graduate of a medical school outside the United States and Canada and who
                    meets one of the following criteria:
                    a.    Have a currently valid certificate from by the Educational Commission
                          of Foreign Medical Graduates (ECFMG)
                    b.    Have a full and unrestricted license to practice medicine in a United
                          States licensing jurisdiction
  Or

             4.     Graduate of a medical school outside the United States and Canada who
                    completed a Fifth Pathway program provided by an LCME-accredited medical
                    school. (A Fifth Pathway program is an academic year of supervised clinical
                    education provided by an LCME-accredited medical school to students who
                    meet the following conditions: (1) have completed, in an accredited college or
                    university in the United States, undergraduate premedical education of the
                    quality acceptable for matriculation in an accredited United States Medical
                    school; (2) have studied at a medical school outside the United States and
                    Canada but listed in the World Health Organization Directory of Medical
                    Schools; (3) have completed all of the formal requirements of the foreign
                    medical school except internship and/or social service; (4) have attained a
                    score satisfactory to the sponsoring medical school on a screening
                    examination; and (5) have passed the foreign Medical Graduate Examination
                    I the Medical Sciences, Parts I and II of the examination of the National Board
                    of Medical Examiners, or Steps 1 and 2 of the United States Medical
                    Licensing Examination (USMLE).
II. REQUESTS FOR INFORMATION

             All requests for information about the residency program will be answered.

III.         All SYNERGY MEDICAL residency programs shall participate in the National Resident
             Matching Program.

             A.    Application: All applications for resident positions shall be submitted via the
                   Electronic Residency Application Service (ERAS) or the Universal Application for
                   Residency Training.

IV.          The Program Director, or designee, will review candidates, and those more qualified for the
             positions available within the residency program will be offered interviews.

       Interview Procedure:

                   1.     Minimum required credentials:

                          a.     Completed application
                          b.     Dean’s letter (original if not ERAS application)
                          c.     Medical school transcript (certified original, if not ERAS application)
                          d.     Step 1 USMLE, NBOME part I, or COMLEX scores
                          e.     Personal statement
                          f.     At least two letters of recommendation from physicians familiar with the
                                 candidate’s performance. If the candidate has previously been in a
                                 post-graduate medical training program, one letter must be from the
                                 candidate’s former Program Director.
                          g.     Verification of graduation from medical school. (Appointments to
                                 PGY1 positions may be made prior to graduation.                    It is the
                                 responsibility of the Program Director to verify graduation prior to the
                                 resident starting in the program.)
                          h.     For candidates who are graduates of medical schools not accredited
                                 by the LCME or AOA, the following additional documentation must be
                                 provided:
                                        I.      Official certified English translations of all documents
                                                listed above.
                                        II.     Certification by the ECFMG

                   2.     All interviewees shall meet with a minimum of:

                          a.     Program Director or designee
                          b.     At least one current resident
           (“Scramble” interviews may occur via telephone and may include only
           one faculty member.)

3.   Candidates who have submitted the required documentation and have been
     interviewed, will be evaluated based on the following criteria:

     a.    Academic credentials
     b.    Communication skills
     c.    Personal qualities (ex. motivation, professionalism)
     d.    Preparedness
     e.    Ability
     f.    Aptitude

4.   The Program Director, in consultation with the GME office, determines the
     final rank list (or offer of residency position for non-entry PGY1 or other
     positions).

5.   Upon selection/match, the Program Director will request contracts from the
     Graduate Medical Education (GME) office. Contracts will only be issued
     when all required credentials have been received.

6.   All candidates who are interviewed, will receive (at the time of the interview)
     the following
             a.    Salary and benefits information
             b.    Description of the SYNERGY MEDICAL malpractice plan
             c.    Any conditions of employment

7.   Synergy Medical Education Alliance is an equal opportunity employer.
     Residency programs will not discriminate with regard to sex, race, age,
     religion, color, national origin, disability, or veteran status.

8.   Residency Programs may set more stringent requirements and procedures
     for resident selection.
POLICY NUMBER:           3.4                    REVISION DATE:           07/01/2007
POLICY NAME:            Resident Duty           APPROVAL DATE:
                        Hours, Supervision
EFFECTIVE DATE:                                 RESPONSIBLE              Departmental
                                                PARTY:                   Program Directors


POLICY:

RESIDENT DUTY HOURS, SUPERVISION

It is the policy of SYNERGY MEDICAL that all resident assignments be based on the curriculum of
the program, the availability of teaching patients, the presence of appropriate supervision, and the
educational needs of the resident. These goals should not be compromised by excessive reliance
on residents to fulfill institutional service requirements.

Residents under supervision will assume increasingly greater responsibility for patient care.
Residents will also participate in teaching of junior residents and medical students, develop
interpersonal skills, and gain an understanding of practice management, medical
socioeconomic, and cost containment issues.

PROCEDURE

I.    Responsibility

      A. The Program Director is solely responsible for the assignment of residents and ensuring
         that adequate supervision from approved faculty or senior residents is available.

      B. The Program Director and Associate and/or Assistant Director(s) shall:

          1. Assume a major teaching role.
          2. Coordinate teaching requirements with other Program Directors and Chiefs of
             Services.
          3. Coordinate teaching rotations with member institutions and approved faculty.
          4. Seek the advice of the Steering Committee, Chief Residents, and Program
             participants.
          5. Ensure that evaluation of educational experiences, faculty, and residents is
             accomplished in accordance with policy and accreditation requirements.
          6. Establish written policies governing resident duty hours and training environment
             that are optimal, both for resident education and for patient care responsibilities,
             while assuring that undue stress and fatigue among residents are avoided.
             Residents shall spend a reasonable number of hours each week in direct patient
             care responsibilities and shall have one 24-hour period each week without
             scheduled clinical responsibilities, when averaged over a four-week period.
          7. Establish policies consistent with the Special Requirements of the Accreditation
             Council for Graduate Medical Education's Residency Review Committee in the
             Program's specialty and assure adherence to these policies.

II.    Operational Guidelines

       A. Assignment of residents must be based on educational value, not service.

       B. Residents’ services shall be limited to patients of SYNERGY MEDICAL or teaching
          faculty.

       C. Experiences outside the curriculum must be approved by the Graduate Medical
          Education Committee.

       D. All assignments must have a provision for supervision by approved faculty and a means
          of evaluation.

       E. Experiences by residents in extramural activities must be approved by the Program
          Director in accordance with existing policy.

       F. Duty hours reflect the fact that responsibilities for continuing patient care are not
          automatically discharged at specific times. Programs must ensure that residents have
          backup support when patient care responsibilities are especially difficult or prolonged.

III.   Call Schedules Procedure

       A. Resident on-call should include a maximum frequency of every third night averaged out
          over a month. Variation from this guideline can occur through negotiations between the
          resident and program directors of the service(s) involved.

       B. The maximum number of calls per month should be approximately eight to ten.
          Residents should not be “penalized” by taking vacation and/or CME, i.e., being
          assigned the same number of calls as a resident not taking vacation/CME.

       C. The Program Director has final authority for any changes in call schedules.

       D. Paid Time Off requests must be submitted to the program director six months prior to
          the requested time.
       E. In the event that individual program special essentials conflict with the call schedules
          policy or procedures, departmental special essentials will supercede the above policy
          and procedure.
       F. Residency Administrative Assistants shall submit a copy of each update to their
          department’s rotation or call schedules to the GME Office.
IV.   “Moonlighting”
      SYNERGY MEDICAL strongly endorses the ACGME and AOA Guidelines, which limit the
      work hours for residents. Furthermore, SYNERGY MEDICAL believes that a residency
      program is a full-time position. With this in mind, and realizing that the financial pressures
      may force some residents to perceive a need to "moonlight", the following guidelines were
      developed.

      1. “Moonlighting” includes professional activity outside the scope of residency.

      2. Every resident desiring moonlighting activities must obtain from his/her program director
         specific programmatic requirements and written permission regarding moonlighting.

      3. Moonlighting may occur under the auspices of SYNERGY MEDICAL for intramural
         hospital night coverage or other activity. The program director has control over
         moonlighting in their program.

      4. Moonlighting outside the auspices of SYNERGY MEDICAL requires a full and
         unrestricted license to practice medicine. This is the responsibility of the individual
         resident.

      5. SYNERGY MEDICAL will not provide professional liability insurance for any moonlighting
          activities. The resident must warrant to SYNERGY MEDICAL that he or she is and will
          remain insured against liability during the term of these moonlighting activities.

      6. Any time off required, as a result of outside employment must be taken as vacation.

      7. Moonlighting which interferes with the academic performance of a resident can be
         cause for disciplinary action.

      8. For specific guidelines for individual programs, please contact the respective program
         director. It is within the sole discretion of the program directors to determine which
         outside activities interfere with the residency requirements. Program directors may
         revoke or modify any moonlighting privileges if these activities interfere in any way with
         the requirements of the residency.

      9. Interns in osteopathic internship training programs are not allowed to engage in
         professional activity outside the scope of their training program.

      10. Residents may not engage in moonlighting activities within SYNERGY MEDICAL or its
         affiliates if the activities are the same for which they would normally require supervision.


V.    Duty Hours
      1.   Duty Hours are defined as all clinical and academic activities related to the residency
           program, ie, patient care (both inpatient and outpatient), administrative duties related
             to patient care, the provision for transfer of patient care, time spent in-house during
             call activities, and scheduled academic activities such as conferences. Duty hours
             do not include reading and preparation time spent away from the duty site.
       2.    Duty hours must be limited to 80 hours per week, averaged over a four-week period,
             inclusive of all in-house call activities.
       3.    Residents must be provided with 1 day in 7 free from all educational and clinical
             responsibilities, averaged over a 4 week period, inclusive of call. One day is defined
             as one continuous 24-hour period free from all clinical, educational, and
             administrative activities.
       4.    Adequate time for rest and personal activities must be provided. This should consist
             of a 10 hour time period provided between all daily duty periods and after in-house
             call.

VI.    On-Call Activities
       1.  In-house call is defined as those duty hours beyond the normal work day when
           residents are required to be immediately available in the assigned institution.
       2.  Continuous on-site duty, including in-house call, must not exceed 24 consecutive
           hours. Residents may remain on duty for up to 6 additional hours to participate in
           didactic activities, transfer care of patients, conduct outpatient clinics, and maintain
           continuity of medical and surgical care as defined in Specialty and Subspecialty
           Program Requirements.
       3.  No new patients, as defined in Specialty and Subspecialty Program Requirements,
           may be accepted after 24 hours of continuous duty.
       4.  At-home call (pager call) is defined as call taken from outside the assigned institution.
           a. The frequency of at-home call is not subject to the every third night limitation.
                However, at-home call must not be so frequent as to preclude rest and reasonable
                personal time for each resident. Residents taking at-home call must be provided
                with 1 day 7 completely free from all educational and clinical responsibilities
                averaged over a 4-week period.
           b. When residents are called into the hospital from home, the hours residents spend
                in-house are counted toward the 80-hour limit.
           c. The program director and the faculty must monitor the demands of at-home call in
                their programs and make scheduling adjustments as necessary to mitigate
                excessive service demands and/or fatigue.

VII.   Exceptions
       1.     It will be the individual program's responsibility to show that the exception is
       necessary for educational reasons. The proposal presented to the GMEC must include the
       following:
              a. Information that describes how the program and institution will monitor, evaluate,
                  and ensure patient safety with extended work hours.
              b. A sound educational rationale should be described in relation to the program's
                  stated goals and objectives for particular assignments, rotations, and level(s) of
                  training for which the increase is requested. Note: Duty Hour exceptions for the
   entire program will not be considered. Only exceptions for specific rotations will
   be considered.
c. Specific moonlighting policies for the periods in question must be included.
d. Resident call schedules during the times specified for the exception must be
   provided.
e. There must be evidence of faculty development activities regarding the effects of
   resident fatigue and sleep deprivation.
POLICY NUMBER:           3.5                    REVISION DATE:           02/03/2006
POLICY NAME:            Program Closure or      Approval Date:           02/03/06
                        Reduction
EFFECTIVE DATE:                                 RESPONSIBLE              GMEC
                                                PARTY:

POLICY:

Medical education in the United States is influenced by many forces that are beyond the ability of
the SYNERGY MEDICAL’s Board of Trustees to control. For example, there may be government
decisions that limit the number of residents in certain programs and government decisions that
make it economically infeasible for hospitals to support medical education.

To the extent that SYNERGY MEDICAL controls its own destiny, it will make every good faith
effort to have all residents who begin a program at SYNERGY MEDICAL complete it, if they meet
the departmental criteria for advancement. If governmental decisions or other forces outside of the
reasonable control of SYNERGY MEDICAL require reducing the number of participants in a
residency program or elimination of a residency program, SYNERGY MEDICAL will notify
residents as soon as possible and make every effort to find any affected residents a comparable
position.

In the event of anticipated reductions in residency positions or program elimination, residents with
12 or fewer months required to complete their program will be continued until completion of their
program requirements unless expressly mandated by outside agencies.
POLICY NUMBER:         3.6                    REVISION DATE:
POLICY NAME:          Residents Changing APPROVAL DATE:
                      Programs
EFFECTIVE DATE:                               RESPONSIBLE             Departmental
                                              PARTY:                  Program Directors


POLICY:

Residents interested in pursuing a residency position at SYNERGY MEDICAL, other than
originally designated at the time of application and acceptance into an SYNERGY MEDICAL
program, must follow the following procedures:

1.    Apply to the desired SYNERGY MEDICAL residency through appropriate channels and
      meet all acceptance criteria.

2.    Participate in any additional interviews as indicated by the new SYNERGY MEDICAL
      residency program director.

3.    Must have previous written approval of release from the current SYNERGY MEDICAL
      residency program director.

4.    Before accepting a resident in transfer from another SYNERGY MEDICAL program, the
      program director must receive a written evaluation of the residents’ past performance from
      the previous SYNERGY MEDICAL program director.

5.    If residents have 50% or less time remaining in their SYNERGY MEDICAL residency or if
      program changes will affect GME funding, transfer into another program will be allowed
      only after approval from the Senior Vice President of Medical & Academic Affairs and both
      residency program directors.
POLICY NUMBER:           3.7                      REVISION DATE:
POLICY NAME:             Away Electives           APPROVAL DATE:
EFFECTIVE DATE:                                   RESPONSIBLE               Departmental
                                                  PARTY:                    Program Directors


POLICY:

I.     Definition: An away elective is an elective in which the majority of the resident’s time and
       effort is at a location outside of Saginaw County.

II.    This document sets forth a general institutional policy.        A program’s policy for away
       electives may be more restrictive.

III.   Away electives must meet the following criteria:

       A.     For each resident, no more than one away elective month per academic year may
              be approved by the residency director. Both the residency director and the Senior
              Vice President of Medical & Academic Affairs must approve additional away elective
              months during an academic year.
       B.     Residents on probation, or on any other type of review or remediation, may not
              participate in an away elective (Unless so directed by the formal remediation plan).
       C.     The away elective must be demonstrated to supplement or compliment the
              resident’s training in their specialty. (Ex. Subspecialty training.) It should meet the
              following:

              1.     Not available locally.
              2.     Meet the unique educational needs of the resident.
              3.     Must be approved by the residency director.

       D.     A written curriculum and formal evaluation process must be in place for each away
              elective.
       E.     In advance of rotation, financial assignment of resident must be determined.
       F.     Letter of acceptance.

IV.    SYNERGY MEDICAL will continue to provide salary, benefits, and malpractice coverage
       (SYNERGY MEDICAL self-insurance fund) while a resident is participating in an approved
       away elective. Any additional costs (ex. Housing, food, travel, required materials) are the
       responsibility of the resident.

V.     It is the responsibility of the residency director to notify the Senior Vice President of Medical
       & Academic Affairs when a resident participates in an away elective
POLICY NUMBER:         3.7(a)                REVISION DATE:
POLICY NAME:          Elective and           APPROVAL DATE:
                      Required Out of
                      System Rotations
EFFECTIVE DATE:       07/01/2010             RESPONSIBLE            Departmental
                                             PARTY:                 Program Directors

POLICY:

Each program allows residents elective rotations consistent with specific RRC requirements.
For the purposes of this policy elective rotations are differentiated from required out of system
rotations which are defined as required learning experiences that are not provided within the
Synergy Medical Education system and for which Synergy Medical assumes the fiscal
responsibility for travel to and from specific rotation locations.

Elective rotations are the choice of the resident and program director approval is required. All
expenses associated with an elective rotation are the responsibility of the resident and not the
responsibility of Synergy Medical.
POLICY NUMBER:       3.8                 REVISION DATE:       08/26/2008
POLICY NAME:        Resident DEA         APPROVAL DATE:
                    Numbers
                                         RESPONSIBLE          Departmental
                                         PARTY:               Program Directors


POLICY:

It is the policy of SYNERGY MEDICAL to make sure all residents are using appropriate DEA
numbers when ordering pharmaceuticals for patients. The DEA number utilized should
correspond to the location of the patient at the time the prescription is written.

PROCEDURE

Residents who do not possess their own DEA License will use a DEA number which is a
combination of hospital DEA numbers with a suffix made up of the last four digits of the
individual resident’s social security number. The numbers would look as follows:

HOSPITAL                       DEA #                    RESIDENT SS #

Covenant Cooper                AS2754984                -     XXXX
Covenant Harrison              AS2753564                -     XXXX
Saint Mary’s                   AT2736304                -     XXXX
POLICY NUMBER:        3.9                    REVISION DATE:        08/26/2008
POLICY NAME:          Licensure of           APPROVAL DATE:
                      Residents
                                             RESPONSIBLE           Departmental
                                             PARTY:                Program Directors

POLICY:

It is the policy of SYNERGY MEDICAL EDUCATION ALLIANCE that as a condition of
employment, all residents must possess a permanent or temporary (Educational Limited)
current physician’s license from the State of Michigan.

The Corporation will further ensure that the State of Michigan Board of Pharmacy’s
requirement that residents possess a current controlled substance registration is met.

PROCEDURE

I. Information and Monitoring

  A. Program Directors’ Responsibilities
     1. Informing residents of licensure requirements;
     2. Assisting residents with compliance;
     3. Ensuring compliance prior to initiation of training;
     4. Monitoring eligibility for permanent licensure.

  B. Human Resources Responsibilities
     1. Ensuring that current required licenses are present in each resident’s personnel file;
     2. Informing Program Directors of any discrepancies.

II. Application

   A. Upon acceptance in the program all appropriate applications should be initiated.

  B. Department/Residency Coordinators and Administrative support staff shall assist their
     house staff through:
     1. Providing information;
     2. Providing applications;
     3. Monitoring progress;
     4. Reviewing and mailing applications;
     5. Forwarding copies of licenses to Human Resources. 
POLICY NUMBER:          3.10                     REVISION DATE:          Revised 03/21/06
POLICY NAME:            Promotion                APPROVAL DATE:
EFFECTIVE DATE:                                  RESPONSIBLE             Program Directors
                                                 PARTY:

POLICY:

I.     Prior to the regularly scheduled February Graduate Medical Education Committee
       meeting, Program Directors shall review their residents and make the decision to
       reappoint and promote (or graduate) each resident.

       A.    The Program Director, at a minimum, shall use the following factors in making
             the decision to reappoint \ promote (See also attachments on Minimum Criteria
             for Resident Promotion and Graduation):
             1.     Evaluations of the resident’s performance
             2.     Performance on in-service examinations
             3.     Professionalism
             4.     Any other factors deemed appropriate by the Program Director

II.    The Program Director will, in writing, notify the Senior Vice President of Medical &
       Academic Affairs and the Chairperson of the Graduate Medical Education Committee of
       reappointment \ promotion \ graduation decisions prior to the regularly scheduled
       February Graduate Medical Education Committee meeting.

III.   If a decision is made not to reappoint or promote a resident, the Senior Vice President
       of Medical & Academic Affairs will be notified. The Senior Vice President will notify the
       resident, in writing, of the Program Director’s decision.         The reason for non-
       reappointment \ non-promotion shall be included in the notification letter. A copy will be
       sent to the Chairperson of the Graduate Medical Education Committee.

IV.    The Graduate Medical Education Committee will review and act                     on   the
       recommendations for reappointment and promotion at its February meeting.

V.     If a residents is on either departmental or institutional remediation (ex. Academic review
       or probation) at the time of evaluation for reappointment \ promotion, the Program
       Director may:
       A.      Extend the current contract until the remediation period is completed (not to
               exceed three months past the end date of the current contract). After completion
               of the remediation period, the Program Director will recommend reappointment \
               promotion \ non-reappointment.
       B.      Reappoint \ promote the resident.
VI.   Residents who are not promoted shall be placed/continued in the appropriate
      departmental or institutional remediation pathway (See Policy 9.4 “Academic Standards
      and Conduct”, 5.6 “Corrective Action”).

In the case of non-reappointment or extension, the resident may request a fair hearing as set
forth by the appropriate SYNERGY MEDICAL EDUCATION ALLIANCE policy (See Policy 5.6
“Corrective Action”, 5.8 “Hearing and Review Procedure for Residents Program Termination”).
                             Synergy Medical Education Alliance

Minimum Criteria for Resident Promotion and Graduation


The following requirements will be enforced for graduation from residency programs at
Synergy Medical:

1. Taken and passed USMLE Step III.

2. Completion of release form (medical records, Synergy Medical property, keys, etc.)

3. Produced a scholarly work i.e. performed a research project with presentation, authored an
   article that is published or developed a Q/A program that assists in the clinical care of
   patients.

4. Pass all rotations with acceptable evaluation ratings.

5. No outstanding problems in the areas of professional behavior or academic deficiencies at
   the date of anticipated graduation.

6. Satisfactorily complete all program specific requirements.


Residents failing to meet either institutional or program specific graduation requirements will be
notified in writing stating specific reasons. Refer to Synergy Medical hearing and review
procedures for further information.
                             Department of Emergency Medicine

Minimum Criteria for Resident Promotion and Graduation

I.     Prior to the regularly scheduled June Graduate Medical Education Committee meeting
       the Program Director, in consultation with the Emergency Medicine Steering committee,
       shall review all residents and make the decision to graduate resident.

       The Program Director shall use the following factors, as minimum requirements, in
       making the decision to graduate.

       A.     Participation in required/approved rotations for a minimum of 46 weeks annually
              for 3 years including vacation and sick time, per American Board of Emergency
              Medicine policy.
       B.     Obtain passing evaluation in all required rotations.
       C.     Maintain conference attendance with active participation at a minimum of 70%,
              per Residency Review Committee-Emergency Medicine requirements.
       D.     Completion of a scholarly activity, per Residency Review Committee-Medicine
              Policy.
       E.     Completion of an administrative quality improvement project, per Residency
              Review Committee-Emergency Medicine policy.
       F.     Any other factors deemed appropriate by the Program Director.

II.    The Program Director will, in writing, notify the Senior Vice President of Medical &
       Academic Affairs of graduation decisions prior to the regularly scheduled June Graduate
       Medical Education Committee meeting.

III.   If the decision is made not to graduate a resident, the resident will be notified in writing.
       The reason for fail to graduate shall be included in the notification letter.

IV.    If a resident is on either departmental or institutional remediation (ex. Academic review
       or probation) at the time of evaluation for graduation, the Program Director may:
       A.      Extend the current contract until the remediation period is completed (not to
               exceed three months past the end of the current contract). After completion of
               the remediation period, the Program Director will recommend graduation or
               continued remediation.
       B.      End the remediation period and graduate the resident.

V.     If a resident is not qualified for graduation, they shall be placed in the appropriate
       departmental or institutional remediation pathway.

VI.    In the case of non-reappointment or extension, the resident may request a fair hearing
       as set forth by the appropriate Synergy Medical Policy.
VII.   Satisfactorily complete all institutional specific requirements.
                                Department of Family Practice


Minimum Criteria for Resident Promotion and Graduation

At the end of the residency in Family Practice the graduating resident will have:

1.    Completion of all requirements needed to satisfy the criteria set forth in the ACGME
      Special Essentials for Family Practice.

2.    Acquired a permanent license to practice medicine in the State of Michigan in time to
      apply for the certification exam in Family Practice.

3.    Passed the intraining exam at least once in the tenure of the resident’s training that
      would imply a successful passing of the Board certification exam (usually a composite
      score of above 380-390).

4.    Produced a scholarly work – i.e. performed a research project with presentation,
      authored an article that is published or developed a Q/A program that assists in the
      clinical care of patients.

5.    Pass all rotations with acceptable evaluation ratings.

6.    No outstanding problems in the areas of professional behavior or academic deficiencies
      at the date of anticipated graduation.

7.    Any other factors deemed appropriate by the program director.

8.    Satisfactorily complete all institutional specific requirements.
                               Department of Internal Medicine

Minimum Criteria for Resident Promotion and Graduation

1.    Completion of the required number of months to satisfy the criteria set by ACGME in
      each year of residency.

2.    Passing of each month, as set by evaluation criteria is required to successfully be
      promoted.

3.    Attendance of at least 80% of all the conferences, attending rounds, morning reports
      and grand grounds is required.

4.    Rotation in certain core electives as set by the Department of Internal Medicine is
      required for promotion and graduation.

5.    Presentation at Journal Clubs and Mortality and Morbidity is required each year for
      promotion and graduation.

6.    Performing adequate number of procedures is also required for graduation (numbers
      are set by the ACGME)

7.    Achieving a minimum score in the inservice examination is also essential for successful
      completion of Residency. Although not a criteria used for graduation, it is used as
      criteria to place residents on probation or academic review.

8.    Successful completion of a research project in their duration of Residency is also
      essential for graduation.

9.    Any additional requirements deemed appropriate by the program director.

10.   Satisfactorily complete all institutional specific requirements.
                         Department of Obstetrics and Gynecology


Minimum Criteria for Resident Promotion and Graduation

1.    Fulfilling the ACGME General Competencies as judged by the Steering Committee.

2.    Achieving adequate evaluations by the faculty and staff.

3.    Demonstrated adequate surgical skill in the essential procedures of the specialty. This
      will be shown by resident experience logs and faculty evaluation skills.

4.    Performance on in-service exam.

5.    Demonstration of adequate supervisory and teaching skills, as with junior residents and
      medical students.

6.    Other requirements deemed appropriate by the program director.

7.    Satisfactorily complete all institutional specific requirements.
                                     Department of Surgery

Minimum Criteria for Resident Promotion and Graduation

Graduation from the general surgery residency program requires satisfactory completion of 4
requirements.

1.     Requirements to sit for the American Board of Surgery examinations
2.     Synergy Medical institutional policies.
3.     Synergy Medical Education Alliance Human Resources resident clearance form.
4.     Satisfactorily complete all institutional specific requirements.

The requirements for application to take the American Board of Surgery examinations vary
somewhat from year to year and consequently the American Board of Surgery will send you a
copy of its booklet entitled “The American Board of Surgery, Inc. Booklet of Information” and
the booklets accompanying instructions during your last year of your residency program. The
requirements for the most part are very specific and tightly written. If you wish to preview
these ahead of time, the administrative assistant can provide you with a copy of a recent
instruction booklet. The residency program is constructed such that completing the residency
program satisfactorily will enable you to fulfill all of the requirements for the board examination.
Changes that occur from time to time during the five years of the residency are communicated
via your mailbox.

You may obtain a copy of the Synergy Medical Institutional policies from the office of the
Senior Vice President of Medical & Academic Affairs. Also you should have received a copy of
this during your orientation process.

The Synergy Medical's Human Resources resident clearance form may be obtained from
Synergy Medical’s Department of Human Resources. It is a form you will receive shortly
before the end of your residency program as it involves signing off on various activities and
departments in the hospitals, and Synergy Medical.

Occasionally other graduation requirements may occur. Please contact the program director if
you have any questions.
POLICY NUMBER:           3.11                    REVISION DATE:           07/01/03
POLICY NAME:            Human Resource           APPROVAL DATE:           05/27/03
                        Records
EFFECTIVE DATE:         07/01/01                 RESPONSIBLE              Human Resources
                                                 PARTY:

PURPOSE:

To ensure existence of accurate and confidential file information for payroll status, insurance
coverage and other benefits, or other related employment record maintenance.

POLICY:

An employee’s personnel file is Synergy Medical’s permanent record of that individual’s
demographic data and employment history, and as such, must be accurately maintained and
treated confidentially. Therefore, the employee is responsible for immediately notifying Human
Resources about any change in personal status including change of address or any
information regarding the person to contact in an emergency, or general issues relative to
benefits and total compensation. An employee may obtain a copy of their personnel file
through making a written request to Human Resources. There will be a fee of $15 per
duplication of each file.

It is the responsibility of Human Resources to maintain personnel records, with additional
access being limited to an employee’s supervisor. For purposes of receiving quotes for
benefits or related business activity, anonymous demographic information will occasionally be
shared with outside vendors.

Employee phone numbers, addresses, or other information pertinent to an employee’s
personal life shall not be disclosed from corporate records for personal use.

Requests of information inquiries received by Synergy Medical, concerning employees and
their employment will be addressed by sharing:

(1) Confirmation of employment;
(2) Confirmation of beginning and (if applicable) ending dates of employment; and
(3) Confirmation of position title.

Employees or their associates requiring divulgence of additional information must provide a
signed, written, “consent to release information” or similar form.
POLICY NUMBER:          3.12                     REVISION DATE:          02/17/2009
POLICY NAME:            Family & Medical         APPROVAL DATE:
                        Leave Act
EFFECTIVE DATE:         07/01/01                 RESPONSIBLE             Human Resources
                                                 PARTY:

PURPOSE:

To provide employees with an overview of the requirements for a Family and Medical Leave
with Synergy Medical Education Alliance.

POLICY:

It is the policy of Synergy Medical Education Alliance that employees be made aware of and
allowed to exercise those rights and provisions granted to them under the federal Family and
Medical Leave Act of 1993 (FMLA).

A.    General Provisions
Under this policy, Synergy Medical Education Alliance will grant up to 12 weeks (or up to 26
weeks of military caregiver leave to care for a covered service member with a serious injury or
illness) during a 12-month period to eligible employees. The leave may be paid, unpaid or a
combination of paid and unpaid leave, depending on the circumstances of the leave and as
specified in this policy.
B.    Eligibility
To qualify to take family or medical leave under this policy, the employee must meet all of the
following conditions:
      1)     The employee must have worked for the company for 12 months or 52 weeks.
      2)     The employee must have completed at least 1,250 working hours during the 12-
             month period immediately before the date when the leave is requested to
             commence.
C.    Type of Leave Covered
To qualify as FMLA leave under this policy, the employee must be taking leave for one of the
reasons listed below:
      1)     The birth of a child and in order to care for that child.
2)   The placement of a child for adoption or foster care and to care for the newly
     placed child.
3)   To care for a spouse, child or parent with a serious health condition
     (described below).
4)   The serious health condition (described below) of the employee.
     An employee may take leave because of a serious health condition that makes the
     employee unable to perform the functions of the employee's position.
     A serious health condition is defined as a condition that requires inpatient care at a
     hospital, hospice or residential medical care facility, including any period of
     incapacity or any subsequent treatment in connection with such inpatient care or a
     condition that requires continuing care by a licensed health care provider.
     This policy covers illnesses of a serious and long-term nature, resulting in
     recurring or lengthy absences. Generally, a chronic or long-term health condition
     that would result in a period of three consecutive days of incapacity with the first
     visit to the health care provider within seven days of the onset of the incapacity
     and a second visit within 30 days of the incapacity would be considered a serious
     health condition. For chronic conditions requiring periodic health care visits for
     treatment, such visits must take place at least twice a year.
5)   Qualifying exigency leave for families of members of the National Guard and
     Reserves when the covered military member is on active duty or called to
     active duty in support of a contingency operation.
     An employee whose spouse, son, daughter or parent either has been notified of
     an impending call or order to active military duty or who is already on active duty
     may take up to 12 weeks of leave for reasons related to or affected by the family
     member’s call-up or service. The qualifying exigency must be one of the following:
     1) short-notice deployment, 2) military events and activities, 3) child care and
     school activities, 4) financial and legal arrangements, 5) counseling, 6) rest and
     recuperation, 7) post-deployment activities and 8) additional activities that arise
     out of active duty, provided that the employer and employee agree, including
     agreement on timing and duration of the leave.
     The leave may commence as soon as the individual receives the call-up notice.
     (Son or daughter for this type of FMLA leave is defined the same as for child for
     other types of FMLA leave except that the person does not have to be a minor.)
     This type of leave would be counted toward the employee’s 12-week maximum of
     FMLA leave in a 12-month period.
       6)     Military caregiver leave (also known as covered service member leave) to
              care for an ill or injured service member.
              This leave may extend to up to 26 weeks in a single 12-month period for an
              employee to care for a spouse, son, daughter, parent or next of kin covered
              service member with a serious illness or injury incurred in the line of duty on active
              duty. Next of kin is defined as the closest blood relative of the injured or recovering
              service member.
D.     Amount of Leave
An eligible employee can take up to 12 weeks for the FMLA circumstances (1) through (5)
above under this policy during any 12-month period. Synergy Medical will measure the 12-
month period as a rolling 12-month period measured backward from the date an employee uses
any leave under this policy. Each time an employee takes leave, Synergy Medical will compute
the amount of leave the employee has taken under this policy in the last 12 months and subtract
it from the 12 weeks of available leave, and the balance remaining is the amount the employee
is entitled to take at that time.
An eligible employee can take up to 26 weeks for the FMLA circumstance (6) above (military
caregiver leave) during a single 12-month period. For this military caregiver leave, the company
will measure the 12-month period as a rolling 12-month period measured forward. FMLA leave
already taken for other FMLA circumstances will be deducted from the total of 26 weeks
available.
If a husband and wife both work for the company and each wishes to take leave for the birth of a
child, adoption or placement of a child in foster care, or to care for a parent (but not a parent "in-
law") with a serious health condition, the husband and wife may only take a combined total of 12
weeks of leave. If a husband and wife both work for the company and each wishes to take leave
to care for a covered injured or ill service member, the husband and wife may only take a
combined total of 26 weeks of leave.
E.     Employee Status and Benefits During Leave
While on FMLA leave, an employee will be retained on Synergy Medical's benefit plan under the
same conditions that applied before leave commenced.
If the employee chooses not to return to work for reasons other than a continued serious health
condition of the employee or the employee's family member or a circumstance beyond the
employee's control, the company will require the employee to reimburse the company the
amount it paid for the employee's health insurance premium during the leave period.
While on paid leave, the employer will continue to make payroll deductions to collect the
employee's share of the premium. While on unpaid leave, the employee must continue to make
this payment, either in person or by mail. The payment must be received in the HR Department
by the last day of each month. If the payment is more than 30 days late, the employee's health
care coverage may be dropped for the duration of the leave. The employer will provide 15 days'
notification prior to the employee's loss of coverage.
F.     Employee Status After Leave
An employee who takes leave under this policy may be asked to provide a fitness for duty (FFD)
clearance from the health care provider. This requirement will be included in the employer’s
response to the FMLA request. Generally, an employee who takes FMLA leave will be able to
return to the same position or a position with equivalent status, pay, benefits and other
employment terms. The position will be the same or one which is virtually identical in terms of
pay, benefits and working conditions. Synergy Medical may choose to exempt certain key
employees from this requirement and not return them to the same or similar position.
G.     Use of Paid and Unpaid Leave
An employee on an approved family or medical leave must utilize accrued catastrophic-sick-
bank time (first) and paid-time-off time (second) before taking any portion of the leave as
unpaid. In the absence of accrued time off within an employee’s catastrophic sick bank,
accrued paid-time-off will be substituted as available. All paid time during the leave will count
toward the 12-week entitlement.
Disability leave including workers' compensation leave (to the extent that it qualifies), will be
designated as FMLA leave and will run concurrently with FMLA.
H.     Intermittent Leave or a Reduced Work Schedule
An employee does not need to use this leave entitlement in one block. Leave can be taken
intermittently or on a reduced leave schedule when medically necessary. Employees must
make reasonable efforts to schedule leave for planned medical treatment so as not to unduly
disrupt the employer’s operations. Leave due to qualifying exigencies may also be taken on an
intermittent basis. In all cases, the leave may not exceed a total of 12 workweeks (or 26
workweeks to care for an injured or ill service member over a 12-month period).
I.     Certification for the Employee or Employee Family Member’s Serious Health
       Condition
Synergy Medical will require certification for the employee or employee family member’s serious
health condition. The employee must respond to such a request within 15 days of the request or
provide a reasonable explanation for the delay. Failure to provide certification may result in a
denial of continuation of leave. Medical certification will be provided using the DOL Certification
of Health Care Provider for Employee’s Serious Health Condition
(http://www.dol.gov/esa/whd/forms/WH-380-E.pdf ).
Synergy Medical may directly contact the employee’s or employee family member’s health care
provider for verification or clarification purposes using a health care professional, an HR
professional, or management official. Synergy Medical will not use the employee’s direct
supervisor for this contact. Before this direct contact is made with the health care provider, the
employee will be a given an opportunity to resolve any deficiencies in the medical certification.
In compliance with HIPAA Medical Privacy Rules, Synergy Medical will obtain the employee or
employee family member’s permission for clarification of individually identifiable health
information.
Synergy Medical has the right to ask for a second opinion. In such cases, the corporation will
select and pay for the employee or employee family member to get a certification from a second
doctor. FMLA leave may be denied to an employee who (or who’s family member) refuses to
release relevant medical records to the health care provider designated to provide a second or
third opinion. If necessary to resolve a conflict between the original certification and the second
opinion, Synergy Medical may require the opinion of a third doctor (to be paid for by the
corporation) mutually selected with the employee. This third opinion will be considered final. The
employee will be provisionally entitled to leave and benefits under the FMLA pending the
second and/or third opinion.
J.     Certification of Qualifying Exigency for Military Family Leave
Synergy Medical will require certification of the qualifying exigency for military family leave. The
employee must respond to such a request within 15 days of the request or provide a reasonable
explanation for the delay. Failure to provide certification may result in a denial of continuation of
leave. This certification will be provided using the DOL Certification of Qualifying Exigency for
Military Family Leave (http://www.dol.gov/esa/whd/forms/WH-384.pdf ).
K.     Certification for Serious Injury or Illness of Covered Service member for Military
       Family Leave
Synergy Medical will require certification for the serious injury or illness of the covered service
member. The employee must respond to such a request within 15 days of the request or provide
a reasonable explanation for the delay. Failure to provide certification may result in a denial of
continuation of leave. This certification will be provided using the DOL Certification for Serious
Injury or Illness of Covered Service member (http://www.dol.gov/esa/whd/forms/WH-385.pdf ).

