Program Letter of Agreement Residency

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Revised November 2009

PROGRAM DIRECTOR’S MANUAL
TABLE OF CONTENTS

Topic Section
Organizational Information 1
Institutional Information 2
Credentialing Information 3
Employment Information 4
Immigration Information 5
Academic Information 6
Professionalism Information 7
Supervision Information 8
Evaluation Process and Procedures 9
Dismissal and Grievance Information 10
Accreditation Resources 11
Institutional Policies and Templates 12
Index 13
ORGANIZATIONAL INFORMATION
Section 1

SUBJECT
Administrative Organizational Chart
Policy Organizational Chart
Program Directory
Calendar of Events in Office of Residency Affairs
Graduate Medical Education Mission Statement
Graduate Medical Education Committee
Program Letters of Agreement
Program Letter of Agreement Template - Detailed
Program Letter of Agreement Template – Bare Bones
Frequently Asked Questions Related to Master Affiliation Agreements
and Program Letters of Agreement
Closure Reduction Policy
SOUTHERN ILLINOIS UNIVERSITY (SIU)

POLICY ORGANIZATIONAL CHART
Springfield Based Residencies

MEMORIAL MEDICAL CENTER (MMC) ⎯Affiliation Agreement ⎯SIU SCHOOL OF MEDICINE (SIUSOM) ⎯ Affiliation Agreement ⎯ST. JOHN'S HOSPITAL (SJH)
⏐

GRADUATE MEDICAL EDUCATION COMMITTEE
⏐
Chairperson/Associate Dean for Graduate Medical Education
⏐

Chief Operating Officer MMC 15 Residency Program Directors - Springfield Chief Operating Officer SJH
Medical Director 3 Affiliate Program Directors - Medical Director
Carbondale, Decatur, Quincy
2 Faculty members at large
2 Fellowship Directors at large
6 Resident members elected by their peers
PROGRAM DIRECTORY
RESIDENCY MAIL PROGRAM RESIDENCY
PROGRAM CODE DIRECTOR COORDINATOR PHONE FAX
Dermatology 9644 Lucinda Buescher, MD Stacy Miller 545-5465 545-4485
Emergency Medicine 9638 David Griffen, MD Linda Schneider 545-3518 545-1793
Family Medicine 9670 Janet Albers, MD Melaney Hughes 757-8197 757-8155
Internal Medicine 9636 Andrew Varney, MD Cathy Brower 545-5568 545-8156
Med/Psych 9636 David Resch, MD Cathy Brower 545-5568 545-8156
Neurology 9643 Rodger Elble, MD, PhD Stacey Dill 545-0168 545-8039
OB/GYN 9640 Erica Nelson, MD Joan Evans 545-6498 545-7958
Orthopaedics 9650/9679 Keith Gabriel, MD Anita Weinhoeft 545-6155 545-7901
Otolaryngology 9649/9662 James Malone, MD Jenny Kesselring 545-4777 545-7512
Pediatrics 9658 Michelle Miner, MD Ellen Marr 545-7827 545-2905
Plastic Surgery 9653 Reuben Bueno, MD Jean Weitekamp 545-6112 545-2588
Psychiatry 9642 Manisha Punwani, MD Vivian Smith 545-7627 545-2275
Radiology MMC John Becker, MD Stacie Skelton 757-2387 788-5582
Surgery 9638 Gary Dunnington, MD Barb Carter 545-4401 545-2529
Urology 9665 Patrick McKenna, MD Rachael Adamczyk 545-3262 545-7305
FELLOWSHIPS
Burn 9653 Michael Neumeister, MD Cheryl Matthews 545-6112 545-2588
Child Psychiatry 9674 Ayame Takahashi, MD Ruth Stark 545-7644 545-2275
Colon & Rectal Surgery 9638 Jan Rakinic, MD Jill Horn 545-7230 545-7762
Endocrinology 9636 Romesh Khardori, MD Carole Gibson 545-0166 545-9125
Hand/Micro 9653 Michael Neumeister, MD Cheryl Matthews 545-6112 545-2588
Head & Neck 9662 Thomas Robbins, MD Jenny Kesselring 545-4777 545-7512
Infectious Diseases 9636 Nancy Khardori, MD Nancy Mutzbauer 545-9148 545-8025
Neurorehab David Gelber Stacey Dill 545-0168 545-8039
Pulmonary Medicine 9636 Joseph Henkle, MD Jacie Burt 545-0187 788-5543
Spine Surgery 9679 Per Freitag, MD Anita Weinhoeft 545-6155 545-7901
Vascular Surgery 9638 Kim Hodgson, MD Rhonda Loyd 545-8856 545-1793
FAMILY MEDICINE AFFILIATES
Carbondale Penelope Tippy, MD Chris Null 618-536-6621ext 221 618/453-1102
Decatur John Bradley, MD Tina Hartwig 876-5850 876-5822
Quincy Tom Miller, MD Mary Ann Epley 217-224-8957 224-7950
AFFILIATE FELLOWSHIPS
Carbondale Sports Medicine Scott Schonewolf, DO Gabe Tippy 618-536-6621 ext 261 618-453-1102
Quincy Sports Medicine James Daniels, MD Linda Savage 217-277-5772 224-7950
All phone and fax numbers are 217 area code unless indicated otherwise
Dr. Karen Broquet: 545-8852 Michelle Adams: 545-8853 Debi Santini: 545-5846 Julie Rhodes: 545-3134
CALENDAR OF EVENTS IN THE OFFICE OF RESIDENCY AFFAIRS

Date Event
July • ERAS open to applicants to provide application documents
• Oral English proficiency forms due
• Orientation documents (New Resident Questionnaire, Harassment & Patient Confidentiality) due
• DEA and NPI information provided to pharmacies
• Update GME Census (FREIDA)
• Assign residents to Hospital Medical Staff Committees
August • House Staff Directory distributed
• Program composites distributed
• GMEC resident nominations and election
September • ERAS open to programs to download applicant information
• GME Census deadline
• Step III reminder sent to PGY2 residents
October
November • Credentialing information deadline for specialty matches
December
January • Credentialing information deadline
• Opening of the NRMP, availability to enter rank order lists
• NRMP Quota Change deadline
February • USMLE Step III notification letters to PGY2 residents
• NRMP rank list certification deadline
• Start licensure process for extensions and transfers
March • NRMP Match Day
• Requests for recruitment reimbursement deadline
• Graduated resident certificate request deadline
• New Resident Manuals distributed to programs
• Licensing information sent to incoming residents/fellows
• Lab coat order deadline
April • Employment information from employing hospitals sent to incoming residents/fellows
• Contracts distributed to residents/fellows
• End-of-Year Surveys distributed
May • Clearance sheets sent to graduating residents/fellows
• Graduation, Promotion, & Remediation list deadline
• Contracts due to Residency Affairs
• House Staff nominations
June • SIU New Resident/Fellow Orientation – June 25th
• Distribute lab coats
• End-of-Year Survey deadline
• Hospital computer based learning completion deadline
• ORA computer based learning completion deadline
• Incoming residents/fellows must complete drug testing
• Incoming residents/fellows must be ACLS certified
• House Staff election
GRADUATE MEDICAL EDUCATION COMMITTEE

MISSION STATEMENT

The Graduate Medical Education Committee is accountable for advising and monitoring all
aspects of residency education in a manner to meet the needs of the residents, programs and
hospitals as well as fully comply with the regulations and directions of the Accreditation Council
for Graduate Medical Education (ACGME) and the Residency Review Committees. Major
responsibilities include:

1) Establishing and implementing policies that affect all residency programs regarding the
quality of education and the work environment for the residents in each program.
2) Establishing and maintaining appropriate oversight of and liaison with program directors
and assuring that program directors establish and maintain proper oversight of and liaison
with appropriate personnel of the affiliated hospitals.
3) Reviewing all ACGME letters of accreditation and the monitoring of action plans for
correction of areas of non-compliance.
4) Conducting regular internal reviews of all residency and subspecialty programs to assess
their compliance with both the ACGME Institutional Requirements and Program
Requirements of the relevant ACGME Residency Review Committees.
5) Establishing and implementing institutional guidelines and policies for the selection,
evaluation, promotion, and dismissal of residents.
6) Assuring residents of an educational environment in which they may raise and resolve
issues without fear of intimidation or retaliation.
7) Establishing and implementing institutional policies and procedures for both the
discipline and the adjudication of resident complaints and grievances relevant to the
Graduate Medical Education programs.
8) Recommending appropriate and equitable funding for resident positions, including
benefits and support services.
9) Monitoring the programs to assure the establishment of an appropriate work environment
to include call schedules and duty hours that are in compliance with the relevant ACGME
Program Requirements and;
10) Assuring and monitoring that the residents' curriculum provides:
a. a personal program of learning to foster continued professional growth with guidance
from the teaching staff
b. a regular review of ethical, socioeconomic, medical/legal, and cost-containment
issues that affect graduate medical education and medical practice
c. an appropriate introduction to communication skills and to research design, statistics,
and critical review of the literature necessary for acquiring skills for lifelong learning
d. access to appropriate institutional committees and councils whose actions affect
resident education and/or patient care
e. appropriate resident participation in departmental scholarly activity, as set forth in the
applicable program requirements and assume responsibility for teaching and
supervising other residents and students
f. annual confidential written evaluations of the faculty and of the educational
experiences.
11) Assuring and monitoring that all programs provide a curriculum and an evaluation system
to ensure that residents demonstrate competence in the general areas of:
a. patient care
b. medical knowledge
c. practice-based learning
d. communication
e. professionalism
f. systems-based practice

The chairman of the committee is the Associate Dean for Graduate Medical Education.
Members of the committee shall include:
• Core Residency Program Directors or their designees
• Hospital representatives
• Two faculty members at large
• Up to two Fellowship Directors
• Four to six residents elected by their peers
• President of the House Staff Association
• SIU legal counsel or designee

Revised & adopted GMEC June 16, 2006
GRADUATE MEDICAL EDUCATION COMMITTEE (GMEC)

The GME Committee is a standing committee that meets the third Friday of each month at
7:00 AM.

The Committee (GMEC) has the responsibility for monitoring and advising on all aspects of
residency education. Voting membership on the committee must include residents
nominated by their peers, all core program directors, other members of the faculty, hospital
representatives, the Associate Dean for Graduate Medical Education and Office of Residency
Affairs administrators.

Minutes must be kept. The responsibilities of the committee include the following:

1. Establishment and implementation of policies that affect all residency programs
regarding the quality of education and the work environment for the residents in each
program.
2. Establishment and maintenance of appropriate oversight of and liaison with program
directors and assurance that program directors establish and maintain proper
oversight of and liaison with appropriate personnel of other institutions participating
in programs sponsored by the institutions.
3. Regular review of all ACGME letters of accreditation and the monitoring of action
plans for the correction of areas of noncompliance.
4. Regular internal reviews of all ACGME-accredited programs including subspecialty
programs to assess their compliance with the Institutional Requirements and the
Program Requirements of the ACGME Residency Review Committees.
5. Assurance that each residency program establishes and implements formal written
criteria and processes for the selection, evaluation, promotion, and dismissal of
residents in compliance with the Institutional and Program Requirements for the
specialties and subspecialties of the ACGME RRCs.
6. Assurance of an educational environment in which residents may raise and resolve
issues without fear of intimidation or retaliation.
7. Collecting of intra-institutional information and making recommendations on the
appropriate funding for resident positions, including benefits and support services.
8. Monitoring of the programs in establishing an appropriate work environment and the
duty hours of residents.
9. Assurance that each program provides a curriculum and an evaluation system to
ensure that residents demonstrate competence in the general areas listed in section
II.B, and as defined in each set of Program Requirements.
Program Letters of Agreement
The Common Program Requirements require program letters of agreement (PLAs) between the
residency program and each participating site providing a required assignment, regardless of
length. The ACGME considers any training site that is not under the direct governance of SIU
School of Medicine to be a participating site, even if the supervisors are all full-time SIU faculty.
Therefore, at a minimum, a program must have a program letter of agreement with St. Johns,
Memorial, Blessing, Carbondale Memorial or Decatur Memorial, as well as any additional sites
to which residents rotate. Some of the examples of these would be the Public Health
Department, Jacksonville Developmental Center, etc.

PLAs need to contain the following items:

A. Identify the faculty, who will assume both educational and supervisory responsibilities
for the residents. A specific site director must be named.
B. Specify their responsibilities for teaching, supervision, and formal evaluation of
residents.
C. Specify the duration and content of the educational experience.
D. State the policies and procedures that will govern resident education during the
assignment.
E. Be renewed every five (5) years.

Following are two PLA templates. One is a bare bones version and the other one provides a little
higher level of detail. All PLAs require the signature of the program director, the site director
(even if they are one and the same) and the DIO.

An FAQ relating to PLA’s is available on the ACGME website at
www.acgme.org/acWebsite/about/ab_FAQAgreement.pdf.
Program Letter of Agreement Template (Detailed)

Program ______________
Clinical Site/Rotation: ________

Institution: (.i.e hospital, facility, Department of Public Health, etc.)

Year of Training: (PGY Year(s) in which rotation occurs)

Duration of rotation: (ie multiple months each year, 2 months in PGY2 year, 1 month FTE at .5
x over 2 months)

Site/rotation Director: (Faculty member who will assume educational and supervisory
responsibility for residents.)

Educational Goals and Objectives :
(for this experience only - must be competency based)

Clinical Experience
Describe what the resident will be doing. If this rotation takes place over multiple years, provide
a description of duties for each PGY year. If the rotation takes place over multiple years, the
description of duty should demonstrate progressive levels of responsibility or supervision.

There must be a statement in here that the rotation will be compliant with ACGME duty hour
regulations.

Supervision and Oversight

Day to day clinical supervision will be provided by______________ or will be provided on a
rotating schedule by the following clinical or full-time faculty members: list them, describe
supervisory structure, including role of senior residents and attendings

Supervision will be provided by attending physicians in accordance with the policy for
supervision of resident physicians and fellows for ___________Memorial Medical Center/St.
John’s Hospital/affiliate hospital or your individual department. The site/rotation director will
be accountable for the educational experience and will monitor resident supervision during this
rotation.

The program director for the ___________________ residency is ultimately responsible for the
oversight of all resident activities. The residents/fellows are subject to all policies and
procedures of the ACGME, affiliated hospitals, SIU School of Medicine and the Department of
___________________. The sponsoring institution’s Graduate Medical Education Committee
(GMEC) assures compliance with the ACGME common and program requirements for residency
training in __________Program and provides oversight, monitoring and evaluation for all SIU
Residency Programs.
Effective communication between the program director and the rotation/site director will be via
Describe: i.e. discussions at weekly or monthly faculty meetings, etc.).
Didactic Experiences
(ie journal club, conference, morning report, any scheduled experiences that are specifically
required during this rotation).

Feedback and Evaluation
Residents will receive ongoing and current feedback from the faculty and senior residents while
on the _____________ rotation, in addition to receiving a summative evaluation at the end of the
rotation. This final evaluation will be done through _____________ (ie written evaluation, New
Innovations, etc) and the written evaluation will be discussed with the resident by the attending,
reviewed by the program director and placed in the resident’s file. The program director
individually reviews all evaluations with the resident at least _________ and more urgently for
evaluations which note concerns.

The resident completes an evaluation of the ____________ rotation ____ie when____. The
program director, faculty and resident representatives will discuss summative data from the
rotation evaluations at the annual program review.

Resources and Facilities.
While on this rotation the resident will have 24 hour access to all laboratory, radiology, medical
records, nursing, ancillary services, food availability and sleeping quarters for any in-house call,
as necessary to function effectively on the ______________ service. ______Hospital/site____
has a medical library to which the resident has access 24 hours a day in addition to internet
access at all times with a direct connection to the SIU School of Medicine library.

This letter of agreement is between the SIU School of Medicine ____________________
residency program and ____ name of hospital/agency _____and will be effective during the
period of July ______ through June ______, until updated, changed or terminated by either
party.