L.     Recertification
Synergy Medical may request recertification for the serious health condition of the employee or
the employee’s family member no more frequently than every 30 days and only when
circumstances have changed significantly, or if the employee receives information casting doubt
on the reason given for the absence, or if the employee seeks an extension of his or her leave.
Otherwise, Synergy Medical may request recertification for the serious health condition of the
employee or the employee’s family member every six months in connection with an FMLA
absence. Synergy Medical may provide the employee’s health care provider with the
employee’s attendance records and ask whether need for leave is consistent with the
employee’s serious health condition.
M.    Procedure for Requesting FMLA Leave
All employees requesting FMLA leave must inform their supervisor. Completion of an
"Application for Family and Medical Leave" form is preferred. Verbal or written notice of the
need for the leave must be given to the HR department. Within five business days after the
employee has provided this notice, the HR department will complete and provide the employee
with a Notice of Eligibility and Rights.
When the need for the leave is foreseeable, the employee must provide the employer with at
least 30 days' notice. When an employee becomes aware of a need for FMLA leave less than
30 days in advance, the employee must provide notice of the need for the leave either the same
day or the next business day. When the need for FMLA leave is not foreseeable, the employee
must comply with their supervisor’s usual and customary notice and procedural requirements for
requesting leave, absent unusual circumstances.
N.    Designation of FMLA Leave
Within five business days after the employee has submitted the appropriate certification form,
the HR department will complete and provide the employee with a Designation Notice to the
employee’s request for FMLA leave.

O.    Intent to Return to Work From FMLA Leave
On a basis that does not discriminate against employees on FMLA leave, Synergy Medical may
require an employee on FMLA leave to report periodically on the employee’s status and intent to
return to work.
POLICY NUMBER:         4.1                     REVISION DATE:
POLICY NAME:           Compensation            APPROVAL DATE:          04/08/03
                       Philosophy
EFFECTIVE DATE:        07/01/03                RESPONSIBLE             Human Resources
                                               PARTY:

PURPOSE:

Synergy Medical’s compensation policy is established to ensure objective and consistent
treatment of all employees.

POLICY:

As with all successful organizations, Synergy Medical is committed to providing pay which is
affordable to the company, encourages longevity, and maintains competitiveness in the
marketplace (administered through written compensation practices).

Any exception to policies relating to compensation must be requested in writing, with specific
reasons for variance, and approved by Human Resources and the Chief Executive Officer.
POLICY NUMBER:         4.2                     REVISION DATE:                 07/01/2009

POLICY NAME:           Pay Periods and        APPROVAL DATE:
                       Distribution of
                       Earnings
EFFECTIVE DATE:        07/01/03               RESPONSIBLE PARTY:              Human Resources


POLICY:

Distribution of Earnings. Employees are paid every other Friday (bi-weekly). When payday
is a holiday, employees are paid on the last working day before the holiday unless otherwise
notified.

Pay period. A pay period consists of two work weeks which, depending on FLSA status (See
Policy 3.2 – Employment Classifications), are defined as follows:

      Non-Exempt employees: The two week period ending the Sunday prior to pay day.

      Exempt employees: The two week period ending on the same day as pay day.


Employees have the option of receiving their pay in a payroll check, having it deposited into
their bank account through the Synergy Medical direct deposit program, or a combination
thereof. Payroll checks are mailed directly to the employees’ home address. Direct deposit
advices    are     viewable  on     Synergy      Medical’s   Workforce    Connections      at
https://ess.synergymedical.org.

Pay advances will be granted to employees only when requested in writing and approved by
the Vice President of Finance.
POLICY NUMBER:        4.3                     REVISION DATE:
POLICY NAME:          Payroll Deductions      APPROVAL DATE:
EFFECTIVE DATE:       07/01/03                RESPONSIBLE           Human Resources
                                              PARTY:

POLICY:

The following items are automatically deducted from an employee’s paycheck (when
applicable).

•     Federal, state, and city income taxes
•     Social Security and Medicare taxes (FICA)
•     State and federal tax levies and garnishments

The following items are among those that may be deducted after receiving an authorization
form signed by the employee. (This list is not intended to be all-inclusive).

•     Individual and Group health insurance premium contributions
•     Section 125 “Flexible Benefit” contributions
•     Retirement plan contributions (403-b)
POLICY NUMBER:          5.1                      REVISION DATE:          03/21/2006
POLICY NAME:            Anti-Harrassment         APPROVAL DATE:
EFFECTIVE DATE:         07/01/01                 RESPONSIBLE             Human Resources
                                                 PARTY:

PURPOSE:

It is the policy of Synergy Medical Education Alliance to prohibit harassing behavior, including
that made unlawful by Title VII of the Civil Rights Act of 1964, Title IX of the Educational
Amendments of 1972 and the Elliott-Larsen Civil Rights Act. Synergy Medical’s policy and the
law also prohibit retaliation against persons who report harassment.

POLICY:

Confidentiality – To the extent permitted by law, the confidentiality of each party involved in a
harassment investigation, complaint or charge will be observed, provided it does not interfere
with the Corporation’s ability to investigate the allegations or take corrective action.

Prohibited Acts – No member of Synergy Medical shall engage in behavior deemed to be
generally harassing. Persons who engage in harassment are subject to disciplinary action up
to and including termination.

DEFINITION OF HARASSMENT

Such conduct which has the purpose or effect of unreasonably interfering with an individual’s
work or performance in a program or of creating an intimidating, hostile or offensive
environment in which one engages in employment, a program or an activity.

DEFINITION OF SEXUAL HARASSMENT

Sexual Harassment is defined as unwelcome advances, requests for sexual favors or other
behavior of a sexual nature when:

      1. Submission to such conduct is made explicitly or implicitly a term or condition of an
         individual’s employment or status in a program (e.g., residency rotation, student
         clerkship) or an activity.

      2. Submission to or rejection of such conduct is used as a basis for a decision affecting
         an individual’s employment or participation in a program or an activity.

      3. Any conduct with sexual overtones as applied to the general harassment definition.

Sexual harassment encompasses any unwanted sexual attention.             Examples of behavior
encompassed by the above definition include, but are not limited to:
      1. Physical assault.

      2. Threats or insinuations which cause the victim to believe that sexual submission or
         rejection will affect his/her reputation, education, employment, advancement or any
         conditions which concern the victim’s standing with Synergy Medical.

      3. Direct propositions of a sexual nature.

      4. Subtle pressure for sexual activity.

      5. Conduct (not legitimately related to the subject matter of the work, program or
         activity in which one is involved) intending to or having the effect of discomforting
         and/or humiliating a person at whom the conduct is directed. This may include, but
         is not limited to, comments of a sexual nature or sexually explicit statements,
         questions, jokes, or anecdotes, and unnecessary touching, patting, hugging, or
         brushing against a person’s body.

Depending upon the circumstances, any of the above types of conduct may be sexual
harassment and subject to disciplinary action, even if that conduct only occurs once.

SEEKING ASSISTANCE OR FILING A COMPLAINT

Any issues, questions or concerns regarding any form of harassment must be directed to an
employee’s supervisor or to the Department of Human Resources in writing, immediately.
Supervisors must in turn, immediately forward such complaints to the Department of Human
Resources and participate in the investigation as necessary.

Staff, residents, and students or associates who believe they are the victims of any form of
harassment may seek information and assistance from the following areas:

      1.   If the staff, residents, and students or associates wish to file a complaint, she/he
           must immediately take the following action(s) in writing:

                   A. If the alleged harasser is a resident, faculty, or staff member, the
                      affected individual(s) must make a written complaint to that employee’s
                      supervisor and to the Department of Human Resources.

                   B. If the alleged harasser is the supervisor, the affected individual(s) must
                      make a written complaint to the Department of Human Resources.

                   C. If the alleged harasser is a student, the affected individual may file a
                      complaint with the Senior Vice President of Medical & Academic Affairs
                      or Office of the President or any of the individuals listed above.
      2.     Complaints must be filed immediately, in writing, with the respective individual
      listed above. All complaints will be investigated by the Department of Human
      Resources or a designee of the CEO, with the results of the investigation being reported
      to the CEO and appropriate action taken.

AWARENESS

Employees of Synergy Medical are responsible for knowing and understanding the Synergy
Medical policies prohibiting of harassment. Suggested information sources are as follows:

Employees who do not understand the policy should contact their supervisors; residents who
do not understand the policy should contact their Program Directors; Organizational Leaders
who need assistance in understanding, interpreting, or applying the policy should Human
Resources or the Office of the CEO.

Retaliation of any kind against an employee who comes forward with a grievance, complaint,
or concern over any form of harassment is prohibited and those suspected of retaliation shall
be subject to disciplinary action.

Any employee who engages in any form of harassment or who falsely accuses other
employees of such activities will be subject to disciplinary action.
POLICY NUMBER:          5.2                      REVISION DATE:
POLICY NAME:            Fair Treatment           APPROVAL DATE:           05/27/03
EFFECTIVE DATE:         07/01/03                 RESPONSIBLE              Human Resources
                                                 PARTY:

PURPOSE:

It is the policy of Synergy Medical to provide all employees with an opportunity and a method
for resolving all work related problems in a timely and fair manner.

POLICY:

RESOLUTION STEPS

The procedure for reviewing and resolving problems is as described below. The procedure
can stop at any point in the process if the employee agrees with the resolution of the problem.

In many cases, a situation can be resolved immediately by initiating an open discussion with
ones’ immediate supervisor. Prior to following these formal steps, it is expected that the
employee discuss the problem with his/her immediate supervisor.

      1.     The employee will bring the problem to his/her immediate supervisor through a
             written complaint. This document should describe the nature of the complaint
             and include all attempts that have been made by the employee to bring the
             problem to a resolution. It should also include a proposed change that will
             resolve the problem.

             The immediate supervisor shall respond in writing within five (5) work days and
             should contain a brief summary of the problem in addition to the supervisor’s
             proposed resolution.

      2.     If the employee is dissatisfied with the resolution of the problem, it is his/her
             obligation to submit a written summary of the complaint to the Director of his/her
             area within five (5) working days of the response (or due date) from the
             immediate supervisor. If the employee’s immediate supervisor is the Director of
             his/her area, then proceed to number 3.

             The Director is to respond in writing within five (5) working days after he/she has
             meet with the employee and has conducted a fair investigation of the complaint.
             Copies of the Director’s response shall be given to the employee, the employee’s
             immediate supervisor, and to Human Resources.

      3. If the employee is again dissatisfied with the proposed resolution, he/she may
              request in writing (within 5 days) to the Director that the matter be presented to a
              Grievance Committee. The director will forward this request to Human
              Resources who will then initiate the formation of the Grievance Committee.

              The Grievance Committee will be comprised of: three (3) non-management
              employees randomly selected by Human Resources, one (1) manager selected
              by the employee (but not within the same work area), one Director selected by
              the immediate supervisor (but not within the same work area), and one (1)
              Human Resources Representative to serve as a non-voting member.

              The committee will come to a majority decision on the matter and communicate
              the resolution to the employee in writing within ten (10) days.

       4. In the event that the employee objects to the committee’s decision, the employee
              must submit a written request to Synergy Medical’s President/CEO within five (5)
              days to arrange a meeting. A final solution from the President/CEO will be
              presented to the employee in writing within five (5) days.

All documentation will go into the employee’s personnel file. Filing of this information will not
be deemed to be prejudicial to the employee in any way but is merely evidence that the
problem has been brought up and potentially resolved to everyone’s satisfaction.
POLICY NUMBER:           5.3                       REVISION DATE:           07/01/03
POLICY NAME:             Substance Abuse           APPROVAL DATE:           05/27/03
EFFECTIVE DATE:          07/01/01                  RESPONSIBLE              Human Resources
                                                   PARTY:

PURPOSE:

Synergy Medical wants to ensure a safe and professional environment for our staff, patients,
and the communities that we serve. To promote this goal, employees, residents, students,
faculty, and volunteers (hereafter “staff”) are required to report to work free of drugs or alcohol
and in an appropriate condition to perform their duties in a manner acceptable to Synergy
Medical.

POLICY:

COVERED SUBSTANCES

       1. Alcoholic beverages of any kind;
       2. Controlled or illegal drugs or substances, which include all forms of narcotics,
          hallucinogens, depressants, stimulants, and other drugs whose use, possession, or
          transfer is restricted or prohibited by law.

EXCEPTIONS

Drugs prescribed by a physician, dentist or other person licensed to prescribe or dispense
controlled substances or drugs used in accordance with their instructions are not subject to this
policy. It is the responsibility of staff to notify their supervisor of use of any substance that may
impair their ability to perform their job in a safe and effective manner (e.g., mental judgment,
alertness).

APPLICABLE WORK RULES

Staff who violate any of the following work rules will be subject to discipline, up to and including
termination:

•   Staff cannot report for work or work while impaired by alcohol (impaired is defined as a
    blood alcohol concentration of .02% or above) or drugs (testing positive at a specified level
    of a covered substance).

•   Use, possession, manufacture, distribution, dispensation, or sale of illegal drugs or alcohol
    during work time, on Synergy Medical premises, or in Synergy Medical supplied vehicle, or
    during active work
•   Failure to adhere to the requirements of any drug or alcohol treatment counseling program
    in which the staff member is enrolled.

•   Conviction under any criminal drug statute or failure to inform the Office of Administration of
    such conviction within five (5) days.

•   Actions or behavior that may have the effect of damaging the reputation, integrity, and
    safety of others regardless of the location, formality, or informality of the event (e.g.
    Company picnics, recruiting fairs, receptions)
POLICY NUMBER:             5.3(a)                      REVISION DATE:              07/01/03
POLICY NAME:               Drug and Alcohol            APPROVAL DATE:              05/27/03
                           Testing
EFFECTIVE DATE:            07/01/01                    RESPONSIBLE                 Human Resources
                                                       PARTY:

POLICY:

Synergy Medical may test for possible substance abuse under the following circumstances:

•   Pre-employment: To determine if an applicant is using illegal drugs or alcohol.
•   Reasonable Suspicion: If reasonable suspicion exists that a staff member is using drugs
    or alcohol or is at work under the influence.
•   Post-Accident: Testing will be conducted if an employee is involved in an accident
    involving personal injury or damage to property no matter how severe the incident or
    damage involved.
•   On-the Job Injury: Testing will be conducted if an employee is involved in an on-the-job
    injury or accident.
•   Follow-up: Testing will be conducted on a scheduled or random basis when a staff
    member returns to work after completing rehabilitation or counseling for substance abuse.

Refusal to submit to a required drug or alcohol test is insubordination and will be considered
cause for immediate discharge. Similarly, any intentional alteration or other tampering with
any specimen provided for a drug test or an alcohol test or, any substitution of another
specimen for the employee’s specimen will result in immediate discharge.

•   If the results of a drug or alcohol test show a positive drug or alcohol screen, Synergy
    Medical may suspend the staff member from work while Synergy Medical investigates the
    incident to determine, in its sole discretion, the appropriate response, which may include
    discharge.

•   Synergy Medical may require staff who violate or are suspected of violating the Substance
    Abuse Policy to seek counseling through its Employee Assistance Program.

•   Synergy Medical may condition the return to work of a staff member who is suspended for
    violation of this policy on entry into an agreement detailing the terms applicable to the staff
    member’s return to work. Refusal to enter the agreement or comply with its terms
    thereafter will be grounds for discharge.

To ensure the safety of all, any staff member who is aware of substance or alcohol abuse on the job by co-
workers should report it to Human Resources promptly. Synergy Medical will comply with all state, federal, and
professional requirements for reporting and managing its staff with documented impairment and/or substance
abuse issues.
POLICY NUMBER:         5.3(b)                 REVISION DATE:
POLICY NAME:           Substance Abuse -      APPROVAL DATE:
                       Drug and Alcohol
                       Testing Procedure
EFFECTIVE DATE:        07/01/03               RESPONSIBLE             Human Resources
                                              PARTY:



MANAGEMENT RESPONSIBILITIES
• Review and understand Synergy Medical’s Substance Abuse Policies 5.3, 5.3(a), 5.3(b).
• Provide appropriate documentation for the situation.
• Coordinate efforts with HR and Administration as appropriate throughout the drug and
  alcohol testing process.

HUMAN RESOURCES RESPONSIBILITIES
• Provide assistance and coaching to management on possible substance impairment
  issues.

GUIDELINES
Managers shall be alert for signs of substance abuse. An impaired employee is one whose
behavior is noticeably different from than normally expected. Behaviors that may indicate
impairment include:
• Changes in motor skill activity, walking style or arm and hand movement
• A suspicious odor
• Slow, careful movements
• Slurred speech
• Radical personality changes
• Changes in performance

NOTE: Numerous health conditions or reactions to chemical substances can cause any or all
of these behaviors.

ASSESSMENT
Once a manager has determined that an employee may be impaired, he/she must act to
safeguard the impaired person, patients, and other employees. Management may do the
following:
• Approach the employee in a professional, non-threatening manner and treat him or her with
    respect.
• Inform the person of the suspicion that he/she is impaired and that a private discussion is
    required.
• Contact local law enforcement authorities if physical confrontation is required or
    anticipated.
•   Advise the employee of the nature of the concern relating to the observed behavior(s) and
    impairment.
•   Allow the employee to offer an explanation for the cause of the unusual behavior.

Management will then make a determination if there is any indication of a violation of the
Substance Abuse Policy. This will be based upon the employee’s ability/inability to provide an
explanation for impairment that includes reference to the use of alcohol or chemical
substances other than prescribed medication, or if the employee fails to provide any
reasonable explanation.

If the manager feels that there is no indication of a possible violation of the Substance Abuse
Policy, he/she still must determine if the employee is fit for work. The manager may judge the
employee fit for work if all of the following apply (Documentation of the event is not necessary
if the manager determines that the employee can do his/her job safely.):
• The employee’s explanation of the cause of impairment is accepted as reasonable.
• The information in the explanation gives the manager confidence that the employee can do
     his/her job in a safe and effective manner.

The manager may also decide that despite not violating Synergy Medical’s Substance Abuse
policy, the employee may not be fit for work if the explanation provided and observations of the
employee’s behavior reflect his/her inability to safely complete their job.
• Arrangements for a ride home will be made for the employee.
• Documentation of the incident and communication with applicable department supervisor(s)
    and Human Resources will be completed.

NOTE: For licensed Health Care Professionals, additional steps may be required. Please
refer to the “Health Professional Recovery Program” section of this policy, below.

TESTING PROCEDURE
If there is an indication that the Substance Abuse Policy has been violated, the employee will
be immediately informed of the decision to administer a drug or alcohol test. A “Consent Form
for Alcohol, Drug and Substance Screen” (see attached) will be completed and accompanied
to the testing facility. The Department Manager, Human Resources Representative, or Security
Officer will escort the employee to the facility conducting the test.

Synergy Medical conducts operations at two locations (Main - 1000 Houghton and North -
1575 Tittabawasee Rd.) and provides staff for Covenant Healthcare and Saint Mary’s Medical
Center. The following shall provide procedures for administering tests when issues of
substance abuse occur at each respective site throughout various times of the day.

Testing during normal business hours (7:00 AM – 7:00 PM Monday – Thursday and 7:00
AM – 5:00 PM on Friday):

Synergy Medical (Main and North Campuses).
• Employee will be escorted to Covenant HealthCare Occupational Medicine (600 Irving St.).
•   For alcohol testing, a breath alcohol technician using a breath alcohol-testing device
    compliant with the approved NIOSH testing equipment list shall conduct testing.
•   For narcotics or drug testing, a urine sample analysis will be conducted. Samples will be
    collected by trained personnel of Occupational Medicine, sealed and initialed by the
    employee and a witness. An approved chain of custody procedure is followed to process
    all specimens/samples.

Covenant HealthCare. Same procedure as Synergy Medical.

Saint Mary’s Medical Center.
• Testing procedures will be followed according to those practiced by Saint Mary’s Medical
   Center.

After hours testing:

Covenant HealthCare.
• Employee will be escorted to the Emergency Department at Covenant HealthCare. On-call
  staff from Covenant’s Occupational Medicine Department will perform testing.

Synergy Medical (Main and North Campus). Same procedure as Covenant HealthCare.

Saint Mary’s Medical Center.
• Testing procedures will be followed according to those practiced by Saint Mary’s Medical
   Center.

HEALTH PROFESSIONAL RECOVERY PROGRAM
For licensed/registered health professions, the Health Professional Recovery Program
(HPRP) exists which was established by the State Legislature in 1993 to meet the needs of
health professions for a confidential, non-disciplinary approach to support recovery from
substance abuse/chemical addiction or mental illness.

If there is enough suspicion that a health care professional may be impaired, the managing
supervisor shall report the employee to the HPRP as required by law (MCL 333.16223). The
HPRP conducts a confidential evaluation of the individual through their very own program.

Despite the non-disciplinary approach of the HPRP, Synergy Medical reserves the right to
determine the need for immediate suspension of all patient care and academic activities,
whether the individual will need a medical leave of absence as part of the rehabilitation
program, or if any other means of corrective action is necessary.
CONSENT FOR ALCOHOL, DRUG AND SUBSTANCE SCREENING

I, an employee of Synergy Medical Education Alliance, understand that the use of drugs, alcohol, and
other controlled substances by employees creates a dangerous work environment.

I understand and agree to undergo substance screening. I hereby allow Synergy Medical Education
Alliance to take the necessary steps to obtain specimens from me to test for any controlled substance.

Further, I release Synergy Medical Education Alliance and its employees, directors, affiliates and
successors from any liabilities, claims, and causes of action, known or unknown, contingent or fixed,
that may result from this drug test.

I have read and understood this agreement.



__________________________________
Print Name



__________________________________
Signature



_________________________________
Date
POLICY NUMBER:         5.4                      REVISION DATE:
POLICY NAME:           Evaluation               APPROVAL DATE:
EFFECTIVE DATE:                                 RESPONSIBLE              Program Directors
                                                PARTY:

POLICY:

I.    Evaluation of Residents

      A.    Residency programs shall develop a process for evaluating residents after each
            rotation. The evaluation process should include the meeting of rotation goals
            and objectives, clinical proficiency, and professionalism. If a significant concern is
            noted, the concern will be communicated to the resident in a timely fashion by
            the Program Director, or designee.

      B.    Semi-Annual Resident Evaluation: The Program Director, or designee, must
            formally evaluate all residents in the residency, at least every six months.
            Graduation criteria will be discussed with the resident to help assess their
            progress. The formal evaluations shall be in writing, dated, and signed by both
            the evaluator and the resident.

      C.    Resident Well-being: Residency programs shall develop a program to monitor
            the well-being of their residents.

      D.    Residents shall have access to their evaluations, upon request, in a timely
            fashion.

II.   Evaluation of Rotations & Faculty

      A.    Evaluations
            1.    At the end of every rotation, residents shall complete an evaluation of the
                  rotation and supervising faculty. The Program Director, or designee, shall
                  review the evaluations. If a significant concern is noted, the concern will
                  be communicated to the rotation coordinator, or faculty member.
            2.    Evaluations by residents shall be anonymous and confidential. The
                  Program Director shall assure that residents are able to comment without
                  fear of retaliation.
      B.    Annual Program Evaluation
            1.    At least annually, residents shall evaluate their residency program and the
                  residency teaching faculty. The Program Director shall assure that
                  residents are able to comment anonymously and without fear of
                  retaliation.
             2.     The residency program shall cooperate with the annual evaluation
                    conducted by the Institution of the program. All residents shall participate
                    in this annual review.

III.   Annual Promotion/Progress Summary
       (See 3.10 “Promotion” on departmental promotion and graduation guidelines)

Summary Evaluation

At the time of the resident’s graduation (or departure) from a residency program, the Program
Director will prepare a written summary evaluation of the resident's performance during the
training program. This written summary evaluation will be submitted to the GME office and a
copy kept by the residency program.
POLICY NUMBER:         5.5                     REVISION DATE:
POLICY NAME:           Faculty & Program       APPROVAL DATE:
                       Evaluation
EFFECTIVE DATE:                                RESPONSIBLE            CAO
                                               PARTY:

POLICY:

It is the policy of Synergy Medical Education Alliance to monitor the quality of its graduate
medical education programs and faculty through systematic evaluations by program
participants.

PROGRAM EVALUATION PROCEDURE

A.   Frequency: Resident shall complete evaluations at the conclusion of each     educational
     experience or at least every six months for experience extending beyond six months.

B.   Format:    SYNERGY MEDICAL Rotation Evaluation Forms shall be utilized for
     evaluations. Evaluators are encouraged to make written comments in addition to numeric
     determinations.

C.   Tabulation: Completed evaluation forms should be returned to the Department Secretary
     for tabulation.

D.   Results: Program Directors shall monitor results, take appropriate measures as
     necessary, and annually provide written feedback as required. A copy of the written
     feedback will be provided to the President.

FACULTY/PROGRAM DIRECTOR EVALUATION PROCEDURE

A.   Frequency: Residents shall complete evaluations at the conclusion of each educational
     experience or at least every six months for experience extending beyond six months.

B.   Format: SYNERGY MEDICAL Faculty Evaluation Forms shall be utilized for evaluating
     both attending staff and Program Directors. A separate form should be utilized for the
     Program Director and his/her Associate(s) and/or Assistant(s). Written comments by
     evaluators are encouraged.

C.   Tabulation: Completed Faculty Evaluation Forms shall be returned to the Department
     Secretary for tabulation. Forms evaluating the Director and/or Associate/Assistant
     Director shall be returned to the President.

D.   Results: The Program Director shall monitor faculty evaluations, take appropriate
     measures as necessary, and annually provide written feedback to each faculty member
     supplemented by verbal feedback as required. A copy of written feedback should be
     provided to the President.


The Senior Vice President of Medical & Academic Affairs shall monitor Program Director
evaluations and meet individually with Directors to review all full-time faculty evaluations.
Directors shall discuss results with their Associate(s)/Assistant(s)

Each faculty member an/or Program Director/Associate/Assistant may examine his/her
evaluations upon request and may make written comments if desired.

RESIDENT EVALUATIONS

A.   Program Directors and Program Faculty shall provide a written evaluation to measure
     educational and professional progress of the Residents, a copy of which will be
     maintained in the Residents personal file.

B.   On-call duty schedules for teaching staff will be structured to ensure supervision is readily
     available to residents on duty. Duty schedules will be made available to both residents
     and staff in each department.
POLICY NUMBER:          5.6                      REVISION DATE:           06/11/07
POLICY NAME:            Corrective Action        APPROVAL DATE:           08/03/07
                                                 RESPONSIBLE              Program Director/CEO
                                                 PARTY:                   /Senior Vice President
                                                                          of Medical and
                                                                          Academic Affairs


PURPOSE:

Synergy Medical Education Alliance recognizes that mutually satisfying and productive
employment relations require the commitment and adherence to acceptable performance
standards and workplace behaviors. When necessary, Synergy will take steps to assure
appropriate conduct by administration of corrective action to assist employees in correcting
work-related problems, performance deficiencies, and behavior that violates Synergy Medical
policies, practices, procedures, or expectations.

POLICY:

I.     Initiation of Corrective Action

Corrective Action involving a Resident may be initiated or recommended by any one of the
following:

             1)     Board of Directors;
             2)     Senior Vice President/President;
             3)     President of any of the participating medical staffs;
             4)     Graduate Medical Education Committee;
             5)     Chairperson of any hospital clinical department or a             Departmental
                    designee
             6)     Program Director
             7)     Human Resources

Written recommendations for corrective action shall be submitted to the Senior Vice
President/President, or a designee. No written recommendation is necessary when corrective
action is initiated by the Senior Vice President/President, or their designee.

All matters relating to corrective action, and hearing and review activities in Policies 5.6, 5.7,
and 5.8 set forth herein, to the extent allowable under federal and state law and regulation
shall constitute peer or professional review. All participants in the processes and hearing and
review, including the individuals listed above, residents, witnesses, members of the hearing
committee, and all records, data and knowledge collected for or by the committee or other peer
review committees are bound by federal and state law as well as the policies of the
Corporation regarding the confidentiality of such matters.

II.    Grounds for Corrective Action

Grounds for corrective action include, but are not limited to, the following:

        A. Unsatisfactory Performance: The failure, refusal, or negligence by a resident to attain
the educational objectives of the Residency Program as required by the Corporation. Such
failure, refusal, or negligence may be documented by evaluations of a resident indicating
below adequate skills, abilities, and/or attitudes.

      B. Failure to Comply: Failure to comply with the bylaws, rules or regulations of the
Corporation, or with the terms and conditions of a Residency Contract.

       C. Substance Abuse: The taking of alcohol or other drugs at dosages that place an
individual's social, economic, physiological, and physical welfare in potential hazard, or to the
extent that an individual loses the power of self control as a result of the use of alcohol or
drugs, or while under the influence of alcohol or drugs endangers public health, morals, safety,
or welfare, or a combination thereof.

        D. Moral Turpitude: If a resident commits an offense involving moral turpitude under
federal, state, or local laws or ordinances, or conducts himself/herself publicly or privately in
any manner which offends against decency or morality or causes him/her to be held in public
ridicule or scorn, or causes a public scandal.

       E. Conviction of a Felony.

      F. Revocation or Suspension of License: Notification by an appropriate agency of the
revocation or suspension of a person's license, or of his/her being placed on probation.

        G. Other Conduct: If a resident engages in acts, statements, demeanor, or professional
conduct, either within or outside of normal working hours, and the same is or is reasonably
likely to be (1) detrimental to patients' safety or the delivery of quality patient care; (2)
disruptive to the operations of the Corporation or any of the participating hospitals; (3) a
violation of any existing professional ethics requirements; or (4) a cause of impairment to the
community's confidence in the Corporation and the participating hospitals.

III.   Procedure

       The Senior Vice President/President may implement the recommended corrective
action or, in his/her sole discretion, forward the recommendation for corrective action to the
appropriate Program Director for further consideration and/or investigation.
      A.     The Resident will receive written notice of the corrective action implemented.

      B.      If the matter is referred to a Program Director for consideration, the Resident will
      receive written notice of the referral and of the recommendation for corrective action.
      The Program Director shall report back to the Senior Vice President/President within
      twenty-one (21) days, or sooner on a request from the Senior Vice President/President.
      If corrective action is taken by any other individual authorized to initiate such action then
      the resident will receive a notification of the corrective action from the party initiating the
      action.

IV.    Corrective Action

The Senior Vice President/President or a designee may implement corrective action, which
may include, without limitation, the following:

      A.     Rejection of the request for corrective action;
      B.     A written warning, a letter of admonition, or a letter of reprimand;
      C.     Terms of probation;
      D.     A reduction, modification, suspension, or revocation of privileges within the
             Corporation or at any of the participation hospitals.
      E.     Termination or other corrective action that results in dismissal, nonrenewal of a
             resident’s agreement, determination that an extension of training is required, or
             failure to certify satisfactory completion of a program.

Neither the Corrective Action Policy nor the exercise of any procedural rights in any way
modify the at-will nature of the employment relationship.

V.     Notification of Corrective Action

 A corrective action notice shall specify the corrective action taken and the reason(s) for it. If
applicable, the notice will state the Resident’s entitlement to a hearing, and include a copy of
the procedure governing the Hearing and Review Procedure (Policy 5.8).

VI.   Procedural Rights

       A.     Corrective action issued under Section 5.6, IV (A) through (D), shall be final and
binding, and the Resident shall have no further procedural rights.

       B.     If the Senior Vice President/President, or a designee, implements corrective
action under Section 5.6, IV (E), the Resident shall have the right to exercise or waive the
procedural rights stated in Policy 5.8, "Hearing and Review Procedure for Residents Program
Termination."
       1.      After receipt of a corrective action notice with a copy of the Hearing and Review
               Procedure, the Resident may, within twenty-one (21) calendar days of the
               Notice, invoke the Hearing and Review Procedure under Policy 5.8. If the
               Resident does not timely invoke the Hearing and Review Procedure, the
               Resident will have waived the opportunity for review and the corrective action
               under Section 5.6, IV (E) will be final.

       2.      Depending on the corrective action implemented, Synergy may end the
               Resident’s employment or Synergy may place the Resident on immediate
               suspension without pay.

       3.      Refer to Policy 5.7 for procedures related to termination of employment.

VII.   Summary Suspension

       A.     The Senior Vice President/President, the Chairperson of the applicable
department, the Chairperson of the Department Steering Committee if applicable, and the
Chairperson of the Board of Directors of the Corporation, shall each have the right, upon a
request for corrective action, and when action is required immediately in the best interest of
patient care, or other reasons require immediate action, to temporarily suspend a resident. The
suspension may, in the Senior Vice President/President’s discretion, include a suspension of
the Resident's compensation and/or educational credit, in addition to the Resident's duties. In
such case, the suspended Resident shall be informed immediately of the charges in writing,
and entitled to a Hearing before an ADHOC Committee appointed by the Senior Vice
President as described in Policy 5.8 as soon as it can be arranged, but no later than twenty-
one (21) calendar days from the date of suspension, to determine whether the suspension
shall be continued, modified, or terminated.

         B.    Whenever an appropriate agency revokes a resident's license or places a
restriction on his/her right to practice, the Corporation shall revoke or limit the Resident’s status
and privileges in an equivalent fashion. No right of appeal or hearing from such action shall
exist.
      C.       Failure to complete medical records shall result in temporary automatic summary
suspension without right of hearing or appeal. Such suspension shall terminate upon
compliance with the applicable regulation. Repeated violations of this section may be grounds
for discipline under Corrective Action.
and privileges in an equivalent fashion. No right of appeal or hearing from such action shall
exist.

        C.     Failure to complete medical records shall result in temporary automatic summary
suspension without right of hearing or appeal. Such suspension shall terminate upon
compliance with the applicable regulation. Repeated violations of this section may be grounds
for discipline under Corrective Action.
POLICY NUMBER:        5.7                    REVISION DATE:          6/11/07
POLICY NAME:          Resident               APPROVAL DATE:          08/03/07
                      Termination
                                             RESPONSIBLE             Senior Vice President/
                                             PARTY:                  Program Director


POLICY:

TERMINATION of RESIDENT EMPLOYMENT

I.   Termination of a Resident's employment (before the expiration date of the current
     contract) may occur as follows:

     A.    Voluntary Termination

           1.    A Resident wishing to terminate employment shall submit a written
                 communication to the Program Director stating the Resident’s request to
                 voluntarily leave the residency program and the reason(s) for the request.
                 The Program Director will forward a copy of the letter to the Senior Vice
                 President.

           2.    A meeting with the resident may be requested by the Program Director, or
                 designee, or by the Senior Vice President.

           3.    Voluntary withdrawal from the residency program (employment contract)
                 requires the approval of the Program Director and the Senior Vice
                 President. If the Program Director and Senior Vice President approve the
                 Resident's voluntary withdrawal from the residency, they will make such a
                 recommendation to Synergy Medical's President, who is responsible for
                 termination of the contract. The Resident will be notified in writing of the
                 final decision.

     B.    Involuntary Termination

           1.    As outlined by the Synergy Medical Corrective Action Policy (See Policy
                 5.6 "Corrective Action"), termination prior to the expiration date of the
                 current contract may result from the following:

                 a.     Unsatisfactory performance
                 b.     Failure to comply with program or Synergy Medical policies and
                        procedures
                    c.     Substance abuse
                    d.     Moral turpitude
                    e.     Conviction of a felony
                    f.     Revocation or suspension of medical license (educational or
                           permanent)
                    g.     Other conduct unbecoming a medical professional

             2.     Synergy will notify the Resident in writing of the decision to terminate the
                    Resident’s employment.

             3.     A Resident terminated under Section 5.6, IV.E, may invoke the procedural
                    rights described in Policy 5.8, Hearing and Review Procedure for Resident
                    Program Termination.

             4.     Neither this policy nor Synergy’s other policies modify the at-will nature of
                    employment at Synergy.


PAY AND BENEFITS

Upon termination of employment, employees with full benefits, medical and dental coverage
will continue to receive those benefits until the end of the month in which employment is
terminated. At that time, eligible employees may have their benefits continued in compliance
with continuation of benefits laws and regulation. The Resident’s pay will cease on the date of
termination.

RETURN OF CORPORATE PROPERTY

Separating employees are responsible for the safe return of all company property assigned to
them as an employee (e.g., keys, pager,, palm pilot) to the Department of Human Resources.
Separating employees must return property as soon as possible and notify the Purchasing
Department if large property/equipment items will be transferred to another employee (e.g.,
personal computer).
POLICY NUMBER:         5.8                     REVISION DATE:          06/11/07
POLICY NAME:           Resident                APPROVAL DATE:          08/03/07
                       Termination –
                       Hearing and Review
                                               RESPONSIBLE             Senior Vice President
                                               PARTY:                  of Medical and
                                                                       Academic Affairs


POLICY:

HEARING AND REVIEW PROCEDURE FOR RESIDENTS PROGRAM TERMINATION

I.    Applicable Procedure

      PROCEDURE FOR RESIDENTS: When a Resident receives notice of a corrective
      action involving termination or other corrective action under 5.6, IV (E), the Resident
      shall upon request be entitled to a hearing before an ADHOC Committee (hereafter
      “ADHOC Committee”). The procedures outlined below shall apply:

II.   Request for Hearing

      A.   After receiving notice of the corrective action, the Resident may request a hearing
           before the ADHOC Committee within twenty-one (21) calendar days of receiving
           the notice.

           1.   The Resident shall make the request in writing and submit it to the Senior
                Vice President.
           2.   The Hearing request must include the following information: the basis for the
                Resident’s disagreement with the corrective action, the facts on which the
                Resident relies, the identity of any persons who may be called as witnesses in
                support of the Resident’s position, the substance of the witnesses proposed
                testimony, and a reference to documents that the Resident may offer in
                support of his/her position.

      B.   Following a request for a hearing before the ADHOC Committee, the Senior Vice
           President shall appoint members to the ADHOC Committee.

      C.   The ADHOC Committee will consist of at least one senior resident representative
           and three other physicians affiliated with Synergy chosen at the discretion of the
           Senior Vice President. A member of the Synergy Human Resources Department
            may also serve as a member of the ADHOC Committee when the Resident’s
            conduct relates to corrective action under Policy 5.6, II B-E..

III.   Scheduling of Hearing

       A.   After receiving a Resident’s request for an ADHOC Committee hearing, Synergy
            shall arrange for such hearing before the Committee, which shall take place within
            21 calendar days of the hearing request, or at a mutually agreed upon later date.
            Synergy will notify the Resident, in writing, of the time and place of the hearing at
            least five (5) business days before the hearing.

       B.   The written Hearing Notice will state the corrective action under review by the
            ADHOC Committee and the basis for such corrective action. The notice shall also
            include a list of the witnesses (if any) expected to testify at the hearing and a
            reference to documents that Synergy may offer at the hearing.

IV.     Hearing Procedure

       A.   Chairperson’s Role: The Chairperson of the ADHOC Committee, or a designee,
            shall preside at the hearing and shall determine the order of procedure, the
            manner of the proceedings, and shall assure that all participants in the hearing
            have a reasonable opportunity to present relevant oral and documentary evidence.
            Fifty percent (50%) members of the ADHOC Committee shall constitute a quorum.
            The hearing need not be conducted strictly according to rules of law relating to the
            examination of witnesses or presentation of evidence.

       B.   Function of the ADHOC Committee: The ADHOC Committee’s sole function
            shall be to ascertain: 1) whether or not any reasonable basis for the corrective
            action existed; and 2) whether the institution's procedures and policies have been
            reasonably followed. The Resident shall be obligated to bear the burden of
            demonstrating by a preponderance of the evidence that the corrective action
            lacked reasonable basis or that the Corporation's procedures and policies have not
            been substantially followed.

       C.   Resident’s Role and Participation:

            1.   The Resident may, at his/her option, have an advisor present at the hearing.
                 The advisor shall act solely in an advisory capacity, but not as an advocate,
                 during the course of the hearing. If the Resident wishes to have an advisor
                 present, the Resident must notify the Senior Vice President in writing at least
                 five (5) business days before the hearing.
     2.   The Resident may present his/her position regarding the corrective action
          through testimony, oral or otherwise, as deemed relevant by the ADHOC
          Committee, regardless of its admissibility in a court of law. The Resident may
          call, examine, and cross examine witnesses; have a record made of the
          proceedings with a direct bearing to the reason(s) for the corrective action
          (character witnesses and family members will not be permitted as witnesses),
          a copy of which the Resident may obtain by payment of any reasonable
          charges associated with the preparation thereof; submit a written statement at
          the close of the hearing.

D.   Synergy’s Role:      The Program Director, designated Program representative,
     and other representatives designated by or on behalf of Synergy shall attend the
     hearing to present Synergy’s position concerning the corrective action.

E.   Adjournment: The Chairperson of the ADHOC Committee, or a designee, may
     adjourn the hearing and reconvene the same without special notice at such times
     and intervals as may be reasonable and warranted, with due consideration for
     reaching an expeditious conclusion to the hearing.

F.   Deliberations and Committee Report: Upon completion of the hearing, the
     ADHOC Committee shall:

     1.   Deliberate in closed session on evidence introduced at the hearing, including
          all logical reasonable inferences from the evidence and testimony. To
          preserve the integrity of the procedure, no member of the Committee who
          was NOT present during the entire hearing may deliberate or vote on the
          ADHOC Committee's decision.

     2.   The ADHOC Committee shall, within twenty one (21) calendar days, render
          its decision in the form of a written report to the Senior Vice Presidnet. The
          Report shall contain a statement of the basis for the decision, including: 1)
          whether or not any reasonable basis for the corrective action existed; and 2)
          whether the institution's procedures and policies have been reasonably
          followed.

G.   Final Decision: The Senior Vice President/President will review the ADHOC
     Committee’s report and make a final decision on the corrective action as the
     Senior Vice President/President deems appropriate. The Resident will receive
     notice of the final action. The Resident will receive a copy of the ADHOC
     Committee’s report along with notification of the final action within twenty one (21)
     calendar days of the ADHOC Committee’s report.

     1. The final decision of the Senior Vice President/President shall be final and
                binding.

           2.   If discipline under Section 5.6, IV (E) is ultimately overturned, the  Senior
                Vice President/President may reinstate the Resident with back pay,    less
                any interim earnings or may deem, some or all of, the period a disciplinary
                suspension without pay.

     H.     Waiver: A Resident’s failure to request or attend any of the hearing provided for
            in this Policy within the time limits stated shall operate as a waiver of his/her right
            to such hearing.

V.        Nature of Employment Relationship: The Hearing and Review Procedure does
          not modify the at-will nature of employment.
POLICY NUMBER:           5.9                     REVISION DATE:
POLICY NAME:            Criteria for Placing     APPROVAL DATE:          8/03/07
                        a Resident on
                        Resident Review
EFFECTIVE DATE:         10/01/07                  RESPONSIBLE            Applicable
                                                 PARTY:                  Departmental
                                                                         Program Director

Criteria for placing a resident on Resident Review

Each clinical department will establish specific criteria that will result in resident review.
Residents are placed on resident review for a period of three to six months at the discretion of
the Program Director. The status of resident review will be reported to the Graduate medical
Education Committee, but does not necessarily remain on the permanent educational record of
the resident. Upon successful completion of a resident review, the status will be removed, and
there will be no adverse effects upon the resident educational file. The resident will be
expected to successfully complete the assigned plan to be released from resident review
which may include, but is not limited to the following:

      1. Residents will meet with a Faculty member monthly (or more frequently if deemed
         necessary) to review progress. They must meet with the Program Director at least
         every 3 months to review progress and be removed from review status.

      2. Residents must complete any assigned monthly readings and/or self-study exams.

      3. Residents who do not meet the standard for the in-service exam will be required to
         review exam material/subjects. In conjunction with the Faculty advisor and Program
         Director, the resident will prepare a plan of action to include readings and test
         questions to be assigned and completed monthly.

      4. For residents placed on resident review for professionalism or behavioral issues, the
         resident will meet with the Program Director to outline a corrective plan of action with
         specific criteria and plan for evaluation.

Criteria for placing a resident on Probation

Each clinical department will establish specific criteria that will result in Probation. For
incomplete or failed rotations, the resident may be required to extend training by the same
number of months that are needed to successfully complete a rotation. Failure to successfully
complete academic review or failure of a competency may require an extension of the
residency. If an extension is required, the RRC will be notified. It may affect the ability of a
resident to be credentialed for employment purposes.
Residents placed on probation for professionalism will require an action plan by the program,
with clear goals and evaluation. This may include an initial evaluation by a clinical
psychologist and subsequent recommendations by same.

Failure to successfully complete the period of probation will result in non-renewal of a contract
or immediate termination of employment as per policies 5.6-5.8.

Definitions

Corrective Action: A decision by the program director, at the advice of the faculty or steering
committee, to address a resident’s academic and/or behavioral deficiency.

Remediation: A plan developed by the Program Director to correct deficiencies in a resident’s
academic, clinical or behavioral performance.

Types of Resident Adverse Actions:

       1. Counseling: A Resident may be subject to counseling regarding a minor
          disciplinary activity. Generally, the resident’s Program Director or Faculty Advisor
          will conduct the counseling session, although any faculty member may counsel a
          Resident. The counseling will be recorded in a written manner and maintained in the
          Resident’s file. Counseling is not reported after residency training and may not be
          appealed by the Resident.

       2. Informal reprimand: For more serious activities after prior counseling on a
          particular issue, a Resident may be subject to an informal reprimand. The informal
          reprimand, in the form of a written letter, will be maintained in the Resident’s file and
          a copy shall be provided to the Resident. Such letters must clearly state in the
          opening paragraph the letter’s intent as an “informal reprimand”. The Program
          Director will issue all informal reprimands in person. Informal reprimands may result
          in the resident’s placement on Resident Review and may not be appealed by a
          Resident.

       3. Resident Review: Issues that require further training or monitoring for
          unsatisfactory academic or behavioral performance will result in Resident Review.
          Each program will have specific criteria for placing a resident on Resident Review.
          Upon successful completion of academic review, the status will be removed, and
          there will be no adverse effects upon the resident educational file. Unsuccessful
          completion of Resident Review will result in Probation.

       4. Formal reprimand: Serious academic or behavioral issues may be handled with a
          formal reprimand. Formal reprimands will be issued in writing by the Program
   Director. Such letters must clearly state in the opening paragraph the letter’s intent
   as a “formal reprimand”. The Resident will meet with the Program Director and a
   member of the Faculty of Human Relations, and the formal reprimand will be read to
   the Resident. The Resident is required to acknowledge the receipt of the formal
   reprimand in writing. Formal reprimands result in placing the resident on Probation.

5. Probation: More serious issues that require further training or monitoring as
   established by each program or for unsuccessful completion of Resident Review
   result in a resident being placed on probation. Failure to successfully complete the
   period of probation will result in non-renewal of a contract or immediate termination
   of employment.

6. Summary Suspension: Severe or repeated violations of department, institutional
   or other policies may mandate suspension. When a Resident cannot safely provide
   patient care for whatever reason, the Resident may be suspended for a period of
   time. A Resident will be notified of the suspension, in writing, by the Program
   Director. See policy 5.6 for corrective action process.

7. Termination: Severe or repeated disciplinary issues, criminal activity and other
   activities may result in termination from the training program. Depending on the
   severity of the infraction, termination may be the first action taken. The Program
   Director must notify the Designated Institutional Official/designee and Human
   Resources when the Resident is notified of termination. See policy 5.7 and 5.8 for
   the process of termination.
                                                                         Synergy Medical Education Alliance
                                                                                Institutional Guidelines
                                                                  Evaluation, Promotion, Remediation and Discipline
                                                      A meeting with the Program Director is required forall corrective actions



                                                                                               Resident Notified        Record in Dept.   Copy to            Resident
Disciplinary Issues   Description                                              Meeting         in Writing               Resident File     Academic Affairs   May Appeal

Counseling            Counseling session to discuss minor disciplinary                         Not Required             □Note to File     Not Required       No
                      activity.                                                Date:                                    Date:

Informal Reprimand    For more serious activities after prior counseling                       □Required                □Required         Not Required       No
                      on a particular issue.                                   Date:           Date:                    Date:

Resident Review       Issues that require further training or monitoring                       □Required                □Required         □Required          No
                      for unsatisfactory academic or behavioral                Date:           Date:                    Date:             Date:
                      performance that areestablished by each residency
                      program.

Formal Reprimand      Serious disciplinary issue or after repeated                             □Required                □Required         □Required          Yes
                      behavior that has not been improved even after           Date:           Date:                    Date:             Date:
                      counseling/informal reprimand. Letter to Resident
                      must clearly state that it is a "formal reprimand".

Probation             More serious issues that require further training or                     □Required                □Required         □Required          No
                      monitoring as established by each residenccy             Date:           Date:                    Date:             Date:
                      program or for unsuccessful completion of
                      Resident Review result in a resident being
                      placed on probation.

Suspension            Severe or repeated violation of department,                              □Required                □Required         □Required          Yes
                      institutional or other policies or when resident         Date:           Date:                    Date:             Date:
                      cannot safely provide patient care.
                            Department of Emergency Medicine
                            Synergy Medical Education Alliance

                                   Resident Review Policy

Criteria for Placing a resident on Resident Review

   I.     A resident will be placed on resident review for any one of the following:
          a. Three monthly summary evaluations of marginal pass in the same competency
             (score <3.0).
          b. Two or more documented similar complaints concerning professionalism from
             nursing, patients, peer residents, students, or faculty (full time or volunteer) in
             any consecutive 12 month time period.
          c. Failure to obtain minimum scores on year adjusted on in-service exam and
             clinical evidence of medical knowledge base deficits:
                  i. Minimal score EM1 = 60% correct.
                 ii. Minimal score EM 2 = 70% correct
          d. First time failure of USMLE Step III exam.
          e. Failure to submit scholarly proposal by the end of the 18th month of the residents
             EM training.
          f. Other clinical deficits or communication/professionalism issues noted by the
             faculty and/or program administration which by the judgment of the program
             director merits extra review efforts by the resident.
             1.      Evaluations of the resident’s performance

   II.    The Program Director may use the following factors in making the decision to place
          a resident on resident review:
          a. Evaluations of the resident’s performance
          b. Performance on in-service examinations
          c. Performance on residency oral and written examinations
          d. Nursing or peer evaluations
          e. Conference attendance and participation
          f. Scholarly activity
          g. Any other factors deemed appropriate by the Program Director

   III.   Residents are placed on resident review for a period of three to six months at the
          discretion of the Program Director. The Program Director will meet and discuss with
          the resident and formally identify, in writing, the following: areas of deficiency, the
          required resident corrective actions, the goals to be obtained, the standards by
          which progress will be judged, and the timelines for attaining those goals. The
          status of resident review will be reported to the Steering Committee and the
          Graduate Medical Education Committee, but does not necessarily remain on the
          permanent educational record of the resident. Upon successful completion of
      resident review, the status will be removed, and there will be no adverse effects
      upon the resident educational file.

IV.   The resident will be expected to successfully complete the following to be released
      from resident review:
      a. Residents will meet with Faculty advisor monthly to review progress.
      b. Residents may be assigned monthly readings with self-study exams that must be
         turned into the Program Director.
      c. Residents who do not meet the standard for the in-service exam will be required
         to review exam material/subjects. In conjunction with the Faculty advisor and
         Program Director, the resident will prepare a plan of action to include readings
         and test questions to be assigned and completed monthly.
      d. For residents placed on resident review for professionalism or behavioral issues,
         the resident will meet with the Program Director to outline a corrective plan of
         action with specific criteria and plan for evaluation, and will be reassessed
         monthly by the program director for at least three months.

V.    The resident will be formally evaluated by the Program Director at least every three
      months. If the decision is made to continue the period of remediation, the resident
      and Chief Academic Officer will be notified in writing.

VI.   If a resident does not make significant progress within six months (two contiguous
      cycles of remediation), they shall be placed on probation as set forth by the
      appropriate Synergy Medical policies at the discretion of the Program Director.
                             Department of Emergency Medicine
                             Synergy Medical Education Alliance

                                        Probation Policy



Criteria for Placing a resident on Probation

     A resident will be placed on probation for any one of the following:

   1. Failure of any rotation.
   2. A total of four confirmed complaints concerning professionalism from nursing, patients,
      peer residents, students, or faculty (full time or volunteer) over 12 consecutive months.
   3. Failure to successfully complete resident review.
   4. Failure of an ACGME Competency as determined by the Program Director , with
      discussion at the EM Steering Committee on the six month review.
   5. Second time failure of USMLE Step III.

For failed rotations, the resident will be required to extend training by the same number of
months that are needed to successfully complete a rotation. Also failure to successfully
complete resident review may require an extension of the residency. A resident must
successfully complete the necessary 36 months of training required by ABEM. If the resident
has their training extended, ABEM will be notified. This may affect the ability of the resident to
sit for the written boards. It may affect the ability of a resident to be credentialed for future
employment purposes.

Residents placed on resident probation for professionalism will require an action plan by the
PD, with clear goals and evaluation. This may include an initial evaluation by a mental health
professional chosen by the institution and subsequent recommendations by same.

Failure to successfully complete the period of probation will result in non-renewal of a contract
or immediate termination of employment.
                        Department of Family Medicine
             CRITERIA FOR PLACING A RESIDENT ON ACADEMIC REVIEW

      1.     Incomplete rotation evaluation

             OR

      2.     Three (3) evaluations of “marginal pass”

             OR

      3.     A total of four (4) complaints that evidence professionalism problems such as:

             a.     Complaints from nursing personnel
             b.     Complaints from patients
             c.     Comments on rotation evaluations from faculty

                                              OR

      1.     Two (2) quarters of patient satisfaction survey evaluations that fall below an
             average rating of <2.9 on the global rating of care

             OR

      2.     Failure to achieve a composite score of at least 350 on the IT exam (or the 10th
             percentile)

             OR

      3.     First time failure of USMLE Step III exam

Residents that are placed on academic review will be expected to do the following to improve:

             1.     Residents will be required to read and turn in the pre and post tests for an
                    AAFP monographs, one each week for a minimum of 3 months. For
                    residents that receive marginal passes, the readings will be directed to
                    those content areas that are related to those rotations that are marginal.

             2.     Residents will be required to meet with their assigned faculty advisor on a
                    monthly basis to review progress.

             3.     For residents that do not achieve or improve patient satisfaction scores in
                    the next successive quarter, they will be required to have additional
                    communication skill training supervised and observed by the departmental
                    behavioral scientist and clinical faculty for a minimum of three months or
                    longer as deemed necessary by faculty.

             4.     Residents who have been placed on review for professionalism issues will
                    meet with the program director to outline a plan to improve this area.
                    Residents will be required to be evaluated on this area by the program
                    director for at least three months.

             5.     Residents who do not achieve the minimum scores on the IT exam will be
                    required to review the exam questions and for those areas of content in
                    which they have failed to achieve at least a 50% score on correct items,
                    will be required to develop a plan of review for those content areas that
                    will include readings in AAFP monographs, articles that will be selected by
                    the faculty advisor and a summary of readings turned into the advisor on a
                    monthly basis (minimum of three (3) articles per month).

The status of academic review will remain in effect for a period of at least three (3) months.
The status of academic review will be reported to the Graduate Medical Education Committee,
but does not necessarily remain on the permanent educational record of the resident. If the
resident satisfactorily completes the requirements as above, the status of academic review will
be removed and there will be no adverse effects upon the educational file, thus precluding any
effects on future privileges or licensure applications.
                             Department of Family Medicine
                   CRITERIA FOR PLACING A RESIDENT ON PROBATION

       1.     Failure to achieve the rotation requirements for any rotation

              OR

       2.     A total of six (6) complaints that evidence professionalism problems such as:

              a.     Complaints from nursing personnel
              b.     Complaints from patients
              c.     Comments on rotation evaluations from faculty

                                               OR

       1.     Three (3) quarters of patient satisfaction survey evaluations that fall below an
              average rating of < 2.9 on the global rating of care

              OR

       2.     Second time failure of USMLE Step III

Residents that are placed on academic probation for rotation failure will be notified that the
failed rotation must be repeated and successfully passed in order to be counted toward the
total number of rotations needed to complete the 36 months of required residency training.

A resident will be allowed to utilize on month of electives to remediate a rotation. Should more
than one month be required to be repeated, the resident will be required to extend the duration
of training by the same number of months that are needed to successfully complete the
required 36 months of training.

A resident will be advised in writing of these issues. The American Board of Family Medicine
will be notified that the resident will be required to extend the training program. This may affect
the ability of a resident to sit for the ABFM certification exam and may affect the ability of a
resident to be credentialed for employment purposes. The examinations are given in July,
August, and December.

Residents that do not achieve or improve patient satisfaction scores in the next successive
quarter, will be required to have additional communication skill training supervised and
observed by the departmental behavioral scientist and clinical faculty for a minimum of three
(3) months or as deemed necessary by faculty.
Residents who have been placed on probation for professionalism issues will meet with the
program director to outline a plan to improve this area, and will be evaluated on this area by
the program director for at least three (3) months. While there may not be an extension in the
training duration, the placement of probation will be noted in the educational file and will
remain a permanent part of the record. This will be noted in the final summary letter and will
be commented upon in any and all subsequent licensure and hospital privilege requests.
                          Synergy Medical Education Alliance
                                Department Of Surgery
                 Criteria For Placing A Resident On Resident Review
                                    August 1, 2007

A resident will be placed on resident review for any one of the following:

A: Resident Review

1. Three evaluations of marginal pass in the same competency (<50%).

2. A total of three documented complaints concerning professionalism from nursing,
   patients, peer residents, students, or faculty (full time or volunteer) in any consecutive
   24 month time period.

3. Consistent poor patient satisfaction survey evaluations as determined by Program
   Director and Steering Committee.

4. Failure to obtain a minimum score on yearly ABSITE exam of at least 60% correct
   answers.

5. First time failure of USMLE Step III exam.

6. Failure to fulfill yearly research project unless granted a waiver due to departmental
   policy which states a resident does not have to do a research project if he/she has
   published 2 papers in a peer review journal during their previous Synergy research day
   presentations( see Resident Manual)

A1: Actions

1. Upon placing a resident on Academic Review the resident will be assigned a Faculty
   Advisor either voluntarily chosen by Steering Committee or appointed by Program
   Director.

2. Residents are placed on academic review for a period of three to six months at the
   discretion of the Program Director. The status of academic review will be reported to the
   Graduate Medical Education Committee, but does not necessarily remain on the
   permanent educational record of the resident. Upon successful completion of academic
   review, the status will be removed, and there will be no adverse effects upon the
   resident educational file. The resident will be expected to successfully complete the
   following to be released from academic review:
   3. In conjunction with the Faculty advisor and Program Director, the resident will prepare a
      plan of action to include readings and test questions to be assigned and completed
      monthly.

   4. Residents will meet with Faculty Advisor monthly to review progress.

   5. Residents who do not meet the standard for the in-service exam will be required to
      review missed ABSITE exam questions and submit a written summary of each missed
      question via typed format and e-mailed to Faculty Advisor and Program Director by
      Sept. 1st of corresponding year test was taken. (ABSITE exam occurs every January)

   6. For residents placed on academic review for professionalism or behavioral issues, the
      resident will meet with the Faculty Advisor or Program Director to outline a corrective
      plan of action with specific criteria and plan for evaluation, and will be reassessed
      monthly by the Faculty Advisor or Program Director for at least 4 months and reviewed
      during the quarterly Resident Evaluation Meetings.

A resident will be placed on probation for any one of the following:

B: Resident Probation

   1. For incomplete or failed rotations, the resident will be required to extend training by the
      same number of months that are needed to successfully complete a rotation. A resident
      must successfully complete the necessary 48 months of training required by the
      ACGME.

   2. Failure to successfully complete an academic review process will require at least a six
      month extension of the residency as determined by the Steering Committee and the
      Program Director, and the RRC will be notified. This will affect the ability of the resident
      to sit for the Qualifying Exam (QE). It may affect the ability of a resident to be
      credentialed for employment purposes.

   3. Residents placed on academic probation for issues relating to inadequate scores in
      Professionalism will require an action plan by the Steering Committee, with clear goals
      and evaluation. This may include an initial evaluation by a clinical psychologist and
      subsequent recommendations by same.

   4. Failure to successfully complete the period of probation will result in non-renewal of a
      contract or immediate termination of employment in accordance to Synergy Policy
      Manual.

   5. Failure to obtain an ABSITE score of at least 60% correct answers on two consecutive
      exams.
                         Department of Internal Medicine
             CRITERIA FOR PLACING A RESIDENT ON ACADEMIC REVIEW

1.    Incomplete rotation evaluation

             OR

2.    Three (3) evaluations of “marginal pass”

             OR

3.    A total of four (4) complaints that evidence professionalism problems such as:

      d.     Complaints from nursing personnel
      e.     Complaints from patients
      f.     Comments on rotation evaluations from faculty


4.    Two (2) quarters of patient satisfaction survey evaluations that fall below an average
      rating of <2,9 on the global rating of care

             OR

1.    Failure to achieve a composite score of at least 30 percentile on the IT exam.

Residents that are placed on academic review will be expected to do the following to improve:

2.    Residents will participate in monthly exams. Marginal passes in these exams will be
      seen as areas for improvement.

3.    Residents will be required to meet with their assigned faculty advisor on a monthly basis
      to review progress.

4.    For residents that do not achieve or improve patient satisfaction scores in the next
      successive quarter, they will be required to have additional communication skill training
      supervised and observed by the departmental behavioral scientist and clinical faculty for
      a minimum of three months or longer as deemed necessary by faculty.

5.    Residents who have been placed on review for professionalism issues will meet with the
      program director to outline a plan to improve this area. Residents will be required to be
      evaluated on this area by the program director for at least three months.
6.    Residents who do not achieve the minimum scores on the IT exam will be required to
      review the exam questions and for those areas of content in which they have failed to
      achieve at least a 50% score on correct items. Residents will be required to develop a
      plan of review for those content areas that will include readings in Internal Medicine
      Curriculum, articles that will be selected by the faculty advisor and a summary of
      readings turned into the advisor on a monthly basis (minimum of three (3) articles per
      month).

The status of academic review will remain in effect for a period of at least three (3) months.
The status of academic review will be reported to the Graduate Medical Education Committee,
but does not necessarily remain on the permanent educational record of the resident. If the
resident satisfactorily completes the requirements as above, the status of academic review will
be remove. There will be no adverse effects upon the educational file, thus precluding any
effects on future privileges or licensure applications.
                        Department of Obstetrics and Gynecology
                            Synergy medical Education Alliance
                    Criteria for Placing a resident on Resident Review

   A resident will be placed on resident review for any one of the following:

   1. Three evaluations of marginal pass in the same competency (1-3 on Likert Scale).
   2. A total of three documented complaints concerning professionalism from nursing,
      patients, peer residents, students, or faculty (full time or volunteer) in any consecutive
      24 month time period.
   3. Two quarters in same year of patient satisfaction survey evaluations that fall below an
      average rating of <3.0 on global rating of care.
   4. Failure to obtain minimum scores on year adjusted on in-service exam:
          a. PGY-1 at least 160 or two standard deviations below the mean.
          b. PGY-2 , PGY-3 and PGY-4 at least 180 or 1 standard deviation below the mean
   5. First time failure of USMLE Step III exam.
   6. Failure to submit research proposal by the end of PGY-1 year.

Residents are placed on resident review for a period of three to six months at the discretion of
the Program Director. The status of resident review will be reported to the Graduate Medical
Education Committee, but does not necessarily remain on the permanent educational record of
the resident. Upon successful completion of a resident review, the status will be removed, and
there will be no adverse effects upon the resident educational file. The resident will be
expected to successfully complete the following to be released from resident review:

   1. Residents will meet with Faculty advisor monthly to review progress.
   2. Residents will be assigned monthly readings with self-study exams that must be turned
      into the Program Director.
   3. Residents who do not meet the standard for the in-service exam will be required to
      review exam material/subjects for which they failed to achieve at least a 50% score of
      correct items. In conjunction with the Faculty advisor and Program Director, the resident
      will prepare a plan of action to include readings and test questions to be assigned and
      completed monthly.
   4. For residents placed on resident review for professionalism or behavioral issues, the
      resident will meet with the Program Director to outline a corrective plan of action with
      specific criteria and plan for evaluation, and will be reassessed monthly by the program
      director for at least three months.
                         Department of Obstetrics and Gynecology
                             Synergy medical Education Alliance
                         Criteria for Placing a resident on Probation

     A resident will be placed on probation for any one of the following:

   1. Incomplete grade or failure of any rotation.
   2. A total of six confirmed complaints concerning professionalism from nursing, patients,
      peer residents, students, or faculty (full time or volunteer) over 24 consecutive months.
   3. Failure to successfully complete resident review.
   4. Failure of an ACGME Competency by the Steering Committee on the six month review.
   5. Second time failure of USMLE Step III.

For incomplete of failed rotations, the resident will be required to extend training by the same
number of months that are needed to successfully complete a rotation. A resident must
successfully complete the necessary 48 months of training required by the ACGME and by the
ABOG.

Failure to successfully complete academic review or failure of a competency may require an
extension of the residency. If an extension is required, the RRC will be notified. This may affect
the ability of the resident to sit for the written boards, which are given annually the last Monday
in June of the senior year of residency. It may affect the ability of a resident to be credentialed
for employment purposes.

Residents placed on probation for professionalism will require an action plan by the Steering
Committee, with clear goals and evaluation. This may include an initial evaluation by a clinical
psychologist and subsequent recommendations by same.

Failure to successfully complete the period of probation will result in non-renewal of a contract
or immediate termination of employment.
POLICY NUMBER:            5.10                    REVISION DATE:
POLICY NAME:             Employment of            APPROVAL DATE:           6/27/06
                         Relatives
EFFECTIVE DATE:          07/01/06                 RESPONSIBLE              Human Resources
                                                  PARTY:

PURPOSE:

The purpose of this policy is to prevent conflicts of interests and establish guidelines regarding
the employment of relatives of Synergy Medical employees.

POLICY:

Synergy Medical seeks the best qualified employees regardless of their relation to other
employees. Hence, Synergy Medical does not consider family relationship a disqualifying
factor, but bases employment on the qualifications of the position, provided that such
employment does not result in:

•   creating a direct line of supervision where one relative is responsible for supervising the job
    performance or work activities of another relative; or

•   relatives working within the same program, division, work group, team or otherwise share
    the same direct supervisor.

For the purposes of this policy, "relatives" are defined as: father, mother, son, daughter,
brother, sister, uncle, aunt, , nephew, niece, husband, wife, grandparents, father-in-law,
mother-in-law, grandparents-in-law, son-in-law, daughter-in-law, brother- in-law, sister-in-law,
stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half sister,
or other family member who resides in the same household.

In addition, relatives of employees who hold a leadership position within the organization are
not eligible for employment at Synergy Medical. For the purposes of this policy, a "leadership
position" is defined as any Synergy Medical position with supervisory responsibilities or those
that manage general operations of a department.

This policy will also be considered in situations when an employee is considered for a transfer
or promotion, which affects the supervisor/subordinate work relationship or results in relatives
sharing the same direct supervisor. Furthermore, Synergy Medical employees shall not be
involved in decisions pertaining (but not limited) to the recruitment, retention, promotion, salary
adjustment, and termination of another relative.


Post Hire Relationships
This policy will be in affect if employees become married, engaged in romantic relationships,
intense personal friendships, or significant business relationships, which may affect the
supervisor/subordinate work relationship or results in such employees sharing the same direct
supervisor.


Remedies

If circumstances between two employees occur to the degree that this policy is violated, every
effort will be made towards resolution that will be mutually advantageous. Action will be taken
within 90 days of the identified situation.

Potential remedies may include, but are not limited to:

•   Transfer (if a position is available)
•   Reassignment of responsibility to another supervisor (e.g., the next higher supervisor).
•   Voluntary resignation
•   Termination

Effective Date

This policy does not effect relatives employed prior to July 1, 2006.
POLICY NUMBER:          6.1                     REVISION DATE:          07/01/03
POLICY NAME:            Benefits                APPROVAL DATE:          03/11/03
                        Continuation
EFFECTIVE DATE:         07/01/03                RESPONSIBLE             Human Resources
                                                PARTY:

PURPOSE:

To notify employees and/or their dependents the guidelines in which they may be eligible for
the continuation of Health and Dental insurance coverage should they become ineligible to
continue under Synergy Medical Education Alliance group contract terms.


POLICY:

Employees and or their dependents who are covered under Synergy Medical’s Health and/or
Dental Insurance program(s) are eligible to elect continuation of those benefits as specified in
the Consolidated Omnibus Budget Reconciliation Act (COBRA) should coverage be terminated
for reasons other than gross misconduct or termination of the group contract.

Employees and/or their dependents who elect continuation of health and Dental Insurance
coverage will pay 100% of the premium charged to Synergy Medical, plus a 2% administrative
fee.

Human Resources will automatically notify employees when employees or their dependents
qualify for health and/or dental insurance coverage continuation.
POLICY NUMBER:          6.2                      REVISION DATE:
POLICY NAME:            Health Insurance         APPROVAL DATE:           03/11/03
                        Portability and
                        Accountability Act
                        (HIPAA)
EFFECTIVE DATE:         07/01/03                 RESPONSIBLE              Human Resources
                                                 PARTY:

PURPOSE:

To provide employees with the benefits of the HIPPA Act and insure compliance with the
Federal Law.

POLICY:

This law limits pre-existing health condition waiting periods, which is the duration that
employers and insurers may exclude health care coverage for medical conditions that existed
before enrollment.

Upon termination the insurance carrier will provide a certificate of prior health care coverage to
the terminated employee and other qualified beneficiaries detailing the HIPAA details.
POLICY NUMBER:          6.3                     REVISION DATE:          01/01/06
POLICY NAME:            Benefits Enrollment     APPROVAL DATE:          03/11/03
EFFECTIVE DATE:         07/01/03                RESPONSIBLE             Human Resources
                                                PARTY:

PURPOSE:

To allow employees to make necessary changes to their Synergy Medical benefits package on
an annual basis.

POLICY:

With few exceptions, the decisions regarding benefits made at the time of initial enrollment are
binding for the entire fiscal year (January 1st - December 31st). Primary exceptions would be
adding/deleting family member from medical, dental, or optional health coverage because of
marriage, divorce, death, birth, or adoption of a child (commonly known as a “qualifying
event”).

Immediately preceding the start of a new calendar year, a period of time known as “open
enrollment” provides the opportunity to freely elect any available health insurance plan and to
add or delete family members without restrictions. The open enrollment period will be
announced by Human Resources with enrollment material distributed to all individuals who are
eligible to receive benefits. Any changes in coverage take effect the beginning of the new
calendar year.
POLICY NUMBER: 6.4                            REVISION DATE:             12/07/2010

POLICY NAME:         Resident Fringe
                     Benefit Schedule
REVISION                                      RESPONSIBLE
EFFECTIVE DATE: 01/01/2011                    PARTY:               Human Resources


Health Insurance Option I
Blue Cross/Blue Shield of Michigan Community Blue preferred provider organization
(PPO) individual and family coverage. $30.00 co-pay for physician office visits and
$10/Generic prescription drugs and $40/Brand Name prescription drugs.
Preventative/Wellness services covered at 100% ($500 annual maximum).
Hospitalization and diagnostics covered at 80%. Annual deductible of $500 (Employee
Only) or $1000 (Employee + Family). Premium cost sharing per pay $42.22 (Employee
Only), $95.01 (Employee + One), $114.02 (Employee + Family). Annual out-of-pocket
maximum set at $1,500.00 (Employee Only), $3,000.00 (Employee + Family).
Coverage effective on date of employment. No pre-existing condition clause.