Program Director,_______________ Residency Date

Site/Rotation Director Date

Karen Broquet, MD Date
Associate Dean for Graduate Medical Education
Program Letter of Agreement (Bare Bones)
between
Sponsoring Institution’s Residency/Fellowship Program
and
Participating Site
This document serves as an Agreement between Sponsoring Institution’s Residency/Fellowship
Program and Participating Site involved in resident/fellowship education.
This Letter of Agreement is effective from _/ _/ ,and will remain in effect for five years, or until
updated, changed or terminated by the Residency/Fellowship Program and Participating Site.

1. Persons Responsible for Education and Supervision
At Sponsoring Institution: Program Director
At Participating Site: Local Director
List other faculty by name or general group:

The above mentioned people are responsible for the education and supervision of the
residents/fellows while rotating at Participating Site.
2. Responsibilities
The faculty at Participating Site must provide appropriate supervision of residents/fellows
in patient care activities and maintain a learning environment conducive to educating the
residents/fellows in the ACGME competency areas. The faculty must evaluate resident
performance in a timely manner during each rotation or similar educational assignment
and document this evaluation at completion of the assignment.
3. Content and Duration of the Educational Experiences
The content of the educational experiences has been developed according to ACGME
Residency/Fellowship Program Requirements,
and include the following goals and objectives:

or
and are specified in the Resident Handbook, pg ____

or
and are delineated in the attached document.

In cooperation with Program Director, Site Director and the faculty at
Participating Site are responsible for the day-to-day activities of the
Residents/Fellows to ensure that the outlined goals and objectives are met
during the course of the educational experiences at Participating Site.

The duration(s) of the assignment(s) to Participating Site is (are):
4. Policies and Procedures that Govern Resident Education

Residents/Fellows will be under the general direction of the Sponsoring
Institution’s Graduate Medical Education Committee’s and Program’s
Policy and Procedure Manual and Participating Site’s policies for
.

Sponsoring Institution

Program Director signature Date

Participating Site

Site Director signature Date

Designated Institutional Official

Karen Broquet, MD
Associate Dean for Graduate Medical Education
INSTITUTIONAL INFORMATION
Section 2
SUBJECT
ACGME Institutional Requirements
ACGME Common Program Requirements
Institutional ACGME Accreditation Letter
ACGME Accreditation
Institutional Internal Review Protocol
Computerized Information for Other Organizations
House Staff Directory
Resident Recruitment Reimbursement
Financial Assistance for Residents
Residency Affairs Brochure
Industrial Sales Reps/Drug Industry Policies
Disaster Plan Procedure Policy
Support for GME Programs and Residents in the Event of a Disaster or
Interruption in Patient Care Policy
Resident Fact Sheet
Guidelines for Serving Legal Papers in Clinic Setting
Selecting a Program Director
Model Position Description - Program/Fellowship Director
Responsibilities of Program Director
Responsibilities of Residency Program Coordinator
St. John’s Hospital Autopsy Policies and Procedures
ACGME ACCREDITATION

Periodically each training program is site-visited by the Residency Review Committee of the
Accreditation Council for Graduate Medical Education (ACGME). The length between site
visits is roughly three to five years. Preparation for the site visit is handled through the
individual department with assistance from the Office of Residency Affairs.

Helpful information about preparing for a site visit is available upon request from the Office of
Residency Affairs.

Accreditation fees are paid by the Affiliated Hospitals.
INSTITUTIONAL INTERNAL REVIEW PROTOCOL
A. Under the direction of the GMEC, the Office of Residency Affairs schedules internal
reviews of residency programs and subspecialty programs to occur mid-cycle of RRC
visits. Office of Residency Affairs recommends Chairperson and at least two other
committee members (1 resident and 1 faculty) to serve on the internal review committee.
Internal review committee members will not be from the GMEC program being
reviewed. Whenever possible, the committee will be from a different department than
the GME program being reviewed.
B. Office of Residency Affairs prepares analysis form and questionnaires that go to the
Program Director, Faculty (clinical and full-time), and Residents. Completed copies are
returned to the Office of Residency Affairs.
C. Program Director submits the following materials to the Office of Residency Affairs:
♦ A completed Program Information Form
♦ A completed Program Directors Questionnaire
♦ A copy of program goals and objectives
♦ All assessment or evaluation tools
♦ A list of faculty and resident publications, presentations and other scholarly
activity if not included with PIF.
D. Program Director will submit information for review by the GMEC Subcommittee on
General Competencies. The GMEC Subcommittee on General Competencies will review
the following information to assess whether the program has provided opportunities for
learning and methods for assessment in all competency domains, gathered aggregate
resident performance data and used this as the basis for improvement and has used
external quality or performance measures to verify resident and program performance
levels.
♦ PIF sections on specialty specific and common competencies, evaluation and
program evaluation
♦ Program Director’s Questionnaire section on program review and evaluation
♦ All assessment and evaluation instruments
♦ Goals and objectives
E. Their findings will be sent to the Office of Residency Affairs for distribution to the
internal review committee and the program director.
F. Program Director will submit information specifying how compliance with the ACGME
duty hour requirements is being maintained, including:
♦ Narrative and schedules describing how compliance is being ensured
♦ A copy of the program’s written duty hours policy
♦ Description of how the program monitors demands of at-home call and adjusts
schedules as needed
♦ How the program educates residents and faculty about the signs of fatigue
♦ Description of back-up system in the event resident fatigue is sufficient to
jeopardize patient care.
G. Office of Residency Affairs provides and collates all information for members of the
internal review committee, along with the following documentation:
1. ACGME Institutional Requirements
2. ACGME Common Program Requirements
3. ACGME ________ Program Requirements
4. ACGME Duty Hour Requirements
5. SIU ________ Program Duty Hour Policy
6. SIU ___________Program Duty Hour Monitoring Report
7. SIU _____________Program Supervision Policy
8. Previous Internal Review
9. ACGME Letters and Reponses
10. Resident End of Year Evaluations
11. Most recent WebADs Resident Survey
12. Program Letters of Agreement
13. Full-time Faculty Surveys
14. Community Faculty Surveys
15. Resident Surveys
16. Hospital Surveys
H. The internal review committee interviews Program Director, residents, and members of
the clinical and full-time faculty. Wherever possible, all residents in a program will be
interviewed. Where this is not possible, at least one peer-selected resident from each level
of training will be interviewed.
I. The internal review committee writes a report to include, but is not limited to, assessment
of the programs compliance with all ACGME requirements, any areas of non-compliance
identified in previous RRC letters or internal reviews, effectiveness in identifying and
meeting educational objectives, the use of evaluation tools, aggregate data and external
outcome data to assess residents’ competence and annual program review and
improvement, level of scholarly activity, availability of educational and financial
resources, the strengths, weaknesses and opportunities, and recommendations for the
program. If specific recommendations are made, time lines should be included. This
report is shared with the Program Director prior to presenting it to the GMEC.
J. At the GMEC meeting at which the report is presented by the internal review committee,
the Program Director will be available to answer specific questions about the program.
K. The GMEC will decide to accept, modify, or refer back to the subcommittee their
findings and recommendations.
L. The Program Director responds in writing to the GMEC regarding concerns noted on the
report.
M. The GMEC will follow-up on any unresolved issues identified by the internal review
committee until resolved.

N. The request for information will go out the Program Director 6 months prior to the date
the Internal Review is due. The Internal Review will actually start when the information
is distributed to the committee.
Amended and approved by the GMEC on September 19, 2008
Computerized Information for Other Organizations

Information pertaining to residents, fellows, and medical training programs is electronically
gathered annually via two secure web-based applications. The data that is gathered is used for
monitoring, planning and research purposes, as well as for use in structuring graduate medical
education programs. Program directors and/or coordinators are responsible for reviewing,
adding, updating, and approving resident and program information for the following electronic
systems.

GME Track

The American Medical Association (AMA) and the Association of American Medical Colleges
(AAMC) jointly created GME Track to gather census data and provide immediate access to
resident and program information. GME Track replaced the AMA’s Survey of Graduate Medical
Education programs and the AAMC’s Resident Census.

GME Track is accessed via the internet by navigating to www.aamc.org/gmetrack.htm. Each
program has been assigned a User ID and has created a password for accessing the site. Once
logged into GME Track, program directors and/or coordinators can review, add, edit, update or
approve program and resident information. Reporting options are available for the use of
program directors and coordinators.

The information entered into GME Track automatically updates the Fellowships and Residency
Electronic Interactive Database Access System (FREIDA), permitting medical students and
residents to access information about various residency programs. It also is used to update the
Graduate Medical Education Directory, the medical education issue of the Journal of the
American Medical Association (JAMA), and the AAMC’s Data Book. Additionally, program
directors can utilize the Program Survey to compare their program with others.

Each year GME Track will set data entry deadlines for programs interested in being included in
the FREIDA Online Update. As a general rule, the deadline for inclusion in the September
update will be mid-August. For inclusion in the November update the deadline will be mid-
October.

GME Track questions and help requests may be e-mailed to GMETrack@aamc.org. Phone
assistance can be obtained by calling 800-866-6793.
WebADS

With the release of the WebADS system, the Accreditation Council for Graduate Medical
Education (ACGME) has implemented an on-line, automated process for programs to submit
required accreditation information. WebADS is an internet-based data collection system that
contains current data on file with the ACGME for the accreditation of all sponsoring institutions
and programs.

ACGME requires that sponsors and accredited programs verify, add, and update program and
resident information regularly, according to a schedule they specify, via the secured WebADS
site at https://www.acgme.org/ADS. Annual updates, consisting of additions and changes, may
be submitted only when scheduled by ACGME. Periodic updates, consisting of changes only,
may be submitted as often as necessary. Programs are notified when annual updates are due.

The data collected by the ACGME is specifically used for licensing and accreditation purposes.
It is not made commercially available to other entities, and only program directors and
coordinators are permitted to submit information for inclusion in the database.

Usernames and passwords were assigned for all program directors and/or coordinators and user
manuals were distributed to each residency program. Certain reporting abilities have been
incorporated into WebADS for the use of program staff. Additional reporting abilities will be
made available as modifications are made to the system.

Questions and help requests for WebADS may be e-mailed to WebADS@acgme.org. Also,
phone assistance is available from 8:00 am to 5:00 pm central time Monday through Friday at
312/464-5393.

In addition to the above help sources, the SIU School of Medicine Office of Residency
Affairs can provide general assistance with GME Track and WebADS.
HOUSE STAFF DIRECTORIES
New residents/fellows have their photograph taken at Orientation. The Office of Residency
Affairs prepares a pictorial directory which includes all house staff currently training at SIU. In
addition, a departmental directory is prepared and e-mailed to the coordinators.
A directory of residents including their name, address, phone number, and name of spouse is also
available upon request and should not be distributed to outside agencies, especially
pharmaceutical representatives.
RESIDENT RECRUITMENT REIMBURSEMENT
The residency reimbursement program is a joint program established between the School of
Medicine, Memorial Medical Center, and St. John’s Hospital to reimburse prospective
residents for lodging and/or meal expenses when interviewing for residency programs.
Guidelines for the reimbursement program are as follows:
1. Residency Reimbursement Request Form should be completed by the
department.
2. Receipts for claimed expenses should be attached.
3. Maximum of $50 per resident candidate for meals OR a maximum of $75 for
hotel per resident candidate is allowed.
4. When candidate is from SIU or nearby school and is just in for the day, the
luncheon or dinner reimbursement will be limited to the candidate and one
department representative.
5. Completed form and receipts should be sent to Office of Residency Affairs,
Mail Code 9656.

FINANCIAL ASSISTANCE
Any resident/fellow currently enrolled in an approved SIU training program is eligible for a
three-month, interest-free, emergency loan from the Caduceus Guild Residency Loan Fund. The
maximum loan amount is $500. Application forms are available in the Student Affairs Office at
SIU School of Medicine, 801 N. Rutledge, Room 3080.

RESIDENCY BROCHURE
A residency brochure is available on the Residency Affairs web page. The Office of Public
Affairs coordinates this effort with the assistance of the Office of Residency Affairs. The
program directors in Springfield and the hospital administrators are asked to update the
information each time a new brochure is developed. Programs are provided with an updated
PDF that they may e-mail to applicants or print and mail to applicants.
DISASTER PLAN PROCEDURE FOR SPRINGFIELD RESIDENTS

In the event of a critical incident, emergency or disaster, residents will be an integral part of the
response. If a disaster situation is declared by either or both hospitals, residents on Trauma
service will report to the trauma team. Other residents will report to whichever hospital is most
accessible to them, unless otherwise directed. Those at St. John’s hospital will meet in the
designated manpower pool located in the Physician’s Lounge. Those at Memorial Medical
Center will meet at a place determined by the Designated Incident Commander.

Notification and assignment of residents to their respective manpower pools will be coordinated
through the Office of Residency Affairs after consulting with the hospital(s).

The Office of Residency Affairs will contact the program director or coordinator of each
program. Individual departments will then be responsible for notifying residents of the disaster
and their hospital assignment. Once they have reached the Designated Manpower Center of their
assigned hospital, residents will follow the disaster plan of that particular hospital.

Adopted by GMEC on October 15, 1999
Revised and Adopted by GMEC on November 17, 2006
Support for GME Programs and Residents in the Event of a Disaster
or Interruption in Patient Care

For these purposes a disaster is defined as an event or set of events causing significant alteration
to the residency or fellowship experience at one or more SIU training programs. Because of the
devastating impact of natural or manmade disaster on information systems, programs are
strongly encouraged to keep back up copies (either written or electronic) of important program
and residency files at a different physical location than their residency office.

In the event of a disaster, the Designated Institutional Official (DIO), SIU officials and
leadership of the affected affiliated hospitals will, as soon as is possible, organize a designated
command site for institutional leadership and a communication pathway to programs.

If, because of a disaster, an adequate educational experience cannot be maintained or provided
for residents/fellows, the sponsoring institution will:

A. Cooperate in and facilitate temporary transfers to other programs/institutions until
such time as the residency or fellowship program can provide an adequate educational
experience.
B. Cooperate in and facilitate permanent transfers to other programs or institutions if
necessary. Programs will make the decisions whether or not residents need to be
transferred permanently as expeditiously as possible to reduce the disruption to any
resident’s training.
C. Inform each transferred resident of the minimum duration of his/her temporary
transfer and continue to keep each resident updated regarding the minimum duration.
If and when a program determines that a temporary transfer will continue through the
end of a residency year, it will inform each transferred resident.

The DIO will be in contact with the ACGME Institutional Review Committee Executive
Director with SIU information and/or requests for ACGME information. Program Directors of
affected programs will communicate with the appropriate Residency Review Committee
Executive Director.

Within 10 days after the declaration of a disaster, the DIO will contact the ACGME to discuss
due dates for ACGME post disaster oversight.

Adopted by the GMEC on October 19, 2007
GUIDELINES FOR WHEN LEGAL PAPERS
ARE SERVED IN THE CLINIC SETTING

1. If it is a medical liability situation, the server should be directed to the Risk
Management Office of the appropriate hospital.

2. For legal papers other than a medical liability situation, the program coordinator
should be contacted to reach the resident and to facilitate the meeting between the
server and the resident, but should not be physically present unless requested by the
resident.

3. The resident should immediately notify the SIU Office of General Counsel that he/she
has been served in a medical liability claim and should be prepared to provide the
name of the case.

4. No staff person should accept legal papers on behalf of any resident.

Approved by GMEC 2/13/98
Amended and Approved by GMEC April 20, 2007
SELECTING A PROGRAM DIRECTOR

All residency and fellowship training programs at SIU School of Medicine are expected to be
accredited by the appropriate Residency Review Committee (RRC) of the Accreditation Council
for Graduate Medical Education (ACGME), if such accreditation is available.

All Program Directors must be fully aware of the ACGME or other applicable accreditation
requirements for their program and for the institution.

In recognition of these requirements, and to assist the departments in the recruitment and
selection of the most highly qualified program directors available, the Graduate Medical
Education Committee (GMEC) will participate in the process as follows:

1. As required by the ACGME Institutional Requirements, the GMEC will review and
approve all appointments of new program directors.
2. The department chair will inform the chair of the GMEC at the outset of any recruitment
process for a program director.
3. The chair of the GMEC will be kept informed of the progress of any search for a program
director.
4. The chair of the GMEC will have the opportunity to interview the final candidate(s) prior
to his/her official appointment.