Health Insurance Option II
Blue Cross/Blue Shield of Michigan Community Blue preferred provider organization
(PPO) individual and family coverage. $30.00 co-pay for physician office visits and no
prescription drug coverage. Preventative/Wellness services covered at 100% ($250
annual maximum). Hospitalization and diagnostics covered at 80%. Annual deductible
of $1000 (Employee Only) or $2000 (Employee + Family). Premium cost sharing per
pay No Cost (Employee Only), $36.19 (Employee + One), $49.23 (Employee + Family).
Annual out-of-pocket maximum set at $2500 (Employee Only), $5,000.00 (Employee +
Family). Coverage effective on date of employment. No pre-existing condition clause.

Dental Insurance
Blue Cross Blue Sheild individual and family coverage; maximum yearly
benefit is $800 per covered member; 100% diagnostic, preventative and emergency
services; 80% (after deductible) for restorative, endodontics, and periodontics.
Prosthodontics 50% (after deductible). Orthodontic coverage at 50% (no deductible) up
to $1,000.00 lifetime benefit. No premium cost to employee; coverage effective 1st day
of month following date of employment. Premium cost sharing per pay $1.11
(Employee Only), $2.11 (Employee + One), $3.67 (Employee + Family)

Life Insurance
Lincoln Financial Life Insurance Company individual coverage; Two-times the annual
salary to a maximum of $300,000. No premium cost to employee; coverage effective
31st day of employment.
Long-Term Disability Insurance
AMA sponsored MedPlus Advantage policy underwritten by UNUM Insurance; pays
$2,000 monthly benefit to PGY-1 and PGY-2 residents; $2,500 monthly benefit to
PGY3, PGY-4 and PGY-5 residents; benefits doubled for total and permanent disability;
no premium cost to resident; coverage effective date of employment; guaranteed
conversion to individual policy upon completion of residency.

Vision Insurance
Vision Services Plan HMO individual and family coverage; exam, frames and lenses (or
contact lenses in lieu of frames and lenses) every 24 months; small monthly premium
cost to employee; coverage effective on date of employment.

Malpractice Insurance
This is a premium based plan that covers all residents and faculty physicians with
$1,000,000/$3,000,000 coverage at any location and $1,000,000/$9,000,000 at
Covenant Healthcare (for OB/GYN risk). The insurance carrier is Fincor Solutions

Membership Dues
Membership dues to appropriate departmental medical associations.

Meals
Synergy Medical provides a meal allowance for the times you are on call and must stay
on the hospital premises. Synergy Medical provides this allowance to cover meals for
your call for the entire academic year. Meal allowances are based on year of residency
and residency program. The meal allowance is intended to cover meals only while you
are on overnight call. Synergy Medical will issue meal allowance checks at the
beginning of each academic year in July.

Physician Coats
Two (2) coats provided first year of training; one (1) coat provided each subsequent
year.

Recombivac Vaccine
Hepatitis B vaccine provided at resident’s request during first year of training; paid by
corporation.

Pension Plan
Variable Annuity Life Insurance Company (VALIC); 4% of monthly salary contributed by
the corporation, enrollment each January 1st or July 1st upon completion of one year of
service and attainment of 21 years of age. With the following graded vesting schedule;
20% vested after 2 years of service, 40% after 3 years, 60% after 4 years, 80 % after 5
years and 100% vested after 6 years of service.
Resident Paid Time Off
PGY-1 - 15 days (3 weeks); non-cumulative; non-vested benefit.
PGY-2+- 20 days (4 weeks); non-cumulative; non-vested benefit.
CSBA 1+ 10 days (2 weeks); non-cumulative; non-vested benefit.

Educational Expense Reimbursement
Reimbursement of expenses for approved* educational activities and materials such as
Conference registration, conference travel and related expenses, text books,
professional journal subscriptions, PDA's (new residents only), laptop computers are
included in the allotted reimbursement (One laptop per residency training period with
pre-approval of the program director), computer software programs, PDA upgrades, and
expenses related to licensure processing are as follows:

             PGY-1: up to $1000          PGY-4: up to $1750
             PGY-2: up to $1250          PGY-5: up to $1750
             PGY-3: up to $1450

*Residents will be reimbursed only for educational support needs that are pre-approved
by the department's Program Director. Reimbursement will be processed upon
submission of original receipts.

There will be NO reimbursement of expenses for any Board Certification Examinations
or repeated Step 3 Examinations.

Transitional Reimbursement:
Up to a $1,000 reimbursement for the following for first year residency: moving
expenses and expenses related to credentialing, that are required by the state.

Flexible Benefits Plan
Section 125 of the Federal Tax Code which allows employee to take deductions
before taxes for insurance premiums, dependent care, and certain medical expenses;
enrollment upon hire or during open enrollment on January1st each year; employee
must designate amount of deductions.

Employee Assistance Programming
Employee Assistance Programs (EAP's) are designed to provide counseling and
treatment for the following: anxiety/depression; marital/relationship/divorce counseling;
child/adolescent issues; substance abuse assessment/evaluation/ treatment/therapy;
familial relationship counseling, etc. Initial assessment plus three problem solving
sessions are available at no cost to all Synergy medical employees and their families.
For more information, contact the Department of Human Resources, or call our EAP
provider, Child and Family Service, at (989) 790-7500.
sessions are available at no cost to all Synergy medical employees and their families.
For more information, contact the Department of Human Resources, or call our EAP
provider, Child and Family Service, at (989) 790-7500.
POLICY NUMBER:          6.4(a)                  REVISION DATE:
POLICY NAME:            Employee Patient        APPROVAL DATE:          05/11/2004
                        Care Discount
EFFECTIVE DATE:         07/01/2004              RESPONSIBLE             Administration/
                                                PARTY:                  Business Services

PURPOSE:

To provide discounts to employees for patient care activities within the company.

POLICY:

Employees and covered family members shall receive patient care discounts for
services administered by a provider employed at Synergy Medical and conducted
during normal hours of operation (8:00 AM to 5:00 PM, Monday through Friday) in
facilities maintained by the company (Main - 1000 Houghton & North - 1575
Tittabawasee).

Patient care discounts are applicable only when proper scheduling and registration
procedures are followed. Services provided by Synergy Medical’s Travel Medicine
Clinic are excluded from this policy. Discount rates and covered services may be
added, deleted or modified at any time, at Synergy Medical’s sole discretion.

EMPLOYEE DISCOUNT CATEGORIES:

1.    Employees and covered family members who elect medical benefits provided by
Synergy Medical (see fringe benefit schedule for full time employees and Health
Insurance Policy 7.4).

•   Physician Office Visits within Synergy Medical facilities – 100% Adjustment*
•   Procedures and other services conducted within Synergy Medical facilities – 100%
    Adjustment*

*Services apply only to those covered under the medical insurance plan maintained by
Synergy Medical. Uncovered services conducted within Synergy Medical facilities may
be eligible for a 50% discount. Provision of covered services will not change the
balance of the patient’s Deductibles and Co-pay Dollar Maximums.

2.   Employees, Medical Students, and covered family members who are covered by a
medical insurance plan other than what is provided by Synergy Medical.

•   Physician Office Visits within Synergy Medical facilities – 50% discount
•   Procedures and other services conducted within Synergy Medical facilities – 50% discount
Note: Discounts apply only after all third-party resources have been billed.

3.    Employees and Medical Students who are ineligible for the medical insurance
plan maintained by Synergy Medical and are not covered by another plan. **

•   Physician Office Visits within Synergy Medical facilities – 50% discount
•   Procedures and other services conducted within Synergy Medical facilities – 50% discount

** Family Members of employees in this category are not eligible for patient care discounts.
POLICY NUMBER:          6.5                     REVISION DATE:
POLICY NAME:            Jury Duty Pay           APPROVAL DATE:           03/11/03
EFFECTIVE DATE:         07/01/03                RESPONSIBLE              Human Resources
                                                PARTY:

PURPOSE:

To help eliminate financial hardship for employees who fulfill mandatory jury duty
responsibilities.

POLICY:

Full-time and part-time employees summoned for mandatory jury duty are paid the difference
between their normal rate of pay and jury duty pay for up to 30 days of jury service.
Thereafter, full-time and part-time employees summoned for mandatory jury duty are granted a
leave of absence in order to serve. All receipts of jury duty compensation must be submitted
with records of work time to Human Resources.
POLICY NUMBER:          6.6                     REVISION DATE:
POLICY NAME:            Bereavement Pay         APPROVAL DATE:           03/11/03
EFFECTIVE DATE:         07/01/03                RESPONSIBLE              Human Resources
                                                PARTY:

PURPOSE:

To assist employees with compensated time off for the death of an immediate family member.

POLICY:

Three paid days will be provided for death in the immediate family. The term “immediate
family” shall be defined as spouse, parents and stepparents, parents/siblings-in-law, son-in-
law, daughter-in-law, grandparents (employee’s only), children and stepchildren,
grandchildren, brother and stepbrother, sister and stepsister.
POLICY NUMBER:            6.7                     REVISION DATE:
POLICY NAME:              Travel                  APPROVAL DATE:
EFFECTIVE DATE:                                   RESPONSIBLE
                                                  PARTY:

PURPOSE:

It is the intent of this policy to establish appropriate levels of reimbursement for
official/required travel and other expenses provided by Synergy Medical Education Alliance,
(SYNERGY MEDICAL). Management staff may establish departmental policies that support
the types of business expenses that will be reimbursed by SYNERGY MEDICAL. This policy
extends to the cost of local (in state) and out-of-state transportation and all other expenses
associated with business travel for all SYNERGY MEDICAL staff members.

 TRAVEL GUIDELINES
•    All travel arrangements for airfare, hotel, and car rental (outside Saginaw) are
     preferred to be made through SYNERGY MEDICAL’s designated travel agency,
     Morley Travel.
•    For your convenience, Accounts Payable will make required advanced payments for
     airfare, hotel, and registration upon completion of a Travel Expense Voucher (see
     attached form). Otherwise, reimbursement will be made after completion of the trip
     and when accompanied by receipts and an approved Travel Expense Voucher.
•    If any SYNERGY MEDICAL forms (Travel Expense Voucher, Check Request form
     etc.) are incomplete for any reason, Accounts Payable will return the form(s) to the
     staff members with instructions as to the information needed.

    APPROVAL
    Staff members must have authorization from their respective supervisor before incurring any
    expenses they intend to be reimbursed by SYNERGY MEDICAL. When using SYNERGY
    MEDICAL forms, please refer to the following list to determine the appropriate authorized
    signature:

    TRAVELER                               AUTHORIZED SIGNATURE
    Manager & Staff                        Director

IN CASE OF CANCELLATION
In the event a staff member needs to cancel a trip, the staff member is responsible for the
following:
•      Notifying Accounts Payable that the trip has been canceled.
•      Notifying Morley Travel to cancel the arrangements.
•      Canceling the hotel and collecting any pre-paid hotel deposit (or cancellation number).
•      Notifying the conference sponsor and collecting any pre-paid registration.
•      Forwarding refund check(s) to Accounts Payable.
I. REIMBURSABLE EXPENSES

HOTELS
SYNERGY MEDICAL will reimburse for lodging at the conference rate or hotel's rate for single
occupancy. It is acceptable to stay over a Saturday night with appropriate approval, if the extra
night reduces airfare and the overall cost of the trip and is documented prior to trip. Hotels for
all events should be selected to provide accommodations convenient to the meeting and at
rates cost-effective to SYNERGY MEDICAL.

TELEPHONE
Necessary business telephone calls will be reimbursed if itemized and noted on hotel
statements. Personal telephone calls are reimbursed up to $5.00 per day.

REGISTRATION
SYNERGY MEDICAL will make direct payment for registration fees, if advanced payment is
required. Use a Travel Expense Voucher form for this payment.

AIRFARE
Domestic air travel must be made for coach class only by the most direct or economical route
to the destination. If a conference rate is available, the staff members should give the
information to Morley Travel so the special rate offer can be accessed.

Every airline ticket purchased through Morley Travel provides the traveler with $250,000 of
travel accident insurance at no additional cost.

TRANSPORTATION & PARKING
Reimbursement will be made for transportation costs as follows:

•     Reimbursement will be made for costs of the most appropriate means of ground
      transportation.

•      Parking fees are reimbursable with the original receipt.

Personal auto usage will be reimbursed at the lesser amount of the following:

•     Mileage allowance to and from the destination by the most direct route, plus related
      toll and parking fees, or the posted round-trip airline coach fare to the destination plus
      reasonable transportation costs to and from the airport at both ends of the trip and the
      hotel or meeting site.

•     Taxi or limousine costs to and from the airport to the conference site.

CAR RENTAL
All car rental arrangements outside the Saginaw area are preferred to be made through
SYNERGY MEDICAL’s preferred travel agency, Morley Travel. In order to obtain a rental car,
a staff member must have a valid driver's license. Car rental will be reimbursed for an
intermediate or mid-size rental unless there are more than four passengers. In this case, an
upgrade of one car class (full-size) is acceptable.

Car rentals should be considered when travel is anticipated to be a greater than 75 miles one
way (150 miles round trip) and the trips are generally one day in duration. Each trip, including
distance and duration should be evaluated to determine the most economical means of
transportation.

Staff members will NOT be reimbursed for personal accident insurance or the full collision
damage waiver offered on rental contracts except if traveling outside the continental United
States. Staff members are covered under SYNERGY MEDICAL's liability insurance policy.

Before returning the rental car to the rental agency' staff members must fill the gas tank to the
level determined by the agreement since rental companies assess a cost surcharge for this
service. The cost of the fuel will be reimbursed to the staff member with the original receipt.

TIPS
Reasonable tips are reimbursable for bellhops, porters, and taxi drivers. Food Service tips
must be included within the Meals section of the policy.

MEALS
The cost of meals is reimbursable for SYNERGY MEDICAL authorized travel. Meals are
reimbursed on a receipt basis or a per diem of $35.00(Allocated $20.00 for dinner, $10.00 for
lunch and $5.00 for breakfast) per day for meals including tips. The reasonable cost of meals
is reimbursable only if not provided by the conference. The SYNERGY MEDICAL employee
may elect either the per diem method or the actual cost of meals reimbursement on each travel
occasion. The method selected must be used for the entire Travel Expense Voucher.

Business meals paid by staff members who include non-SYNERGY MEDICAL personnel are
reimbursable when supported by the original receipt(s) and included with the Travel Expense
Voucher. The Travel Expense Voucher must include the date of the meal, name of the dining
establishment, nature of business conducted, and names and business affiliations of the
guests.

Business meals, which are paid by staff members for other SYNERGY MEDICAL staff
attending the same conference, are reimbursable. The staff member should then submit
his/her Travel Expense Voucher listing the names of the other staff members on the meal
receipts.

CASH ADVANCES
Cash advances are not granted, except in extreme circumstances and require the approval of
the Chief Financial Officer. (E.g., A cash advance would be granted to a traveler attending a
course lasting a week or longer, which would require the traveler to obtain meals and other
long-stay necessities.)

RECEIPTS
Receipts (other than meals) are not required to be submitted for items less than $25.00 each.
These items will be detailed on the Travel Expense Voucher prepared by the SYNERGY
MEDICAL employee.

EXPENSE RECONCILIATIONS

SUBMIT WITHIN FIVE (5) BUSINESS DAYS AFTER COMPLETION OF TRAVEL (to
Accounts Payable):
      1.    ALL TRAVEL REIMBURSEMENTS:
            • Complete and sign an Travel Expense Voucher and enclose original
                   itemized receipts. Copies of receipts are not acceptable.
            • Forward the completed Travel Expense Voucher to the appropriate
                   authorized individual for approval.

II. LOCAL MILEAGE REIMBURSEMENT

Mileage will be reimbursed at the IRS allowed rate per mile, which is updated periodically.

III. NON-REIMBURSABLE EXPENSES

MEAL ENTERTAINMENT EXPENSES OF STAFF MEMBERS
Staff members may not use his/her SYNERGY MEDICAL budget to pay the
meal/entertainment expenses of other SYNERGY MEDICAL staff members unless these
expenses are the result of a meeting with a specific business purpose. These expenses are
the responsibility of the individual staff member except as otherwise approved by the
appropriate authorized signer.

GUESTS
Staff members are allowed to have a travel companion accompany them on business trips. A
personal credit card must be provided for payment of guest related costs (hotel, meals,
airfare, etc.). Please note SYNERGY MEDICAL will only reimburse the staff members for
hotel accommodations at the conference or single-room rate.

PERSONAL EXPENSE
The following are considered "personal" charges and are not reimbursable:

•   Movies
•   Alcoholic beverages
•   Valet service or Laundry
•   Recreation activities
•   Parking tickets or traffic violations
POLICY NUMBER:          6.8                     REVISION DATE:
POLICY NAME:            Religious               APPROVAL DATE:           03/11/03
                        Observations
EFFECTIVE DATE:         07/01/03                RESPONSIBLE              Human Resources
                                                PARTY:

POLICY:

Synergy Medical Education Alliance believes the basic rights regarding religious preference
should be extended to all employees. Reasonable effort will be made to grant employees time
off for attending worship services or celebrating religious observances, consistent with one’s
expressed faith. All requests for the observance of religious holiday or worship service must be
submitted in accordance with departmental procedures for requesting time off.
POLICY NUMBER:          6.9                     REVISION DATE:          05/12/05
POLICY NAME:            Educational             APPROVAL DATE:          04/26/05
                        Assistance
EFFECTIVE DATE:         07/01/03                RESPONSIBLE             Human Resources
                                                PARTY:

PURPOSE:

To encourage the educational advancement for employees of Synergy Medical Education
Alliance.

POLICY:

Qualified employees are entitled assistance of up to $1,000 per fiscal year for
registration/tuition fees, required books and other materials. Employees must be regular full-
time (at least 32 scheduled hours per week) and must be employed for a minimum of six
months to qualify for educational assistance. Courses must be from an accredited college or
university, pre-approved, and satisfactorily completed (minimum grade of "C" or equivalent or
graded "pass"). Approval for educational assistance is based upon the course and its
relevance to the employee's current or future potential position. Educational assistance in this
policy does not pertain to professional conferences, continuing education credits and similar
professional certification credits (e.g., CEU, CME, etc), professional certification exams, or
courses providing preparation for professional certification exams.

Employees on leave and dependents of employees are not eligible. Employees with
concurrent financial aid from any other source to defray the cost of education may not qualify.
Costs for meals, lodging, and transportation are not eligible.

PROCEDURE:

Prior to the start of their course, employees must seek approval from their immediate
supervisor through the completion and execution of an Educational Assistance Request and
Agreement form (See Attached).

After enrolling and paying for the course, the employee must forward all receipts to the Human
Resources Department. The Human Resources Department will confirm that reimbursement
requests meet the policy guidelines and dollar limits and a check will be processed.

After completing the course the employee must forward grade information (or confirmation of
passing the course) to the Human Resources Department. Employees who fail to satisfactorily
complete the course and/or those who cease employment with Synergy Medical prior to
completing the course will be expected to refund the entire amount of the reimbursement.
                 EDUCATIONAL ASSISTANCE REQUEST AND AGREEMENT


Name ____________________________________                    Date of Hire    ________________________

Department     ______________________________                Position        ________________________

Educational Institution:
Academic Program:

Course Title & Number (e.g., Accounting 101)                                   Total Credit Hours

Course Description



Tuition                    Books                    Start Date                 Completion Date



In consideration of payment of these expenses, you agree to the following:

That concurrent financial aid will not be received from any other source to defray the cost of this course.

If you do not satisfactorily complete this course (minimum grade of "C" or equivalent or graded "pass"),
you will refund the entire amount of the educational expenses provided to you.

If your employment with Synergy Medical ceases prior to completing the course, you will refund the
entire amount of the educational expenses provided to you.

This Educational Expense Agreement creates no contract of employment between you and Synergy
Medical. You may terminate your employment with this company at any time with or without cause, and
Synergy Medical may terminate your employment at any time with or without cause.


_____________________________________                ________________________________________
Employee Signature                                   Supervisor's Signature ( approved denied)

_______________________________
 HR use only Receipts Rec'd /             /         ______________________________ ________
                                                   Grade Doc. Rec'd /    /      Grade
Date                                                 Date
  Approved    Denied (Reason Denied:_______________________________________) Amount ________________

_________________________________________________             ____________________________
Signature                                                     Date
POLICY NUMBER:           6.10                    REVISION DATE:          12-07-2010
POLICY NAME:             Resident Time Off
REVISION                 01/01/2011              RESPONSIBLE             Program Directors/
EFFECTIVE DATE:                                  PARTY:                  Human Resources


PURPOSE:

To provide a system as a benefit of employment which ensures residents are provided with
specified time off for rest, relaxation, illness, and personal or family needs.

POLICY:

PAID TIME OFF (PTO)

Upon their first day of employment, all full time residents are provided with a lump sum amount
of PTO days as follows:

                 PGY-1         =         15 Business days
                 PGY-2+        =         20 Business days

Appropriate Use of PTO

   All absences, paid or unpaid, must be reported to the resident's program director using
    departmental standards of reporting.

   Residents must utilize available PTO for all time off (except for applicable Bereavement or
    Jury Duty pay - see respective policies in Section 7 - Benefits).

   Residents may only utilize their own paid time off.

   When PTO is utilized for 5 consecutive business days (Monday through Friday), the
    resident’s time off shall include the weekend days (Saturday and Sunday) either before or
    after the 5 business days, but not both.

   PTO shall be utilized in a manner that does not impede the organization's operation. To
    that end, residents, when possible, must provide at least three (3) months notice prior to
    the event requiring time off. Such notice should be documented and acknowledged by the
    department. And to the resident within 7 days.

   If a resident works for 24 hours or more on the day immediately preceding their first day off
    then that day should be a post call day not a vacation day. (e.g. If they went to work at 8
    am on Sunday and worked through 8 am on Monday, then Monday is a post call day not a
    vacation day, if they went to work at 8 pm on Sunday and they worked through 8 am on
    Monday then Monday is a vacation day.)

   PTO may not be "cashed out" at any time. Furthermore, any unused PTO time may not be
    carried over from one post-graduate year to the next.

   Residents will receive 5 days per year to be utilized for conference.

   Resident will be given time off of duty without being required to take PTO or conference
    time for their initial Step 3 examination. However, if a resident must repeat the
    examination, they WILL be required to take PTO for the days of the exam.


CATASTROPHIC SICK BANK ACCOUNT (CSBA)

Upon their first day of employment, all full time residents are provided with a lump sum amount
of 10 days of CSBA time.

Use of CSBA

   CSBA time shall only be utilized for illnesses or injury, which prevents attendance in excess
    of three (3) scheduled business days (i.e., three continuous days of absence). In such
    cases CSBA time shall be assigned to the 4th day of absence.

   CSBA earnings shall also be made available for those absences covered by the Family
    Medical Leave Act (See Synergy Medical’s policy on FMLA compliance - Policy 3.13).

   When available, the first three days of absence shall be covered by the resident's PTO
    bank. Residents who are absent without available Paid time off or CSBA shall not be paid.

   Catastrophic Sick Bank Account is also not a vested benefit, can not be carried over from
    year to year, and may not be transferred to a resident's PTO account.


LEAVE TIME LIMITATIONS

Depending on the program, leave time for resident physicians using any combination of paid or
unpaid leave (PTO, CSBA, Family Medical Leave, bereavement time off, jury duty, etc.) may
exceed program board eligibility limitations. In such cases, an extension of the residency
program will likely be required in order to meet board requirements.

All residents should work closely with their program to ensure their planned or unplanned leave
time does not exceed such restrictions.
POLICY NUMBER:          7.1                     REVISION DATE:
POLICY NAME:            Amendments to           APPROVAL DATE:           02/25/03
                        Protected Health
                        Information (PHI) by
                        Patients
EFFECTIVE DATE:         04/14/03                RESPONSIBLE
                                                PARTY:

POLICY:

Patients who believe information in their health records is incomplete or incorrect may request
an amendment to the information as outlined below. This is an addendum or supplement, not
physical correction or alteration.

PROCEDURE
1. The patient or patient representative must contact the Synergy Medical Medical Data
   Services department.

2. The Medical Data Services staff will assist the patient in completing the health record
   amendment form.

3. Upon completion of the form, staff will make three copies.

4. COPY ONE: Give the first copy of the form to the patient

5. COPY TWO: Place the second copy in the patient’s health record immediately

6. COPY THREE AND ORIGINAL: Route the original and third copy with the patient’s record
   to the author.

7. After the author complete the amendment form, send a copy of this form to the patient.

8. Place the original of the amendment form with the author’s signature in the patient’s record.
   Discard Copy Two.

9. The Manager of Medical Data Services will ensure that:

   a.) Copies of the amendment form are given to those individuals or organizations the
       patient deems necessary and documents on the amendment form.
   b.) Copies of the amendment form are sent to the facility’s business associates or others
       who have the information subject to the amendment and that may have relied or might
       rely on that information to the detriment of the patient.

10. Disclosures will be noted on the amendment form with a short notation indicating to whom
    the amendment form was sent, the date, and the staff member processing the disclosure.

11. When a amendment form is used, the Medical Data Services staff will make an entry at the
    site of the information that is being amended indicating, "See amendment," and will date
    and sign that entry. The amendment form will be attached to the amended entry.

12. Whenever a copy of the amended entry is disclosed, a copy of the amendment form will
    accompany the disclosed entry.
Health Record Amendment Form

Patient Name: __________________________________ Birth date: __________________

Patient Address: ____________________________________________________________

Date of entry to be amended: ____________________         Patient chart number: ___________

Description of entry to be amended:




Please explain how the entry is in error or incomplete. What should the entry say to be more
accurate or complete? Please note: It is against the law for use to delete or erase
printed chart information. If we agree that your information should be amended, it will
appear as an attachment to your record. The information being amended will be marked
to refer to this attachment.




Would you like this amendment sent to anyone to whom we may have disclosed the
information in the past? If so, please specify the name and address of the organization or
individual.




_________________________________________                    ______________________
Signature of patient or legal representative                 Date
For Synergy Medical use only:


Date received:                                  Amendment has been           ACCEPTED         DENIED


Name of Healthcare Provider ________________________________ Title ___________________


If denied, check reason for denial:

  PHI was not created by this organization
  PHI is not part of patient’s designated record set
  PHI is not available to the patient for inspection as required or permitted by federal law (e.g.,
psychotherapy notes)
  PHI is accurate and complete


Comments of Author or Supervising Healthcare Practitioner: (may also be dictated and attached)




Signature of Healthcare Provider _________________________             Date _____________________
POLICY NUMBER:           7.2                     REVISION DATE:
POLICY NAME:            Authorizations For       APPROVAL DATE:           02/25/03
                        Use of Protected
                        Health Information
EFFECTIVE DATE:         04/14/03                 RESPONSIBLE              Management/Medical
                                                 PARTY:                   Records/Privacy and
                                                                          Security Committee

DEFINITIONS:

TPO – Treatment, payment or other routine healthcare operations such as peer review,
graduate medical education., etc.

GENERAL POLICY:

Synergy Medical staff and students will follow current laws and regulations governing protected
health information for uses not related to treatment, payment, research or routine healthcare
operations. Staff and students may not use or disclose PHI unless by a valid authorization. The
Manager of Medical Records, Director of Research or Privacy Officer must approve all
authorizations in writing before use. Only authorized Medical Records staff may release
information requested from Synergy Medical via a written authorization.

An authorization is NOT required for:
▪ Disclosures for treatment, payment or routine healthcare operations (peer review, quality
   control);
▪ Disclosures required by law;
▪ Disclosures about victims of abuse, neglect or domestic violence;
▪ Disclosures for worker’s compensation.

General Requirements for Authorization:
• Must contain core and any additional required elements
• May contain additional elements that are not inconsistent with required elements
• Defective if: (i) expired; (ii) missing required information or element; (iii) known by Synergy
Medical to have been revoked; (iv) combined with another document other than as authorized
below, or (v) known to contain false information
• See regulations for details relating to documentation and retention

Compound Authorization: Authorization may not be combined with another document to
create a compound authorization except as follows:
• Authorization re: PHI created for research that includes treatment of the individual may be
combined in the same document with a consent to participate in the research, consent for the
use/disclosure of PHI for TPO, or the Privacy Notice
• Authorization for the disclosure of psychotherapy notes may be combined only with another
authorization for the disclosure of psychotherapy notes
• Authorization other than for disclosure of psychotherapy notes may be combined with any
other authorization except where Synergy Medical has conditioned treatment, payment,
enrollment in health plan or eligibility for benefits on provision of one of the authorizations

Prohibition on Conditioning of Authorizations: Synergy Medical may not condition
treatment, or payment on provision of authorization except:
• Synergy Medical may condition provision of research-related treatment on provision of
authorization for disclosure of PHI created for research that includes treatment of the
individual;
• Synergy Medical may condition provision of health care that is solely for purpose of creating
PHI for disclosure to third party on provision of authorization for disclosure to third party.

Revocation: A patient may revoke authorization at any time, in writing, except to the extent
that Synergy Medical has already taken action in reliance upon this authorization (i.e., Synergy
Medical cannot ‘recall’ PHI already released).

VALID AUTHORIZATIONS
Authorizations requesting Synergy Medical to release PHI must be written in plain language
and include:
• Description of information to be disclosed, with sufficient specificity
• Identification of person, or class of persons, authorized to make requested disclosure
• Identification of person, or class of persons, to whom Synergy Medical is authorized to
make requested disclosure
• Expiration date or event related to individual or purpose of disclosure
• Statement of individual's right to revoke, noting exceptions and describing how to revoke
• Statement that information disclosed may be subject to redisclosure
• Signature of individual, and date
• If signed by personal representative, description of representative's authority to act for
individual

Additional Requirements for Authorizations Requested by Synergy Medical for its own
Use/Disclosure: In addition to meeting core requirements:
• For authorizations not permitted to be conditioned, statement that Synergy Medical will not
condition treatment, payment, enrollment in health plan or eligibility for benefits on provision of
authorization
• Description of each purpose of requested disclosure
• Statement that individual may inspect or copy PHI to be disclosed and may refuse to sign
the authorization
• Statement of remuneration to Synergy Medical as result of disclosure, if applicable
• Copy of signed authorization must be provided to individual

Additional Requirements for Authorizations Requested by Synergy Medical for
Disclosures by Others: In addition to meeting core requirements, the authorization for
Synergy Medical to release PHI must include:
• A description of each purpose of requested disclosure
• Except for authorization on which payment may be conditioned, statement that Synergy
Medical will not condition treatment, payment, enrollment in health plan or eligibility for benefits
on provision of authorization
• Statement that individual may refuse to sign authorization
• And a copy of signed authorization must be given to the patient or representative.

Limitations re: Psychotherapy Notes: Synergy Medical must obtain authorization for any
disclosure of psychotherapy notes except:
• To carry out TPO consistent with consent requirements, only for: (i) use by the originator of
the notes for treatment; (ii) disclosure in supervised counseling training programs, or; (iii)
disclosure to defend legal or other action brought by the individual.
• Disclosure: (i) required to be made to the Secretary of Health and Human Services
regarding compliance; (ii) as otherwise required by law; (iii) as permitted for health oversight
activities with respect to oversight of the originator of the notes; (iv) as permitted to coroners
and medical examiners, and; (v) as permitted to avert serious threat to health and safety
POLICY NUMBER:           7.3                     REVISION DATE:
POLICY NAME:            Minimum Necessary APPROVAL DATE:                 02/25/03
                        Use of PHI
EFFECTIVE DATE:         04/14/03                 RESPONSIBLE             Privacy and Security
                                                 PARTY:                  Committee

POLICY:

Synergy Medical will use or disclose only the minimum amount of information necessary to
provide authorized requestors with the information they need to accomplish their approved
request.

This policy does NOT apply to:
      Disclosures to or by a health care provider for treatment;
      Disclosures made to the individual about his or her own protected health information;
      Uses or disclosures authorized by the individual that are within scope of the
      authorization.
      Disclosures required by law.

PURPOSE:

Improve the privacy of confidential information disclosed by Synergy Medical staff in their work;
ensure that Synergy Medical staff has the information they need to meet our mission.

1. Role-based access: Synergy Medical staff will have access to electronic and print
   protected health information based on their need to know to accomplish their job duties.
   Access will be based on their roles in the organization. The Privacy and Security
   Committee will review this grid annually and resolve any questions about PHI access.

2. Entire medical records: In compliance with the HIPAA regulations, Synergy Medical staff
   may not disclose an entire medical record, except where the entire medical record is
   specifically justified as the amount reasonably necessary to accomplish the purpose.

3. Payment: Only the minimum necessary PHI will be used or disclosed for payment
   functions. Staff members handling PHI for payment purposes shall restrain from publicizing
   patient diagnosis information. This policy shall apply to checks collected, credit card paper
   receipts, and envelopes and invoices sent to patients.

4. Educational purposes: Faculty, students, and staff are to de-identify information when in
   a classroom setting and the patient’s identifying information (name, age, sex, etc.) is not
   needed
5. Management purposes: Directors and managers without patient care responsibilities
   usually have access only to PHI related to healthcare operations that has been aggregated
   and summarized for management decision making. This includes quality improvement
   activities, credentialing and peer review of health care professionals, auditing function
   results, business planning for cost management and volume projection and analysis and
   others. PHI may also be accessed for investigation and mitigation of associated with
   HIPAA compliance and risk management.
POLICY NUMBER:          7.4                      REVISION DATE:
POLICY NAME:            Minors: Consent          APPROVAL DATE:           02/25/03
                        and Treatment;
                        Informing Parents
EFFECTIVE DATE:         04/14/03                 RESPONSIBLE
                                                 PARTY:

POLICY

Synergy Medical will provide health care services to minors in a confidential manner when
appropriate and in accordance with the laws of the State of Michigan.

PURPOSE

The purpose of this policy is to provide clear parameters within which Synergy Medical health
care providers may provide medical care to minors in accordance with applicable Michigan
law, and to ensure that confidentiality is appropriately maintained by medical records
correspondence, billing services and all other staff.

DEFINITIONS

Minor: Any person under the age of 18 years.

Consent: Consent requires:

(1) the actual provision of information sufficient to allow the parent or minor (in cases where
the minor's consent is legally permissible) to make an informed and uncoerced choice based
on knowledge of the procedure, its risks and benefits, and alternative treatments; and

(2) documentation of the choice in the chart. If actual documentation before treatment is not
feasible, oral consent from the parent (for instance, by telephone) may suffice. If the consent is
oral, it should still be witnessed by having a disinterested person listen in, and afterward
should be confirmed in writing (for example, by fax or email).


POLICY STANDARDS

A. Consent

1) General Rule. A parent or legal guardian must provide consent on behalf of a minor
before health care services are provided to a minor.
2) Exceptions to General Rule.

      a) Emergency Situations. A health care provider may treat a minor without the consent
      of the minor's parent or guardian if there is a true life-or-limb threatening emergency and
      reasonable attempts have been made and documented to contact the minor's parent or
      legal guardian.

      b) Emancipated Minors. When a minor is emancipated, he/she is no longer subject to
      parental control or regulation and can request and receive treatment for himself/herself.
      Emancipation occurs under Michigan law when:


             1. the minor reaches age 18;
             2. the minor is emancipated by court order;
             3. the minor is married;
             4. the minor is on active duty in the armed forces;
             5. the minor is consenting to routine, non-surgical medical care or emergency
             treatment and the minor is in the custody of a law enforcement officer and the
             minor's parent or guardian cannot be promptly located; or
             6. the minor is a prisoner under the jurisdiction of the Department of Corrections
             or is a probationer in alternative incarceration under a specific state law and the
             parent or guardian cannot be located by the Department of Corrections.
             However, the minor cannot consent to health care treatment related to a
             vasectomy or any procedure related to reproduction.

      c) Special Circumstances. Michigan law specifically addresses several additional
      special circumstances and/or Michigan courts.

             1. Birth Control Information and Devices. Provision of birth control information
             and contraceptive care devices to minors is permissible with the consent of the
             minor and without consent or knowledge of the parent or guardian.

             2. Substance Abuse. A minor who professes to be a substance abuser may
             request and receive medical or surgical care, treatment or services for substance
             abuse. Consent of any other person including a parent, guardian or spouse is not
             necessary. A treating physician may, but is not obligated to, inform the parent or
             guardian as to the treatment given or needed. Information may be given to or
             withheld from a parent, guardian or spouse without consent of the minor and
             notwithstanding the express statement of the minor to the contrary.

             3. Sexually Transmitted Infections. A minor who professes to be infected with
             a venereal disease or HIV may request and receive medical or surgical care,
             treatment or services for venereal disease or HIV infection. Consent of any other
person including a parent, guardian or spouse is not necessary. A treating
physician may, but is not obligated to inform the parent or guardian as to the
treatment given or needed. Information may be given to or withheld from a
parent, guardian or spouse without consent of the minor even if the minor
expressly requests the contrary.

4. Unwed Minor Mothers. A minor can request and receive prenatal and
pregnancy related health care as well as health care for a child of the minor
without parental consent or knowledge. For medical reasons the treating
physician may, but is not obligated to, inform the supposed father of the minor's
child or the spouse, parent, or guardian of the minor as to the health care given
or needed. The information may be given or withheld without the minor's consent
even if the minor expressly requests the contrary. Note that before providing
care, the health professional must inform the minor that these persons may be
notified and that at the initial visit to the facility or health professional the minor
must be asked if the minor's parents may be contacted for any additional medical
information which may be necessary or helpful to the provision of health care.
(Note that while this minor can provide consent for medical treatment of her child,
she is still considered a minor until she becomes 18 years of age. Confidential
services for medical care unrelated to prenatal and pregnancy care may only be
provided to this minor pursuant to applicable exceptions in this policy.)

5. Outpatient Mental Health Services. A child age 14 or older can receive up to
twelve (12) outpatient sessions or four (4) months of outpatient counseling (but
not abortion referral and use of chemotherapy) without parental consent or
knowledge. Services must be provided on an outpatient basis only, and services
should promote the minor's relationship to the parent or guardian and "shall not
undermine the values that the parent . . . has sought to instill in the minor." The
minor's parents shall not be notified of the services without the consent of the
minor unless the mental health professional treating the minor determines that
there is "a compelling need for disclosure based on a substantial probability of
harm to the minor or to other persons, and if the minor is notified of the mental
health professional's intent to inform the minor's parents." After the twelfth
session or fourth month of referral, the professional must end the services or,
with the minor's consent, notify the parents or guardian to obtain their consent for
further care of the minor.

6. Abortion. Michigan law prohibits abortions performed on minors without
written consent of the minor and either written consent from one parent or legal
guardian or a court order. If the parent or guardian is not available or refuses to
consent, or if the minor does not want to get consent from her parent or guardian,
the minor may petition the court for a waiver of the parental consent requirement.
The court will grant such a waiver if the minor is "sufficiently mature and well
             enough informed to make the decision independently of her parents or legal
             guardian" or if a waiver would be in the minor's best interest. The requirements
             for parental consent do not apply to an emergency abortion, defined as "a
             situation in which continuation of the pregnancy of the minor would create an
             immediate threat and grave risk to the life of the minor, as certified in writing by a
             physician." This Act applies to all minors, whether or not they are Michigan
             residents and failure to comply results in a misdemeanor.

Questions:
Please contact the Synergy Medical’s Patient Representative or Risk Manager.
MINOR CONSENT TO TREATMENT FLOWCHART
                                            Page 1 of 2
                         NOTE: For use ONLY in conjunction with written policy


    Is patient                  Use
                    NO
    age 17 or                   regular
    less?                       consent


            Y
    Is patient                   No
  emancipated
                    Y          parental
                               consent
   minor with
 documentation?                needed

            NO


   Is patient                    No
   member of
                    Y          parental
                               consent
 armed forces?
                               needed

            NO


    Is patient                   No
    married?
                    Y          parental
                               consent
                               needed

            NO


  Is patient in                No parental
      law           Y           consent
  enforcement                  needed; try
    custody?                    to reach
                                parents*
            NO



    Is visit for
 emergency (life                No parental
  or limb threat)
                    Y             consent
    treatment?                   needed for
                               this type care

            NO
                              MINOR CONSENT FLOWCHART
                                      Page 2 of 2


  Is visit for
                            No parental
pregnancy or
prenatal care,
                       Y      consent
birth control?               needed for
                           this type care
           NO


Is visit for HIV            No parental
 or STD care?                 consent
                           needed for this
                       Y     type care
           NO


  Is visit for care
     of child of            Minor   may
      minor?           Y    consent  for
                            own child’s
                            care
                                                                            TYPE OF CARE
           NO




 Is visit for                  No parental
 outpatient            Y    consent needed
mental health?             for this type care*
                             if 14 – 17 y.o.
           NO


  Is visit for              No parental
 exam/treat of         Y       consent
   substance               needed for this
    abuse?                   type care *

           NO




         STOP
    Do not treat
    without parental
    consent

                                             * - limits apply. See policy
POLICY NUMBER:           7.5                    REVISION DATE:
POLICY NAME:            Obtaining Consent       APPROVAL DATE:           02/25/03
                        or
                        Acknowledgement
                        for Routine, TPO –
                        Based Use of PHI
EFFECTIVE DATE:         04/14/03                RESPONSIBLE              Privacy and Security
                                                PARTY:                   Committee


GENERAL POLICY

1. Synergy Medical staff will make a good faith effort to obtain a signed acknowledgement of
   receipt of our Notice of Privacy Practices.

2. If a patient has permitted a family member or friend to accompany them into an exam room,
   Synergy Medical staff should ask if the patient consents to share protected health
   information with that person. This consent does not require documentation.

3. The Front Desk Coordinator will ensure that each patient is asked once a year to fill out a
   patient information sheet and general consent-to-treat form.
                               Acknowledgement of Receipt of
                                 Notice of Privacy Practices

I understand that Synergy Medical may share my health information for treatment, billing and
healthcare operations. I have received a copy of the Notice of Privacy Practices that describes
how my health information is used and shared.

I understand that Synergy Medical has the right to change this notice at any time. I may obtain
a current copy at any time by contacting Synergy Medical or by visiting the website at
www.synergymedical.org.

I have the right to revoke this consent, in writing, at any time, except to the extent that Synergy
Medical or Synergy Medical has taken action in reliance on this consent.


__________________________________                   ______________
Print Patient Name                                     Date of birth


__________________________________                   ______________
Signature of Patient or Legal Representative            Date




                                     Insurance Assignment

I authorize Synergy Medical to furnish information to insurance carriers concerning my illness
and treatments, and I hereby assign to Synergy Medical all payments for medical services
rendered to me or my dependents.

I understand I am responsible for any amount not covered by insurance.



__________________________________                   ______________
Signature of Patient or Legal Representative            Date


If signed by legal representative, indicate relationship to patient: _________________

Witness: _______________
POLICY NUMBER:              7.6                          REVISION DATE:
POLICY NAME:                Patient                      APPROVAL DATE:               02/25/03
                            Photography
EFFECTIVE DATE:             04/14/03                     RESPONSIBLE                  Information Resources
                                                         PARTY:

POLICY:

Photographs may be treated as part of the medical record. They are subject to the same
requirements for confidentiality. The benefits of photography for any reason must be weighed
against the privacy rights of the patient and liability risks to Synergy Medical.

Note: The likeness of a patient may be recorded through a number of visual means, including still photography,
videotaping, digital imaging, scans, and others. Throughout this document, the term "patient photography" will be
used for any such recording of a patient’s likeness or voice.

CONSENT:

The practice of obtaining written consent only in the case of full length or facial photographs is
not sufficient. One cannot rely on a photographer’s judgement that a particular patient is
unlikely to be identified from a particular photograph.

Synergy Medical’s policy is to obtain consent to all photographs and in all cases. This includes
all photography by Synergy Medical staff or students of patients in any location (e.g., hospital
patients, EMS patients). This includes photography with the sole purpose of care or the
auditing of this care. Synergy Medical staff or students must also follow the photography
consent policy of the institution where they are taking the photograph. If no policy exists, staff
or students must follow Synergy Medical policy. Synergy Medical requires a signed Synergy
Medical consent form.

Consent must be obtained before photography. Patients must know that they are free to stop
the photography at any time. Patients must be allowed to view the unaltered photographs upon
request. Patient may withdraw or modify their consent at any time. The patient, guardian or
holder of power of attorney must give consent.

PROCEDURE:

The patient or his or her legal representative should sign and date the consent form. Anyone
other than the patient who has the legal authority to sign should indicate his or her relationship
to the patient. The signature should be witnessed, and the witness' signature should be in the
space provided on the form. The signed consent form should be filed with the patient's health
record.
In the case of minors, the parent or guardian must sign the consent. If the minor objects, no
photographs are allowed even if the parent/guardian consents.

Family Practice patient interview training videos must be erased the same day made. All
photos, videos, and other images should be stored in a manner that ensures timely retrieval
when requested so that if a patient withdraws consent for use or disclosure of the image, that
the image may be destroyed or labeled appropriately.

Inability to consent: In rare cases, a patient may be comatose or otherwise unable to give
informed consent. The photographer must get consent as soon as the patient retains capacity.
If the patient is unlikely to regain capacity, the photographer must seek consent from the
person who can consent to treatment. If no consent is given, all images of said patient will be
removed or destroyed.

Photography as a routine part of a procedure: Consent for such photography must be
obtained as part of the consent for the procedure. Written consent specific to the photography
will be part of the procedural consent form. This includes laparoscopy, endoscopy,
culposcopy, ultrasound, etc. These photographs become part of the medical record at the
institution where the procedure was performed.

Consent not required: Photography without consent is allowed in only such cases as
suspect injury to a child when it is unlikely that the parent or guardian will consent and
the photography is clearly to the patient’s benefit.

Copies: Synergy Medical staff acquiring copies of photographs in the course of their work
may retain them for teaching or publication purposes, but must use them only within the terms
of the original consent.

Ownership: Before leaving Synergy Medical employment or training programs, staff must
receive written permission from the Manager of Medical Records to retain any images.
Synergy Medical may or may not grant such permission, but will retain copyright, ownership
and reproduction rights.

Images of patients, in whole or in part, may be transferred to personal computers solely for the
preparation of teaching materials or publications. Synergy Medical staff and trainees are
required to bring the original images with a copy of the signed consent to the
Information Resources department for downloading. Information Resources staff will
ensure that the consent is forwarded to Medical Records, which will have access to these
images. These images may be used only in accordance with the terms of the consent. It is the
image user’s responsibility to know and apply these terms.
Retention: Since photographs, videotapes, and other images used to document patient care
are considered part of the patient's record, they should be kept for the same time period state
law requires medical records to be kept. Negatives and electronic photography files must be
stored and secured appropriately. Particular care must be taken to maintain the integrity of
digital photographs used for patient documentation.

Images for patient documentation: The original image(s) may not be altered or compressed.
Information Resources staff will ensure that each image is assigned a filename by which it can
be clearly identified and filed with the patient name, Synergy Medical medical record number if
any, and date of recording. Medical Data Services will retain a copy in the patient’s medical
record or an annotation as to the location of the image(s).

Research: Photographs taken as part of a research protocol must be approved by an
institutional review board. Consent for such photography must be incorporated into the consent
form the patient signs to participate in the research protocol.

Copyright : Copyright belongs to Synergy Medical. It is important that any contract for
publication that the copyright in the recording remains with Synergy Medical and does not
automatically pass to the publishers. If otherwise, Synergy Medical is unable to protect the
patient’s interests by exercising control over further publication of the recording. Those
Synergy Medical staff signing agreements with publishers should delete from the contract any
suggestion that copyrights will pass to the publishers.
                  CONSENT TO RECORDING OF IMAGES AND/OR VOICE



Description of Photo or Recording: ______________________________________________

Patient Name: __________________________________ Date: ______________________

Photographer Name: _____________________________________


I authorize the above-named person to photograph or videotape me or my child.

Synergy Medical will keep these images secure to protect my privacy. Synergy Medical will
make every attempt to conceal my identity before any publication or display of these images.
Synergy Medical may use these photographs or video for teaching, research, publication in a
scientific journal, or publicity for Synergy Medical’s services. I impose no restriction on the use
or publication of these photographs.

I understand that Synergy Medical will retain the ownership rights to these photographs or
video for use in all venues. I release Synergy Medical, its directors, officers, agents, and
employees from all claims of every kind because of such use. I also waive all right to any
claims for royalties or payments for any use of these photographs.

I grant this consent as a voluntary contribution to medical education and knowledge, or to
promote the services of Synergy Medical Education Alliance.


____________________________________ ____________________________________
[Signature]                          [Witness]



       The patient cannot consent because:

_______________________________________________________

       I consent on behalf of the patient.

____________________________________ ____________________________________
 [Signature of authorized representative] [Relationship to patient]
POLICY NUMBER:          7.7                      REVISION DATE:
POLICY NAME:            Protected Health         APPROVAL DATE:          02/25/03
                        Information Privacy
                        Complaints or
                        Breaches
EFFECTIVE DATE:         04/14/03                 RESPONSIBLE             Medical Data
                                                 PARTY:                  Services/Privacy and
                                                                         Security Committee

GENERAL POLICY:

To mitigate and prevent recurrences of breaches of patient privacy; to respond promptly and
compassionately to patient privacy concerns.

1. Every identifiable complaint should generate an investigation and a response. The
   investigation should focus on both the specific complaint and any patterns of similar
   complaints. It is helpful to coordinate privacy complaints with security incidents to
   determine potential causal relationships.

2. If after an investigation it is determined that no actual violation occurred, Synergy Medical
   must recognize that perception of a violation is as important as an actual violation and may
   need to take corrective action steps to overcome erroneous perceptions. Privacy is a very
   personal matter and can therefore be a very ambiguous area to address. What one
   individual may consider an invasion of privacy or violation of privacy rights may not be a
   violation to another individual. The Patient Representative will send an appropriate
   communication to the individual(s) after review by the Compliance and Privacy Officers.

3. Synergy Medical should respond to every identifiable complaint received. If the complaint
   was filed in person or on the phone, it should be documented and followed with a phone
   call or letter. The response should include a statement of appreciation for the individual's
   value as a patient/customer and a recognition of the time and interest taken in advising the
   covered entity of the privacy concern.

4. However, in the event of a complaint or breach of patient privacy, the first employee
   contacted must report the complaint immediately to their supervisor.

5. The employee and supervisor must notify the Patient Representative immediately and
   complete the attached Privacy Complaint or Breach form.

6. The Patient Representative will also notify the Privacy Officer immediately. The Patient
   Representative is responsible for ensuring that the Manager of Medical Data Services,
   Director of Information Resources or others are notified promptly as appropriate for the
   nature of the breach.

7. The Privacy Officer will ensure the completion of the Synergy Medical response section
   and report on the incident as appropriate to the Executive Leadership or Privacy and
   Security Task Force. The Privacy Officer is responsible for retaining records of complaints
   and actions taken.

8. Synergy Medical staff will mitigate the harm, if any, done immediately whenever reasonable
   and practicable. For example, if a third party inadvertently learns of information in a
   domestic abuse situation, staff must contact the patient and appropriate authorities.

If a breach has occurred, Human Resources will ensure that the Compliance Officer is notified,
and that appropriate disciplinary and/or educational action takes place and is documented in
the corporate personnel file(s). The Compliance Officer, Risk Manager, and Legal Counsel
should be involved in drafting the response that best suits the situation, including any offer of
mitigation.
Privacy Complaint or Suspected Breach
Report Form


Name of patient(s) involved: __________________________________________________

Name of complainant/reporting individual: ______________________________________

Contact information for this person: ____________________________________________

Type of information:   electronic    paper      oral       combination     unknown

       (circle)

Description: ________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Date(s) during which incident occurred: _________________________________________

Name of person filling out this form: ____________________________________________

Department and contact information for this person: ______________________________

Signature: _____________________________               Date: _____________________
                                         RESPONSE
                                 to Privacy Breach Complaint

Instructions: Express your concern to the person complaining. Do not apologize for
wrongdoing: allow the investigation to take place first. Report breach or complaint immediately
to your supervisor. Complete form and give to Patient Representative ASAP. The Patient
Representative will contact the Privacy Officer and ensure that the complaint/breach reaches
appropriate parties immediately.


   Patient representative contacted: _____________ by __________________________
                                     (date)           (name)


Investigation showed that:     __________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Persons consulted: _________________________________________________________

___________________________________________________________________________

Action to be taken as a result: _________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Communication to complainant: _______________________________________________

___________________________________________________________________________
___________________________________________________________________________

___________________________________________________________________________


Privacy officer notified _________________ by _____________________________
                                (date)           (name)


Accounting of erroneous disclosure required? If yes, notify Medical Data Services.

Medical Data Services notified_________________ by _____________________________
                                    (date)           (name)
POLICY NUMBER:          7.8                      REVISION DATE:
POLICY NAME:            Revocation,              APPROVAL DATE:           02/25/03
                        Restriction or
                        Modification of use
                        or Disclosure of PHI
EFFECTIVE DATE:         04/14/03                 RESPONSIBLE              Medical Records
                                                 PARTY:

Patients have the have the right to request a restriction or limitation, or to revoke consent on
the use or disclosure of their protected information for their treatment, payment or health care
operations.

1. Patients must make this request in writing to Synergy Medical’s Medical Data Services. We
   will not ask for a reason for their request. We will accommodate all reasonable requests.

2. The Manager of Medical Records will ensure that all Synergy Medical staff are consulted or
   informed about this request as necessary, and that appropriate documentation of this
   notification and communication with the patient occurs promptly. This includes notifying the
   Director of Research and Educational Programs to place this individual on the “no
   marketing” list.

3. The patient must describe (1) what information to limit; (2) whether to limit our use,
   disclosure or both; and (3) to whom the limits to apply.

4. We are not required to agree to these requests if these restrictions may interfere with our
   ability to care for the patient or to receive payment. If we do agree, we must comply with
   the request unless the information is needed to provide emergency treatment.

5. We will respond to requests within sixty days.

6. We will require patients to pay in cash in advance of services if these restrictions prevent
   requesting payment from a third party.

7. In the rare event that a patient refuses disclosure to a third party and cannot pay, Synergy
   Medical staff will notify the physician of record and offer a ‘hardship’ financial application
   form. If the patient does not meet Synergy Medical requirements for financial assistance,
   they will be referred elsewhere for their care. These actions will be documented in the
   patient’s chart.

A copy of the current form is appended.
                                            Request for Restriction
                               On Use or Disclosure of Protected Health Information
                                                       OR
                                             Revocation of Consent
                                     for Use of Protected Health Information

                               OUR PLEDGE ABOUT YOUR HEALTH INFORMATION
                     We understand that medical information about you and your health is personal. We
                                             are committed to protecting it.


You have the right to request a restriction or limitation on the medical information we use or
disclose about you for treatment, payment or health care operations.
You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care
or in the payment for your care, such as a family member or a friend. For example, you could ask that we not use or disclose
information about a surgery that you had to a sister who is driving you to your appointments.

To request restrictions, you must make your request in writing to Synergy Medical Medical Records. We will not ask you the reason
for your request. We will accommodate all reasonable requests.

You may also revoke or modify your consent for the use of your health information.

You must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom
you want the limits to apply, for example, disclosures to your spouse.

We are not required to agree to your request if these restrictions may interfere with our ability to care for you or receive
payment. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

Please print

First Name: _______________________ Middle Initial: ___ Last Name: ________________________

Date of birth: _______________________                   Phone Number: __________________________________
    Address: _______________________________________________________________________________

    City, State, and Zip: _____________________________________________________________________

Description of the information I wish to limit:

Please limit Synergy Medical’s:
       use of this information in routine treatment, payment or healthcare operations
       disclosure of this information to others for routine treatment, payment or healthcare operations

Please do not disclose this information to: _________________________________________________
                                                                  (please describe individuals or organizations)

___________________________________________                         ____________________________
[signature]                                              [date]
                                            RESPONSE TO
                                         Request for Restriction
                        On Use or Disclosure of Protected Health Information
                                                OR
                       Revocation of Consent for Use of Protected Health Information

For REVOCATIONS:
   The Revocation of Consent for Use was enacted and all required steps taken.
_______________________________      _________________
Manager, Medical Data Services               Date


For RESTRICTIONS:
   The request for modification of use or disclosure of Protected Health Information is APPROVED
and appropriate actions will be taken.


_______________________________      _________________
Manager, Medical Data Services               Date



    The request for modification of use or disclosure of Protected Health Information is DENIED for the
following reason(s):
___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________




    The patient was contacted and informed in writing of this decision. A copy of the communication is
attached.


_______________________________      _________________
Manager, Medical Data Services               Date
POLICY NUMBER:           7.9                       REVISION DATE:
POLICY NAME:             Sending PHI               APPROVAL DATE:           02/25/03
                         Electronically
EFFECTIVE DATE:          04/14/03                  RESPONSIBLE              Medical Records
                                                   PARTY:

GENERAL POLICY:

Synergy Medical staff will exercise extreme care in the electronic transmission of protected
health information. Information transmitted must be the minimum necessary to meet the
requester’s needs.

Electronic data files
At the time of this policy, the only authorized transmission of electronic data is by the Billing
Office staff using either the SDM, MISYS, ExpressBill and similar software as instructed by
Synergy Medical vendors and the corporate Privacy or Security Officer.

Telefax
1. Synergy Medical staff may send PHI to support treatment to a healthcare provider.
   Synergy Medical will accept a faxed copy of an authorization to release PHI. Staff must
   exercise care when sending protected health information via facsimile to local hospitals,
   physicians’ offices, labs and pharmacies. Guidelines include:

          a. Verify the identity of receiver.
          b. Use the attached cover sheet for all transmissions.
          c. Pre-program buttons for routine receivers into machines to reduce the possibility
             of a wrong number.
          d. When dialing numbers manually, use care to avoid wrong numbers.
          e. Address the fax to a specific destination like a job title (“Ob Nurse Educator”) or
             individual.

2. When Synergy Medical staff receives a telefacsimile containing PHI on an unauthorized
   (e.g., non-clinical) fax machine, the staff member responsible for that fax machine is
   required to shred the PHI and to fax the attached form to the responsible party.

3. Event of a misdial to a fax, the staff member sending the PHI must check internal logging
   system of fax machine to obtain number erroneously dialed. If possible, a phone call should
   be made to unauthorized recipient requesting entire content of misdirected fax be
   destroyed. In any case, the first page of the attached form should be faxed.
4. The staff member must inform the Manager of Medical Data Services so that this
   unauthorized release can be made part of the accounting of disclosures database. A copy
   of the error report will also be placed in the patient’s chart. The Manager will notify the
   Privacy Officer of any repeated errors.

PHI may not be faxed to patients.
TO: ___________________________________________

Fax Number: ___________________________________________




               WARNING:
      YOUR FAXED INFORMATION HAS
     REACHED THIS MACHINE IN ERROR.


You may be using an outdated telefax number. This facsimile is for general business use,
not for confidential patient information.

Federal patient health information regulations mandate our compliance in patient privacy
and confidentiality issues.

Please contact the intended recipient for an approved fax number. Please resend the
information to that number with a coversheet stating the recipient’s name and
department. If you are unable to reach the intended recipient, please call 989-583-6800
to be transferred to their extension.

Your cooperation is greatly appreciated. If this information is intended for Synergy
Medical use, we appreciate your extra effort in ensuring the confidentiality of our
patient’s information and its transmission to the correct place of need.
           CONFIDENTIAL HEALTH
              INFORMATION
Health care information is personal and sensitive information related to a person's health care. It is being faxed to you after
appropriate authorization from the patient or under circumstances permitted without patient authorization. You, the recipient,
are obligated to maintain it in a safe, secure and confidential manner. Re-disclosure without additional patient consent or as
permitted by law is prohibited. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties
described in federal and state law.



    Sender’s name: ____________________________________________

    Sender’s phone: ______________________________________

    Authorized recipient’s name: ________________________________________

    Authorized recipient’s phone: ___________________________________

    Comments:




    Number of pages transmitted (including cover sheet): ____




IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is addressed and may
contain information that is privileged and confidential. If the reader of this message is not the intended recipient, or the
employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination,
distribution or copying of this information is STRICTLY PROHIBITED.

If you have received this information in error, please notify the sender immediately and arrange
for the return or destruction of these documents.
                             ERROR REPORT
We believe that information on one of our patients was transmitted to you in error:


Patient Name: ________________________________________

Date and time of transmission: __________________________

Fax number used in erroneous transmission: ______________

This is confidential information belonging to Synergy Medical Education Alliance that is
legally privileged.

Please take the necessary steps to destroy this information immediately.



Contact information:
Name:
Phone:


Thank you for your prompt attention to this matter.
                                     ERROR REPORT
                                        Page two


Contact information for staff member making erroneous transmission:

Name: ________________________________________________

Phone: ________________________________________________


Action taken to ameliorate unauthorized release of PHI:




I notified:

   the Manager, Medical Data Services on ________________ (date)

OR

   the Synergy Medical Privacy Officer on _________________(date)

Please send the original faxed error report with this form to the Manager of Medical Data
Services.

Medical Data Services use only:

Data on unauthorized transmission entered into Accounting of Disclosures database:

_____________       ________________________
(date)                     (staff member name)
POLICY NUMBER:          7.10                    REVISION DATE:
POLICY NAME:            Use of PHI in           APPROVAL DATE:           02/25/03
                        Marketing
EFFECTIVE DATE:         04/14/03                RESPONSIBLE              Director of Research
                                                PARTY:                   and Educational
                                                                         Programs

DEFINITIONS:

“Marketing” means the promotion or advertisement by Synergy Medical of specific products
and services. This does not include information related to treatment, such as referral to a
consultant or an in-house service.

POLICY:

Synergy Medical and its staff and students will follow current laws and regulations governing
protected health information in marketing. All supervisors are responsible for enforcing this
policy.

Synergy Medical and its staff may not coerce an individual to consent to the disclosure, use, or
sale of PHI.

Synergy Medical may not use or disclose PHI for marketing purposes without the authorization
of the patient who is the subject of the PHI. Staff must use the attached authorization form for
marketing consents.

EXEMPTED ACTIVITIES:

Synergy Medical staff may use and disclose PHI without consent or authorization for the
following activities:

      1. Treatment, payment and other routine healthcare operations;
      2. Information provided in a face-to-face encounter with the patient on health related
         products and services;
      3. Common healthcare communications, such as disease management, wellness
         programs, prescription refill reminders and appointment notifications;
      4. Provision of sample products to the patient;
      5. Provision of promotional gifts of nominal value (e.g., stickers, pens, key chains that
         promote Synergy Medical or its services) (less than $10.00)
      6. Communication is contained in a newsletter or similar type of general
         communication device that is distributed to a broad cross-section of patients,
         enrollees, or other broad groups of individuals.
RULES FOR WRITTEN MARKETING COMMUNCIATIONS:

       Synergy Medical’s executive leadership must make a determination prior to sending out
marketing communications that the product or service being marketed may be of benefit to the
patient’s health. In addition, this communication must:
       1. State the name and phone number(s) of Synergy Medical or the Synergy Medical
           entity sending the marketing information;
       2. Explain clearly the recipient’s right to opt out of Synergy Medical’s marketing
           activities and the means by which they may make such a request;
       3. Explain clearly why the patient has been targeted and how the product or service
           relates to their health.
       4. Synergy Medical will include in small print on communication materials that the
           organization is HIPAA compliant and they can access the privacy policy on the
           organization’s web site.

NO MARKETING LIST
        The Synergy Medical Director of Research and Educational Programs coordinates
Synergy Medical marketing efforts. He or she is responsible for maintaining a “no marketing”
list and ensuring its use whether Synergy Medical is using internally-generated mailing lists or
commercial mailing lists.
        The Finance Manager will designate an individual to be responsible for maintaining this
list.

PHI AND OTHER ORGANIZATIONS
 Synergy Medical will not sell information about its patients to other entities. Synergy Medical
will not provide PHI to other entities without an express, specific written authorization from the
patient.

Synergy Medical will document and retain the signed authorization for a period of at least 6
years from the date of its creation or the date when it last was in effect, whichever is later.

RIGHT TO OPT-OUT OF MARKETING COMMUNICATIONS

1. Synergy Medical patients have the right to opt-out of any and all marketing
   communications.
2. The Front Desks and Medical Records departments will provide “opt out” forms to anyone
   who asks, or anyone who complains about a contact.
3. Complaints about contacts may also be referred to the Patient Representative or Privacy
   Officer to promote patient satisfaction.
                                                       Request to Opt Out
                                                of Patient Communications


                          OUR PLEDGE ABOUT YOUR HEALTH INFORMATION
                We understand that medical information about you and your health is
                personal. We are committed to protecting it.



We may use medical information about you to contact you about Synergy Medical products or services that may benefit your
health. For example, we may send a private mailing to tell you of a new test we offer for your age or medical condition.

We may also use this information to contact you in an effort to raise money for Synergy Medical and its operations. We also may
disclose medical information to a foundation related to Synergy Medical so that the foundation may contact you in raising money
for Synergy Medical. For example, we may send a private mailing to request your support of a fund for medical missionary work.

If you do not want us to contact you for fundraising efforts, please complete this form and turn it in to the Front Desk or mail to:
Medical Records, Synergy Medical Education Alliance, 1000 Houghton Avenue, Saginaw MI 48602-5398. We will remove your
information from our contacts list(s) within ten working days of receipt of this request.

Please print

First Name: _______________________ Middle Initial: ___ Last Name: ________________________

Date of birth: _______________________
    Address: _______________________________________________________________________________

    City, State, and Zip: _____________________________________________________________________

Phone Number:
            ________________________________________________________________________

         Please do not contact me for marketing of health products and services that may benefit my health.

         Please do not contact me for fund-raising.



___________________________________                     ___________________
[signature]                                                     [date]

                                                                                    SYNERGY MEDICAL USE

                                                                                    Date received: ____________________

                                                                                    Date removed from list(s): ___________

                                                                                    Initials: ________________
POLICY NUMBER:           7.11                    REVISION DATE:
POLICY NAME:            Termination of           APPROVAL DATE:
                        Physician-Patient
                        Relationship
EFFECTIVE DATE:                                  RESPONSIBLE               Program Directors
                                                 PARTY:

POLICY:

An individual physician or Administrative Representatives has the prerogative to terminate the
physician-patient relationship for appropriate cause. It is the policy of the Corporation that each
patient be provided a release statement containing the following information:

1.     Date;
2.     Notice of termination;
3.     Reason for termination;
4.     Offer to provide emergency or urgent care;
5.     Suggestion of availability of medical service within the community;
6.     Signature of the Program Director

Residents may only terminate physician-patient relationships upon approval of the Program
Director.

PROCEDURE

The patient-physician relationship shall be terminated through the following procedures:

1. If resident, contemplated action will be discussed with Program Directors;
2. The physician will discuss termination action with the patient;
3. The record of the discussion will be recorded in the patient’s chart;
4. A release statement using the format in Attachment A will be sent to the patient;
5. The release statement and other germane documents, notes, or records of conversation will
   be placed in the patient’s chart;
6. The computer schedule will be programmed to read “no appointment” in all programs if
   applicable.
                                        SAMPLE LETTER



(Date)



Dear ______________________:

This is to inform you that your care shall be terminated (by, at, with) ________________. (place,
facility)

The reason for this action is


A physician has the prerogative to do this if he/she wishes, and this is our desire.

If you require medical attention, we suggest that you place yourself under the care of another
physician without delay. If you do desire, we shall be available to attend you for a medical
emergency for 30-days after receipt of this letter. This should give you ample time in which to
select another physician of your choice from the many competent practitioners in the area.

Sincerely yours,



Program Director
POLICY NUMBER:           7.12                     REVISION DATE:
POLICY NAME:             Patient Collection       APPROVAL DATE:
                         and Termination
EFFECTIVE DATE:                                   RESPONSIBLE
                                                  PARTY:

POLICY:

It is the policy of SYNERGY MEDICAL that any patient transferred to collection will not be seen
by any physician in any department, including Family Practice II, until the collection balance is
paid in FULL. After the collection is paid in full, the patient will be seen on CASH ONLY basis.

Termination of any patient shall be consistent with (See Policy 8.11 “Termination of Physician -
Patient Relationship Policy”).

PROCEDURE

After the patient receives four notices and due diligence is performed in effecting collection of
the unpaid balance, a final letter is then mailed to the patient via certified mail. The letter states
that the patient has ten (10) days in which to pay in full or contact our office to make
arrangements for a satisfactory payment plan. If the patient fails to respond to this final attempt,
upon approval from a department head or director, the account is then transferred to collection.
POLICY NUMBER:           7.13                    REVISION DATE:
POLICY NAME:            Missed or Cancelled APPROVAL DATE:
                        Appointment
EFFECTIVE DATE:                                  RESPONSIBLE             Program Directors
                                                 PARTY:

POLICY:

For the purpose of monitoring continuity of care and reducing “no shows’, it is the policy of
SYNERGY MEDICAL to monitor missed patient appointments. Repeated “no shows” and
frequent late appointment cancellations will be evaluated as to the advisability of continuing as a
patient of SYNERGY MEDICAL

PROCEDURE

1.    Every “no show” chart should be given to the resident that day. If no action is necessary,
      the resident should just initial it and return it to Medical Records to be filed.

2.    After two no shows, if the resident who usually sees that patient wants, a warning letter
      can be sent to the patient (SEE ATTACHMENT A). All requests for warning letters should
      be screened by a Director before being sent. If there is no regular resident doctor for the
      patient, one of the Directors can approve sending a warning letter.

3.    After sending a warning letter, if the patient again misses an appointment one of the
      Directors can approve sending a termination letter, as advised in (See Policy 8.11
      “Termination of Physician - Patient Relationship Policy”). The chart should then be given to
      the Medical Records department who will send a properly worded termination letter for
      each individual case.

4.    If a patient keeps missing appointments for important procedures or follow-up on
      abnormal lab results, etc., the usual letters do not apply and the resident or Director
      should dictate an appropriate letter.
ATTACHMENT “A”

                     SAMPLE - Letter to be sent for missed appointments



(Date)

ADDRESS

RE:

Dear (PATIENT):

Our records show that you have missed (ENTER NUMBER) of appointments since (ENTER
TIME PERIOD) without calling us to cancel. It is the policy of Synergy Medical Education
Alliance to terminate patients who continually “no show” for their appointments. We feel we
must do this for reasons of office efficiency and to make time available for other patients.

Please call our office at (INSERT APPROPRIATE TELEPHONE) if you still require an
appointment. In the future, however, if you miss any more scheduled appointments, we will be
forced to terminate you from our practice. You will then have to find another doctor for your
health care needs.

Sincerely,



(ENTER PHYSICIAN/STAFF NAME)


cc: Patient Chart
POLICY NUMBER:           7.14                    REVISION DATE:
POLICY NAME:            Second Opinions,         APPROVAL DATE:
                        Referrals, and
                        Consultations
EFFECTIVE DATE:                                  RESPONSIBLE              Program Directors
                                                 PARTY:

POLICY:

It is the policy of SYNERGY MEDICAL that second opinions may only be rendered by the
teaching faculty. In these cases the resident is not expected to give this service.

Referrals and consultations between Program Departments are to be encouraged for the
purpose of providing continuity of care within the facility, cross training of house staff, and
appropriate utilization and integration of in-house teaching expertise.

In all cases, choices of referrals and consultations shall be based on the best interest of the
patient.
POLICY NUMBER:          7.15                    REVISION DATE:
POLICY NAME:            Quality                 APPROVAL DATE:
                        Improvement
EFFECTIVE DATE:                                 RESPONSIBLE             Program Directors
                                                PARTY:

POLICY:

SYNERGY MEDICAL has maintained a quality improvement program directed at ambulatory
services since 1980. Residents have played an integral role in the process with residents
assigned to perform chart audits on a monthly basis.

Assessment of care issues with direct feedback to the resident provider is a critical educational
tool assessing specific care issues and providing residents the opportunity to gain knowledge of
the QA process.

Program Description:

SYNERGY MEDICAL Quality Improvement Program will focus on four specific areas of
care. The areas selected will be at the discretion of the Chair of the Committee and
change annually depending on identified needs or areas of concern.

Baseline data will be obtained in July, August, and September of each academic year.

Baseline data will be compared to benchmark data. Records will be monitored monthly with
feedback to the resident providers when appropriate based on audit data.

Committee Structure:

•   Committee Chair
•   Department faculty representative from each clinical department engaging in ambulatory
    patient care services at SYNERGY MEDICAL.
•   One chief resident representative from each department engaging in ambulatory patient care
    services at SYNERGY MEDICAL.
•   Director of Managed Care Services
•   Residents selected for chart audit
•   Medical records representative

Committee Chair:
Selected annually by the Senior Vice President of Medical & Academic Affairs.
Responsibilities of the Chair include but are not limited to the following:

•   Selection of committee members
•   Selection of 4 care related topics to be audited
•   Chair QI meeting
•   Develop educational tools to improve resident knowledge and performance
•   Provide individual and group feedback for identified areas of concern
•   Selection of monthly meeting day and time
•   Schedule follow up care and appropriate diagnostic testing for any patient identified through
    the audit process
•   Provide necessary audit forms for chart audit

Medical Record Representative:

It is the responsibility of the medical records representative to:
• Ensure a notification of meeting dates and times are sent to committee members
• Schedule a meeting room
• Schedule the resident audits
• Select charts for audits
• Maintain minutes of meetings
• Send minutes of meetings to appropriate SYNERGY MEDICAL departments

Chart Auditors:

Will consist of residents in teams under the direction of the Managed Care Manager. The
residents will be assigned by the medical records representative on a quarterly basis beginning
in October following the collection of baseline data.