Adopted by GMEC September 14, 2001
Amended and Approved by the GMEC February 16, 2007
MODEL POSITION DESCRIPTION: PROGRAM DIRECTOR
FOR RESIDENCY AND FELLOWSHIP PROGRAMS

Organizational Relationship
The Program Director works independently and reports to his/her Department Chairperson.
He/she assures compliance with the RRC requirements for his/her program. In addition, he/she
works cooperatively and is accountable to the Graduate Medical Education Committee (GMEC)
and the Designated Institutional Official (DIO) to assure compliance with the institutional
requirements of the ACGME. He/she is a member of the Graduate Medical Education
Committee and maintains a working relationship with other program directors.

Function
The program director is responsible for organizing and implementing the residency training
program in his/her specialty.

Qualifications
A. Be licensed to practice medicine in the State of Illinois.
B. Have an appointment in good standing with the medical staff(s) of hospital(s)
employing residents enrolled in the training program.
C. Be certified by appropriate specialty board.
D. Meet professional standards of ethical behavior.
E. Have the requisite years of experience in academic medicine beyond residency
training which are required of ACGME.

Responsibilities of the Program Director are for the general administration of the program,
including all activities related to recruitment, selection, instruction, supervision, counseling,
evaluation and advancement of residents and the maintenance of all records related to program
accreditation.

A. Recruitment and Selection
1. Recruits residents of the highest caliber.
2. Interviews and selects applicants in a fair and equitable manner.
3. Provides applicant credentials to the affiliated hospitals for approval.
4. Participates in the NRMP as part of the Institutional Agreement.
5. Maintains information for FREIDA

B. Supervision
Provides overall supervision of the residency program by
a) Selecting and supervising faculty members and other program
personnel as they relate to the residents.
b) Creating written policies outlining the lines of responsibilities and
supervision for the care of all patients and all clinical sites and staff.
C. Goals and Objectives
1. Prepares written goals and objectives of the program with respect to
knowledge, skills and other attributes of residents at each level of training and
for each major rotation or assignment.
2. Ensures that the objectives and expectations are readily available for review
and are distributed to residents and faculty.
3. Develops residency assignments and schedules to meet the educational goals
of the program.
4. Plans, coordinates and implements curriculum and evaluation methodology
for the six general competencies.

D. Resident Well Being
1. Adheres to the program’s and Institution’s duty hour policy.
2. Ensures that the residency program emphasizes education and minimizes
service obligations.
3. Monitors resident stress, including mental or emotional conditions or drug or
alcohol-related dysfunction.
4. Evaluates and modifies training situations that consistently produce
undesirable stress.
5. Advocates for each resident, residency concerns in general, and interests
within the department, institution and affiliated hospitals.
6. Provides discipline when appropriate.
7. Is available for advice and counseling.

E. Evaluation
1. Maintains an evaluation program for each resident with regular feedback
regarding individual progress.
2. Maintains an evaluation program for faculty regarding their effectiveness in
teaching residents.
3. Maintains an evaluation program for residents to evaluate teaching faculty.

F. Administrative Duties
1. Meets all requirements of the Accreditation Council for Graduate Medical
Education (ACGME) to maintain full accreditation.
2. Communicates to the Residency Review Committee (RRC) any major
changes in the program.
3. Maintains residency files in a complete and confidential manner.
4. Participates in the GMEC and other assigned ad hoc GMEC subcommittees to
develop policies and procedures and to internally review other residency
programs.
5. Serves as a role model for residents in training by nurturing the attributes of
the clinician, scholar, scientist, teacher and humanist.
6. Exercises authority to ensure effective teaching including obtaining teaching
commitments from other departments which are necessary for the training of
residents.

Approved by the GMEC August 12, 2002
RESPONSIBILITIES OF THE SIU SOM
RESIDENCY PROGRAM DIRECTOR

According to the ACGME Institutional Requirements, “the Sponsoring Institution must provide
graduate medical education (GME) that facilitates residents’ professional, ethical, and personal
development. The Sponsoring Institution and its GME programs, through curricula, evaluation,
and resident supervision, must support safe and appropriate patient care”. In SIU sponsored
GME programs, the residency program director is responsible for the organization and
implementation of these objectives for his/her program. Specific responsibilities may be
delegated by the program director but he/she is responsible to the GMEC, the designated
institutional official (DIO), and to the ACGME Residency Review Committee (RRC) for the
timely and accurate completion of all tasks.

In addition to the ACGME, a number of other bodies impose requirements on our GME
programs. These include (but are not limited to) SIU School of Medicine , SIU Health Care,
bylaws of our Affiliated Hospitals, the Illinois Department of Financial and Professional
Regulation, Division of Professional Regulation, the Joint Commission and the NRMP.
Compliance with these requirements is the responsibility of the program directors, working in
concert with the institution.

Physicians in training include residents and fellows, who, for the purposes of this policy, will be
referred to as “residents.”

Responsibilities of the residency program director include all of the following 1

Participation in the institutional governance of GME programs (I-A).
• Maintain current knowledge of and compliance with SIU GME policies and procedures
(http://intranet.siumed.edu/residency/)
• Maintain current knowledge of and compliance with ACGME institutional, common
program, and program requirements (www.acgme.org).
• Participate in GMEC, subcommittees and task forces, and internal review committees as
requested including program representation at all GMEC meetings.
• Cooperate promptly and accurately with requests by the GMEC or Office of Residency
Affairs (ORA) for information, documentation, etc.
• Ensure that residents comply with periodic surveys by the ACGME (the ACGME
Resident Survey).

Internal Reviews
• Prepare documentation of internal review materials and reports as required by GMEC
internal review protocol and submit above information to the Office of Residency Affairs
by the dates requested.

1
References are to the ACGME Institutional Requirements effective July 1, 2007 www.acgme.org.
• Develop action plans for correction of areas of non-compliance as identified by internal
reviews, and provide periodic updates to the GMEC.

ACGME Residency Review Committee Requirements
• Maintain Current knowledge of and compliance with the ACGME manual of polices and
procedures for GME review committees (www.acgme.org).
• Maintain current knowledge of and compliance with ACGME program requirements
pertaining to his/her program.
• Respond promptly to RRC requests for information and provide copies of any such
requests to the Office of Residency Affairs.
• Prepare an accurate and complete program information form (PIF) prior to RRC site visit.
• Ensure that the DIO reviews and co-signs all program information forms and any
correspondence or documents submitted to the ACGME by program directors that either
address program citations, RRC requests for information, or program requests for
changes in the program that could have a significant impact, including financial, on the
program or institution.
• Develop action plans for correction of areas of non-compliance as identified by RRC site
visits or other mechanisms and provide periodic updates to the GMEC.
• Update annually both program and resident records through the ACGME’s accreditation
data system.
• Prepare program Letters of Agreement (Affiliation Letters) with all clinical sites for
which rotations are required and revise these program agreements at least every five
years.
• Ensure that HIPAA Business Associate Agreement forms (template on the ACGME
website) are prepared for any clinical training site in which residents have access to
protected health and or demographic information.

Educational Aspects of the Program
• Develop an educational curriculum as defined in the ACGME program requirements for
the specialty or, if the program is a non- ACGME accredited program, periodic
review/revision of the educational curriculum.
• Provide instruction and experience with quality assurance/performance improvement.
• Develop and implement dependable measures to assess residents’ competencies in the
general competencies of Patient Care, Medical Knowledge, Practice Based Learning and
Improvement, Interpersonal and Communication Skills, Professionalism and Systems
Based Practice.
• Develop and implement dependable measures to assess residents’ competence in other
areas as defined in the ACGME program requirements for that particular specialty.
• Implement a process that links educational and clinical outcomes with program
improvement.
• Ensure at least annual review of the educational effectiveness of the program (common
program requirements VII.C.1) via a formal documented meeting for which written
minutes are kept.
• Facilitate residents’ participation in the educational and scholarly activities and ensure
that residents assume graduated responsibility for teaching and supervising other students
and residents.
• Assist residents in obtaining appointment to appropriate institutional and departmental
committees.
• Procure confidential written evaluations of the faculty and of educational experiences by
the residents at least annually.
• Ensure residents’ attendance at educational sessions required by the program, the
institution and the agencies listed in the second paragraph.

Administrative and Oversight Aspects of the Program
• Provide oversight and liaison with appropriate personnel of other institutions
participating in residency training.
• Ensure that each resident maintains an up-to-date temporary license with the Illinois
Department of Financial and Professional Regulation until/unless the resident obtains a
permanent license.
• Ensure that each non-citizen resident maintains an up to date visa or work authorization.
• Create, implement, and review annually program specific policies consistent with SIU
School of Medicine GMEC policies for the following: resident selection, resident
evaluation, resident promotion, resident dismissal, resident supervision, resident duty
hours, moonlighting policy and written documentation for any resident participating in
moonlighting.
• Facilitate institutional monitoring of resident duty hours.
• Ensure that the program is in compliance with duty hour requirements.
• Ensure that non-eligible residents are not enrolled in the program.
• Ensure that all interviewed residency applicants are provided, at a minimum, a written
information sheet containing the website at which the terms and conditions of
employment and benefits, policies and the most recent resident contract may be found.
• Maintain accurate and complete program files in compliance with ACGME requirements.
• Ensure that written notice of intent not to renew a resident’s contract or not to promote is
provided no later than four months prior to the end of the resident’s current contract,
unless there are extenuating circumstances.
• Ensure that the DIO reviews and co-signs all letters to any resident notifying him/her that
they are on probation, suspension, termination or non-renewal of contract.
• Provide appropriate supervision of residents by faculty so as to allow safe and effective
patient care and progressively increasing responsibility by the resident according to their
level of education ability and experience.
• Manage scheduling of residents including, but not limited to, creating clinical rotation,
conference and on-call schedules.
• Ensure that residents complete time records and medical records in a timely and accurate
manner.
• Structure on-call schedules to provide readily available supervision to residents on duty,
appropriate monitoring for fatigue and appropriate back up support when needed.

Approved by the GMEC August 21, 2009
RESPONSIBILITIES OF THE SIU SOM
RESIDENCY PROGRAM COORDINATOR
GENERAL DESCRIPTION
On behalf of the Residency Program Director, the Program Coordinator performs managerial
duties related to the planning, directing, and coordinating academic and operational activities of
the residency program; and provides sound guidance and advice on other pertinent residency
program issues. While duties and responsibilities may vary, the program coordinator is
responsible for the day-to-day administration of the residency training program and is directly
responsible to the program director or department chair.

Knowledge, Skills and Abilities
• Knowledge and ability to plan for and manage the administrative activities of a
residency education program through application of prescribed standards, policies,
and procedures.
• Knowledge and skill in the use of computer systems and software; knowledge of
information data systems and the expertise in adapting them to support a clinical
education program.
• Knowledge of basic, licensing regulations for both temporary and permanent
physician license in the state of Illinois.
• Knowledge and basic understanding of J-1 sponsorship for those programs that
sponsor such visas.
• Skill in communicating effectively both orally and in writing.
• Skill in exercising independent judgment, flexibility, and discretion when setting
priorities, implementing procedures, maintaining standards and resolving problems.
• Ability to gain comprehensive knowledge of the terminology, principles, and methods
utilized in the residency program.
• Ability to independently perform a wide variety of routine, as well as, complex
assignments required in the day-to-day management of a residency program.
• Skill in prioritizing, planning, working independently, and organizing projects and
assignments effectively and efficiently.
• Ability to demonstrate tact and diplomacy when dealing with others and relaying
confidential information. Recruitment activities require that the coordinator be
sensitive to many races and cultures and their traditions.
• Ability to exercise good judgment and decision-making skills.
• Ability and skill in establishing and maintaining effective working relationships with
other residency program personnel, faculty, staff, residents, students and the general
public.
Responsibilities

Recruitment Responsibilities
• Manages and coordinates all administrative duties relative to the resident
recruitment and selection process. Manages computerized Electronic Resident
Application System (ERAS). Ensures receipt of required application materials
and maintains confidential applicant files.
• Prepares rank order lists of applicants for the National Resident Matching
Program (NRMP), and specialty training programs (i.e. NEMP).
• Updates and edits program policy manuals, procedure manuals and recruitment
materials.
• Coordinates entire candidate interview, and resident recruitment and selection
processes. Responds to applicant inquiries, organizes application review and
interview process, and coordinates “interview days.” Develops and maintains
applicant data bases; staffs residency selection and applicant ranking committees;
submits credentials for approval by affiliated hospitals, prepares and submits
resident rank order lists to the corresponding matching programs by deadline.
• Consults with residency program director and advises on pertinent issues
concerning resident selection, appointment and reappointment to the program.
• Assists program directors with the design and development of brochures and
pamphlets regarding the various training programs and prepares information
packets for applicants.
• Assists with the development of orientation and curriculum materials for residents
and fellows.

Information and Data Management
• Updates information for residency program web sites.
• Establishes and maintains a systematic file system with proper security measures
for confidential documents.
• Performs data management, tracking, and reporting functions utilizing various
Graduate Medical Education soft ware programs including GME Track,
WebADS, and AMA FREIDA.
• Manages computerized information systems related to collecting and storing data,
generating management reports and documentation; maintains computerized and
hard-copy files of residency program records including New Innovations or other
residency management software. Promptly updates this information as needed
and ensures that all necessary information for hospital reimbursement needs, as
well as, demographic data is provided.

Accreditation Issues
• Prepares, organizes, and participates in accreditation site visits. This includes
gathering all materials needed for the Program Information Form (PIF) as well as
making arrangements for rooms, food, and accommodations for site visitors and
making appropriate appointments for site visitors.
• Assists the Program Director on an ongoing basis to ensure the residency program
maintains compliance with the ACGME, RRC and American Board requirements.
• Maintains all program records.
• Assists in preparation of Program Information Forms (PIF) for both site visits as
well as for Internal Reviews. This includes gathering all requested data such as
hospital admission rates, surgical outcomes, and other data from outside sources.
Preparing for both internal reviews and site visits require large amounts of
dedicated time on the part of residency coordinators.
• Maintains proficiency in ACGME and specialty board requirements and monitors
program compliance.
• Participates with the Program Director and faculty in program planning and in the
development of residency program academic and clinical requirements to ensure
accreditation standards are maintained and met.

Resident Evaluations
• Tracks resident evaluations and conference attendance.
• Maintains resident evaluation system and provides feedback to Program Director.
• Manages confidential resident performance evaluations as well as evaluations of
faculty and the educational program. Prepares reports and correspondence related
to highly confidential materials.

Resident Workload
• Prepares, coordinates, and distributes residents’ conference schedules, call
schedules, clinic schedules and schedules for both on an off-site rotations in
consultation with the program director, supervising faculty and chief residents.
• Schedules continually change and the coordinator must stay on top of the changes
to maintain accurate records. The coordinator must also notify everyone affected
by the changes as they occur, this includes faculty, secretaries, residents, students,
clinic staff, hospital administration and floors, ER’s and operators.
• Ensures the accuracy of records regarding resident training and maintains
documentation for program accreditation, specialty board requirements, Medicare
reimbursement, annual reports, and letters of recommendation needed when
residents seek fellowship or private practice opportunities after graduation.
• Monitors resident schedules to insure compliance to ACGME work hours rules by
both residents and faculty. Bring discrepancies to the attention of all affected
parties for correction.
• Organizes residency program workload; monitors status of work in progress and
keeps the program director informed of activity priorities and deadlines.

Administrative Responsibilities
• Coordinates yearly in-service examination.
• Assist residents in obtaining and maintaining valid licensure and ECGME
sponsorship documentation.
• Generates contracts for new and continuing residents.
• Processes new hire paperwork for incoming residents.
• Provides information, support, and problem solving for residents and program
faculty on a wide range of residency personnel and program issues.
• Advises Program Director and assists in responding to and resolving resident
issues and program administrative problems.
• Coordinating all daily conference schedules including Grand Rounds and other
conferences. These duties include travel arrangements for outside speakers,
working with pharmaceutical representatives to arrange sponsorship or speakers,
reserving the conference room space (6 mos – 1 year in advance each year),
making the faculty assignments (including the hospital medical specialty
meetings, morbidity/mortality conferences, and resident teaching assignments),
and reimbursing traveling speakers for expenses.
• Conference management also includes coordinating CME for faculty members.
These responsibilities include providing the CME with required documentation so
that the CME can remain in compliance with the LCCME (their accrediting
organization). Each conference requires that the following documentation be
obtained: Faculty letter (to confirm objectives, date/time/location/notify of
ACCME policies on Commercial support), Faculty disclosure form, Accreditation
statement, Letter of agreement (if applicable), Budget information, company
providing support, Disclosure verification, and Evaluations/questionnaires.
Faculty attendance is tracked at conferences and a report is created so that faculty
can receive CME credit each year.

Relationships With Other Organizations
• Acts as liaison between residency and off-site rotations, affiliated hospitals and
medical schools.
• Residency program liaison with the GME office and various other agencies,
organizations, and groups including but not limited to education commissions,
accreditation councils, licensing organizations, and medical specialty boards.
Prepares a variety of documentation associated with residency program
operations; distributes documentation or retains records as appropriate.
From St. John’s Hospital Departmental Manual (Directive No. 7232-3)

POLICY:
The St. John's Pathology Department realizes the need for proper procedures to provide autopsy services at the
request of medical staff member or the Coroner and to provide such service with reverence and dignity.

PURPOSE:
• To organize an efficient and effective routing system for permits and charts.
• To assign responsibility for proper notification of Pathology Department when there is to be a post-mortem
exam.
• To assure proper handling of the deceased in keeping with St. John's Philosophy and Beliefs.
• To establish guidelines for expediting post-mortem exams within a reasonable time frame and workload of
the Pathology Department.

INSTRUCTIONS:
A. As soon as an autopsy is requested, the Nursing Unit has the following obligations:
1. Obtain Permit:
The autopsy permit must be signed by the legal next of kin. In the event that this individual is
mentally incapacitated, then the kin who is next in line is authorized to grant permission for
autopsy. If signatures cannot be obtained without undue burden, telephone permission is
acceptable providing it is witnessed by two hospital personnel, preferably employees of the
patient’s nursing unit. The permit will note any restrictions imposed by the legal next of kin.
2. Notify the Pathology Department:
Please call the Laboratory Office, extension 44185.
3. Enter the name, date and time of death and autopsy required into morgue database through
communication with Security staff.
4. Deliver Autopsy Permit And Chart To Pathology:
The nursing unit is to deliver the medical chart and the signed permit to the Laboratory Main Office.
5. Move The Body To The Morgue And Assure Refrigeration:
At the earliest convenient time, nursing personnel are to move the properly labeled body of the
deceased to the morgue, place it in the cooler, and check that the cooler is operational. This
may be done either before or after the permit is obtained.
6. On weekends and holidays, Nursing Coordinator will contact the on-call pathologist (generally
only during daytime hours after 8:00 a.m. unless unusual circumstances require immediate
notification) to inform him/her of the authorized autopsy. (During the regular work week, the
pathologist will be notified by the pathology secretary).

B. The Laboratory personnel have the following obligations:
1. When the Laboratory office personnel receive telephone notification of an autopsy, they should record the
name of
the caller and time of call.
2. As soon as Laboratory office personnel receive a chart and permit, they are to deliver permit and chart to
Pathology
secretary’s office.
3. The Pathology secretary will give the chart and permit to the Pathologist or Pathologist’s Assistant
performing the
autopsy. (If on a weekend or holiday, the on-call pathologist will retrieve the chart and permit from the
pathology
secretary’s office).

C. 1. The Pathologist or Pathologist’s Assistant, under supervision of the pathologist, will perform the autopsy
as soon as workload and practical considerations allow. In general, autopsies are performed Monday
through Sunday between the hours of 8:00 a.m. and 2:00 p.m. only. After discussing the case with the
attending physician, the pathologist may elect to perform a “limited” or focused post-mortem examination
even if an unrestricted autopsy permit is obtained.
2. The Pathologist or Pathologist’s Assistant will notify the autopsy diener of the autopsy and the time it is to
be performed.
3. The Pathologist is responsible for ensuring that the chart is returned to the Health Information
Management
Department following completion of his/her review.

D. The Diener is responsible for:
• Assisting with post mortem exam and the proper labeling of all tissues and samples,
• assuring that the body and all coverings are clean and the ID tag is attached and readable,
• assuring that infectious bodies are appropriately marked before the body is released to the funeral director,
• observing all applicable infection control policies and procedures,
• notifying Security and
• changing status to “completed” in the morgue database and notifying housekeeping upon completion of the
autopsy.

E. Autopsies on St. John’s Hospital inpatients who have been followed at the SIU Center for Alzheimer's
Disease and Related Disorders (CADRD) or a Satellite Diagnostic and Treatment Center (STDC--
Primary Provider) will be performed for the purpose of harvesting the brain at no charge. The
Pathology Department should be notified according to the standard procedures described above and
the brain harvesting will be performed at a convenient time. Generally, this will occur weekdays
between 8:00 a.m. and 2:00 p.m. The autopsy diener will notify SIU at 217/782-8249 and arrange for
the brain to be transported to SIU. If death occurs outside of St. John’s Hospital, the body should be
transported to Memorial Medical Center for examination.

F. On rare occasions, an autopsy might be requested on a St. John’s Hospital patient for the purpose of tissue
harvest for research other than (E) above. In that situation, the institution requesting the autopsy
must contact the Nursing Coordinator who will verify that the appropriate authorization has been
obtained and who will then ensure that an autopsy permit is obtained as described in (A) above.
The Nursing Coordinator will then ensure that all appropriate records and documents including the name and
phone number of a contact person at the requesting institution are delivered to the pathology
department. If such a request is received after hours or on weekends or holidays, the Nursing
Coordinator should contact the pathologist on call, preferably only during daytime hours after 8:00
a.m. The tissue harvest will then be performed as soon as is convenient and expedient. The pathologist
will arrange for the tissues to be transported to the requesting institution by the Reference lab section.

G. The Sangamon County Coroner’s office is responsible for notifying the forensic pathologist on call for all
coroner autopsies.

The Coroner’s pathologist is responsible for:
• Arranging use of the autopsy suite with Histology supervisor or designee.
• All evidence, clothing and other personal possessions removed at autopsy.
• Providing a diener to assist.
• Notifying Security when the autopsy is completed and changing status to “completed” in morgue database.
• Assuring that the body and all coverings are clean and the ID tag is attached and readable.
• Assuring that the morgue and all equipment used is cleaned and/or disposed of properly and calling
Housekeeping.

Effective February 27, 2006
CREDENTIALING INFORMATION
Section 3

SUBJECT
Selection, Evaluation, Supervision and Graded Responsibilities,
Promotion/Non-Promotion Dismissal Policy re: Selection
NRMP and Hiring Outside the Match
Resident Transfer Policy
Resident Credentialing Policy
Non-Accredited Fellowship Policy
EXCERPT FROM

SELECTION, EVALUATION, SUPERVISION, GRADED RESPONSIBILITY,
PROMOTION/NON-PROMOTION AND DISMISSAL OF RESIDENTS POLICY

SELECTION

The selection of residents in each program shall be carried out by the Residency Program
Director with the assistance of the teaching staff. Programs will select applicants who are
eligible for appointment to accredited residency programs. (See Policy on Resident Eligibility
and Employment Authorization)

Programs will select applicants on the basis of their preparedness, ability, aptitude, academic
credentials, communication skills, and personal qualities such as motivation and integrity.
Programs will not discriminate with regard to race, religion, national origin, citizenship, sex, age,
handicap or other factors prohibited by law. The School of Medicine will participate in the
National Resident Matching Program as an Institution.
Recruiting and Hiring Residents through the Match and Outside the Match

All SIU core programs use the National Resident Matching Program (NRMP). The Office of
Residency Affairs registers the Institution and individual programs register their individual
programs as well. Before entering a rank order list into the NRMP system, programs must
follow the credentialing policy as approved by GMEC.

Occasionally, there is a need for positions to be filled outside of the match. Communication with
the Office of Residency Affairs is essential when considering a candidate for residency outside
the Match. Resident physicians will not be accepted if approved positions do not exist.
Credentialing must be completed and approved before an employment contract may be offered to
a resident. Licensing and visa compliance are necessary before a residents starts working.

Any letter of offer must include the statement, “This offer is pending approval of credentials by
the SIU School of Medicine and its affiliated hospitals as well as a valid Illinois license and valid
visa if applicable.”
Policy on Non-Accredited Fellowships

Some formal training programs are not offered accreditation by ACGME. Unaccredited formal
programs are subject to GMEC oversight and fellows in these programs are acknowledged by the
GMEC and afforded the same rights and responsibilities as fellows in accredited programs.

For GMEC approval of a new unaccredited program, the following information is required.

1. Description of Training - Brief definition of scope of sub-specialty, length of training,
number of fellows, and clinical or research responsibilities
2. Eligibility Criteria
o Medical school requirements (LCME accredited, AOA accredited, WHO
recognized, etc.)
o Residency requirements (residency or residencies completed, Board eligible or
Board certified, etc.)
o Visa requirements if applicable
o Licensure Requirements (permanent or temporary IL license)
3. Funding source (Fellowships funded via SIU P and S must also involve SIU HR for SIU
appointment)
o Stipend/benefits
o Malpractice
4. Goals and Objectives of the Program
5. Rotation Schedule and Curriculum
6. Names of People Responsible for Program (Director and Coordinator)
7. List of Supervising Faculty
8. Duty Hours Policy for Programs (must be consistent with ACGME Duty Hour
Regulations)
9. Both the program and fellow must agree to abide by all GMEC policies and procedures
regarding post-graduate education. If the fellow will not be on a hospital training
contract, please describe the mechanism by which the fellow is made aware of this.
For existing unaccredited programs, the GMEC must review and approve any changes in training
complement, major changes in program length or structure, or appointment of new Program
Directors. Each unaccredited program will undergo a periodic internal review. Whenever
possible, this will occur at the same cycle as the most closely related accredited program.
Approved by GMEC August 4, 2006
EMPLOYMENT INFORMATION
Section 4

SUBJECT
Selection, Evaluation, Supervision, Graded Responsibility, Promotion/Non-Promotion
and Dismissal Policy
Institutional Duty Hour Policy
Letter of Offer Templates
Licensure
Medical License Policy
DEA & NPI Numbers
Prescription Writing and Controlled Substance Schedule
Orientation, Identification, Parking, Security
St. John’s Hospital Parking
Memorial Medical Center Parking
Stipend Policy
Resident Wellness
Fitness for Duty Evaluation
Impairment Policy
Speaking Skills
Guidelines for Residents Who Start Late
Americans with Disabilities Act Policy
Procedure for Completion of Agreement with Physician and Sample Contract
Contract Sample, Current Year
Leave Policies
Military Leave Policy
Employment Eligibility Requirements
Drug Screening Policy and Protocol
Completion of Medical Records and Suspension Protocol
Completion of Time Records and Suspension Protocol
Delinquent Medical Records and Duty Hour Records
Professional Activities Outside Scope of Residency Training
Liability Coverage
Recruitment for Unfilled Positions
TEMPLATE - LETTER OF OFFER FOR MATCHED
RESIDENTS/FELLOWS

Date
First name, Last Name, Credentials
Address
City, State, Zip

Dear Dr. _____:

We are so pleased that you matched with us. It is my pleasure to inform you that the Southern
Illinois University School of Medicine Department of __________ wishes to offer you a position
in our ____________ residency program. This is a ____ year program and, upon successful
completion of each year of training, it is expected that you will be promoted to the subsequent
year level. We are incredibly proud of our team and of the collaborative efforts between SIU and
our affiliated hospitals. We will make every effort to insure that your time here will be both
personally and professionally rewarding.

This letter serves as an official letter of offer as a PGY___ at a salary of ____. Please sign one
copy of this letter and return it. You may want to keep an original for your records.

Also, you will soon be receiving an employment agreement for you to sign and return. When
you get it, please read the agreement carefully, and if you have any questions you may contact
me directly.

Please be aware that this offer and the agreement are contingent upon your successful completion
of medical school and USMLE Steps I and II prior to the start of your training. It is also
contingent on satisfactorily completing prerequisites that SIU or your employing hospital may
require, such as credentialing, a pre-employment health and drug screen, criminal background
check and other routine employment processing.

Employment and participation in our residency training program is also contingent upon your
obtaining and maintaining a license and valid work authorization throughout your training. This
is sometimes a lengthy process. I would encourage you to get started on your licensure and, if
applicable, visa application forms as soon as possible.
Welcome to SIU!

Sincerely,

________________ ___________________
Program Director Candidate Signature
TEMPLATE - LETTER OF OFFER FOR NON-MATCH
RESIDENTS/FELLOWS

Date

First name, Last Name, Credentials
Address
City, State, Zip

Dear Dr. _____:

It is my pleasure to inform you that the Southern Illinois University School of Medicine
Department of __________ wishes to offer you a position in our ____________ residency
program. This is a ____ year program and, upon successful completion of each year of training,
it is expected that you will be promoted to the subsequent year level. We are incredibly proud of
our team and of the collaborative efforts between SIU and our affiliated hospitals. We will make
every effort to insure that your time here will be both personally and professionally rewarding.

This letter serves as an official letter of offer as a PGY___ at a salary of ____. If you wish to
accept the offer, please sign one copy of this offer letter and return it. You may want to keep an
original for your records.

Also, you will soon be receiving an employment agreement for you to sign and return. When
you get it, please read the agreement carefully, and if you have any questions you may contact
me directly.

Welcome to SIU!

Sincerely,

________________ ___________________
Program Director Candidate Signature
LICENSURE
All residents and fellows must hold either an Illinois Temporary Medical License or an Illinois
Permanent Medical License. First year residents must apply for a temporary license. This
process takes approximately 8-12 weeks. Applications can be printed from the internet at
www.idfpr.com. Residents can take the United States Medical License Exam (USMLE) Step 3
after 12 months of clinical training in the state of Illinois. Application for permanent licensure
can be made after successfully passing Step 3 and completion of 24 months of clinical training.
After securing a permanent license, a physician must apply for a state controlled substance
number and the federal DEA number.
Temporary Fee is $100
Each resident in a program at SIU is required to obtain an Illinois medical license before
beginning their training. Residents in their first two years of training are only eligible for a
temporary physician license. Once a resident has successfully completed 24 months of residency
training at SIU or another program, that resident is eligible for a permanent license. Temporary
licenses are valid for three years and can be extended for the duration of their training. The
original license is held in the Office of Residency Affairs. See attachment A or B.

Permanent License Fee is $300
Application forms are in the Office of Residency Affairs. Residents are required to have had 24
months of clinical training before they can apply for a permanent license. A copy of the medical
school diploma and official transcripts from college and medical school are required when the
application is submitted. See attachment C. Illinois controlled substance license and DEA
license can be applied for once a permanent license has been received.

Limited Temporary License Fee is $100
A limited license is valid for six months. This type of license is appropriate for the individual
who is currently in a residency program outside of SIU but would like to come to SIU to do an
elective, usually one or two months.
Extension of License Fee is $100
Any resident who has an existing temporary license may apply for an extension of that license as
long as they are in an approved residency program. The resident needs to complete a temporary
license application along with the WH form and submit it to the Office of Residency Affairs.
The Office of Residency Affairs completes the CA-MED form, attaches the current license, and
submits the application to the Department of Professional Regulation. A letter of explanation
supporting the extension needs to come from the program director.

Transfer of Temporary License Fee is $20
In order to transfer a resident from one program to another program within the institution or from
one institution to another within Illinois, it will be necessary for the resident to complete a
temporary application form and the WH form and submit them to the Office of Residency
Affairs. The Office of Residency Affairs will complete the CA-MED form and submit it with
the application to the Department of Professional Regulation along with the original temporary
license. A letter of explanation supporting the transfer needs to come from the program director.
MEDICAL LICENSE POLICY FOR RESIDENTS

All residents at SIU training programs are required to obtain and maintain an active medical
license. It is the resident’s responsibility to maintain an active license. PGY-1 and PGY-2
residents must obtain a temporary medical license and are required to apply for the license in a
timely fashion once agreeing to start at SIU. Residents cannot practice or be paid until they have
been issued an active license.