Committee minutes will be maintained by the medical records representative and distributed to
the following:

•   Executive Leadership Team
•   Program Directors
•   Practice Management Committee

Chart Selection:

•   Charts of patients with a visit within the previous four weeks are eligible for audit.
•   All residents will have charts reviewed through the audit process.
•   Charts for each resident will be randomly selected.
•   Approximately 10% of all charts will be audited monthly.
•   Charts selected for audit will be placed in a file in the medical records department, auditors
    will be notified by the medical records representative when charts are available for review.
POLICY NUMBER:          8.1                     REVISION DATE:
POLICY NAME:            Medical Records         APPROVAL DATE:
                        Responsibilities
EFFECTIVE DATE:                                 RESPONSIBLE             Department Program
                                                PARTY:                  Director


POLICY

It is the policy SYNERGY MEDICAL that accurate, timely, and complete documentation of
medical records is an essential part of both quality of patient care and medical education. To
this end, each Program will train its participants in those attitudes, habits, abilities, and
requirements germane to patient care documentation. It is further policy, that SYNERGY
MEDICAL considers the failure to document medical care on a timely basis a condition of
unsatisfactory academic performance.

PROCEDURE

It is necessary that SYNERGY MEDICAL Program participants conform to the medical records
regulations and standards of each participating teaching facility and the SYNERGY MEDICAL
ambulatory care center.

COMMUNICATIONS

It is each teaching facility’s responsibility to communicate record requirements to individual
residents and/or the appropriate department in the same manner as attending physicians. In
the case of delinquencies and problems applicable to residents and students under their
supervision.

FAILURE TO COMPLY

Residents who have delinquent records which exceed or will exceed the regulations and
standards established by each participating facility or the SYNERGY MEDICAL ambulatory
care center will be immediately counseled by his/her Program Director and provided 72 hours
to complete all such delinquent records. If records have not been completed within the 72-
hour period, said resident will be suspended from the Program and all Corporate activities until
the records have been completed. Residents are required to make up each day of suspension
in order to fulfill the requirements for a complete postgraduate year. Similarly, time under
suspension is time for which a resident will not receive stipend payments.

EXCEPTIONS
Exceptions to this policy and procedure due to illness or circumstances beyond the control of
the resident may be granted by the President.

PROCEDURE

1. Upon receipt of notification of delinquent records, which exceed or which will, within 72
   hours, exceed the regulations and standards of the participating facility or the SYNERGY
   MEDICAL Ambulatory Care Facility, the department secretary shall:

    A. Prepare a separate resident notification letter for each institution. (Attachment 3.)
    B. Have Program Director sign letter or sign if authorized.
    C. Have resident sign certification portion of letter and insert due date on letter
       (approximately 72 hours from time resident signs).
    D. Return copy in suspense file
2. When resident completes records, secretary:

    A. Checks certification from record department.
    B. Removes file copy from suspense file.
       1. Notes on letter “RECORDS COMPLETE” and initials.
       2. Gives file copy to resident.

3. If records are not complete by deadline:

   A. Secretary informs Program Director.

   B. Director dictates suspension letter to resident with copies to the President and
      Personnel. (Attachment 2.)

   C. When records complete:
     1. Repeat 2, A & B
     2. Inform personnel of total length of suspension and forward copy of notification letter to
         personnel for inclusion in resident’s file.
DICTATION GUIDELINES

1.      Dictate clearly and at an understandable rate. You are not in a race with anyone when dictating.
Speaking too fast causes words to run together, syllables to be left out and extra work for you as you will be
required to complete the blanks in the clinic notes.

2.       When you start a dictation please identify yourself, the patient and the chart number. At the end of the
dictation please identify yourself again.

3.      Please do not eat, chew gum or suck on candy while dictating!

4.      Please turn your head away from the phone when you sneeze, cough or burp!!

5.     Spell new medications, unusual words, tests, diseases, procedures, etc.            If you have a hard time
pronouncing something, please spell it.

6.     It is much easier to develop good documentation habits that it is to rearrange your schedule for court
appearances and depositions. Concise clinic notes satisfy insurance and lawyer requests and take less of your
time.

7.      SYNERGY MEDICAL policy requires you to follow a:
        S:      Subjective
        O:      Objective
        A:      Assessment
        P:      Plan
format when dictating. EVERYONE will dictate in this format. No special individual formatting will be done.

8.      When seeing a patient, make any necessary notes in the left side margin or in the clinic note area NOT
on a separate sheet of paper.

9.     If you need to make a correction on a chart - - Cross out the error with ONE line through the middle,
make your correction above it and initial and date the correction.

10. Referrals can be made and copies of the appropriate clinic note, labs, etc. sent without writing a long letter.
The nurses have an example of a recommended format for a referral letter and will be happy to provide you with
this to help when you need to dictate a referral letter.

11. Letters written at the request of patients MUST either be written to the patient or with a patient’s authorization
they can be sent to a specific person/place. NO letters are to be done TO WHOM IT MAY CONCERN.
12. PLEASE do not do letters yourself on your computer or word processor. These are to be done on SYNERGY
MEDICAL stationery by a transcriptionist. The secretaries in Family Practice Clinic will do letters for Residents in
their clinic that does not concern patient referrals.
POLICY NUMBER:           8.2                     REVISION DATE:           01/16/01
POLICY NAME:            Resident Teaching        APPROVAL DATE:
                        Responsibilities
EFFECTIVE DATE:                                  RESPONSIBLE              Department Program
                                                 PARTY:                   Director

POLICY

The resident's role as a teacher is of critical importance to the success of the SYNERGY
MEDICAL residency and medical student programs and is part of the ACGME institutional
requirements for all residency programs.

OBLIGATIONS OF A TEACHING RESIDENT

1.     To become familiar with the requirements of the student program or junior resident’s
rotation.

2. To provide supervision and guidance for students and junior resident in their ward
performance, their clinical skills, reading assignments, etc.

3.   To discuss clerkship and rotation expectations with students and junior resident at the
beginning of each rotation.

4.    To serve as role model for students and junior residents, and to set an example by
providing high quality medical care.

5.      To provide ongoing, constructive verbal feedback to students and junior resident
throughout the teaching experience, in order to give them the opportunity to remedy
deficiencies. If problems arise that a resident is not comfortable discussing directly with a
student or junior resident, the clerkship or program director should be contacted. Residents
should not wait until the clerkship or rotation is over to provide such feedback.

6.    To complete all required evaluations of medical students and other residents promptly
and include written comments.

OPPORTUNITIES AVAILABLE TO A TEACHING RESIDENT

1.     The MSU College of Human Medicine has created a special "Instructor/Resident"
category in its faculty appointment system in order to recognize the teaching efforts of resident
physicians. All SYNERGY MEDICAL residents are offered an SYNERGY MEDICAL volunteer
faculty appointment, and the benefits thereof.
2.     The opportunity to refine residents' own clinical skills and medical knowledge by
teaching others.

3.   The opportunity to receive an assessment of residents' teaching abilities, as provided by
student and junior resident feedback and that of clerkship and program coordinators.

4.     The possibility of being recognized for teaching excellence by students and other
residents.
POLICY NUMBER:         8.3                     REVISION DATE:
POLICY NAME:          Scholarly                APPROVAL DATE:
                      Requirements
EFFECTIVE DATE:       01/1999                  RESPONSIBLE               Academic Affairs
                                               PARTY:                    Committee

POLICY

1.   All Residency Programs have scholarly project requirements. Typically this is a
     minimum of one (1) paper submitted and presented internally during the 3 – 5 years of
     residency.

2.   The submitted paper should conform to the standards of medical/scientific publications
     (e.g. abstract, background, methods, results, discussions, references) and should be a
     minimum of 5 pages in length (excluding references, graphs, tables, and figures). The
     paper should be submitted to the Director of Research and the Program director prior to
     presentation.

3.   The requirement for presentation will be fulfilled only when an abstract is submitted and
     the paper is presented at the SYNERGY MEDICAL Research Day, and/or Manning
     (Surgery Research) Day, or OB Research Day if appropriate for the project type.

4.   The project will be considered research if it’s a retrospective or prospective study,
     clinical trial, epidemiology or descriptive study, case series, or meta-analysis. A case
     study involving only one case, will only be acceptable if the Program Director has
     determined in advance, that the case is extraordinarily important and/or the work put
     into the effort is justifiable to fulfill the requirement. Each Program Director may chose
     to modify the type of project submitted, for example a review paper or other scholarly
     work may be deemed acceptable and appropriate.

5.   Completion of the resident scholarly project requirement will be determined by the
     Program Director, the Director of Research, and the Senior Vice President of Medical &
     Academic Affairs.

6.   If the scholarly project requirements is not fulfilled by June 30 of the year of graduation,
     that resident will not be certified for graduation until the requirement is completed. The
     presentation of the paper will be fulfilled through a special meeting of the department
     (e.g. Grand Rounds).
In the presence of extreme extenuating circumstances, the resident requirement may be
waived by a joint decision of the Program Director, the Director of Research, and the Senior
Vice President of Medical & Academic Affairs.
POLICY NUMBER:           8.4                     REVISION DATE:
POLICY NAME:             Academic                APPROVAL DATE:
                         Standards &
                         Conduct
EFFECTIVE DATE:                                  RESPONSIBLE              Department Program
                                                 PARTY:                   Directors
POLICY
It is the policy of Synergy Medical that residents maintain satisfactory academic progress and
exhibit abilities and attitudes, which reflect positively on their profession, Department,
SYNERGY MEDICAL and themselves. As a means to this goal, residents shall be evaluated
on a regular basis to monitor basic skills, overall abilities, and attitudes.

PROCEDURE

A. Evaluations

The Program Director and Program Faculty shall assess the educational and professional
progress and achievement of the Residents on a regular and periodic basis. The Program
Director shall present to and discuss with the Resident a written summary evaluation at least
once during each six-month period of training. A copy of the written summary will be
maintained in the Resident’s personnel file. Evaluation criteria may include, but not limited to:

Basic Skills

•   Histories and Physicals
•   Progress Notes
•   Comprehensive Assessment of Patient Problems
•   Appropriateness of Laboratory Tests
•   Appropriateness of Therapy of Treatment Program
•   General Medical Knowledge
•   Case Presentation (Organization)
•   Technical, Procedural Skills
•   Use of Literature

Overall Abilities and Attitudes

•   Ability to relate to Patients and to Nurses and other healthcare personnel;
•   Professional attitude toward Teachers and fellow Residents;
•   Initiative, reliability, and willingness to accept responsibility;
•   Ability to accept constructive criticism;
•    Acceptable professional appearance;
•    Overall Physician capabilities (ability, judgment, attitude)

B. Academic Deficiency Procedure

1. In cases wherein a resident is evaluated or judged to have performance, skills, abilities or
   progress below that considered adequate, the resident shall meet with the appropriate
   Program Director and shall also be advised, in writing, of the results of his or her
   evaluation. The Director shall identify areas of deficiency, required resident corrective
   actions, and/or goals to be attained and timelines for attaining those goals.

2. Upon completion of the aforementioned time period (see Step 1), the resident shall be
   reevaluated. The results of this reevaluation shall be summarized in writing. In cases
   wherein the academic deficiencies remain, the Program Director shall forward a copy of the
   written summary or evaluation to the President/Senior Vice President of Medical &
   Academic Affairs. The President/Senior Vice President of Medical & Academic Affairs may
   meet with the Program Director or Resident, jointly or singly, to discuss relevant issues and
   additional actions. Actions may include relevant issues of additional time periods for
   resident corrective action or a request for:
   a) Terms of probation;
   b) Reduction, modification, supervision or revocation of privileges
       within the Corporation or at any of the participating hospitals; or
   c) Termination

3.    All requests for probation, changes in privileges or termination shall be governed by
     Policies 5.6 – 5.8, “Corrective Action, Termination, and Hearing and Review” as may be
     amended from time to time.

4. Where additional time periods are established, the resident shall be so advised of such fact
   in writing including a specific definition of the time period and the actions or goals the
   resident is to complete or attain.

5. Upon completion of the time period (See Step 4) the resident shall be reevaluated. The
   results of the re-evaluation shall be summarized in writing. In cases wherein academic
   deficiencies have been resolved, no further action shall be taken. In cases wherein
   deficiencies remain, the Program Director shall forward a copy of the written evaluation to
   the President/Senior Vice President of Medical & Academic Affairs for further action.
   Actions may include request for:
     a)                                                                      Probation;
     b)        Reduction, modification, suspension or revocation of privileges within the
               Corporation or at any of the participating hospitals; or
     c)        Termination
All such requests shall be governed by Policies 5.6 – 5.8, “Corrective Action, Termination,
and Hearing and Review” as may be amended from time to time.
                                            CORPORATE PROFILE
Date Founded: June 4, 1968

Type:                                                                                A community-based Non-
Profit Medical Education Corporation

Purpose:
            To provide medical education at all levels in response to community and regional needs;
            To maintain and upgrade the quality of medical care in the community and region;
            To disseminate and advance knowledge in the fields of learning in which programs of instruction and
            research are maintained.
            To provide medical service and deliver health care through clinics.

Affiliations:
             Covenant HealthCare Systems
             Saint Mary’s Medical Center
             Michigan State University/College of Human Medicine

Governing Body:
The nine member Board of Trustees consists of the President or chief executive officer of each of the two
affiliated hospitals, a physician executive of each of the two affiliated hospitals, the Dean of the College of Human
Medicine of Michigan State University and one other person designated by the College of Human Medicine of
Michigan State University (provided that neither of such persons shall be employees of Synergy Medical) the
President/CEO of Synergy Medical, and two (2) members at large who are community representatives not
affiliated with the hospitals in MSU.

Synergy Medical Activities and Programs:
• Postgraduate Medical Education: Approved residencies conducted in Family Practice, Internal Medicine,
   Obstetrics/Gynecology, Surgery, and Emergency Medicine.

•   Undergraduate Medical Education: Serves as a community campus of Michigan State University College of
    Human Medicine by providing clerkships to third and fourth-year medical students.

•   Continuing Medical Education: Coordinates, sponsors, and co-sponsors accredited CME programs for
    attending physicians.

•   Information Resources: Operates combined medical library facility for affiliated hospitals and medical
    community.

•   Research: Conducts applied medical research and clinical investigations through local and Federal grant
    support.

•   Teaching Clinics and Patient Services: Operates ambulatory care center. Furnishes in-patient service in
    conjunction with attending physicians. Provides sub-specialty consultations. Hosts sub-specialty-teaching
    clinics.

•   Other Teaching Services: Corporate professionals participate in a wide range of activities including
    consulting, lecturing, writing, and serving as members of health planning, education, standards, professional
    and legislative committees.
•    P.A Student Program: P.A. students from Central Michigan University, Western Michigan University and the
     University of Detroit/Mercy spend time on clinical rotations with MSU medical students and Synergy Medical
     residents.
                                            KNOWLEDGE SERVICES
                                                   (989) 583-6848
                                  SYNERGY MEDICAL EDUCATION ALLIANCE
                                            KNOWLEDGE SERVICES



MAIN LIBRARY:                      1000 Houghton Avenue, Suite 2000
                                   Second Floor
                                   Synergy Medical Education Alliance
                                   Saginaw, Michigan 48602
                   Hours:          Monday – Friday 8:00am to 5:00pm


ST. MARY’S OF MICHIGAN:            800 South Washington Avenue
                                   Second Floor
                                   Saint Mary’s Medical Center
                                   Saginaw, Michigan 48601
                                   Phone: (989) 907-8204
                   Hours:          Monday – Friday 8:00am to 4:30pm

Holiday hours are posted at the library entrances.

SERVICES:         www.synergymedical.org/ir

As a student and resident at Synergy Medical, you have access to the following education services. There are no charges for
our services. You are welcome to bring sodas and snacks into the Knowledge Services department and to stay as long as
needed after we have closed for the day.

A.      CIRCULATION privileges for non-reference books and audiovisuals.
        1 – Every item you borrow must be checked out; at night you are on the honor system to do this.
                 Checkout instructions are kept on the circulation desk after hours.
        2 – Journals do not circulate but you may photocopy what you need from them. There is no charge for copies.
        3 – Books circulate for four weeks; board review videotapes for one week; audiovisual equipment overnight; other
        audiovisuals for two weeks. There are no renewals of borrowed items.

B.      COMPUTERIZED literature searches done by professional librarians.
        1 – You may request by phone or in person
        2 – You may do your own searches on an Internet workstation in the library; staff will teach you to use this software.
        3 – With the barcode number on your library, you have access from any computer to all of the library’s full-text
        journals, electronic medical books, and MEDLINE databases.

C.      INTERLIBRARY loans for materials not available here:
        1 – We will borrow materials unavailable in our collection. You need to supply us with the title, author, and source
        of what you want borrowed. We will send for it the day we receive your request, but can’t guarantee delivery time,
        as this is a voluntary sharing service among hospital libraries.
        2 – In accordance with agreements with other libraries, we can ask for fax service for emergency patient care
        requests only.
D.   COMPUTER SOFTWARE we have over 3 dozen titles for you to borrow, including EKG, ACLS, and Step 2 and
     3 preparation.

     See any librarian for training on how to search the Internet quickly and effectively, how to use MEDLINE, and how
     to find full-text articles.

E.   BOARD REVIEW AUDIO-VISUALS we have several board reviews available for check-out. They circulate for
     one week at a time.

F.   DISCOUNTS to receive a 10% discount on books purchased for your private collection follow the instructions on
     the form available at the circulation desk.

G.   24 – HOUR ACCESS you may request to have a keypad number for 24 – hour access to the library. Call Security
     at Saint Mary’s to let you in after hours.

H.   PHOTOCOPIES you may photocopy educational materials at no cost if connected with your work or education.

I.   AUDIO-VISUAL EQUIPMENT Audio-visual equipment is available at the main Knowledge Service site. We
     have slide projectors, video players, computer video-projectors, laptop computers, and other equipment for use in
     presentations and teaching.
     1 – Phone ahead for reservations since the equipment has many users.
     2 – Please return equipment on time for the sake of the next person who has reserved it.
     3 – please allow at least one hour before using the laptop or video-projector to learn how to use them and set them
     up. Even though you’ve used similar equipment, don’t risk embarrassment or having to rush through your
     presentation.
     4 – Please let us know if you have problems with the equipment (slides sticking, you’ve used the spare bulb) so we
     can fix it before the next person uses it.

J.   PRIVILEGES we do not charge for overdues at this time. We expect that all items will be returned on time so
     others may use them.

K.   SUGGESTIONS taken any time by any staff member for any resource or service.
                          INFORMATION TECHNOLOGY
                                               HELP DESK (5-5669)


As a student or resident at Synergy Medical, you have access to the following computer support services. There are no
charges for these services.

A.      Computer Support - Trouble shooting of Synergy Medical equipment and computer technology
        available in Student/Resident rooms, Cooper & Harrison sleep rooms and Information resources.

B.      Web Outlook Access (e-mail) – Provide help with setting up accounts, changing passwords, and general questions
        regarding the use of the Synergy Medical e-mail system.

C.      Handheld/PDA Support – Questions/problems with Synergy Medical related Handheld applications, for all
        wireless connectivity, etc.

D.      Multimedia Support – Assistance with scanning, slides, video production, pictures, etc.




Revised 04/05/2006
                 Department of Research and Education Programs

                               Manager: Nhu S. Dargis, M.P.A.
                                ndargis@synergymedical.org
                            Phone: 583-6995                Fax: 583-6892
Department of Continuing Medical Education
CME Coordinator: Heather Turner          583-6884                   hturner@synergymedical.org
CME Assistant:   Rasheedah Wazeerud-Din  583-6982                   rwazeerud@synergymedical.org
Fax:                                     583-6907

The CME Department certifies all Continuing Medical Education events in Saginaw County including
resident Grand Rounds. The goals of the Department of CME are:
       • Provide physicians in Saginaw County with information to advance their knowledge of
           medicine
       • Upgrade the quality of health care given in Saginaw through continuing medical education
       • Provide physicians with Category I credit needed for relicensure

Student Clerkship
Administrative Assistant      Melissa Morse          583-6821       mmorse@synergymedical.org
Fax:                                                 583-6892

Synergy Medical Education Alliance is a clinical campus of the College of Human Medicine at
Michigan State University, Kirksville College of Osteopathic Medicine at A.T. Still University, St.
Matthew’s University School of Medicine, and St. Luke’s University School of Medicine. Between 30-
40 students live in Saginaw during the last two years of their medical school training to receive their
clinical education. In addition, we also accept students for clerkship rotations as visiting students from
other medical schools throughout the United States. At some point during your residency you may be
asked to act as a preceptor for a medical student. Residents have found it to be a great learning
opportunity for both the student and resident.
                                  Department of Research
                  Research Specialist:    Leslie Francke                      583-6984
                                   lfrancke@synergymedical.org

Secretary:              Donna Gnotek          583-6982       dgnotek@synergymedical.org
Fax;                                          583-6907

The Department of Research provides expertise to assist all residents, faculty and staff with every step
of their research efforts, including:

       •     Research protocol development from study design through implementation
       •     Institutional Review Board applications
       •     Database management
       •     Statistical analysis
       •     Preparation of tables, graphs, charts and slides for lecture presentations
       •     Preparation of posters for professional meetings
       •     Develop and submit abstracts for professional meetings
       •     Manuscript preparation and assistance with submission of publication
       •     Research related computer needs
       •     Networking with investigators at MSU and other medical schools
       •     Grand searches, applications and management
       •     Research electives
                                 Institutional Review Board
                                    Leslie Francke, Chair
                               lfrancke@synergymedical.org
                            Phone: 583-6984         Fax: 583-6907

The IRB at Synergy Medical Education Alliance was formed in response to guidelines set forth by the
National Commission for the Protection of Human Subjects in Biomedical and Behavioral Research.
These principles, The Belmont Report and Title 45, Part 46 of the Code of Federal Regulations, guide
research with human subjects and ensure their protection in the design and conduct of research. Synergy
Medical has made the decision that all research with human subjects, whether funded or unfunded, or
subject to the Federal regulation or not, will be reviewed.

The IRB is responsible for determining that:
• The welfare and rights of human subjects are adequately protected and informed consent
   procedures are in place, if necessary.
• Human subjects are not placed at unreasonable physical, mental, or emotional risk as a result of
   research.
• The benefits of the research outweigh the risks to subjects.
• The researcher(s) is/are qualified to conduct research involving human subjects.

Meetings
The IRB meets once per month on the fourth Tuesday of the month. IRB applications are due not later
than two weeks prior to the meeting. If this deadline is not met, the application will not be reviewed
until the next meeting. There will be no exceptions to this requirement.

Information and Forms
Application forms can be found at www.synergymedical.org/research/schi-irb.html. In addition, sample
informed consent documents are also available. IRB policies will be updated at this site as they occur.
The protocol for review of applications is also available.

   If you have any questions about the IRB or the forms please contact one of the research staff.
            SYNERGY MEDICAL EDUCATION ALLIANCE
                   SAFETY MANUAL INDEX



1.0    Safety Management Program
       1.1    General Safety
       1.2    Incident Reporting
       1.3    Reporting Incidents from Medical Device Malfunction
       1.4    Covenant Emergency Codes
       1.5    Synergy Medical Emergency Numbers
       1.6    Safety Emergencies and Staff Response Description
2.0    Ergonomics Program
3.0    Severe Weather
4.0    Fire Safety Rules and Responsibilities
       4.1    Fire Detection and Control Systems
       4.2    Handling Fires
       4.3    Fire Alarm Report
5.0    Electrical Safety
6.0    Waste Management
7.0    Hazard Communication Program
8.0    Threat Calls
9.0    Office/Clinic Security
10.0   Violence in the Workplace
11.0   MSDS Location Sheet & Product List
12.0   Bloodborne Pathogens Exposure Control Plan




                                                                    1
                      Synergy Medical Education Alliance
                               Safety Manual

      1.0    Safety Management Program
      The Safety Management Program has been developed in order to provide the safest
      possible environment for all patients, visitors and staff; and to adhere to and follow
      laws and regulations governing safety. As a healthcare provider in the community,
      Synergy Medical Education Alliance has the responsibility to provide patient care
      and a safe environment.
      The Board of Trustees and Administration provide support to this function through
      appointment of a Safety Officer and a Safety Committee.

Reports
      Quarterly reports to Administration (the Executive Leadership Team) are provided
      through Risk Management. Annual reports to the Board are contained within the
      Risk Management Annual Report To The Board.

Meetings
      Safety Committee meetings are held quarterly at a minimum.

      The Safety Management Program includes, but is not limited to:
      1.    Employee Incidents/Workers’ Compensation
      2.    Employee Health
      3.    Risk Assessment and Control
      4.    Equipment and Utility Management
      5.    Security
      6.    Hazardous Materials and Waste Management
      7.    Fire Safety
      8.    Disaster Response

Safety Education
      1.     Safety orientation is provided to all new employees by the Risk Manager or
             designee.
      2.    The educational needs of the organization are assessed annually by the
            Safety Committee. Special safety programs are provided to all employees as
            indicated by risk analysis, performance and incidents or events.
      3.    Orientation to Safety is also provided to temporary and contract staff,
            students, and volunteers via a publication before starting work.
      4.    Safety education is provided for all staff periodically in variety of formats
            via publications and other media.
      5.    Records of annual safety education will be maintained in Risk Management
            Office


                                                                                           2
1.1    General Safety
The following is a list of general safety rules to adhere to in order to provide a
safe environment for all Synergy Medical patients and staff.

1.     Report all incidents/accidents or potential incidents to the department
       manager.
2.     If you observe a hazardous condition, take steps to rectify the condition
       immediately. Contact the appropriate person, and make sure no one is
       injured until the condition is resolved.
3.     Remove from service any defective equipment, and tag it for repair.
4.     Inspect all electrical equipment before use and periodically for frayed cords
       or connections. Remove from service any equipment found to not operate
       safely or as intended.
5.     All appliances, whenever possible, should have 3-prong plugs (grounds); some
       do not.
6.     Use proper receptacles for needles and syringes. Do not recap.
7.     Be careful to place broken glass in a can or cardboard box before disposing
       in regular trash containers.
8.     Always use equipment as instructed and intended by the manufacturer.
9.     Store supplies, hazardous materials, flammable liquids in the proper and
       acceptable manner. Be especially careful in areas where children have
       access.
10.    Use body mechanics when lifting. Get help or use a lifting aid when the load
       is heavy. Use a cart to transport heavy loads.
11.    All corridors, exits, fire doors, and passages must remain unobstructed and
       clean. Service hallways should remain hazard free.
12.    Storage should not be less than 18” from the ceiling if your area has
       sprinklers. Sprinkler heads must be free of obstruction to do their job.
13.    Wear sensible low-heeled boots in the winter on snow and ice. Be sure shoes
       and boots are free of ice, snow or water.
14.    Door wedging and propping is strictly forbidden.
15.    Use personal protective equipment when indicated or necessary.
16.    Never remove or reach under guards on equipment – they are there for your
       protection.
17.    Never eat, drink, apply cosmetics or lip balm, or handle contact lenses in the
       patient exam rooms, procedure rooms, soiled utility rooms, or any other
       patient care area.
18.    When leaving work go in groups, walk with your head high and constantly
       watch your surroundings. If you are at the Main Campus you may request
       and escort from Covenant Security. If possible move your car closer to the
       door before dark.




                                                                                     3
1.2     Incident Reporting
Incident reporting provides a mechanism for timely reporting to risk management
of events that require immediate investigation, damage control and quality/safety
review. It is the policy of Synergy Medical to report any event or circumstance,
which is not consistent with the normal routine care of the patient. The event or
circumstance may be an error, an accident, or a situation, which could have, or has,
resulted in an injury to a person or damage to the facility. For the purposes of this
policy, the definition of an incident is as follows: An incident is any event that
happens in the clinic or on the premises that is not consistent with routine patient
care or with the routine operation of the facility, which adversely affects or
threatens to affect the health, life, or comfort of a patient, visitor, or employee.

Incidents that require completion of an Incident Report include, but are not limited
to: slips, trips, and falls; medication errors, incidents involving equipment,
treatment errors, medication errors, consent issues, property damage/loss, fire,
and any injury/illness sustained while working.
The Incident Report is to be completed by the person discovering or involved in the
incident. If in doubt, it is better to complete a report than not.
Document factual information and interventions that followed. Use terms that
reflect what happened. Do Not:
-misrepresent the facts.
-make accusations, speculate, or draw conclusions regarding the event or
circumstances.
-make references to the Incident Report in a patient’s medical record.
-copy the Incident Report.

All reporting documents are confidential and prepared for committee use. All
reports are to be forwarded to the Risk Manager within 24 hours of the event.
Incidents, which require immediate investigations, will be done so by the
appropriate personnel, which depending on the situation, may be a Manager or
designee. A report shall be forwarded to the Risk Management office.
Verbal reporting of significant accidents or injuries may be done by any individual
to the Risk Manager. The Risk Manager will then fill out the appropriate report.

Incident Reports are also used for communicating quality/safety concerns, for
suggesting measures to reduce loss exposure, requesting information, or to express
concern regarding the care of a particular patient or the care being provided by a
particular practitioner. The Report is also used to report incidents anonymously
(optional). Anonymous reporting is not preferred because it generally inhibits the
investigation process, and it prohibits the Risk Manager from following up with the
individual on what actions were taken in response to the report.




                                                                                      4
Incident Reporting – Page 2
All verbal and written Incident Reports will be followed up by the Risk Manager or
designee. Aggregate summaries of all incidents will be reviewed by the ELT
(Executive Leadership Team) on a quarterly basis. Reports are then forwarded to
the Synergy Medical Board of Trustees by an administrative representative.




                                                                                     5
1.3    Reporting Incidents from Medical Device Malfunction

The purpose of this policy is to identify and report incidents in which a medical device:
        1.     May have caused or contributed to a patient’s death, serious illness, or
               serious injury.
        2.     Provides the Food and Drug Administration (FDA) and/or manufacturer with
               required information while ensuring that hazardous devices are removed
               from service.
The Safe Medical Devices Act of 1990 (Public Law 101-629) requires that whenever a
device user facility receives or otherwise becomes aware of information that reasonably
suggests that a device has caused or contributed to death, serious injury or serious illness
of a patient, a report has to be filed with the FDA within ten (10) workdays after the
facility becomes aware of the defective device. In the event of an employee-related
incident of the same nature, the facility may voluntarily submit a report to the FDA or to
the manufacturer. Summary reports must be filed with the FDA semiannually by July 31
and January 31. A summary report can be obtained from company also.

Definitions
A.     Serious Illness and Serious Injury
       An event that is:
       1.    Life threatening.
       2.    Results in permanent impairment of a body function.
       3.    Results in permanent damage to a body structure.
       4.    Requires timely medical or surgical intervention to preclude permanent
             impairment of a body function or permanent damage to a body structure.

B.     Medical Device
       Any instrument, apparatus, durable or disposable implant, in vitro reagent, or
       similar related article, component or part, which is:
       1.      Recognized in the official National Formulary, United States Pharmacopoeia,
               or any supplement to them.
       2.      Intended for use in the diagnosis of disease or in the cure, mitigation,
               treatment, or prevention of disease.
       3.      Intended to affect the structure or function of the body, which is not a
               drug.

C.     Patient
       Anyone who is being treated, diagnosed, or otherwise receiving medical care in a
       facility.




                                                                                           6
Reporting Incidents from Medical Device Malfunction – Page 2

Procedure
1.    Any person, including a physician or employee, who becomes aware of information
      that reasonably suggests a medical device has caused or contributed to the death,
      serious illness or serious injury of a patient within the facility will immediately
      notify the Risk Manager or the appropriate Administrator and follow the oral
      report with a written incident report. Involved equipment will be immediately
      removed from service, labeled, and placed in a secure area.

2.    Upon notification, the Risk Manager or the Administrator will carry out the
      following:
      a.     Certify the removal, labeling and placement in a secure area, of the device in
             question. Professional liability carrier claims contact will be notified by Risk
             Management.
      b.     Immediately begin an investigation of the incident.
      c.     Directly oversee any examination of the implicated equipment by authorized
             personnel. A determination may be made at this time as to whether user
             error was responsible for the death, serious illness or injury to a patient.
      d.     Prohibit manufacturer’s or service representatives from repairing or
             removing the implicated device from the facility. Equipment will not be
             released to a manufacturer or vendor until approved by legal counsel and/or
             Risk Management.

3.    When the preliminary investigation is completed, a report of the preliminary
      findings will be retained by the Risk Manager.
      a.     At that time the Risk Manager will decide whether to accept the findings or
             recommend additional investigation.
      b.     If the Risk Manager accepts the findings that the equipment contributed to
             an event, they will then prepare and send a report to either the FDA or
             manufacturer, or both, within ten (10) working days of determining that a
             device was involved in the death, serious illness, or serious injury of a
             patient.

4.    Responsibility for submitting reports to the FDA and/or manufacturer is assigned
      to the Risk Manager, who will also be responsible for updating facility policy and
      procedure as indicated and for reporting changes to affected department directors
      and physician staff.
      a.     If the device contributed to, or caused death, a report must be submitted
             to both the FDA and the manufacturer, if known.




                                                                                            7
Reporting Incidents from Medical Device Malfunction – Page 3

       b.     If the device contributed to or caused serious illness or injury, a report
              must be submitted to the manufacturer. If the manufacturer is not known,
              a report must be submitted to the FDA.
       c.     The following sections must be completed on the mandatory reporting form
              (FDA) MedWatch Form 3500A:
              (1)    patient information
              (2)    adverse event or product problem
              (3)    suspect medical device
              (4)    initial reporter
              (5)    for use by user facility/distributor – devices only

Information on individual equipment necessary for the completion of the report should be
found in the equipment file located in the purchasing department or in the department
which uses and maintains the equipment.

NOTE: Information submitted directly to the FDA by the device user facility is
protected from disclosure. No report submitted to the FDA can be used as evidence in a
civil action against the author of the report or the device user facility unless the facility
or individual preparing the report knew that the information provided was intentionally
false. Information submitted to the manufacturer is discoverable under the Freedom of
Information Act at this time. Therefore it is important that information provided to the
manufacturer be scrutinized carefully; information provided to the manufacturer need not
be as detailed as that provided to the FDA.

All pertinent material collected as a result of the investigation will be treated in
accordance with facility incident reporting policies.

Device Reporting Forms FDA MedWatch Form 3500 will be kept for a minimum of two (2)
years.

5.     The Risk Manager will submit a semiannual report of device related events.
       a.     The semiannual reports summarize all reports made during the applicable six
              month period preceding the semiannual report. The reports are due by July
              31 and January 31.




                                                                                            8
Reporting Incidents from Medical Device Malfunction – Page 4

      b.    The summary must include the following information:
            (1)    identity of the facility
            (2)    name of the device
            (3)    serial number of the device
            (4)    model number of the device
            (5)    manufacturer’s name and address
            (6)    a brief description of the event
      c.    The envelope containing a semiannual report should have “semiannual report”
            typed or written on the lower left-hand corner. Device user facilities that
            made no reports during a semiannual period are not required to submit a
            semiannual report to the FDA.

6.    Information on the requirements of the Safe Medical Devices Act as well as
      facility policy and procedure dealing with the same will be provided for new
      employees.