All temporary medical licenses will be kept in the Office of Residency Affairs. The Office of
Residency Affairs will provide copies of licenses to hospitals, programs, the resident and others
as requested. If a resident on a temporary medical license leaves an SIU training program, the
Office of Residency Affairs will return the license to DPR, in accordance with state law.

Residents at level PGY-3 or above may either obtain a temporary medical license or a permanent
license. Once a resident obtains a permanent license, the resident is required to also obtain state
and federal DEA numbers. Programs will notify the Office of Residency Affairs if a resident
moves from a temporary to a permanent license.

Although many individuals at the program level and the Office of Residency Affairs assist
residents in remembering that a license will expire, it is ultimately the residents’ responsibility to
maintain an active license. Residents who fail to do so cannot practice and will be immediately
suspended without pay until a license is reissued.

Approved By GMEC April 15, 2005
DEA NUMBERS
Once a resident/fellow has received his/her permanent Illinois medical license, he/she is eligible
to apply for an Illinois State Controlled Substance number and a DEA federal drug number. The
forms for controlled substance and DEA numbers are available from the Office of Residency
Affairs.

Those residents who have a temporary medical license are assigned a DEA number through their
employing hospital. That number is a combination of the hospital DEA number and the
resident’s dictation number.

NPI NUMBERS
Once a resident/fellow has obtained his/her temporary or permanent Illinois license, SIU will
obtain a National Provider Identifier (NPI) number for new residents and fellows. The NPI
number will remain with the individual throughout their medical career.

Although residents/fellows do not practice as independent practitioners unless they are
moonlighting, with the advent of the EHR, NPI numbers will be necessary to allow our hospitals
and SIU to arrange the flow of lab results, etc., to residents for review before attendings. This is,
in turn, necessary for them to learn and to assume progressive levels of responsibility

In August a complete listing of residents and their DEA and NPI numbers is distributed to
Springfield area pharmacies.
ORIENTATION
Orientation of new residents to the Springfield site occurs between June 25 – June 30 of each
year as possible. It is a joint effort between SIU, Memorial Medical Center and St. John’s
Hospital. Preparation for orientation begins in April. The hospitals alternate hosting orientation.
Orientation is required for all new residents and fellows regardless of training level.

Orientation begins at 8:00 AM. Once the itinerary is confirmed, sufficient copies are sent to the
program directors to send to the new residents/fellows. Things to be accomplished at
Orientation:
• Welcome and instructions from SIU
• Welcome and instructions from Memorial Medical Center
• Welcome and instructions from St. John’s Hospital
• Enrollment for payroll and benefits
• Official photograph of each resident/fellow for Residency Affairs
• Photo and acquisition of identification card for St. John’s and Memorial Medical Center

Food is provided compliments of the hosting hospital. Current CPR and ACLS instruction is a
mandatory requirement by the affiliated hospitals. An ACLS class is usually given the week-end
before orientation. ACLS is paid by the affiliated hospitals. The resident pays for CPR.

IDENTIFICATION
For security reasons, photo identification badges will be issued by both St. John’s Hospital and
Memorial Medical Center at the beginning of training at SIU. All residents and fellows are
required to wear a hospital/ SIU photo identification badge when on duty in the hospital.

PARKING CARDS/STICKERS/SECURITY
PARKING – SECURITY
All St. Johns and Memorial parking lots/garages are monitored in real time by multiple security
cameras. In the 9th Street ramp, emergency call buttons or phones are located on all levels in all
four corners of the parking garage and in the elevator foyer. At the MMC parking garage, if you
enter through the tunnel, there is an emergency call button located at the entrance to the hospital.
Residents coming to MMC at night can avoid the tunnel by entering the hospital directly through
Engineering Exit #19, which is located across from the west side of the parking lot. Security
personnel are available 24 hours a day to provide escorts to or from the parking area. Please do
not hesitate to utilize this service if you have concerns for your personal safety.

SOUTHERN ILLINOIS UNIVESITY SCHOOL OF MEDICINE
SIU stickers may be purchased from the Security Office at 801 North Rutledge. When an SIU
sticker is displayed, a vehicle may be parked in any of the SIU parking areas.
MEMORIAL MEDICAL CENTER
The Security office at Memorial Medical Center issues a blue hang tag to residents after they
complete an application card. Residents should park in the blue spaces in the physician’s
parking ramp adjacent to the hospital. The entrance is on 1st Street. Residents may park in the
white (attending) spaces between 4:00 p.m. and 7:00 a.m. Monday through Friday and all day on
weekends. Residents who park in an attending space during the night must move their vehicle
before 7:00 a.m. or risk being towed.
ST. JOHN’S HOSPITAL
Residents are to have a green/white adhesive sticker attached to their vehicle’s rear bumper or
back window. Additional or replacement vehicle stickers may be obtained from the Security
office, Room 1004A. You are asked to park in locations designated for residents at all times (see
map).
Reserved parking for residents is located on the east side of the first level of the 9th Street ramp.
In addition, residents may park in the attending physician parking area, bays 5-7, (accessed via
7th Street) between 4:00 p.m. and 7:00 a.m. Monday through Friday and all day on weekends.
Residents who park during the night in an attending space must move their vehicle before 7:00
a.m. or risk being towed. If you are exiting the hospital into the attending parking lot during the
day, watch for cars very carefully. There is a glare and cars coming down the ramp into the lot
may not be able to see you well.
In order to access the 9th Street ramp, north employee doors, library, ICU, 3rd floor connecting
link into the WCC, the attending physician’s entrance, the emergency department hallways, the
medical records, physicians lounge/physician’s completion area, the residents need to get their
employee ID activated at the security office. Any questions regarding parking, security or
personal safety may be directed to Security at extension 44020.
LAB COATS
All residents will be given 3-5 coats at the beginning of their training. It will be up to the
program to determine the appropriate number for their residents. All fellows will be given 2
coats for the entire length of their fellowship. Each department will place their own order for
coats for their incoming residents/fellows and have them shipped directly to their own office,
with the bill going to the Office of Residency Affairs. Any current residents or fellows can
purchase additional coats at their own expense. The Residency Affairs Office will provide
each department the necessary number of SIU patches which are to be sewn above the upper left-
hand pocket.

STIPEND NEGOTIATIONS
In December the Office of Residency Affairs meets with the administrators of both affiliated
hospitals in Springfield to discuss stipends and stipend increases which will become effective
July 1 of the current year. Stipend information is used from the AAMC Council of Teaching
Hospitals to arrive at the 75th percentile. Once the stipends are confirmed, a memo is sent to
the program directors indicating the new stipends.

RESIDENT STIPEND POLICY

It is agreed that SIU School of Medicine, Memorial Medical Center and St. John’s Hospital will
follow the guidelines below in setting resident stipends:
1. Negotiate resident stipends annually.

2. Maintain stipends at the 75th percentile for the Midwest.

3. Pay stipends at the functional level of training.

4. Stipends will be approved by the GMEC.

5. Cap resident stipends at the PGY VII level.

6. Compensate beginning fellows based upon the minimum number of prior graduate
medical education required for admission to the fellowship program.

7. Pay residents who must repeat a year for academic reasons at their functional level of
training.

8. Not refuse residents who have completed a prior residency, but pay them at their
functional level.
Revised and Adopted by GMEC on November 16, 2007
RESIDENT WELLNESS
Residency training is a time of tremendous personal and professional growth. It can also be very
stressful. It is not at all uncommon for residents from time to time feel stressed, overwhelmed,
burned-out, or even to develop clinical depression. If you should experience any of these, we
encourage you to seek or accept help. You do not need to shoulder these burdens alone. If you
are feeling overwhelmed, find someone you trust to talk to, whether it be a colleague, friend or
family member, your doctor, your pastor, or your program director. For any resident who needs
some professional assistance, multiple resources are available.
1) An employee assistance program is provided for all residents and fellows by their employing
hospital. This program provides professional, confidential assistance to anyone who is having
difficulties with marital or family situations, depression, drugs or alcohol, job stress, aging
parents, chronic physical disability or other personal problems. Trained employee assistance
counselors offer information, assessment and short-term counseling, as well as referral for
special situations on longer-term needs.
This service is free, and no record of contact with the employee assistance counselor is placed in
your medical records, Health Service records or personnel file. All contact is kept confidential,
except as required by law or in situations deemed potentially life-threatening by the EAP
coordinator.
Memorial Medical Center Toll Free (888) 817-8989
Employee Assistance Program
St. John’s Hospital (217) 744-2255
Employee Assistance Program
2) Any resident or fellow who is in need of brief intervention by a psychiatrist has available to
them one evaluation and up to six follow-up visits, free of charge and no questions asked.
Residents can choose from psychiatrists in the community or SIU faculty. Any resident wishing
to utilize this service can contact the Office of Residency Affairs (545-8853) and be assigned a
confidential number. You do not need to give your name. The resident can then contact one of
the following psychiatrists, give them the confidential number, and set up an appropriate
appointment. All treatment information is kept confidential except as required by law, or if the
resident gives permission. Participating psychiatrists are:
• Joseph Bohlen, MD (546-3100)
• Catherine Fox, MD (793-0680)
• SIU Psychiatrists (contact Jill Teopfer 545-7675 for an appointment)
• Laura Shea, MD (726-7300)
• Andrea Stonecipher, MD (793-0680)
3) Coverage for longer term counseling, psychiatric care or formal substance abuse treatment is
available through your health insurance. Details regarding mental health benefits for the various
policies available to residents can be found at the websites listed below or by contacting the
Office of Residency Affairs.

Health Alliance HMO – www.healthalliance.org
Personal Care HMO – www.personalcarehmo.com
4) The Illinois Professionals Health Program is an advocacy program for impaired Illinois health
professionals sponsored by the Illinois State Medical Society, the Illinois State Medical
Insurance Exchange and other professional health organizations. This program is available to
provide initial intervention, screening, and referral services as well as coordination of care and
case management for impaired professionals (including substance abuse.) They can coordinate
intervention services, handle referrals to approved treatment providers for assessment and
treatment, and make after-care arrangements. This program is available to all Illinois physicians,
residents, and medical students. This program is independent from the Illinois Department of
Professional Regulation. The contact person is:
Stafford Henry, MD, FASM
(847) 795-2875
stafford.henry-md@advocatehealth.com
5) A variety of interesting materials regarding nutrition, wellness, stress management and mental
health are available at the Office of Residency Affairs website (www.residency@siumed.edu).
This can be accessed via the internet.
Recognition of Impairment in Residents/Fellows
Impairment: “A physical or mental condition which causes a resident/fellow to be unable to
practice medicine with reasonable care and safety commensurate with his/her
level of training”
(SIU SOM)
Signs of Impairment: Not diagnostic – non-specific indicators that something is wrong
You may observe these or others might report them to you
Many of these signs can occur intermittently in any resident
(especially post-call) – patterns raise concern
*These items warrant immediate intervention
Physical *alcohol on breath (at work)
Looks bad - poor grooming, poor hygiene, overly tired
Increase in physical complaints
Decrease in attention span
Noticeable change in weight
Pupils dilated or constricted
Long sleeves in hot weather
Social/Behavioral *Intoxicated at work/on-call
*Reports of stated suicidal ideations by resident
*Suicide attempt
*Resident asks for help
Withdrawn/isolating
Less responsible/unpredictable
Irritable
Defensive/argumentative
Having conflicts with peers/supervisors/staff
Unexplained accidents/ER visits
Frequent intoxication at department functions
Crying
Mood changes
Inappropriate comments, jokes, etc.

Professional *Critical incident
*Self-prescribing (controlled substances)
*Asking peers to prescribe controlled substances for them
Unexplained absences
Decline in dependability (doesn’t answer pages, etc.)
Decline in quality of work
Inappropriate orders
Complaints from supervisors
Complaints from patients, staff, peers

Residency Program Director Responsibilities/Resources

Responsibility Resources

Talk to the resident Dr. Broquet, Chief Resident

Determine if resident is impaired Impairment Policy
Dr. Broquet

If impaired, take steps to protect patient safety Impairment Policy
(extra supervision, medical leave, suspension, etc.) Dr. Broquet

Whether impaired or not, Quick Reference for Mental Health Treatment
help resident access help: be familiar with Illinois Professionals Health Program
assessment/treatment resources Dr. Broquet
(physical, substance abuse, mental health)
Fitness for Duty Evaluations
From time to time program directors have requested psychiatric fitness for duty evaluations. The
information below may be helpful for program directors in preparing a trainee for a fitness duty
evaluation and for understanding what can be gleaned from this.
Specific questions may center on the presence of psychiatric or neuropsychiatric impairment.
Impairment is defined as the inability to practice medicine with reasonable skill or safety
commensurate with the trainee’s level of training, as a result of illness or injury. Illness may
refer to psychiatric disorders including substance use disorders, as well as physical disease or
disability. Impairment is closely related to fitness for duty. Boundary violations (such as sexual
misconduct, unethical or illegal behavior, or maladapted personality traits) may precipitate an
evaluation but do not necessarily result from disability or impairment due to a psychiatric illness.
Likewise a physician may have difficulty practicing safely based on lack of adequate knowledge,
training or skill. Detailed evaluation of such problems is not within the scope of the psychiatric
fitness for duty evaluation.
A psychiatrist may be asked to:
• Examine the trainee
• Prepare a report of detailed diagnostic findings and treatment options
• Offer an opinion regarding fitness for duty.
A fitness for duty evaluation must address the specific functional tasks of the particular trainee’s
duties. Therefore, the following information should be provided to the examiner:
• A criterion- based job description, or a list of resident responsibilities
• Specific questions the program would like addressed
• Any collateral information that can help the psychiatrist more fully understand the
resident’s functional level.
Since the purpose of a fitness for duty evaluation is generally to provide information to an
employer (or in this case the program director), the resident needs to know in advance of the
limits of confidentiality and sign appropriate releases for communication between the evaluating
psychiatrist and the program director.
In a fitness for duty report, the evaluating psychiatrist will attempt as completely as possible to
address the following:
• The specific questions posed by the program director.
• An opinion about whether the resident physician suffers from a psychiatric illness and
whether that illness, if present, interferes with the physician’s ability to practice safely in
his/her particular job,
• The specific reasons for and areas of impairment
• Whether training can safely take place under specific conditions (such as prescribed work
place conditions, treatment and/or treatment monitoring, etc, )
• As noted earlier, the report will limit the evaluator’s expert opinion to questions of
psychiatric impairment, not assessments of unsafe medical practice due to lack of skill,
knowledge or training.
Adapted from Anfang S, et al. The American Psychiatric Association’s resource Document on Guidelines for
Psychiatric Fitness-for-Duty Evaluations of Physicians. J Am Acad Psychiatry Law 33:85-8, 2005
SPEAKING SKILLS
ORAL ENGLISH
According to Public Act 84-1434: Oral English Proficiency in Instruction, it is mandatory that all
individuals who provide “clinical teaching” must be certified as being proficient in the oral use
of the English language. After completing the form for each new resident, it should be
forwarded to the Office of Residency Affairs where it will be retained in the resident’s file.
(Copy of form on the next page.)

ENGLISH PRONUNCIATION
If English is a resident’s second language, he/she may experience some difficulty making
himself/herself understood by English-speaking listeners. Accent differences can create
significant difficulties when communicating with patients and their families. The resident may
also experience reduced effectiveness during formal presentations and clinical interactions with
medical colleagues.
POLICY REGARDING AMERICANS WITH DISABILITIES ACT
In accordance with the Americans with Disabilities Act, it is the responsibility of the Office of
Residency Affairs to ensure that residents with disabilities who are otherwise qualified are
afforded reasonable accommodations to enable them to perform their duties and to insure that
qualified physicians with a disability who are applying to residency positions are not
discriminated against because of any non-disqualifying disability.

SIU and its Affiliated Hospitals are an Affirmative Action/Equal Opportunity employer and do
not discriminate on the basis of race, religion, national origin, gender, age, disability or other
factors prohibited by law in any of our educational programs, activities, admissions, or
employment practices.

It is the responsibility of the program director and the faculty to rank the individual candidates by
fair and reasonable standards which are not biased by the presence of non disqualifying
disabilities.

Approved by the GMEC October 16, 1992
Revised and Adopted by the GMEC on November 16, 2007
PROCEDURE FOR COMPLETION OF AGREEMENT WITH PHYSICIANS

Program Coordinators will be sent an electronic copy of the contract(s) for their respective affiliate
hospital(s). Five copies of each Agreement, with original signatures of the resident and the program
director, should be forwarded to the Office of Residency Affairs.

The hospital executive will enter the date onto the first line of the contract. Inform the resident not to fill
in this area.
The hospital executive officer will be the last person to sign the Agreement.
Legal Counsel will not accept white-out on any of the Agreements. Therefore, any contract with errors
will be returned to you for a newly executed contract.

A sample Agreement is attached for your convenience: The defaults in which to enter information are:
1. Type full name of resident including "M.D." or “D.O.”.
2. Type name of university where M.D. or D.O. degree was obtained.
3. Type year M.D. or D.O. degree was obtained.
4. Type "first-year resident" or "second-year resident" etc., whichever is applicable.
5. Type name of your department.
6. Type starting date, setting date in full: e.g., July 1, 2002 (not 7/1/02).
7. Type ending date, setting date in full: e.g., July 1, 2003 (not 7/1/03).
8. Type in dollar amount setting it in full, e.g. Thirty-eight thousand fifteen dollars and no/100.
9. Type in numerical delineation of dollar amount, e.g. $38,015.
10. Dates determined by your RRC.
11. Dates determined by your RRC.
12. Dates determined by your RRC.
13. Type in MD or DO
14. Type in name of the Program Director
15. Type in the resident license number, if other than a first year resident

After all five copies of the contract are printed and signed by the resident and Program Director, please
forward them to the Office of Residency Affairs, P.O. Box 19656, Springfield, IL 62794-9656 or Mail
Code 9656. The Office of Residency Affairs will secure the signature of the Dean and for Springfield
programs, the respective hospital official. After the signatures are obtained, two copies of each
Agreement will be returned to your department -- one copy for your files; the other for the resident.

Each resident must be provided a copy of the following as part of the Agreement document:
• Vacation and Other Leaves of Absence Policy
• Employing hospital benefits package
• Impairment Policy
• Resident Grievance Procedure
• Program Reduction and Closure Policy.
• Duty hours section of the current RRC program requirement
• USMLE Licensing Policy
• Disruptive Physician Policy
Affiliate
Hospital
Logo

AGREEMENT WITH PHYSICIAN - 2009-2010
THIS AGREEMENT, made and entered into this day of __
, 20 by the BOARD OF TRUSTEES OF SOUTHERN ILLINOIS UNIVERSITY,
a body politic and corporate of the State of Illinois, located at Carbondale, Illinois, for and on
behalf of Southern Illinois University School of Medicine, hereinafter referred to as the “School
of Medicine,” and AFFILIATE HOSPITAL, SPRINGFIELD, ILLINOIS, a not for profit
corporation of the State of Illinois, located at Springfield, Illinois, hereinafter referred to as the
“Affiliated Hospital,” and 1, a graduate of 2 , class of 3, hereinafter referred to as the
“Physician.”

WITNESSETH THAT:

The Physician hereby accepts the position of 4, in the Department of 5 at the School of
Medicine. The term of this agreement shall be for one (1) year commencing on 6, hereinafter
referred to as the “commencement date,” and terminating on 7 and shall renew automatically for
additional periods until completion of the Physician’s Residency or Fellowship Program,
hereinafter referred to as the “Residency Program,” unless notice of non-renewal is provided in
accordance with Paragraph H. hereof. This Agreement and any renewal hereof are contingent
upon proof acceptable to the Program Director that the Physician has been issued (i) a temporary
or permanent license from the Illinois Department of Professional Regulation and (ii) a valid visa
(when required by law). Anything to the contrary herein notwithstanding, in the event that such
proof of licensure and visa status is not provided by the Physician to the Program Director by the
commencement date of this Agreement or any renewal thereof, this Agreement and any renewal
hereof may be terminated without advance notice at the joint discretion of the Affiliated Hospital
and the School of Medicine. In consideration of the Physician’s acceptance of the aforesaid
position, and of the covenants and agreements herein contained, the parties hereto do mutually
agree as follows:

A. THE AFFILIATED HOSPITAL SHALL:

1. Pay the Physician total annual compensation of 8 ($9) for the term of this
Agreement, which compensation shall be prorated and paid on a bi-weekly basis.
The amount of compensation to be paid to the Physician will be subject to
adjustment on July 1 based on any generic changes in the rate of physician
compensation authorized by the Affiliated Hospital during the term of this
Agreement.
2. Provide the Physician with professional liability coverage under the insurance
program of the Affiliated Hospital. Said professional liability coverage, whether
by enrollment in a program of self-insurance, inclusion under a professional
liability insurance policy or a combination thereof, shall extend to the Physician
while the Physician is performing professional duties and responsibilities as a part
of the Physician’s Residency Program, provided, however, that said professional
liability coverage shall not apply to professional acts performed outside the scope
of the Residency Program. Said professional liability coverage shall provide legal
defense and protection against awards from claims reported or filed during or
after the completion of the Residency Program, if the alleged acts or omissions of
the Physician were within the scope of the Residency Program, in accordance
with the Affiliated Hospital’s self-insured trust and liability policy.
3. Provide health, dental, disability and life insurance benefits for the Physician
under the employee insurance program of the Affiliated Hospital, described in the
Summary of Plan Benefits attached hereto. Health insurance benefits shall begin
on the first recognized day of training. The Affiliated Hospital shall have the
right to change such Plan Benefits during the term of this Agreement if said
changes are consistent with changes made in the Plan Benefits of the Affiliated
Hospital. The Physician shall have the option to include immediate family
members under said insurance program at the Physician’s own expense.
4. Provide designated sleeping quarters and meals for the Physicians during in-house
call.
5. Provide the Physician with vacation (paid time off), educational leave, child care
leave, bereavement leave, sick leave and job search leave according to the
“Vacation and Other Leaves of Absence Policy” attached hereto. This is also
available on the SIU website at
http://www.siumed.edu/resaffairs/ResidentResources/resresources.html.
a. In the event that the Physician accumulates a total of more than 10
calendar days of absence from the Residency Program during the term of
this Agreement (including vacation [paid time off], educational, child care,
bereavement and sick leave, suspension [with or without pay] or other
absence), the Physician shall be notified in writing by the Program
Director as to whether such absence necessitates remedial work in order to
fulfill the requirements of the Residency Program. Such notification shall
be provided to the Physician prior to any planned leave (or at the earliest
practicable time after any unplanned leave) which causes the Physician to
exceed this limit on absence from the Residency Program.
6. Provide the Physician with counseling, medical and psychological support
services and measures to address physician impairment, including that due to
substance abuse as described in the Impairment Policy attached hereto. This is
also available on the SIU website at
http://www.siumed.edu/resaffairs/ResidentResources/resresources.html.
7. Provide the Physician with such other benefits (including military leave), which
are not inconsistent with the provisions of this Agreement, as are provided by the
Affiliated Hospital through its existing policies.

B. THE SCHOOL OF MEDICINE SHALL:

1. Establish and provide general supervision and guidance to the Physician as well
as an educational program within each Department which complies with the
education requirements as determined by the Accreditation Council for Graduate
Medical Education (ACGME) and/or American Osteopathic Association (AOA).
2. Provide program direction and select faculty who determine resident proficiency
to perform clinical duties and the degree of supervision necessary in the
management and treatment of patients.
3. Consult with and obtain approval of the Affiliated Hospital prior to any change,
expansion or extension of the Residency Program outside the facilities of the
Affiliated Hospitals.
4. Adhere to duty hours which comply with the appropriate institutional and
program ACGME/AOA requirements. (A copy of current ACGME/AOA
requirements is appended to this Agreement. This is also available on the SIU
website at
http://www.siumed.edu/resaffairs/ResidentResources/resresources.html)
5. Adhere to the Residency Program Closure/Reduction Policy of the Graduate
Medical Education Committee attached hereto. This is also available on the SIU
website at
http://www.siumed.edu/resaffairs/ResidentResources/resresources.html.
6. Adhere to the ACGME/AOA or requirement to not require the Physician to sign a
non-competition guarantee.

C. THE PHYSICIAN SHALL:

1. Perform such duties as may be assigned to the Physician by the Program Director
in accordance with the description of the Residency Program prepared by the
Program Director and subject to the approval of the Affiliated Hospital, which
duties shall be performed by the Physician conscientiously, to the best of the
Physician’s ability and under the highest personal bond of professional morals
and ethics.

The Physician shall meet the qualifications for resident eligibility as outlined in
the Selection, Evaluation, Supervision, Graded Responsibility, Promotion/Non-
Promotion And Dismissal Of Residents Policy and as determined by the
ACGME/AOA.

As the position of the Physician involves a combination of supervised,
progressively more complex and independent patient evaluation and management
functions and formal educational activities, the competence of the Physician shall
be evaluated by the Program Director on a regular basis with a record of the
evaluation being held in the Physician’s program file. Such evaluation will be
part of the quality assurance program established for the purposes of reducing
mortality and morbidity within the Affiliated Hospital.

Under the supervision of approved credentialed attending teaching staff, the
Physician shall:
a. Provide patient care that is compassionate, appropriate, and effective for
the treatment of health problems and the promotion of health
b. Demonstrate medical knowledge about established and evolving
biomedical, clinical, and cognate (e.g. epidemiological and social-
behavioral) sciences and the application of this knowledge to patient care
c. Participate in practice-based learning and improvement that involves
investigation and evaluation of their own patient care, appraisal and
assimilation of scientific evidence, and improvements in patient care
d. Practice interpersonal and communication skills that result in effective
information exchange and teaming with patients, their families, and other
health professionals
e. Exhibit professionalism, as manifested through a commitment to carrying
out professional responsibilities, adherence to ethical principles, and
sensitivity to a diverse patient population
f. Participate in systems-based practice, as manifested by actions that
demonstrate an awareness of and responsiveness to the larger context and
system for health care and the ability to effectively call on system
resources to provide care that is of optimal value
g. Participate fully in the educational and scholarly activities of his /her
program and, as required, assume responsibility for teaching and
supervising other residents and students
h. Participate in appropriate institutional committees and councils whose
actions affect residents' education and/or patient care
i. At least annually submit to the Chair of the GMEC (through the Office of
Residency Affairs) a confidential written evaluation of the program
faculty and of the educational experiences
j. Regularly, or at a minimum of once a week, log on and review electronic
mail on the Physician's School of Medicine electronic mail account

2. Abide by and at all times conform to the Corporate and Medical Staff Bylaws,
Occupational Safety and Health Administration (OSHA), Health Insurance
Portability and Accountability Act (HIPAA), and the Illinois Department of
Public Health (IDPH) infection control policies and other rules, regulations and
policies of the Affiliated Hospital; the rules and regulations of the School of
Medicine and all other general guidelines and moral codes, both stated and
published, governing the practice of medicine; and the statutes, rules and
regulations of the State of Illinois, including without limitation the Medical
Practice Act and any and all other laws, rules and regulations relating to the
licensing of physicians in training and the practice of medicine in the State of
Illinois.
3. Accept no responsibilities for professional activities outside the scope of the
Residency Program provided herein (including, but not limited to "moonlighting")
unless approved in writing by the Affiliated Hospital and the Program Director,
who shall have discretion as to whether or not such outside professional activities
are permitted. With regard to those residency programs in which outside
professional activities may be permitted, the physician shall adhere to the policy
on professional activities outside the scope of residency training as approved by
the GMEC.

D. Board requirements applicable to the Residency Program specify that the Physician must
perform 11 months of actual service in a 12 -month period. Anything in this Agreement
to the contrary not withstanding, it is understood and agreed by the Physician that if,
because of approved leave or other absence, the Physician does not meet said Board
requirements, it may be necessary for the Physician to extend the duration of the
Residency Program until said Board requirements have been satisfied.

E. The Physician agrees to abide by a risk management and quality control program which
shall provide, without limitation, for the following:
1. The joint review of the Physician's credentials by the Affiliated Hospital and the
School of Medicine.
2. The joint indoctrination of the Physician with respect to the Physician's
responsibilities to the patient, the School of Medicine, and the Affiliated Hospital.
3. The suspension of the Physician for an indefinite period of time, for failure to
comply with this Agreement or for reasonable cause, by the appropriate officials
of the School of Medicine or the Affiliated Hospital. If such an event occurs, the
Physician may be suspended from training and clinical duties without
compensation as identified herein.
4. Compliance by the Physician with the institution's policy regarding licensing
examinations.
5. Compliance by the Physician with regulations regarding completion of medical
records at Memorial Medical Center and St. John's Hospital.
6. Compliance by the Physician with regulations regarding completion of time
records at Memorial Medical Center and St. John's Hospital.
7. Compliance with all required education modules including on-line modules as
proscribed by the Affiliated hospitals and the School of Medicine.

F. Physician agrees and understands that the School of Medicine is responsible for teaching,
supervision and formal evaluation of the Physician in the Residency Program.

G. This Agreement may be terminated at any time by joint decision of the Affiliated
Hospital and the School of Medicine, in which case the Physician's compensation
specified herein will be prorated to the date of termination and the Physician will be paid
for vacation (paid time off) earned but not used prior to the date of termination. In the
event that a grievance is filed by the Physician under the Resident Grievance Procedure
attached hereto, pay and benefits may be continued at the discretion of the Affiliated
Hospital. Decisions regarding advancement in the program will be made in accordance
with the Selection, Evaluation, Supervision, Graded Responsibility, Promotion/Non-
Promotion And Dismissal Of Residents Policy.

H. The Physician shall be notified in writing by the Program Director, subject to the
approval of the Affiliated Hospital, in the event the Physician's contract shall not be
renewed for the following year. Said notice shall be provided at least four months prior to
the expiration of the contract year or when a resident will not be promoted to the next
level of training. As of the same date, the Physician shall notify the Program Director in
writing of an intention not to return for the following year. However, if the primary
reason(s) for the non-renewal or non-promotion occurs within the four months prior to
the end of the agreement, the Program Director will provide the Physician with as much
written notice of the intent not to renew as the circumstances will reasonably allow, prior
to the end of the agreement.

I. It is the policy of the School of Medicine and the Affiliated Hospital to maintain an
environment which is free from all forms of harassment based on a person's legally
protected status (including race, sex, national origin, religion, military status, age and
disability) and sexual harassment (herein after referred to as harassment), improprieties
and intimidation. The Physician is entitled to the protections afforded by these policies
while serving as a resident hereunder.

The Physician agrees to abide by the School of Medicine's and the Affiliated Hospital's
respective policies regarding equal employment, sexual harassment and harassment on
the basis of other protected status as set forth above. The Physician acknowledges that
failure to abide by these policies may result in immediate termination of this Agreement.
Allegations of discrimination and/or harassment will be addressed in accordance with the
applicable policies of the School of Medicine or the Affiliated Hospital.

J. It is understood and agreed by the parties hereto that, except as provided in Paragraph G.
of this Agreement, grievances initiated by or against the Physician shall be addressed in
accordance with the terms and conditions of the Resident Grievance Procedure.

K. Unless otherwise mutually agreed by the Physician and the Program Director, at least
thirty (30) days' advance notice of intent to resign from the Residency Program must be
given, in writing, by the Physician to the Program Director.

L. This Agreement constitutes the entire agreement and understanding between the parties
with respect to the subject matter hereof; supersedes all prior agreements, written or oral,
between the parties with respect to such subject matter and may be modified only by a
written agreement signed by all of the parties.

M. The validity, interpretation and effect of this Agreement shall be governed by the laws of
the State of Illinois. The parties hereby consent to the jurisdiction of the appropriate
courts located in Illinois for the resolution of any dispute arising hereunder.

N. In the event that one or more of the provisions of this Agreement is or are declared
illegal, void or unenforceable, that shall not affect the validity of the remaining
provisions of this Agreement.

O. This Agreement and the enrollment of the Physician in the Residency Program is
contingent upon the Physician submitting to and successfully passing a post-offer drug
and alcohol test as specified by the Affiliated Hospita1’s drug and alcohol testing
program. The Physician shall not have the right to grieve his/her failure to successfully
pass the post-offer drug and alcohol test pursuant to the Resident Grievance Procedure.