                                                                                      9
1.4 Covenant Emergency Codes for Synergy Medical Main Campus



                               Emergency Codes
 Dial 5 2 2 2 2 to Page Any Emergency Main Campus and Michigan
                         11-30-06 revised

Code Red………………….
                                                                              Fire
                                                     Arrest/Medical Emergency
Code Blue…………………

Code Little Blue…………
                                                     Arrest LDRP and RNICU
                                                            Level 1- Tornado Watch
Code Black………………                                             Level 2- Tornado Warning


Code Orange…………….
                                                                  Bomb Threat

Code White………………                                                     Evacuation
                                                             Disaster          Level 1 = Alert
Code Yellow…………….                                                    Level 2= Implement plan


Code Pink………………..                                               Labor Emergency
                                                           Situational Disturbance
Code Green………………
                                                          Switchboard is Not Manned
Code Purple………………
                                                           Infant/Child Abduction
Code A……………………
                                                                   Missing Patient
Code M……………………
                                             Shooter in Building / on Grounds
Code 357…………………
                                             Level 1- injured patient is requiring many resources for stabilization
Trauma Alert (team)…….                       Level 2- injured patient that has potential for significant bodily harm


*Not all codes apply to Synergy Medical but are listed as a reference
SYNERGY MEDICAL MAIN CAMPUS EMERGENCY NUMBERS:
• FOR MEDICAL EMERGENCY CALL 911
• COVENANT SECURITY DISPATCH 36149
*NORTH CAMPUS: FOR ALL EMERGENCIES CALL 911


                                                                                                         10
1.5 Covenant’s Safety Emergencies and Staff Response Description
      *Applies at Synergy Medical Main Campus ONLY, for informational purpose only


  SAFETY EMERGENCIES AND STAFF RESPONSE DESCRIPTION
      EVENT          INITIAL RESPONSE                     SECONDARY RESPONSE
BOMB           Person receiving the call:                Upon Code Orange notificaiton:
THREAT         1) Pull threat call sheet from            1) Perform a quick visual sweep
(Code             quick file and record                      of your department/unit
                  thoroughly                               A. divide the area into the top
Orange)
               2) Flag someone else in your area               half and the bottom half
                  to call your emergency number            B. look for things that don’t belong,
                  52222 and 911                                Such as a fast food container,
                                                               shopping bag, shoe box etc.
                                                         2) Call Security 36149 or 911 if you
                                                            find something suspicious
ABDUCTION      Upon hearing Code A                       1. All staff stay in affected area
(Code A)       1. block all exits, elevators,            2. Place all babies with mothers
                   stairwells in and near your           3. Account for all peds patients
                   department or unit                    4. Administrative Coordinator or
               2. Check all ID badges before                 Manager report to affected area
                   allowing anyone through. Send
                   those who want to leave the           One Security Officer to affected
                   building lobby to be searched.        area
               Security - initial incident command
TORNADO        Level 1: Make plans for evacuation        Do not open window, stay alert to
(Code Black)              to designated shelter          changing conditions
               Lever 2: Evacuate to designated           Gather flashlights, etc..
               shelter cover with blankets/pillows
               Protect head, complete OR
               procedures as soon as possible
Situational    Call a Code Green if physical             NOT TO BE USED for belligerent
Disturbance    fighting, weapons are produced,           patients or irate visitors
(Code Green)   violence in progress


FIRE           R   rescue anyone in danger               Assess condition of patients
(Code Red)     A   activate the alarm in your facility   evacuated, make contact with mutual
               C   confine the fire-close doors          aid as necessary and arrange for
               E   extinguish and/or evacuate            transportation
                                                         Conduct loss assessment, develop
                                                         recovery plan and resume services
Evacuation     If you need to evacuate, call your        Upon hearing code white and location,
(Code White)   emergency number and begin                report to affected facility if able
               evacuation to safe area using
               emergency carries and/or equipment
HOSTAGE        If you see a hostage situation:           DO NOT attempt to negotiate
SITUATION      1. get yourself/others out of the         DO NOT attempt a rescue


                                                                                              11
                  area and don’t go back in              If you become a hostage stay calm so
               2. call 52222 on campus or 911 off        that you can do some critical
                  campus                                 thinking; escape is your own personal
                                                         decision; stay physically to the ground
                                                         until over
CODE 357       To report a shooter, call 52222 on        Stay secured until released by law
(three fifty   campus or 911 if you are in an off        enforcement and/or Covenant
seven)         campus building. Secure building          employees. Contact critical incident
               occupants according to plan - Law         stress management team
               enforcement is in charge
BLOOD AND      For skin – wash with soap and water       Contact Employee Health as soon as
BODY FLUID     For eyes – flush with water for 15        possible, you have 1 hour to start
EXPOSURE       minutes                                   possible treatment
                                                         ext. 36188 or 34284
CODE BLUE      Harrison, Cooper, Houghton, ECC           Begin CPR
               call 52222 state st. building and
               area Michigan campus call 9-911           Begin CPR – access PA System and
                                                         announce Code Blue and location
               Mackinaw & POB campus call 9-911          Begin CPR Call 35000 to announce
                                                         code
               Irving & all other facilities call 9911   Begin CPR
WEATHER        Management assess staffing needs          Contact transportation to arrange for
EMERGENCIES    and ability to remain open                4 wheel drive volunteers
                                                         If only a few are needed –
                                                         Administrative Coordinator may
                                                         contact
POWER          HOSPITALS: Use red outlets                All other facilities contact Manager.
OUTAGE         All other facilities: reassure            Assess the need to close until power
               patients Contact Facilities               has been restored
               Services
NATURAL        Evacuate those in immediate area          Stand by for instructions
GAS LEAK       DO NOT flip any electrical switches
               On Main Campus: call 52222
               Off Campus: cal 9911
INFANT         Call Security Dispatch stat 36149         Blue strobe lights will flash in the
SECURITY                                                 skywalk – do not open any doors until
ALARM          Secure all babies                         strobe lights are turned off
ELEVATOR       Contact Facilities immediately            Make contact with elevator via phone
FAILURE        Call 52222 if medical assistance is       reassure occupants – wait for
               needed                                    contractor or Fire Department
TELEPHONE      Follow procedure in Safety Manual         See list of phone failure station
FAILURE        Locate failure station phones             numbers use runners, use pay phones


MAINFRAME      Follow instructions in computer           Maintain paper records
/NETWORK       contingency plan
FAILURE


                                                                                              12
MEDICAL    Follow contingency plan in Safety   Assess 02 tanks on hand
GAS        Manual
FAILURE
WATER      Contact Facilities immediately,     Mackinaw – distribute bottled water
LOSS       conserve water, and maintain
           building temperature
                                                       REVIEWED/REVISED 4/24/06
SECURITY DISPATCH 36149
MACKINAW SECURITY 35010
SAFETY 32756
COOPER ENGINEERING 36064
MICHIGAN ENGINEERING 32839
HARRISON ENGINEERING 34027
MACKINAW ENGINEERING 35280




                                                                                     13
1.6               Emergency Alerting List


MAIN Locations Person            Person                Office Phone   Cell Phone

Sue Vollbrecht 3-6862            Dawn Suitor           3-7900

                                 Cindy Letzkus         3-7918

                                 Denise Smith          3-7965         501-0146

                                 Noel Wagner           3-7940

Shelley Kubczak 3-6834           Managed Care          3-7971

                                 Joyce Pruitt          3-7917         714-2102

                                 Sue Scheibner         3-7966         327-7880

                                 Cheryl Such           3-7937

                                 Ed Jackson            3-7916

Patty Alfano 3-7411              FP Nursing            3-7974

                                 Lisa Carter           3-7967

                                 Dr Hot Line           3-7962

                                 Stuart Rupke          3-7911

                                 Debbie Sanders        3-7968         860-5241

Monica Federico 3-6883           Mary Jo Thomas        3-7959

                                 Kallee Pearson        3-7913         274-0092

                                 Osama Elsabagh        3-7912         992-9408

Jim Wegner 3-6863                Deborah Kelly         3-7921         598-6688

                                 Cathy Lipe            3-7940

                                 Deb Bonitz            3-7922         330-635-0850

                                 Lori Julian           3-7973

Wayne Albrecht 3-6803            Sue Stahlbaum         3-7960

                                 Family Med. Manager   3-7954

                                 Elaine Gunn           3-7914         980-2629

                                 Sue Vollbrecht        3-7968         798-2558




                                                                                     14
2.0    ERGONOMICS PROGRAM

Ergonomics is the relationship between the people and their work environment. A work
environment includes both the tasks to be performed as well as the equipment available to
perform those tasks. These are several reasons for employers to comply with the
ergonomic recommendations:
1. Financial – ergonomically correct furniture and equipment is less expensive in the long
   run than worker compensation claims.
2. Workers become more productive in efficient, comfortable work areas.

Who is Affected?
All workers whose jobs involve repetitive motions, hand force motions, awkward postures,
contact stress, vibration, lifting transferring, pushing, pulling. These conditions include
jobs in offices, those involved with patient care, jobs which include the transfer of
materials (usually in boxes or cases), computer input and desk jobs, maintenance workers;
virtually every job in the house. Even those workers in high paying administration positions
can be affected if, for instance, their office furniture does not fit their body
configurations. Those workers are at risk for several conditions that have specialized
themselves to ill-ergonomic conditions. They include, but are not limited to: Cumulative
Trauma Disorders (CTD), such as carpal tunnel syndrome, tendonitis, epicondylitis,
tenosynovitis, back pain, especially low back, shoulder, neck injuries, eye strain and
headaches.

RISK FACTORS:
Risk factors are workplace conditions that pose a biomechanical stress to the worker.
Examples include the weight of materials lifted, powered, pushed, pulled or carried. Risk
factors also include repetitive work activities involving the hands and wrists. Workplace
conditions such as slippery floors, crowded areas and poor illumination, excessive heat,
cold or humidity also increase risks. Solutions such as lifting teams, more mechanical
lifting devices, employee training programs, (ergonomic specific), and ergonomic
assessment programs with Ergonomic Committees can lower work related injuries by as
much as 70%.

The following are identifiable Risk Factors, divided into groups according to the functions
Performed:




                                                                                            15
ERGONOMICS PROGRAM – Page 2

                    OFFICE, COMPUTER ENTRY, DESK-TYPE JOBS
Evaluate to be sure chairs “fit” workers:
• Hips, knees, elbows and ankles at right angle (90 degrees) or greater
• Desk at correct height to facilitate right angles (2” below elbows)
• Back alignment comfortably straight (varies person to person)
• Avoid prolonged sitting, stand and stretch periodically
• Office furniture should be adjustable to accommodate workers’ needs
• Office chairs should have a 5-point base, lumbar support, arm rests

                            COMPUTER SCREENS/KEYBOARDS
•   A straight line forms from forearm to wrist when keying
•   Computer screen at eye level and proper distance (18-24” away)
•   Upper arms hanging comfortably
•   Lighting should not create glare on screen and work surfaces
•   Repetition avoided: identical or similar motions performed every few seconds for long
    periods of time without breaks in the work performed
•   Computer screens should be adjustable
•   Documents should be next to the screen, at eye level, to avoid neck repetitive
    movements
•   Head should not be tilted forward more than 15 degrees

                                     ENVIRONMENTAL
•   Room temperatures too hot or too cold
•   Proper lighting, not too bright nor too dim
•   Mechanical equipment in proper working order
•   Availability of mechanical equipment for high risk tasks
•   Slippery, narrow, obstructed, congested areas eliminate
•   Excessive noise – hearing protection should be given
•   Education afforded to workers, re: body mechanics, posture, lifting techniques
•   Prevent walking on unsafe surfaces
•   Avoid poor layout of work area




                                                                                        16
ERGONOMICS PROGRAM – Page 3

                               NURSING and PATIENT CARE
•  Transferring patients, seated to standing, reclining, etc. without assistive measures
•  Common multiple person transfers should:
   *minimize travel distance
   *transfer from surfaces of equal height
• Slide boards, transfer belts, patient lifts not readily available
• Prolonged bending at waist, with or without lifting involved
• Should not lean to the side, bend torso forward or backward more than 15 degrees
• Sharp, non-padded objects extended or poorly visible
• Wheelchairs should have footrests, armrests and padding when needed
Management’s Responsibility:
1. Be proactive in identifying the risk factors in your departments.
2. Evaluate work sites, tasks performed and environmental factors. (Environmental
   factors including lighting, temperature, noise, etc.)

                            GENERAL POINTS OF INTEREST
•   Does the worker take all breaks that are allowed during the workday?
•   Can jobs be rotated to avoid repetition for prolonged periods?
•   Does the worker maintain good posture throughout the workday?
•   Can some jobs be conducted standing instead of sitting, and vice versa?
•   Does the worker accept the work area?
•   Is the worker required to lift moderate to heavy loads without assistance?

Employee’s Responsibility:
1. Be proactive in identifying the risk factors in your work area.
2. Report any CTD problems you are having so your work area can be evaluated




                                                                                           17
3.0           SEVERE WEATHER

THUNDERSTORMS
Thunderstorms can generate life-threatening lightening and wind, downbursts of up to 80
mph. Most thunderstorms in Michigan are usually in the form of a squall line or gust front;
although super cells can form. Tornadoes from a squall line will usually form in the
southerly end of the storm.

WATCH – Means conditions are favorable – be alert to changing conditions.

WARNING – Means the storm is dangerous and imminent – ask staff, visitors and patients
to stay away from windows – stay inside until storm is over – usually 20 to 30 minutes.
Offer shelter to patients and visitors.

TORNADOES
By definitions, a tornado is a violent rotating column of air that comes in contact with the
ground (those that do not touch the ground are termed funnel clouds). The tornado can be
seen when it contains condensation, dust or debris. Wind speeds can reach over 200mph,
with the average path length of 9 miles, and a width of 200 yds. They travel an average of
30 mph – but speeds ranging from stationary to 70 mph have been seen.

WATCH – Means conditions are favorable – be alert to changing conditions.

WARNING - Means a funnel cloud or tornado has been sighted visually or on radar.

Synergy Medical Main will have the alert notification staff contact the selected employees
at Main and at Generations Family Care of the Warning. Please consider the following:
       -       Informing patients and visitors; Moving patients using evacuation route;
               Services may need to be discontinued; Accounting for Staff on duty and
               Patients checked in.

Main Campus: Front desk staff will post a sign informing any new patients that may enter
the building to take shelter in the basement, the front desk staff will then guide patients
to the basement conference room and remain with them until all clear is announced, also
take sign in sheets to account for all patients

North GFC Campus: Front desk staff may guide patients in the waiting area to the lab
hallway area and remain with them, also take sign in sheets to account for all patients




                                                                                          18
SEVERE WEATHER – PAGE 2
General Consideration:
   1) It is recommended that everyone stay until conditions improve
   2) Patients and Visitors are responsible for their own safety if they choose to exit
       the building
   3) Staff: If warning occurs during normal staffing hours, approval to leave would need
       Managers approval also, any employee that leaves would be responsible for their
       own safety if they choose to exit the building.
Main Campus:
- Upon notification, move patients and visitors away from outside wall, and all windows,
move patients and staff to the conference room in the basement, and no new cases should
be started until the warning period is over.

*IF TIME PERMITS, SECURE PATIENT CHARTS TO A LOCKED OFFICE FOR HIPAA
COMPLIANCE

North GFC Campus:
      -Patients and staff are to take shelter in the lab, audiology room, and lab hallway. -
      “Spill over” will take place in the main hallway just outside of the lab hallway.
      Reception staff should direct all patients (and their belongings) in the waiting
      room/bathroom to the designated area mentioned above.
      -Nursing staff A schedule will relocate any patients in the clinical areas to the lab
      hallway area and wait with them. The RN in each of the clinical hallways should take
      the patient schedules with them to account for all patients. RN and MA on the B
      schedule will make sure all clinical areas are clear of patients and staff and close all
      doors before moving to the appointed shelter area. If time permits, one of them
      may quickly take the stairs to make sure no one is upstairs. *Designated RN will
      secure patient charts for HIPAA compliance.
      -All personnel from the Attending suite and Medical Records should close their
      department doors, report to the lab hallway and take shelter.
                    DO NOT TAKE SHELTER IN THE PROCEDURES SUITE
                       CLOSE DOUBLE DOORS IN THE MAIN HALLWAY

FLOODS
When a flood watch is issued, be alert to changing conditions. Flash floods can occur
within a matter of minutes.

If flooding of the building occurs, the following procedure should be followed:
a.     Alert staff, visitors and patients to NOT enter a flooded area;
b.     All persons entering the flood area should attempt to wear protective gear, such as
       water proof boots;
c.     Notify Department Manager and Purchasing Coordinator @ 36883.




                                                                                            19
SEVERE WEATHER – PAGE 3

ICE STORMS
Ice storms occur when rain from warm air, falls on the ground that is at a temperature of
32 degrees or less. When roads are covered with ice, ALL vehicles have difficulty. Having
a four wheel drive vehicle is of no use on ice. Ice storms can down power and phone lines
from the weight of the ice.

SEVERE WINTER WEATHER
WINTER SOTRM WATCH – means heavy precipitation accompanied by winds may move
into the area in the next 24 hours. You should stay alert to changing conditions.

WINTER STORM WARNING – means heavy precipitation accompanied by winds will move
into the area. You should make decisions about keeping your office open for patients.
Monitor weather reports closely. If the weather deteriorates during office hours,
consider closing early so that patients and staff can get home safely.

BLIZZARD WARNING – means snow, blowing snow and winds over 35mph will create white
out conditions. Blizzard warnings should always be heeded. NEVER venture outside in a
blizzard unless it is an emergency; and then have your vehicle prepared with emergency
supplies. Do not attempt to go out on foot; chances are you will become disoriented and
lost.

“SLIP AND FALL PREVENTION:WINTER CONDITIONS”


Winter related slips and falls are generally related to icy conditions. On behalf of the
Synergy Medical Safety Committee, we’d like to share the following tips to help prevent you
from being involved in any type of slip and fall:

*THINK PREVENTION!
~Wear winter footwear, even for short walks.
~Select your shoes to fit the surface on which you are walking (boots, etc.)
~Avoid routes that have not been cleared or appear glazed over.
~Don’t carry large objects or packages that may obstruct your view or cause you to loose your
balance.
~Walk slowly and take short steps (“shuffle” if needed) to keep your centre of balance under you.

*YOUR ENVIRONMENT!
~Use extra care when getting in and out of vehicles; parking lots are particularly difficult to
maintain between parked vehicles.
~Use handrails on steps/ramps.
~Delay using recently plowed areas as they can be slippery until the salt/sand has taken effect (salt
may not be as effective during excessive accumulations of snow).
~Attention to some walkways and parking lots may not be possible until at least 24 hours after a
storm has subsided.


                                                                                                    20
~Look before you walk-surfaces can re-freeze during the nighttime hours, making sidewalks and
parking lots slippery in the morning.

~~Remember… winter brings a special set of hazardous conditions. Just like winter driving—
winter walking requires anticipation of the “road conditions”. Just like the term “defensive
driving”, please use “defensive walking” to help prevent slips and falls! Rule of thumb:
ANTICIPATE THE CONDITION OF THE SURFACES AND BE CAREFUL!!




                                                                                                21
4.0           GENERAL FIRE SAFETY – RULES AND RESPONSIBILITIES

Policy: The fire safety plan has been developed and established to provide a safe
environment for patients, visitors and staff. The plan includes and monitoring of detection
and suppression devices, as well as environmental surveys to look for hazards. By doing
these activities, we are able to mitigate the risk of fire for the occupants of our buildings,
and improve the safety of the environment.

Each employee and volunteer has the responsibility to help prevent fires, and know what to
do if a fire does start.

Fire Duty Assignments for ALL Departments

Fire Duties #1       Man the main telephone, secure patient records and financial records
                     if possible
Fire Duties #2       Help with traffic control – stop people from moving through smoke
                     barrier doors
Fire Duties #3       go to the area of the alarm – take an extinguisher with you if on the
                     same floor
                     a) Help secure the area
                     b) Help evacuate the area as necessary
                     c) RN’s triage and give initial first aid to any casualties
Fire Duties #4       Stand by to evacuate the patients with their records; If evacuation
                     occurs, close patient doors when empty and place a piece of tape on
                     the door.
Fire Duties #5       Shut off all non-essential equipment – stop all routine activities
                     except patient care.
Fire Duties #6       Check fire extinguishers – make ready for use
Fire Duties #7       close all doors and windows
Fire Duties #8       do not let anyone use the elevators

Those reporting to the area of the alarm may be asked to perform the following functions:
1. Help secure the area
2. Help evacuate the area
3. RN’s would triage and give first aid to any casualties




                                                                                            22
4.1           FIRE DETECTION AND CONTROL SYSTEMS



Detection/Activation Systems:

Smoke Detectors: are located throughout our facilities. They are located in ceilings; some
are concealed. Activation of a smoke detector will cause a small red light to go on.
Activation is automatic.

Heat Detectors: are located in ducts, stairwells, and mechanical or furnace rooms. These
            will automatically activate at 150-180 degrees.

Pull Stations: Are located throughout the Houghton Street Main Campus. To operate,
               grasp the lever or handle and pull.

Types of Extinguishers:

ABC Multipurpose extinguisher – can be used on any fire; leaves a residue unless it is
Halon. These are found throughout our facilities to be used only on small fires.

BC CO2 extinguishers– Located in places like labs, mechanical rooms.

These extinguishers are for one time use on small fires. Always send a used extinguisher
to Purchasing for replacement. Extinguishers without the plastic tab secured may not be
reliable. Each Campus has their fire extinguishers check annually by:

Houghton Campus: Security checks the fire extinguishers at this location. €

North Campus: Galen Fire Inspection inspects the fire extinguishers yearly in April.




SPRINKLER: The basement of Houghton St. is sprinkled. Sprinklers are activated when
small solder in the sprinkler head melts from the heat of the fire.




                                                                                           23
4.2           HANDLING FIRES

Policy: Synergy employees and volunteers will handle or manage a fire, using (NFPA)
National Fire Protection Association and (MIOSHA) Michigan Occupational Safety Health
Administration regulations. Safety and the protection of building occupants is the primary
concern. If the fire is too large, or the employee is unsure of how to proceed, initiate
compartmentalization (close the door) and leave the area.

REPORTING A FIRE:
Houghton Campus: Call Security @52222.
North GFC Campus: Call 911

Procedure:
If you hear an alarm at the Houghton Campus:
1. Listen to the audible page “CODE RED” for location of the alarm
2. If you are outside of your department, and the alarm is in your department, take a
    safe route back to your work area.
3. Do not take elevators, unless they have been deemed safe by the Fire Department.
4. Discontinue routine business, stay alert to changing conditions. Be sure you have
    accounted for everyone in your area.
5. Follow instructions as issued from Administration, Engineering, or Security.

If you discover a Fire
R      Rescue or remove patients, visitors in immediate danger
A      Sound alarm, activate nearest pull station, call your facilities emergency number
C      Initiate compartmentalization – confine the fire (close doors)
E      Extinguish the fire or evacuate all occupants from the area



North GFC Campus:
When you hear an alarm or a fire occurs in your area
1. Communicate information on the fire to everyone.
2. Discontinue routine business and complete any patient procedures in progress. Have
   patients get dressed as quickly as possible.
3. Prepare for evacuation out of the building. Secure patients records if possible.

If you discover a fire at GFC:
R      Rescue or remove patients, visitors in immediate danger
A      Call 911, sound alarm and notify building occupants of fire
C      Initiate compartmentalization – confine the fire (close doors)
E      Extinguish the fire or evacuate all occupants from the area




                                                                                           24
4.2           HANDLING FIRES – PAGE 2



Handling Small Fires:

   ALWAYS REPORT FIRE FIRST NO MATTER WHAT THE SIZE
1. Waste receptacle fire – pour water over fire, and/or cover tightly with wet towels,
   blankets
2. Never use water on electrical fires or other electrical device unless it’s unplugged.
3. Use fire extinguishers only on small fires
4. ALWAYS use compartmentalization to control smoke.



Handling Large Fires:

   ALWAYS REPORT FIRE FIRST NO MATTER WHAT THE SIZE
1. Remove patients immediately from the area through smoke containment doors or to
   your designated area of safe refuge.
2. Initiate compartmentalization , or close doors
3. DO NOT re-enter the area.




                                                                                           25
4.3              FIRE ALARM REPORT
This form is used to document observations during a drill or actual fire, to be completed by a member of the
Safety Committee

Date____________________Time of Alarm:_____________Time Alarm Paged:_____________

Time Fire Discovered:__________        Facility Name and Area: Houghton Campus - 1000 Houghton
                                                              Generations - 1575 Concentric Blvd.
Type of fire (or drill scenario): __________________________________________________

Time of ALL CLEAR: ______________ Scene cleared by: ______________________________
Responders:          Surveyor Name _____________________________________________
_____ Fire Department_____ Administration Notified_____ Facilities * List responders on back

1.      R Removed People from immediate danger                                     Y N
2.      A  Activated the alarm appropriately, and called the emergency number      Y N
3.      C Confined the fire – closed doors, initiated compartmentalization         Y N
4.      E Used an extinguisher if the fire is small, relocated staff, patients and Y N
            Visitors to a safe area
5.     Was someone in charge of evacuation? Y N who?____________________________
6.     Was relocation site appropriate?                                            Y N
7.     Did employees have a fire assignment?                                       Y N
8.     Did employees follow fire assignment?                                       Y N
9.     Were hallways cleared, and exits unobstructed?                              Y N
10.    Did employees know the location of the nearest pull station, and how        Y N
       to activate it?
11.    Could employees describe or demonstrate how to use an extinguisher and/or Y   N
       a suppression system as intended?
12.    Did Managers and staff return to their areas?                               Y N
Adjacent areas (compartments) surveyed:__________________________________________

For Houghton Campus:
1.     Was the switchboard called?                                  Y       N        N/A
2.     Did the switchboard update the Fire Department?              Y       N        N/A
3.     Was Security Paged?                                          Y       N        N/A

For North GFC Campus:
____ Alarm Company Contacted
____ Detector selected for activation for drill
____ Visitors in building advised of drill
____ Fire extinguishers checked, ready for use
Conclusions/Recommendations:___________________________________________________
__________________________________________________________________________
Action/Monitoring:____________________________________________________________
__________________________________________________________________________




                                                                                                               26
5.0           ELECTRICAL SAFETY

Even as sophisticated as our society has become, electrical safety is still an issue for any
office, clinic or practice. Electrical codes have reduced the risk of shock and fire, but all
the codes in the world still cannot replace your vigilance in electrical safety.

As a practice or clinic, you are under the jurisdiction of the local fire department and Fire
Marshal for electrical regulations and codes. Any time you have questions about these
codes, feel free to contact your fire department for help. They will be happy to give you
assistance. You may even want to ask for a hazard survey; however, if deficiencies are
found, the Fire Department will expect those problems to be corrected.

A Short Lesson in Electricity
There are several components to electricity. Before we progress, you should become
acquainted with some definitions.

Current:    The flow of energy
Voltage:    The amount of driving force
Amps: The measurement of the strength of the current. It’s the amps that can kill you.
Conductors: Materials that provide a pathway for electricity; such as wires.
Grounds:    A low resistance pathway for the electricity to take should a piece of
            equipment malfunction; the electricity is more likely to follow the ground
            rather than you; grounding will help protect you against shock, but does not
            guarantee it.
Insulator:  Electric resistant materials such as glass, plastic, or rubber that serves to
            ensure the electricity stays on its path or conductor.
Ground      Monitors the current and shuts off the power immediately if something
Fault       happens to the pathway; GFI is required in bathrooms in all new
            construction; consider installation of GFI in the office or clinic bathrooms if
            not already present.

ELECTRICAL CIRCUIT
As long as the pathway is not disturbed and the pathway remains insulated from other
conductors, the circuit will be complete. Electricity always takes the path of least
resistance. Danger of shock occurs when something happens to make you a part of the
circuit, such as a broken wire, water, or metal contact with the current.
If electricity enters your body, it can follow your own nerve pathways, since those
pathways normally carry electrical impulses to and from the brain. It can also cause pain,
burns, muscle contractions or paralysis. Leakage current is found on the surface of
all electrical equipment, and is so low you don’t feel it, unless something has happened to
connect the surface to the electrical circuit.




                                                                                            27
ELECTRICAL SAFETY – Page 2

The severity of a shock is measured by three conditions:
1.            The quantity of current
2.            The path it takes as it flows through the body
3.            The duration of the electrical flow.

If you get a small shock off a piece of equipment, take it out of service and have it
repaired. That small shock may be the only warning you get that something has
malfunctioned in the circuits of the equipment.

We could never get along without electricity. It has changed the world as nothing else
has. A healthy respect for electricity and your attention to preventative measures will
help to ensure an electrical safety record second to none!




                                                                                          28
GENERAL ELECTRICAL SAFETY RULES

1.     Report electrical accidents/incidents to manager immediately.
2.     No cheater cords are to be used. Multi-outlet surge protectors are acceptable.
3.     Remove from service any electrical device not working properly, that sparks, stalls,
       blows a fuse or gives off a shock, and have it repaired before further use.
4.     All electrical equipment should be inspected when borrowed or when returned from
       being loaned.
5.     Always inspect equipment and plugs after a power failure.
6.     Whenever possible, use equipment with a 3-prong plug. If this is not possible, make
       sure plug is polarized.
7.     Never stretch cords across sinks or other wet areas.
8.     Never string cords across walkways.
9.     Cords are never to be compressed or pinched in drawers, between pieces of
       furniture, or in any other way. Cords should always be heavy duty with 3-prong
       plugs if possible.
10.    Use the appropriate watt light bulb for the outlet. Lamps will have a specified limit
       of watts that can be used.
11.    Always keep small appliances not in use, unplugged.
12.    Always follow the manufacturer’s instruction for use.

INSPECTION OF ELECTRICAL CORDS, PLUGS AND EQUIPMENT
1.   Inspect cords and plugs periodically. Look for splitting of the outer covering on the
     cord. Plug prongs should be straight, not bent.
2.   If the casing on a cord is split, or the wires are exposed at the plug connection,
     have the equipment appropriately repaired; never use electrical tape to “fix” these
     problems.
3.   Periodically check all electrical equipment for problems such as cracked housings,
     build-up of dirt and/or grease, or switches that do not work properly.
4.   All cords should be UL approved.

ELECTRICAL EMERGENCY
In case of fire:
       1.     Get everyone out, sound the alarm.
       2.     Disconnect the circuit if possible, by pulling the plug, tripping the circuit
              breaker or turning off the power switch.
       3.     Use an ABC Extinguisher.
       4.     NEVER USE WATER ON AN ELECTRICAL FIRE!
In case of shock:
       1.     Do not touch the person.
       2.     Turn off the power or pull the plug.
       3.     Begin first aid or call 9-1-1 (or 5-2222 if at the Main Campus)




                                                                                              29
6.0         WASTE MANAGEMENT




                          Medical Waste Management Plan

                              In Conformance with:
                      Act No. 368 of the Public Acts of 1978
                     Part 138 Medical Waste Regulatory Act
                                     And the
                   Medical Waste Management Plan Requirements
                      Michigan Department of Public Health




                                      For:
                        Synergy Medical Education Alliance
                               1000 Houghton Ave.
                               Saginaw, MI 48602

                                       And
                              Generations Family Care
                            1575 Concentric Blvd, Ste. 1
                                Saginaw, MI 48604




      Reviewed & Revised: 07/06
      Reviewed & Revised: 05/07
      Reviewed :   05/08




                                                                30
                              Medical Waste Management Plan
                             Synergy Medical Education Alliance
                                    1000 Houghton Ave.
                                 Saginaw, Michigan 48602

DEQ Registration # 7249

Individuals Responsible for Management of Medical Waste:
Wayne Albrecht, Vice President of Operations 989-583-6803
Monica Federico, Purchasing Coordinator 989-583-6883

Disposal and temporary storage of items, which are soiled with blood or other potentially
infectious materials such as:

   -Semen                    -Synovial Fluid
   -Vaginal Secretions       -All Body Fluids
   -Amniotic Fluids          -Peritoneal Fluids
   -Saliva                   -Human Tissue

The above items are placed in plastic lined red storage bins marked with the universal
precaution symbol, in the soiled utility rooms or designated areas in each patient room. All
plastic bags used as a liner in a receptacle for infectious waste will also be red. Synergy
Medical housekeeping will pick it up nightly and it will then be put inside of the big red bins
also marked with the universal precaution symbol located in the medical waste holding
room in the basement for our medical waste company to come pick up for disposal bi-
weekly.

Handling, Segregation, Packaging, Labeling and Collection Procedures:

Handling: Medical, nursing and other clinic personnel at Synergy routinely wear gloves and
uniforms when involved in patient contact during the workday. This is also required of all
employees handling any medical waste. The gloves are required to be worn until the waste
has been segregated and packaged.

Segregation: The wastes are segregated at the source of production. The actual practice
is that all “sharps” are put in a sealed plastic container on the wall or countertops in each
clinical area. Other medical waste is routinely put in biohazard bags, which are red bags
marked “Bio Hazardous Infectious Waste. “

Packaging: The bags labeled medical waste are purchased from a medical supply
distributor and are specifically designed to hold medical waste. The hard plastic
containers for “sharps” are clearly labeled with the words, “DANGER, BIOHAZARD,
INFECTIOUS WASTE” and the bio hazard bags are red and labeled, “DANGER,


                                                                                             31
BIOHAZARD, INFECTIOUS WASTE” in bold black lettering. Both types of packaging
have the universal biohazard symbol on them.

Collection: As noted, medical waste is segregated at its point of production and is
maintained at that location until the packages are filled to capacity and are ready for
disposal.

Disposal and temporary storage of needles, lancets and other sharps:
Synergy Medical discards their needles and sharps in a rigid plastic puncture resistant
container at the use site. When full, the containers are then taken to the medical waste
holding room located in the basement in room 370. In the holding room there are big red
storage bin marked with the universal precaution symbol and the containers are put inside
of the big red bins for our medical waste company to come pick up for disposal bi-weekly.

Medical Waste Disposal:
Synergy Medical contracts with a waste disposal contractor (Stericycle) for each of the
different types of waste that is generated.



Located At:
Stericycle
13975 Polo Trail Drive Suite 201
Lake Forest, IL 60045
800-457-9167
Stericycle Customer ID# 1025885

Training: Blood Borne Pathogen Exposure training is conducted annually for incoming
students and residents at their orientation. New clinical employees receive this training
during their orientation and annually thereafter. Training records are maintained in the
employee health office.

NOTE: For more complete exposure protection see our BBPE Plan.

General Waste: Liquid human waste, including blood, blood products, and body fluid will be
disposed of in the sanitary sewer via flush sinks. All persons handling these items are
required to wear personal protection and practice universal precautions. Suction canisters
can be rinsed out prior to disposal in the general waste stream.

Infectious Waste: These items will be discarded in bio hazard trash bags at the use site.
The items will then be placed in a plastic lined red storage bin marked with the universal
precaution symbol, located in the soiled utility rooms or designated areas in each patient
room. All plastic bags used as a liner in the receptacles used for infectious waste will also
be red and labeled with the universal precaution symbol.


                                                                                            32
Spills: Any area contaminated by a spill, break, aerosol action, drop or other possible
actions are to be cleaned with disinfectant such as bleach or Precise QTB. Spill kits are
available at each campus for use as deemed necessary. Decontamination consists of
flooding the area with Precise QTB for 10 minutes. The disinfectant is to be wiped up
(while wearing gloves) with damp paper towels. All materials used in the clean up will be
discarded or processed as contaminated items.

Employees are responsible for managing their own spills. Synergy shall assure that an
employee who handles medical waste is trained before the employee assumes duties that
involve the handling of medical waste. To enable the employee to handle and dispose of
medical waste in a safe and proper manner the follow steps should be followed:



1.   Remove ALL persons for threat of exposure
2.   Determine the material involved – what is it, what kinds of hazards are involved
3.   Wash any skin contact as outlined in the MSDS Book. Eye splash should be treated
       with an 15 minute eyewash
4.   Wear protective clothing: gown, gloves, shoe covers, eye protection, masks




                                                                                            33
                              Medical Waste Management Plan
                             Synergy Medical Education Alliance
                                1575 Concentric Blvd. Ste. 1
                                 Saginaw, Michigan 48604

DEQ Registration # 40384

Individuals Responsible for Management of Medical Waste:
Wayne Albrecht, Vice President of Operations 989-583-6803
Monica Federico, Purchasing Coordinator 989-583-6883

Disposal and temporary storage of items, which are soiled with blood or other potentially
infectious materials such as:

   -Semen                    -Synovial Fluid
   -Vaginal Secretions       -All Body Fluids
   -Amniotic Fluids          -Peritoneal Fluids
   -Saliva                   -Human Tissue

The above items are placed in plastic lined red storage bins marked with the universal
precaution symbol, in the soiled utility rooms or designated areas in each patient room. All
plastic bags used as a liner in a receptacle for infectious waste will also be red. Synergy
Medical housekeeping will pick it up nightly and it will then be put inside of the big red bins
also marked with the universal precaution symbol in the medical waste holding room,
located on the 2nd floor room 206, for our medical waste company to come pick up for
disposal bi-weekly.

Handling, Segregation, Packaging, Labeling and Collection Procedures:

Handling: Medical, nursing and other clinic personnel at Synergy routinely wear gloves and
uniforms when involved in patient contact during the workday. This is also required of all
employees handling any medical waste. The gloves are required to be worn until the waste
has been segregated and packaged.