IN WITNESS WHEREOF, the parties hereto have caused this agreement to be executed the day
and year first written above.
ACCEPTED: PHYSICIAN:

M.D. , 13
14 Illinois License No 15
Residency Program Director

BOARD OF TRUSTEES OF AFFILIATE HOSPITAL
SOUTHERN ILLINOIS UNIVERISTY SPRINGFIELD, ILLINOIS

J. Kevin Dorsey, MD, PhD
Dean and Provost for Chief Operating Officer
Samuel Goldman, PhD, Interim Chancellor
Southern Illinois University at Carbondale

Amended and Approved by GMEC October 17, 2008
POLICY REGARDING MILITARY LEAVE OF
ABSENCE FOR SIU RESIDENTS AND FELLOWS
All affiliated hospitals have current policies regarding military leave for their employees which
preserve the employee’s position and coordinate benefits, such as health insurance. In the event
that it becomes necessary for a resident or fellow to be called into active duty, the policy of the
employing hospital will become effective. It will be the responsibility of the resident to work
with the appropriate employing hospital to ensure that the necessary paperwork is completed
before the resident leaves for duty.

Approved by GMEC October 19, 2001
Reviewed and Approved by GMEC January 19, 2007
Memorial Medical Center

Delinquent Medical Records and Duty Hour Records
Residents have a contractual obligation to complete medical records, annual on-line training
requirements and duty hour records in a timely fashion. SIU School of Medicine and its
affiliated Springfield hospitals have set standards for when these are considered delinquent and
have established clear methods of notification for the residents. If delinquent medical records,
annual on-line training and/or duty hour records are not completed by the designated deadline,
the resident will be suspended with loss of clinical/hospital privileges and clinical credit toward
training requirements, until the delinquency is corrected. The minimum time of suspension will
be one day. Vacation or other leave time cannot be used to make this time up.

If a resident incurs a cumulative number of days of clinical suspension that is equal to the
number of years in their training program (i.e. 3 days for a 3 year program), he/she will then
receive a 7 day suspension with loss of clinical/hospital privileges, clinical credit and pay. This
7 day suspension will be scheduled by the resident’s program director at a time when it is least
disruptive to the program and will in all likelihood result in delayed graduation date.

If a resident then amasses 2 more cumulative days of clinical suspension (even if they occur
before the 1 week suspension has been served), the resident will be subject to termination.

Approved by the GMEC March 20, 2009
RECRUITMENT OF RESIDENTS/FELLOWS
FOR UNFILLED POSITIONS

From time to time situations will arise in which a residency position may be offered for unfilled
slots (e.g. unanticipated vacancies, expansion of program number etc.). Communication with the
Office of Residency Affairs is essential when considering a candidate for residency in these
circumstances. Approved positions must exist before resident physicians can be accepted.
Credentialing must be completed and approved by the hospitals before a final employment
contract may be offered to a resident. Licensing and visa compliance are always necessary
before a resident starts working.

Applicants must submit to the program:
1. Application for residency
2. Dean’s letter and/or official transcripts
3. At least three letters of recommendation
4. Board scores

A letter of intent is binding for both the applicant and the program. If a letter of intent is
necessary, the letter must include the following:

1. Statement indicating the level of training
2. Dates of the contract being proposed
3. Yearly stipend amount
4. Statement indicating the offer is contingent upon departmental and hospital approval
(Resident Credentialing Policy)
5. Statement indicating employment is contingent upon obtaining an appropriate Illinois
State License.

Approved by the GMEC September 13, 2002
Reviewed by GMEC December 21, 2007
IMMIGRATION INFORMATION
Section 5

SUBJECT
Resident Eligibility and Employment Authorization Policy
ECFMG Policy
AAMC Immigration Primer for Institutional GME Officials
J-1 Issues Within GME Context
ECFMG (EDUCATIONAL COMMISSION FOR FOREIGN MEDICAL GRADUATES)

All International Medical Graduates (IMGs) must hold a valid ECFMG certificate to be eligible
for SIU residency positions and to receive an Illinois medical license. To receive an ECFMG
certificate the IMG must pass the ECFMG and VQE exam, the FMGEMS, or the USMLE.
IMGs from Canada do not need an ECFMG certificate.

In order to receive a visa for an International Medical Graduate who is not a permanent US
resident, it is necessary to submit an application to the ECFMG office to receive an IAP-66 form
which will allow the IMG entry into the US and to be able to work. This is a J-1 Visa (exchange
visitor). Copies of guidelines to complete sponsorship papers are attached along with an
application form. A requirement of the J-1 visa is that the resident must return to his home
country for two years.

The ECFMG office is located at 3624 Market Street, Philadelphia, PA 19104-2685. The
telephone number is 215-386-5900. Current information and forms are available on the internet
at www.ecfmg.org.

Graduates of Canadian medical schools do not need an ECFMG certificate. Canadian graduates
still need a visa and documentation that they have passed Step 2 CK and CS exams.
ACADEMIC INFORMATION
Section 6
SUBJECT
Advanced Cardiac Life Support and Cardio Pulmonary Resuscitation
Medicare Teaching Physician Guidelines and Procedures
Procedure for Post Graduate Medical Observership
SIU Resident Selected Off-Site Required Rotations and Off-Site Electives
Residents From Outside Programs Coming to SIU for Elective or Required Rotations
Policy for Off-Site Rotations Which Are Established as an Integral and Recurring
Component of a Residency Training Program
Certificates of Completion for Residents and Fellows
Licensing Examination (USMLE and COMLEX) Policy
Educational Resources at SIU
ADVANCED CARDIAC LIFE SUPPORT (ACLS)
AND CARDIO PULMONARY RESUSITATION (CPR)

Memorial Medical Center and St. John’s Hospital mandate that residents and fellows be
proficient in CPR and ACLS. Classes are provided by the affiliated hospitals. It is a pre-
requisite to have a current CPR card to take the ACLS course. It is the responsibility of the
resident/fellow to pay for CPR. The affiliated hospitals have agreed to pay for the ACLS course
if taken at MMC or SJH.
MEDICARE TEACHING PHYSICIAN GUIDELINES AND PROCEDURES
I. GENERAL RULE
If a resident or fellow participates in furnishing a service or procedure with a teaching physician,
a Part B payment may only be made if the teaching physician is present during the “key or
critical” portion of the service or procedure. Services performed by a resident or fellow outside
the presence of a teaching physician are not billable under Medicare Part B.

II. SPECIFIC RULE
There are three components to consider to comply with the new regulations.
A. Presence – of billing physician
B. Documentation – what and by whom
C. Level of Service – CPT-4 coding choices
The three major components are as follows:
A. PRESENCE
As a general rule the teaching physician must be present during the “key or critical”
portions of the procedure or service.

Physical presence during the key or critical portion of the service may be satisfied by:
• The teaching physician personally performs the service without a resident present or,
• The teaching physician and resident furnish the service jointly, or
• The resident, in the presence of the teaching physician, performs the service or
procedure.
Specific presence requirements are outlined below:
A-1 EVALUATION AND MANAGEMENT SERVICES
Personal presence is required during that portion of the service that determines the
level of service (DPT-4) billed. The three major portions of an E/M service
in determining the service level are; history, examination, medical decision
making.

EXCEPTION TO PERSONAL PRESENCE REQUIREMENT

Some lower level E/M services furnished in certain primary care centers and meeting certain
condition may be exempted from the personal presence requirement. The conditions are:
• The center must be located in an out-patient department of the hospital, or
ambulatory care site in which time spent by the resident is included in
determining direct GME payments to the teaching hospital. The program
must submit in writing a request for waiver to the Medicare fiscal
intermediary, and
• the resident must have finished at least six (6) months of an approved
residency program, and
• the teaching physician may not supervise more than four (4) residents
simultaneously, and
• the teaching physician must be in the immediate area where the services are
being rendered so as to constitute immediate availability, and
• the teaching physician should have no other responsibilities during the time
services are being delivered, and
• the teaching physician must assume responsibility for the care being
provided by the resident and ensure that the services are appropriate, and
• the teaching physician must review with each resident either during or
immediately following each visit the beneficiary’s history, physical
examination, diagnosis, tests and therapies, and
• the teaching physician must personally document his/her own participation
in the review and direction of the services furnished each beneficiary, and
• the patients seen must be an identifiable group of individuals (patient panels)
who consider the center their primary and continuing source of health care.
The levels of service under which the special primary care exception may be granted
are limited to the following CPT-4 service levels:
NEW PATIENT ESTABLISHED PATIENT
99201 99211
99202 99212
99203 99213

A-2 SURGICAL PROCEDURES
Surgical/Endoscopic Operations
• For surgical, high-risk, or other complex procedures, the teaching
physician must be present during all “critical or key” portions of the
service and immediately available to furnish the service during the entire
procedure.
• The teaching physician need not be present for the opening and closing of
the surgical field but must remain in immediate proximity and available to
return to the procedure immediately.
• If the teaching physician leaves the O.R. after the completion of the key
portion of the procedure to begin another case and the new case would
prohibit him/her from returning to the original case, the teaching physician
must make arrangements with another physician to be immediately
available for the original case.

• For procedures performed through an endoscope, the teaching physician
must be present during the entire viewing portion, which includes the
insertion and removal of the device.
Minor Procedures, which are extremely short in duration and involve
relatively little decision-making once the need for the procedure is determined,
requires the teaching physician to be present for the entire procedure.

A-3 DIAGNOSTIC RADIOLOGY AND OTHER DIAGNOSTIC
TESTS
Payment may be sought if the interpretation is personally performed by the teaching physician or
reviewed with the resident and so noted by the teaching physician.

A-4 PSYCHIATRY
• The requirement of personal presence of the teaching physician may be met
by concurrent observation of the service through the use of one-way mirrors
or video equipment.
• The concurrent observation of the resident-patient session must be in the
immediate area of the actual session.
• If the level of service has a time-based component, only the teaching
physician’s actual time of presence and/or observation may be considered
when choosing the appropriate billing level.

A-5 OTHER COMPLEX/HIGH RISK PROCEDURES
If the use of a CPT-4 code requires the personal presence and involvement of a physician (as
stated in the CPT-4 code description), the teaching physician must be present for the entire
procedure to satisfy the teaching physician guidelines.

B. DOCUMENTATION
General Documentation Instructions and Common Scenarios
CMS has clarified that for purposes of payment, Evaluation and Management (E/M) services
billed by teaching physicians require that they personally document at least the following:
a. That they performed the service or were physically present during the key or critical
portions of the service when performed by the resident; and
b. The participation of the teaching physician in the management of the patient.

On medical review, the combined entries into the medical record by the teaching physician and
resident constitute the documentation for the service and together must support the medical
necessity of the service. Documentation by the resident of the presence and participation of the
teaching physician is not sufficient to establish the presence and participation of the teaching
physician.

The following are three common scenarios for teaching physicians providing E/M services:
Scenario 1 –
The teaching physician personally performs all the required elements of an E/M service without
a resident. In this scenario the resident may or may not have performed the E/M service
independently.
In the absence of a note by a resident, the teaching physician must document as he or she
would document an E/M service in a non-teaching setting.
Where a resident has written notes, the teaching physician’s note may reference the
resident’s note. The teaching physician must document that he or she performed the critical
or key portion(s) of the service and that he or she was directly involved in the management
of the patient. For payment, the composite of the teaching physician’s entry and the
resident’s entry together must support the medical necessity of the billed service and the
level of the service billed by the teaching physician.

Scenario 2 –
The resident performs the elements required for an E/M service in the presence of, or jointly
with, the teaching physician and the resident documents the service. In this case, the teaching
physician must document that he or she was present during the performance of the critical or key
portion(s) of the service and that he or she was directly involved in the management of the
patient. The teaching physician’s note should reference the resident’s note. For payment, the
composite of the teaching physician’s entry and the resident’s entry together must support the
medical necessity and the level of the service billed by the teaching physician.

Scenario 3 –
The resident performs some or all of the required elements of the service in the absence of the
teaching physician and documents his/her service. The teaching physician independently
performs the critical or key portion(s) of the service with or without the resident present and, as
appropriate, discusses the case with the resident. In this instance, the teaching physician must
document that he or she personally saw the patient, personally performed critical or key portions
of the service, and participated in the management of the patient. The teaching physician’s note
should reference the resident’s note. For payment, the composite of the teaching physician’s
entry and the resident’s entry together must support the medical necessity of the billed service
and the level of the service billed by the teaching physician.

Rules for Student Documentation of Services
The revised regulations note that students may document services in the medical record.
However, the regulations stat “the documentation of an E/M service that may be referred to by
the teaching physician is limited to documentation related to the review of systems and/or past
family/social history.” The guidelines add that a “teaching physician may or may not refer to a
student’s documentation of physical exam findings or medical decision making in his or her
personal note. If the medical student documents E/M services, the teaching physician must
verify and redocument the history of present illness as well as perform and redocument the
physical exam and medical decision making activities of the service.”

EVALUATION & MANAGEMENT SERVICES-PRIMARY CARE
EXCEPTION
• The teaching physician must document the extent of his/her own personal participation
in the care of the beneficiary or the level of review and direction of the services
rendered to the beneficiary by the resident.
• At a minimum, a notation made in the medical record must clearly demonstrate:
• presence in the clinic with immediate availability to the residents, and
• personal oversight or detailed review with each resident of each case
including the history, exam, diagnosis and treatment plan.
B-2 SURGICAL PROCEDURES
Surgical Operations – When the teaching physician is involved in only a single
surgery, documentation of physical presence during the critical portion between
opening and closing of the surgical field can be made either by a personal note of the
teaching physician or by a resident’s or operating nurse’s notation.
If the teaching physician is involved in two overlapping surgeries, the teaching
physician must be present for each session’s key component. The teaching
physician must personally document the key portion of each and document his
physical presence for both cases.
Endoscopic Procedures – The teaching physician must document his/her presence
during the entire procedure which includes the insertion and removal of the device.

B-3 DIAGNOSTIC RADIOLOGY AND OTHER DIAGNOSTIC TESTS
The teaching physician must state that he/she personally viewed the image and
reviewed the resident’s interpretation and either agrees with or modifies the findings.

B-4 PSYCHIATRY
If personal presence during the service was not provided, the teaching physician
must explicitly state that his/her observation of the service was via a one-way mirror
or video equipment and was done concurrently with the service being rendered.

B-5 TIME-BASED COMPONENT
For these services the teaching physician must be personally present for the period
of time being billed and must explicitly document the time period he/she was
physically present and record any notes which substantiate the billed service. Time
expended by a resident outside the presence of the teaching physician may not be
included.

B-6 OTHER COMPLEX OR HIGH-RISK PROCEDURES
The teaching physician must document that he/she was physically present during that
portion of the procedure considered key or critical for billing purposes.

C. LEVEL OF SERVICE

The CPT-4 section dealing with E & M services is divided into broad categories
which are then divided into sub-categories which are further classified into levels of
E & M services. The hierarchy is a follows:
CATEGORIES – Office Visits, Hospital Visits, Consultations
SUB-CATEGORIES – New Patient, Established Patient, Initial Hospital
LEVELS OF SERVICE – Problem Focused, Expanded, Detailed,
Comprehensive (Moderate or High)
The levels of E/M services encompass a wide variation in skill, effort, time,
responsibility and medical knowledge. The descriptors of the various levels
recognize seven (7) components.
1. History
2. Examination
3. Medical Decision Making
4. Counseling
5. Coordination of Care
6. Nature of Presenting Problem
7. Time
Components 1 through 3 are considered the key or critical components in selecting the
appropriate level of service. Components 4 through 6 do not have to be considered in all
situations, but may aid the selection process. Component 7, Time, is to be considered as
averages of each of the levels of service and should be used as a general guide to aid in the
appropriate selection.

(July 1, 1996)
GRADUATE MEDICAL EDUCATION COMMITTEE
POLICY ON OFF-SITE ROTATIONS
WHICH ARE ESTABLISHED AS AN INTEGRAL AND RECURRING COMPONENT OF A
RESIDENCY TRAINING PROGRAM

Definition of Off-Site Required Rotation: The site must be beyond commuting distance (greater
than 60 miles away from home program), have in-house call or call-back required, and must last
longer than one week, but less than one year.