Segregation: The wastes are segregated at the source of production. The actual practice
is that all “sharps” are put in a sealed plastic container on the wall or countertops in each
clinical area. Other medical waste is routinely put in biohazard bags, which are red bags
marked “Bio Hazardous Infectious Waste. “

Packaging: The bags labeled medical are purchased from a medical supply distributor and
are specifically designed to hold medical waste. The hard plastic containers for “sharps”
are clearly labeled with the words, “DANGER, BIOHAZARD, INFECTIOUS WASTE” and
the bio hazard bags are red and labeled, “DANGER, BIOHAZARD, INFECTIOUS WASTE”


                                                                                             34
in bold black lettering. Both types of packaging have the universal biohazard symbol on
them.

Collection: As noted, medical waste is segregated at its point of production and is
maintained at that location until the packages are filled to capacity and are ready for
disposal.

Disposal and temporary storage of needles, lancets and other sharps:
Synergy Medical discards their needles and sharps in a rigid plastic puncture resistant
container at the use site. When full, the containers are then taken to the medical waste
holding room located on the 2nd floor room 206. In the holding room there are big red
storage bin marked with the universal precaution symbol and the containers are put inside
of the big red bins for our medical waste company to come pick up for disposal bi-weekly.

Medical Waste Disposal:
Synergy Medical contracts with a waste disposal contractor (Stericycle) for each of the
different types of waste that is generated.

Located At:
Stericycle
13975 Polo Trail Drive Suite 201
Lake Forest, IL 60045
800-457-9167
Stericycle Customer ID# 1025889

Training: Blood Borne Pathogen Exposure training is conducted annually for incoming
students and residents at their orientation. New clinical employees receive this training
during their orientation and annually thereafter. Training records are maintained in the
employee health office.

NOTE: For more complete exposure protection see our BBPE Plan.

General Waste: Liquid human waste, including blood, blood products, and body fluid will be
disposed of in the sanitary sewer. .All persons handling these items are required to wear
personal protection and practice universal precautions. Suction canisters can be rinsed out
prior to disposal in the general waste stream.

Infectious Waste: These items will be discarded in bio hazard trash bags at the use site.
The items will then be placed in a plastic lined red storage bin marked with the universal
precaution symbol, located in the soiled utility rooms or designated areas in each patient
room. All plastic bags used as a liner in the receptacles used for infectious waste will also
be red and labeled with the universal precaution symbol.




                                                                                            35
Spills: Any area contaminated by a spill, break, aerosol action, drop or other possible
actions are to be cleaned with disinfectant such as bleach or Precise QTB. Spill kits are
available at each campus for use as deemed necessary. Decontamination consists of
flooding the area with precise QTB for 10 minutes. The disinfectant is to be wiped up
(while wearing gloves) with damp paper towels. All materials used in the clean up will be
discarded or processed as contaminated items.

Employees are responsible for managing their own spills. Synergy shall assure that an
employee who handles medical waste is trained before the employee assumes duties that
involve the handling of medical waste. To enable the employee to handle and dispose of
medical waste in a safe and proper manner the follow steps should be followed:



 1. Remove ALL persons for threat of exposure
 2. Determine the material involved – what is it, what kinds of hazards are involved
 3. Wash any skin contact as outlined in the MSDS Book. Eye splash should be treated
    with an 15 minute eyewash
 4. Wear protective clothing: gown, gloves, shoe covers, eye protection, masks




                                                                                            36
7.0     HAZARD COMMUNICATION PROGRAM

*Each employee has access to the Hazard Communication Program
*MSDS sheets are kept in a clearly marked MSDS notebook
*Risk Management is responsible for providing specific training on hazardous materials and
educating all employees on the MSDS book location
*All products considered hazardous must have an MSDS on file
*Purchasing is responsible for obtaining MSDS on all new orders. An MSDS must be
available in the building before a product is put into use

CONTRACTORS:
Contractors would be scheduled through the Purchasing department with notification to
the affected areas or Departmental Manager before starting any work or bringing any
hazardous materials into the building.

FIRE DEPARTMENT: See Fire Policy

REQUESTS FOR INFORMATION:
Request forms for MSDS are located with the MSDS book, the request form should be
filled out and sent to Purchasing for acquisition

EXPOSURE MONITORING:
All exposures will be reported to the Risk Management Department. If exposure occurs,
immediate health assessments will be provided from a physician, with appropriate follow-up

EMPLOYEE RIGHTS AND RESPONSIBILITIES:
Employees have the right to:
A) be informed
B) request information and training
C) not be discriminated against for requesting information
D) refuse to work in an area with unlabeled pipes and containers and no MSDS available
Employees have the responsibility to:
A)   attend training sessions
B)   wear PPE when it is provided
C)   report hazardous conditions and act in a prudent manner
D)   ask if they do not know how to safely work with a product

LABELING:
A special label must be applied to the container any time a hazardous material is
transferred into a second container. A special label will be applied anytime a container
label has been defaced or destroyed. A substance should never be used if the label is
missing and the contents cannot be confirmed.




                                                                                           37
8.0    THREAT CALLS

Threat calls usually mean a bomb threat. If you received a threat call, stay as calm as
possible.

EXPLOSIVE DEVICES:
Homemade bombs are either open or disguised and often consist of sticks of dynamite tied
together with a fuse and blasting cap. A substance that resembles putty may be used.
Disguised bombs may be hidden in shoeboxes, lunchboxes and briefcases. 7-Up bottles
with Draino added might also be a device used for explosion, as well as mousetraps,
clothespins, mercury switches, radios and clocks.

IF YOU RECEIVE A THREAT VIA TELEPHONE:
1.    Immediately record information;
2.    Try to keep the caller on the line as long as possible;
3.    Listen to the voice quality and any background noise;
4.    Call 9 1 1 immediately (or 5-2222 if you are calling from the Main Campus);
5.    Quietly and quickly clear all patients from the building;
6.    Be sure everyone is outside and make sure no one re-enters the building;
7.    Wait for the police to arrive.

IF YOU SEE A SUSPICIOUS OBJECT:
1.    Report the object immediately by dialing 9-1-1 (or 5-2222 if at the Main Campus);
2.    Give the object’s location and description (DO NOT HANDLE/TOUCH THE OJBECT!)
3.    Secure the area. Move all personnel out of the area and do not allow any person to
      enter.

IN CASE AN INCENDIARY DEVISE IS IGNITED (and Fire is started):
1.   Leave the building immediately and gather at your designated safe area outside;
2.   Call 9-1-1 (or 5-2222 if you are calling from the Main Campus).

IN CASE OF ACTUAL EXPLOSION:
1.   Evacuate immediately and gather at a safe distance away from the building;
2.   Call 911 (or 52222 if you are calling from the Main Campus) to report the explosion;
3.   Wait for the police/fire department to arrive. Do not attempt to search and
     rescue in the area of the explosion.




                                                                                          38
THREAT CALLS – PAGE 2

CODE ORANGE: In the event of a bomb threat:

Main Campus: a “Code Orange” will be paged overhead, Be alert and check your area for
suspicious objects;

North GFC Campus: Call 911
1.    Report any positive findings to Security (3-6149) and then remove yourself and
      others to a secure location and remain there until Security or Administration
      announces an “all clear”.




                                                                                        39
9.0           OFFICE/CLINIC SECURITY

This section will cover basic information you can use to help yourself not become a victim.



OFFICE SECURITY:

1. Lock doors. Areas not open to the public should be locked;
2. Watch for suspicious or strange behavior. A client that is intoxicated is more likely to
    commit an assault. Call 911 (or 5-2222 if you are calling from the Main campus) to
    report any situational disturbance;
3. When working late, make sure someone knows where you are located in the facility;
4. Keep your car doors locked at all times and have your keys ready before reaching your
    vehicle;
5. Do not leave valuables or anything that may identify you or where you live in plain sight
    in your vehicle;
6. Keep your work area well lit; this includes interior and exterior lighting. Lighting is the
    least expensive security tool available;
7. When leaving work, go in groups, if possible. There is strength in numbers;
8. Walk with your head high and constantly watch your surroundings. Criminals look for
    the weak and unaware because they are easy targets;
9. If you are in the main campus, you may request an escort from Security.
10. If possible move your car closer to the door before dark.



IF YOU ARE ATTACKED:

1.     Remain calm. You need to keep a clear head to be able to protect yourself;
2.     Keep talking with your attacker. A dialogue can help keep their mind off of their
       intentions;
3.     Be prepared to defend yourself. Many items you carry on a daily basis can be used
       as a weapon (keys, pens, etc);
4.     Pay attention to the attacker’s height, weight, clothing, etc. By being able to supply
       a description, Law Enforcement will have an edge in their search and identification
       of the attacker;
5.     Do not allow yourself to be taken to another location; you may have to decide you
       are going to get hurt, but are not going with the attacker;
6.     If you decide to react, make it quick and make it forceful.




                                                                                            40
10.0          VIOLENCE IN THE WORK PLACE

OBJECTIVE:

To eliminate, reduce or mitigate the effects of an event involving violence or a perceived
threatening event. To establish and maintain a plan to prevent or reduce the risk of injury
and/or property damage.

GOAL:

Synergy Medical has a commitment to provide its employees a work environment that is
safe, secure, and free of harassment, threats, intimidation and violence. Violence in the
workplace has become more common and of greater concern in the past few years. In
fact, workplace violence is a major concern of MIOSHA, as well as other regulatory and
accrediting agencies such as The Joint Commission on Accreditation of Healthcare
Organizations (JCAHO). Synergy Medical adopts a zero tolerance policy for workplace
violence. Synergy Medical will make reasonable provisions for a safe environment of care
throughout our organization. In this policy, Synergy Medical prohibits physical, verbal,
nonverbal, or visual harassment, threats, intimidation, and violence to employees, patients,
visitors, or guests of the organization which involve or affect Synergy Medical employees
or which occur on Synergy Medical property.

Security must be notified whenever a weapon is found, or a violent incident occurs.
Employees are asked to call 911 or Covenant Healthcare security. Incident reports must
be used to record any and all violent events, and filed with Risk Management within 24
hours. All employees, physicians, residents, nurses, and volunteers are responsible for the
security of the facilities.

DEFINITIONS:

bWEAPON: Any object or device used to threaten or inflict harm to self or others,
and/or cause property damage.

bVIOLENCE: An event or activity, verbal or non-verbal related to a threat of harm.
Violence includes, but is not limited to, stalking, intentional destruction of property,
intimidation and coercion, robbery, vandalism, arson, bomb threats, threatening calls,
sexual assault, and assault and battery.

bTOLERANCE: Threats or related actions of violence at Synergy Medical. No reprisal
will be taken against any employees or members of the medial staff who report or
experience workplace violence. Examples of conduct that may be considered threats or
acts of violence prohibited under this policy include but are not limited to, the following:
VIOLENCE IN THE WORK PLACE – Page 2


                                                                                               41
       -Hitting or shoving an individual.
       -Threatening to harm an individual or his/her family, friends, associates, or their
       property.
       -The intentional destruction or threat of destruction of property owned, operated
       or controlled by Synergy Medical.
       -Making harassing or threatening telephone calls, or sending harassing or
       threatening letters or other forms of written or electronic communications.
       -Intimidating or attempting to coerce an employee to do unlawful acts, as defined
       by applicable law, administrative rule, policy, or work rule, that would affect the
       business interests of Synergy Medical.
       -The willful, malicious, and repeated following of another person, also known as
       “stalking”, and making of a credible threat with intent to place the other person in
       reasonable fear for his or her safety.
       -Making a suggestion or otherwise intimating that an act to injure persons or
       property is appropriate, without regard to the location where such suggesting or
       intimation occurs.
       -Unauthorized possession or inappropriate use of firearms, weapons, or any other
       dangerous devices on Synergy Medial property.

bVULNERABILITY ANALYSIS:
The Safety Committee has determined the following violent acts are a risk for employees,
based upon a review of events and activities that have occurred in the surrounding
neighborhood. This is not an all-inclusive list of risks:
       -Assault                -Robbery             -Sexual Assault     -Car Thefts
       -Anger Vandalism        -Gang Activity       -Car Jacking
       -Verbal Abuse          -Arson         -Breaking & Entering
       -Bomb Threats           -Threatening Calls -Drive-by Shootings
A vulnerability analysis will be accomplished through a variety of methods such as
assessment of any trends, identification of potentially violent individuals based on their
threatening behavior, and a strategy of Synergy Medical to intervene immediately
whenever conditions pose an immediate threat to life or health. All reports of threats,
violence or potential violence will be investigated. Corrective actions will be implemented
when necessary to provide a safe environment. A policy of zero Torrance is in force at all
times throughout Synergy Medical, which could result in corrective action up and including
termination.

bWARNING SIGNS AND RISK FACTORS OF POSSIBLE VIOLENT BEHAVIOR (this list
is not exhaustive):
-Direct or indirect threats to another employee
-Harassing phone calls




                                                                                          42
VIOLENCE IN THE WORK PLACE – Page 3



-Physically or verbally intimidating others
-Exhibiting paranoid behavior
-Showing an unusual fascination with weapons
-Drastic change in belief system
-Inability to handle criticism
-Expression of extreme despair over family problems, finances
-Obsessive involvement with job, to the exclusion of almost all other activity
-Attendance, behavior and/or performance problems
-Stealing or sabotage
-Romantic obsession with a co-worker who does not share same interest
-Alcohol or drug abuse
-Persistence to obtain a certain narcotic drug prescription and not taking no for an answer

bCRISIS MANAGEMENT PROCEDURE:
-Emergency Situations:
In the event of an imminent or in-progress assault occurring at one of the Synergy
Medical facilities, the following procedures will apply:

Visitor Violence:
1. Try to de-escalate the situation.
2. Contact Security immediately.
3. Contact 911 if at off-campus sites.
4. If you feel personally threatened, you should: Activate the panic button if you
    have one; leave the area; call 911 and/or security.
-Employee Violence:
1. Try to de-escalate the situation; if unsuccessful, contact someone from
    management immediately. Document the event on an incident report, and submit it
    to Risk Management immediately.
2. If physical contact, shouting, shoving, threats, etc. are occurring at the following
    campuses:,
    Main Campus: contact Security immediately.
    North GFC Campus: Call 911
3. Send both employees home and contact the manager immediately.
4. Document as objectively as possible.
5. If you feel personally threatened, you should:
    -Activate your panic button if you have one
    -Leave the area.
    *Synergy Medical promotes a safe and healthy environment for all staff and clients.
    There is a zero tolerance for any form of violence or possible violent situations.




                                                                                         43
11.0      MSDS SHEET LOCATION & PRODUCT LIST



MATERIALS SAFETY DATA SHEETS (MSDS) LOCATION:

WHAT ARE MSDS SHEETS:
MATERIAL SAFETY DATA SHEETS ARE DOCUMENTS STATING THE CHEMICAL
COMPOSITION OF THE VARIOUS PRODUCTS
USED BY SYNERGY MEDICAL

WHERE ARE THEY LOCATED:
MSDS POSTINGS - ARE LOCATED IN EACH COPY ROOM AT EACH CAMPUS
A BINDER CONTAINING ALL OF THE MSDS SHEETS IS LOCATED IN THE
FOLLOWING CAMPUS LOCATIONS:
• MAIN CAMPUS - PURCHASING DEPARTMENT BOOKSHELF
   (ROOM 142)
• NORTH CAMPUS – DIRTY UTILITY BOOKSHELF (ROOM 126)

WHY ARE THEY IMPORTANT:
THESE BINDERS ARE MAINTAINED TO PROVIDE EMPLOYEES
A REFERENCE FOR THE MATERIALS UTILIZED IN
THE CORPORATION, THE HAZARDS ASSOCIATED WITH
THOSE MATERIALS, AND AT WHICH LOCATION THEY ARE
UTILIZED. THIS INFORMATION IS REQUIRED TO BE
AVAILABLE FOR EMPLOYEES IN A READILY
ACCESSIBLE MANNER.




                                                                 44
MSDS Location Sheet & Product List




                                     45
                          Materials Safety Data Sheets

Acetic Acid
Afrin/Duration Nasal Spray              Schering-Plough Healthcare Products
Alcohol Pads                            Triad/H&P Industries
Aleve                                   Bayer
Aluminum Chloride Anhydrous             Fisher Scientific
Bacitracin Ointment               NMC Laboratories
Benzalkonium Chloride Solution 17%      Spectrum Laboratories
Benzalkonium Chloride Ant. Towelette Triad Disposable
Benzoin Compound Tincture               Humco Holding Group
Betadine Solution                       Purdue Frederick Co.
Botox                                   Allergan
Brethine Ampuls                         Novartis Pharmaceuticals Corp.
Celestone Soluspan                      Schering Corporation
Cetacaine Topical Anesthetic Spray      Cetylite Industries
Cholestech GDX A1 Test Cartridges       Cholestech Corporation
Cholesterol Controls                    Boehringer Mannheim Corp.
Cidex                                   Surgikos, Inc.
Cidex OPA                               Advanced Sterilization Products, J&J
Cool Soak Stain and Rust Remover        Burnishine Products
Cytology Fixative                       Surgipath Medical Industries
Depo-Medrol Sterile Aqueous Susp.       Pharmacia & Upjohn Co.
Depo-Provera         Contraceptive Inj. Pharmacia & Upjohn Co.
Depo-Testosterone Sterile Solution      Pharmacia & Upjohn Co.
Dishwashing Detergents –Liquid Hand     Proctor & Gamble
Dispatch                                Caltech Industries
Domepaste Bandage 3                     Bayer
Engerix-B Hepatitis B Vaccine           SmithKline Beecham Pharmaceuticals
Enzymatic Cleaner                       Enzyme Solutions, Inc.
Epipen 0.3mg Epinephrine Auto inj.      Dey
Eucerin Original Moisturizing Cream     Beiersdorf Inc.
Ferric Subsulfate Solution              Medical Chemical Corp.
Folic Acid                              American Pharmaceutical Partners
Frigiderm                               Delasco Dermatologic Lab & Supply Inc
Gelfoam Sterile Sponge                  Pharmacia & Upjohn
Glucagon for Injection                  Eli Lilly and Co.
Glycerin/Non-Acetone                    Vi-Jon Laboratories, Inc.
Haemophilus b Conjugate Vaccine(hib) Lederle Laboratories
Hemoccult Developer Solution            SmithKline Diagnostics, Inc.
High Subs                               Haemo-Sol Inc.
Hurricaine Spray                        Beutlich Pharmaceuticals, LP



                                                                                46
Materials Safety Data Sheets – Page 2

Hydrogen Peroxide 3% solution           Cumberland
ICON Fx Strep A                         Beckman Coulter
ICON SC Strep A Reagent A               Beckman Coulter
Infanrix                                GlaxoSmithKline
Fluzone Influenza Virus Vaccine         Aventis Pasteur
Ipecac Syrup                            Paddock Laboratories, Inc.
Isopropyl Alcohol                       Cumberland Swan
Kenalog 10 Injection                    Bristol Myers Squibb Co.
Kenalog 40 Injection                    Bristol Myers Squibb Co.
K-Y Lubricating Jelly                   Johnson & Johnson
Maalox Suspension                       Novartis Consumer Health, Inc.
Urine Control Set                       Mainline Technology
MMR (measles, mumps & Rebella) Vac. Merk & Co.
Meningococcal Polysaccharide Vaccine Aventis Pasteur
Meter Trax                              Hematronix, Inc.
Miltex Spray Lube                       Miltex Instrument Co.
Mineral Oil                             Cumberland Swan
Neupogen                                Amgen Inc.
Nitrous Oxide                           Michigan Airgas
Nu Gauze Iodoform Packing Strips        Johnson & Johnson
Oxygen 02 Refrigerated Liquid           Michigan Airgas
Phisohex                                Winthrop Pharmaceuticals
Poliovirus Vaccine Inactivated IPOL     Aventis Pasteur
Potassium Hydroxide 10%                 Medical Chemical Corp.
Precise Hospital Foam Cleaner Disfect. Dow Chemical Co.
Prolixin Decanoate Fluphenazine Inj.
Quantscopics                            Quantimetrix Corp.
Rocephin                                Roche Laboratories
Safetex Cytology Spray (Fixative form)Abbott Industrial Supplies
Scotchcast Plus Casting Tape            3M
Sedi-Stain Concentrated Stain           Becton Dickinson
Silver Nitrate Applicator – Grafco      Graham Field
Sodium Bicarbonate                J.R. Simplot Co.
Solu-Cortef Sterile Powder              Pharmacia & Upjohn
Solu-Medrol Sterile Powder              Pharmacia & Upjohn
Sporicidin Brand Disinfect Towelette    Sporicidin International
Surgilube                               Altana Inc. – BYK Pharmaceutical Grp.
Silcone Oil                             Merck Eurolab




                                                                                47
Materials Safety Data Sheets – Page 3

Speed Clean                           Midmark Corp.
Synvisc                               Wyeth Labs
Temp-Chex Temp refrig/freez Mts.      Streck Labs
Tetanus and Diphtheria Toxoids Abs.   Aventis Pasteur
Thermometer                           Mallinckrodt
Triple Anti. Ointment
Ultrasound Couplant – Aquasonic 100   Parker Laboratories, Inc.
Unasyn – Ampicillin Sodium
Vacutainers                           Beckton Dickinson
Vaqta – Hepatitis A Vaccine           Merck & Co.
Windex – Blue                         S.C. Johnson & Son
Wisdom Adhesives                      H.E. Wisdom & Sons, Inc.
Xylocaine                             Astra
Xylocaine 2% Jelly                    Astra




                                                                  48
12.0          BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN



BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN



Facility Name: Synergy Medical Education Alliance

Date of Preparation: August 2005
Updated: May 2008

In accordance with the OSHA Bloodborne Pathogens standard, 29 CFR 1910.1030, the
following exposure control plan has been developed:

1. Exposure Determination

OSHA requires employers to perform an exposure determination concerning which
employees may incur occupational exposure to blood or other potentially infectious
materials (OPIM). The exposure determination is made without regard to the use of
personal protective equipment. This exposure determination is required to list all job
classifications in which all employees may be expected to incur such occupational exposure,
regardless of frequency. At this facility the following job classifications are in this
category:

•   Faculty and Resident Physicians
•   Medical Students
•   Registered Nurses
•   Medical Assistants
•   Mid-Level Providers
•   Other Allied Health Students

In addition, if the employer has job classifications in which some employees may have
occupational exposure then a listing of those classifications is required. Since not all the
employees in these categories would be expected to incur exposure to blood or OPIM,
tasks or procedures that would cause these employees to have occupational exposure are
also required to be listed in order to clearly understand which employees in these
categories are considered to have occupational exposure. The job classifications and
associated tasks/procedures for these categories are as follows:

Job Classification                 Task/Procedures
Housekeeping                       Biohazard Waste Handling/BBF Spill Cleanup/
                                   General Cleaning
Maintenance                        Plumbing Repair
                                   Equipment Repair

                                                                                               49
Implementation Schedule and Methodology

OSHA requires that this plan also include a schedule and method of implementation for
the various requirements of the standard. This Plan remains in effect and will be reviewed
on an annual basis.

        Compliance Methods
Universal precautions will be observed at this facility in order to prevent contact with
blood or OPIM. All blood or OPIM will be considered infectious regardless of the
perceived status of the source individual. Engineering and work practice controls will be
utilized to eliminate or minimize exposure to employees at this facility. Where
occupational exposure remains after institution of these controls, personal protective
equipment shall also be utilized. At this facility the following engineering controls will be
utilized:

•   Sharps Containers
•   Safety sheath on needle
•   Biohazard waste containers
•   Toilet seat covers
•   Spill kits

The above controls will be examined and maintained on a regular schedule. The schedule
for reviewing the effectiveness of the controls is as follows:

Engineering Controls                Frequency             Responsible Party
Safety sheaths on needles           Each use              Clinical Staff
Sharps containers                   Each use              Clinical Staff
Biohazard waste container           Daily                 Housekeeping Staff
Seat covers                         Daily                 Housekeeping Staff
Spill kits                          Each use              Clinical Staff

Handwashing
Handwashing facilities are also available to the employees who incur exposure to blood or
OPIM. OSHA requires that these facilities be readily accessible after incurring exposure.
At this facility handwashing facilities are located:

•   All exam rooms
•   All procedure rooms
•   All restrooms (staff and public)
•   Laboratory
•   Central supply
•   Medication workstations




                                                                                                50
After removal of personal protective gloves, employees shall wash hands and any other
potentially contaminated skin area immediately or as soon as feasible with soap and water
or waterless hand cleaner. If employees incur exposure to their skin or mucous membranes
then those areas shall be washed or flushed with water as appropriate as soon as feasible
following contact.

Eye-Wash Station
Eyewash stations are available at the main campus in 2 locations:

       •   Laboratory
       •   C – Corridor nurse’s station

At GFC – the eye wash station is located in the utility room.

Following exposure of chemical or body fluid exposure – a 15 minute wash is recommended.

       Needles
Contaminated needles and other contaminated sharps WILL NOT BE bent, recapped,
removed, sheared or purposely broken. OSHA allows an exception to this if the procedure
would require that the contaminated needle be recapped or removed and no alternative is
feasible and the action is required by the medical procedure. If such action is required
then the recapping or removal of the needle must be done by the use of mechanical device
or a one-handed technique.

       Containers for Reusable Sharps
Contaminated sharps that are reusable will be removed from an exam or procedure room
and transported using a labeled closed container to an instrument processing area after
each patient procedure.

        Work Area Restrictions
In work areas where there is a reasonable likelihood of exposure to blood or OPIM,
employees are not to eat, drink, apply cosmetics or lip balm, smoke, or handle contact
lenses. Food and beverages are not to be kept in refrigerators, freezers, shelves,
cabinets, or on counter tops or bench tops where blood or OPIM.

Mouth/pipetting/suctioning of blood or other potentially infectious materials is prohibited.

All procedures will be conducted in a manner which will minimize splashing, spraying,
splattering, and generation of droplets of blood or OPIM.
Methods which will be employed at this facility to accomplish this goal are:

•   All centrifuged specimens shall be capped, i.e., urines and blood specimens.




                                                                                          51
       Shipping Diagnostic Specimens
Specimens of blood or OPIM will be placed in a container which prevents leakage during
the collection, handling, processing, storage and transport of the specimens.

Note: The following has been excerpted from documents published in CFR. This
information is also available at
http://www.access.gpo.gov/nara/cfr/waisidx_03/49cfr173_03.html

•   Diagnostic specimens must be packaged in a triple packaging, consisting of a primary
    receptacle, a secondary packaging, and an outer packaging.
•   Primary receptacles must be packed in secondary packaging in such a way that, under
    normal conditions of transport, they cannot break, be punctured, or leak their contents
    into the secondary packaging.
•   Secondary packagings must be secured in outer packagings with suitable cushioning
    material such that any leakage of the contents will not impair the protective properties
    of the cushioning material or the outer packaging.
•   The completed package must be capable of successfully passing the drop test at a drop
    height of at least 1.2 meters (3.9 feet). The outer packaging must be clearly and
    durably marked with the words “Diagnostic Specimen.”

      Contaminated Equipment
Equipment which has become contaminated with blood or OPIM shall be examined and
decontaminated as necessary by clinical staff.

Equipment requiring servicing or shipping shall be decontaminated as necessary and
required by the receiving party, unless decontamination is not feasible.

Personal Protective Equipment
All personal protective equipment used at this facility will be provided without cost to
employees. Personal protective equipment will be chosen based on the anticipated exposure
to blood or OPIM. The protective equipment will be considered appropriate only if it does
not permit blood or other potentially infectious materials to pass through or reach the
employees’ clothing, skin, eyes, mouth, or other mucous membranes under normal conditions
of use and for the duration of time which the protective equipment will be used.

The following personal protective equipment will be provided to employees and is located in
clear plastic boxes in all patient exam rooms:
• CPR Masks
• Face Shield
• Protective eyewear with solid side shields
• Masks
• Paper Gown
• Vinyl Apron
• Utility Gloves

                                                                                          52
•   Examination Gloves

All personal protective equipment will be cleaned or disposed of by the employer at no cost
to employees. All repairs and replacements will be made by the employer at no cost to
employees.

All garments which are penetrated by blood shall be removed immediately or as soon a
feasible. All personal protective equipment will be removed prior to leaving the work area.

The following protocol has been provided to facilitate leaving the equipment at the work
area:

•   Disposable personal protective equipment will be disposed of in the nearest bio-
    hazardous waste container
•   Contaminated sharps that are reusable will be removed from an exam or procedure
    room and transported using a labeled closed container to an instrument processing area
    after each patient procedure.

Gloves
Gloves will be used for all clinical encounters that present potential contact with blood and
body fluids. Gloves will be available in all clinical areas.

Disposable gloves used at this facility are not to be washed or decontaminated for re-use
and are to be replaced when they become grossly contaminated or torn, punctured, or
when their ability to function as a barrier is compromised.

Masks
Masks in combination with eye protection devices, such as goggles or glasses with solid
side shield, or chin length face shields, are required to be worn whenever splashes, spray,
splatter, or droplets of blood or OPIM may be generated and eye, nose, or mouth
contamination can reasonably be anticipated. Situations at this facility which would require
such protection are as follows:

•   Incision and drainage
•   Removal of a cyst or lesion
•   Aspiration of wounds
•   Cleaning, disinfecting of instruments (i.e., sigmoidoscope)
•   Other similar procedures




                                                                                           53
Protective Garments
It is the employers responsibility not only to provide PPE (listed on page 4), but to clean,
maintain, and/or dispose of it.

If an employee wishes to choose, wear, and maintain his/her own uniform or laboratory
coat, then he/she would need to don additional employer handled and employer controlled
PPE when performing tasks where it is reasonable to anticipate exposure to blood or
OPIM.

Cleaning
This facility’s clinical areas will be cleaned and decontaminated according to the following
schedule:

Clinical Area                               Frequency                   Cleaning Agent
Exam & Procedure Rooms                      Daily                       Precise QTB
Lab & Central Supply                Daily                        Precise QTB

All contaminated work surfaces will also be decontaminated after completion of
procedures and immediately or as soon as feasible after any spill of blood or OPIM, as well
as the end of the work shift if the surface may have become contaminated since the last
cleaning.

All bins, pails, and similar receptacles shall be inspected and decontaminated as soon as
possible by nursing staff.

Any broken glassware which may be contaminated will not be picked up directly with the
hands. The following procedures will be used:

•   Secure the area
•   Contact housekeeping

Regulated Waste Disposal
All contaminated sharps shall be discarded as soon as feasible in sharps containers which
are located in all clinical areas.

Regulated waste other than sharps shall be placed in biohazard waste containers located in
all clinical areas.

Hepatitis B Vaccine
All clinical employees who have been identified as having exposure to blood or OPIM will be
offered the Hepatitis B vaccine, at no cost to the employee. The vaccine will be offered
within 30 working days of their initial assignment to work involving the potential for
occupational exposure to blood or OPIM unless the employee has previously had the


                                                                                               54
vaccine or who wishes to submit to antibody testing which shows the employee to have
sufficient immunity.

Clinical employees who decline the hepatitis B vaccine will sign a waiver which uses the
wording in Appendix A of the OSHA standard.

Clinical employees who initially decline the vaccine but who later wish to have it may then
have the vaccine provided at no cost. The above procedures are coordinated through our
Employee Health Clinic.



Post-Exposure Procedure
The post-exposure procedure varies based upon the location where the incident occurred.
When the employee incurs an exposure incident, it should be reported as outlined below (a
pocket reference is provided as a step by step guide).

ALL exposures need to be reported immediately (within 2 hours) to maximize effective
treatment. If indicated, prophylactic medications must be administered within 3 hours.



Location of Incident:

COVENANT HEALTHCARE:
     Step 1: Report incident immediately to Departmental Charge Nurse and complete
     employee/student incident report form.

       Step 2: Exposure Assessment, Source Testing and Initial Treatment (if required)
       will be provided by Covenant Occupational Health located at:
               600 Irving #989-583-6130         M-F 8:00 a.m. – 4:30 p.m.
               *After hours, holidays, weekends care provided by the Covenant E.D.

       Step 3:
       A.     Employees, Residents, Faculty Exposure Follow Up: If initial treatment was
       provided after hours by the Covenant E.D. report to Covenant Occupational Health
       the next business day with a copy of the incident report or other paperwork
       completed to date. All post exposure follow up will be provided by Covenant
       Occupational Health.
              600 Irving #989-583-6130           M-F 8:00 a.m. – 4:30 p.m.

       B.    Medical Students Exposure Follow Up: Report to Synergy Medical Community
       Administrator to complete Medical Student Incident Report.




                                                                                           55
SAINT MARY’S
     Step 1: Report incident immediately to Associate Health Department at (989)
     907-8244 and complete incident report.

      Step 2: Exposure Assessment, Source Testing and Initial Treatment (if required)
      will be provided by Saint Mary’s Associate Health.
              *After hours, holidays, weekends, contact pager # (989) 929-4020 for
      direction and care at Saint Mary’s.

      Step 3:
      A.     Employees, Residents, Faculty Exposure Follow Up: If initial treatment was
      provided after hours by Saint Mary’s report to Covenant Occupational Health the
      next business day with a copy of the incident report or other paperwork completed
      to date. All post exposure follow up will be provided by Covenant Occupational
      Health.
             600 Irving #989-583-6130           M-F 8:00 a.m. – 4:30 p.m.

      B.   Medical Students Exposure Follow Up: Report to Synergy Medical
      Community Administrator to complete Medical Student Incident Report.



SYNERGY MEDICAL EDUCATION ALLIANCE:
     Step 1: Report incident immediately to the Departmental Nurse Manager and
     complete incident report.

      Step 2: Exposure Assessment, Source Testing (as shown on page 11) and Initial
      Treatment (if required) will be provided by Covenant Occupational Health located
      at:
            600 Irving #989-583-6130            M-F 8:00 a.m. – 4:30 p.m.
            *After hours, holidays, weekends care provided by the Covenant E.D.

      Step 3:
      A.     Employees, Residents, Faculty Exposure Follow Up: If initial treatment was
      provided after hours by the Covenant E.D. report to Covenant Occupational Health
      the next business day with a copy of the incident report or other paperwork
      completed to date. All post exposure follow up will be provided by Covenant
      Occupational Health.
             600 Irving #989-583-6130           M-F 8:00 a.m. – 4:30 p.m.

      B.    Medical Students Exposure Follow Up: Report to Synergy Medical Community
      Administrator to complete Medical Student Incident Report.




                                                                                      56
All employees who incur an exposure incident will be offered post-exposure evaluation and
follow-up in accordance with the OSHA standard. This follow-up will include the following:

•   Documentation of the route of exposure and the circumstances related to the incident

•   If possible, the identification of the source individual and, if possible, the status of
    the source individual. The blood of the source individual will be tested (after consent is
    obtained) for HIV and a hepatitis panel according to the standing order on page 11.

•   Results of testing of the source individual will be made available to the exposed
    employee with the exposed employee informed about the applicable laws and
    regulations concerning disclosure of the identity and infectivity of the source
    individual.

•   The employee will be offered the option of having their blood collected for testing of
    the employee’s HIV/HBV serological status. The blood sample will be preserved for at
    least 90 days to allow the employee to decide if the blood should be tested for HIV
    serological status. However, if the employee decides prior to that time that testing will
    be conducted then the appropriate action can be taken and the blood sample discarded.

•   The employee will be offered post exposure prophylaxis in accordance with the
    current recommendations of the U.S. Public Health Service.

•   The employee will be given appropriate counseling concerning precautions to take during
    the period after the exposure incident. The employee will also be given information on
    what potential illnesses to be alert for and to report any related
    experiences to appropriate personnel.

•   The employee health staff has been designated to assure that the policy outlined here
    is effectively carried out as well as to maintain records related to this policy:

Synergy Medical Employee Health Records: An employee health record is maintained in
the employee health clinic for all employees documenting immune status and services
provided.

Affiliate Employee Health Records: Post exposure records documenting services provided
are maintained by our affiliates.



Training
Training for all employees will be conducted prior to initial assignment to tasks where
occupational exposure may occur.

Training for employees will include the following:

                                                                                            57
1) The OSHA standard for Bloodborne Pathogens

2) Epidemiology and symptomatology of bloodborne diseases

3) Modes of transmission of bloodborne pathogens

4) This Exposure Control Plan (i.e. points of the plan, lines of responsibility, how the
plan will be implemented, etc.)

5) Procedures which might cause exposure to blood or other potentially infectious
materials at this facility

6) Control methods which will be used at the facility to control exposure to blood or
other potentially infectious materials.

7) Personal protective equipment available at this facility and who should be contacted
concerning locations and indications for use

8) Post Exposure evaluation and follow-up

9) Signs and labels used at the facility

10) Hepatitis B vaccine program at the facility

All clinical employees will receive training at orientation and refreshed annually. The
outline for the training material is located in the Employee Health Clinic.



Recordkeeping
All records required by the OSHA standard will be maintained by the employee health
clinic and corporate compliance/risk manager.

Dates
All provisions required by the standard will be implemented by 8/01/05.




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