Required compensation during off-site rotation will include full reimbursement for salary plus
benefits. Medical liability will be provided through a negotiated arrangement

Lodging
Provision for adequate lodging arrangements must be made to accommodate the
resident and his/her family in a completely furnished house or apartment.

Education
Educational provisions should include easy library access, Internet access at temporary
domicile and work, and appropriate standard text books easily available at home or work.

Travel
Reimbursement for reasonable travel expenses for residents and/or family between
home and off-site location.

Miscellaneous
Extra amenities at home should include telephone with local service, cable TV, a
computer with a printer. An allowance should be given for food when on in house call.

A supplemental stipend to cover such expenses could be provided in lieu of direct funding.

Amended and Approved by GMEC February 16, 2007
RESIDENT FROM OUTSIDE PROGRAM COMING TO SIU FOR
ELECTIVE OR REQUIRED ROTATIONS

1. The SIU Program Director must send a letter of request to the Office of Residency
Affairs at least 45 days prior to the start date of the rotation (85 days if the resident
does not already hold an Illinois license). The letter must include: 1) Dates the
resident will be at SIU and 2) Description of the rotation experience. 3) the SIU
Program Director must provide documentation of approval of rotation from resident’s
home Program Director.
2. The visiting resident must be licensed by the State of Illinois. The licensure
application must be in the Office of Residency Affairs at least 2 ½ months prior to the
rotation in order to secure licensure in time for the elective/rotation.
3. The Office of Residency Affairs will seek approval for the rotation from Memorial
Medical Center and St. John’s Hospital.
4. The resident’s credentials must be approved by Memorial Medical Center and St.
John’s Hospital and should be submitted 45 days in advance to the Office of
Residency Affairs. The credentials include: 1) Application for residency; 2) Dean’s
Letter; 3) Letter from the resident’s Program Director stating that he/she is in good
standing in the home program.
5. The SIU program must provide the Office of Residency Affairs a letter from the
home hospital stating that they will continue the resident’s stipend, benefits, and
liability insurance.
6. Because both St. John’s Hospital and Memorial Medical Center are over their “cap”
of funded residents, neither will reimburse the stipends benefits or liability insurance
for a visiting resident on an approved rotation except under extraordinary
circumstances.

Note: Items # 1 and 2 are applicable to all programs. Items #3-6 apply to Springfield-based
programs. Affiliate sites should follow their local procedures for credentialing and
negotiation of stipend, benefits and liability insurance.

For the purposes of this policy, Affiliate-based SIU residents who are not employed by SJH
or MMC coming to Springfield are considered to be from an outside program (hospital).

Replaces Policy: Resident from outside program coming to SIU for electives or required rotations dated May
12, 2000
Approved by the GMEC October 18, 2002
Revised and Adopted by the GMEC on November 16, 2007
CERTIFICATES OF COMPLETION FOR RESIDENTS AND FELLOWS

In March, the Office of Residency Affairs requests that all programs provide a list of graduating
residents and a list of promotions or remediations for junior residents. In April an email is sent
all programs requesting their certificate needs, which includes a template showing how the name
is to appear on the certificate, the program, and the appropriate dates. All certificate requests
must be entered into the template and submitted to the Office of Residency Affairs. The Office
of Residency Affairs will have the certificates produced, then obtain the signatures of the dean
and the hospital Chief Executive Officers. The certificates will then be sent to the program
directors for their signature and distribution to residents.
EDUCATIONAL RESOURCES

From time to time Program Directors call about residents who seem to be doing okay clinically
but are having difficulty with standardized exams, generally USMLE Step 3. If you have a
resident who you feel needs evaluation for learning disabilities, attention deficit problems or test
taking problems, the following resources are available.
1. Evaluation for Learning Disabilities and/or Adult ADD
Glen Aylward, PhD
Director, Division of Developmental and Behavioral Pediatrics,
545-2618
gaylward@siumed.edu.
2. Computer Based (Tova System) Evaluation for Adult ADD
Sandy Vicari, PhD
SIU Department of Psychiatry
545-3935
svicari@siumed.edu
3. Counseling Session Regarding Basic Test Taking Skills and Test Anxiety
Patricia James Davis, MSW
SIU Office of Diversity, Multicultural and Minority Affairs
545-7243
pdavis3@siumed.edu
PROFESSIONALISM INFORMATION
Section 7
SUBJECT
Patient Information/Records
Release of Medical Information
Dress and Decorum
Resident Professional Conduct Policy
Harassment Policy
Guidelines for Maintenance of Records and Disclosure of Information about
Residents and Fellows
PATIENT INFORMATION/RECORDS

Many medical workers have access to medical records, x-rays, laboratory reports, and other
sources of information concerning patients. All such information is considered confidential and
must not be revealed under any circumstances. Only physicians and others specifically
authorized to do so may divulge laboratory, medical and surgical findings, and then only to the
proper persons. Carelessness leading to release of confidential information about patients is not
only ethically wrong but could also involve both the individual and SIU in legal action. At no
time should individuals call for their own medical record or the records of friends, relatives, or
others without legitimate reason. Unauthorized release of confidential information concerning
patients may be cause for immediate dismissal.
The medical record is the most complete and permanent repository of all data gathered during
examination, diagnosis and treatment by health care providers. It is among the most important
assets and is also a very important resource for the care of patients. The ready availability of the
patient’s medical record facilitates his/her care, serves the convenience of the physician and may
be of lifesaving importance on occasions.
Because a sizeable group of personnel are legitimately concerned with the use of medical records
in many areas, certain policies have been established so that medical records are properly
preserved and safeguarded and their whereabouts are known at all times. As a resident or fellow
at SIU, you are expected to know these policies and follow the procedures for safeguarding the
integrity of medical records. The general guidelines are as follows:
• The Medical Records Access Policy applies to all medical information, whether in written,
oral, reproduced or electronic form.
• No part of a patient’s medical record or reproductions thereof may be released to anyone
outside of the institution other than the patient without written authorization from the patient.
(For exceptions, see “RELEASE OF MEDICAL INFORMATION”.)
• Medical records shall be requested only for SIU business or routine duties.
• Personal medical records or those of family members cannot be requisitioned.
• The medical record must stay on site and be traceable in the record-keeping system.
• The medical record and the patient will not be separated in the hospital.
• Handle sensitive tests and results appropriately according to institutional procedures, but do
not be overly restrictive or draw attention to the tests or reports.
• Patient information obtained from electronic systems must be treated with the same degree of
confidentiality as the paper medical record. You are responsible for information accessed
using your password. Temporary printed reports must be discarded appropriately. Patient
information must not be left on screens where it would be visible to others. Please logoff the
system when you are done.
RELEASE OF MEDICAL INFORMATION

ILLINOIS LAW AND SIU POLICY
Information given by a patient to a physician or acquired by a physician through examination
and treatment of a patient is confidential. Under Illinois law medical information should not be
communicated to anyone unless the patient has given written consent or unless the situation falls
within one of the exceptions to the law. This applies regardless of the seemingly innocent nature
of the request or the character of the inquirer (e.g., health care provider, attorney, insurance
representative, investigator, relative).

LEGAL EXCEPTIONS
• Release of medical information may be made without a patient’s written consent in a medical
emergency when you are unable to obtain the patient’s consent due to the patient’s condition
or the nature of the medical emergency.
• Medical information may be exchanged with an SIU provider without written patient
authorization when necessary for current treatment, unless the patient has requested that
medical information not be sent to that provider. Additionally, specific written authorization
would still be required in accord with Federal law if the information to be released contains
drug and/or alcohol treatment information.
• Statutes or appropriate regulations may require that you give information to specified public
authorities. Examples are the reporting of gunshot wounds, suspected maltreatment of
minors, animal bites, certain communicable diseases, and the information required for a
certificate of death. If you are in doubt in these cases, do not assume that the information
may be given. Instead, seek the advice of a member of the Legal Department.
DRESS AND DECORUM
The “best interest of the patient…” is the most fundamental consideration for the establishment
of policies and procedures at SIU, and Dress and Decorum is no exception. The appearance and
attitude of the people at SIU have a tremendous impact on the perception of our patients and,
consequently, their impression of SIU and their willingness to return.
These guidelines have been established to provide appropriate direction to SIU staffs. Residents
and fellows are expected to use their best judgment in maintaining SIU’s conservative,
professional image in the perception of our patients and visitors.

ATTIRE ACCEPTABLE UNACCEPTABLE
Business • Suits, dresses, blouses, skirts, jackets, pants • See through clothing
Attire • Suits or jackets for men with a collared shirt • Casual attire
• Sleeveless or low cut tops
• Torn or ripped
Tops and • Blouses, tops, turtlenecks • Scrub tops, sweat shirts
Jackets • Fitted jackets/blazers • Tee shirts
• Sweaters • Halter or tube tops
• Collared shirts • Low cut or midriff blouses
Pants and • Mid-ankle length or longer • Capri pants
Jumpsuits • Sweat pants
• Leggings or leotards
Skirts and • Split skirts • Sundresses
Dresses • Dresses or Jumpers • Miniskirts
• Skirts • Shorts or Skorts
Shoes • Clean and in good repair • Sport sandals
• Closed toe • Canvas
• Dress shoes or boots • Colored emblems
Hosiery/Socks • Required • Lacy or appliquéd hose
• Bare feet/sockless
Undergarments • Required; Discreet • Bright and/or noticeable colors, patterns
or lines
Accessories • Conservative jewelry with moderation
Lab Coats • Protective garment
• May be worn over surgical scrubs or
business attire
Grooming • Clean and neat
• Hair neatly cut and styled
• Conservative use of cosmetics, nail polish,
colognes and perfumes
Name Tags • Worn at all times • Damaged or peeling
• Worn on upper torso • Multiple decorative stickers
RESIDENT PROFESSIONAL CONDUCT POLICY
Introduction
Good working relationships, teamwork and appropriate conduct are necessary among all
members of the health care team to facilitate quality patient care. All members of the team must
treat others with respect, courtesy and dignity and conduct themselves in a professional and
cooperative manner. Disruptive behavior is not acceptable.
Behavior that is unusual, unorthodox, or different is not alone sufficient to classify as “disruptive
behavior”. Examples of inappropriate conduct might include, but are not limited to:
• abusive or profane language
• degrading or demeaning comments (verbal or written)
• aggressive comments to others that are personal, irrelevant or go beyond the
bounds of fair professional comments
• inappropriate physical contact
• yelling at patients, their families and/or other members of the health care team
• threats and/or physical assaults on anyone.
• behaviors of omission: chronic or recalcitrant failure to comply with stated program or
hospital procedures or policies, answer pages, complete medical records, etc.
Procedures
Any individual who observes disruptive behavior by a resident or fellow shall make a written
report of the behavior to the program director or to the complainant’s supervisor who will then
forward the report to the program director. Documentation of the disruptive behavior shall
include 1) the date, time and location of the questionable behavior; 2) a description of the
behavior limited to direct observations and including factual objective language as much as
possible 3) circumstances that precipitated the situation 4) actual or expected consequences, if
any, to patient care 5) record of any action taken to remedy the situation and 6) the name of the
individual who is making the report, as well as any other witnesses.
All parties in the complaint process are obligated to protect the privacy of all persons involved
and the program director will take reasonable steps to protect confidentiality of the complainant.
However, confidentiality cannot be guaranteed. Retaliation for reporting disruptive behavior or
participating in an investigation of reported disruptive behavior is strictly prohibited.
Behaviors or incidents occurring at a hospital site will be addressed by the program in
conjunction with appropriate hospital staff, according to the Code of Conduct policy of the
appropriate hospital. Incidents involving inappropriate sexual comments or behaviors will be
addressed by the program in conjunction with appropriate hospital or SIU SOM staff, according
to the Sexual Harassment Policy. Behaviors which indicate the presence of impairment in the
resident or fellow will be addressed according to the Impairment Policy.
If the program director determines that disruptive activity has occurred, it will be addressed in
accordance with the Academic Deficiencies and Corrective Action policy as a deficit in the area
of professionalism.
Revised and Adopted by the GMEC October 20, 2006
GUIDELINES FOR MAINTENANCE OF RECORDS AND DISCLOSURE OF
INFORMATION ABOUT RESIDENTS AND FELLOWS

These guidelines govern the maintenance by Southern Illinois University School of Medicine
(hereinafter called the “School”) of records and disclosure of information about Residents and
Fellows (hereinafter called “Residents”) who participate in Residency and Fellowship
Programs (hereinafter called “Residency Programs”) operated by the School of Medicine and
its affiliated hospitals.

1. Records of evaluation of a Resident by the School (hereinafter called “Evaluation
Records”) required by Section C.1.b. of the Agreement With Physician (hereinafter
called the “Agreement”) shall be stored permanently in the Program Director’s office
(subject to the School’s records retention policy). In addition to evaluations of the
Resident’s performance, such records may include, without limitation, records of
suspension pursuant to Section E. of the Agreement, termination pursuant to G. of the
Agreement, non-renewal pursuant to Section H. of the Agreement, termination or other
discipline pursuant to Section I. of the Agreement, and any action taken by or against
the Resident pursuant to the Resident Grievance Procedure, but such records shall not
include information recorded pursuant to the Impairment Policy of SIU School of
Medicine and Affiliated Hospitals for Residency and Fellowship Programs (hereinafter
called the “Impairment Policy”), which information shall be maintained only in
accordance with paragraph 2. below.

2. Records about a Resident created pursuant to the Impairment Policy (hereinafter called
“Impairment Records”) shall be maintained apart from the Resident’s Evaluation
Records and shall be stored in the Program Director’s office as long at the Resident is a
participant in the Residency Program. Impairment Records may contain information
protected from disclosure by federal and state laws and rules, including, without
limitation, the following:

a The federal Americans With Disabilities Act
b The federal Health Insurance Portability and Accountability Act
c Federal regulations at 42 CFR Part 2 prohibiting disclosure of information
regarding drug or alcohol dependency
d The Illinois Medical Patients Rights Act
e The Illinois AIDS Confidentiality Act
f The Illinois Mental Health and Developmental Disabilities Confidentiality Act
g The Illinois Alcoholism and Other Drug Abuse and Dependency Act.

3. The Resident shall be permitted to review the foregoing records and to receive copies
thereof, except when prohibited by law (e.g., Section 3. of the Illinois Mental Health
and Developmental Disabilities Act, which requires that that psychological tests be
disclosed only to a psychologist designated by the tested individual).
4. When Impairment Records are no longer needed by the Program Director, they shall be
transferred to the Office of Residency Affairs for permanent storage (subject to the
School’s records retention policy), provided that such transfer shall take place not later
than when the Resident completes or otherwise leaves the Residency Program, and no
copy of Impairment Records, or any part thereof, shall be maintained elsewhere.

5. Requests for information about a Resident or former Resident for whom no Impairment
Records have been created shall be answered by the Program Director, with the
assistance of the Office of Residency Affairs, as needed. No information about a
Resident shall be disclosed unless the Resident has signed a written authorization for
the disclosure.

6. Requests for information about a Resident or former Resident for whom Impairment
Records have been created shall be answered only by the Office of Residency Affairs
(or by the Program Director with the concurrence of the Office of Residency Affairs).
No information about a Resident shall be disclosed unless the Resident has signed a
written authorization for the disclosure which satisfies the requirements of the
appropriate laws and rules, such as those listed in paragraph 2. above.

7. In certain circumstances the Office of Residency Affairs may, in consultation with legal
counsel, disclose information about a Resident or former Resident without
authorization from the Resident or former Resident if such disclosure is in the public
interest.

Adopted by GMEC June 22, 2001
SUPERVISION INFORMATION
Section 8
SUBJECT
Selection, Evaluation, Supervision, Graded Responsibility, Promotion/Non-Promotion
and Dismissal of Residents Policy re: Supervision
Policy for Supervision of Resident Physicians and Fellows
EXCERPT FROM

SELECTION, EVALUATION, SUPERVISION, GRADED RESPONSIBILITY,
PROMOTION/NON-PROMOTION AND DISMISSAL OF RESIDENTS POLICY

SUPERVISION
Supervision of the residents shall be carried out by the designated teaching faculty under the
direction of the Residency Program Director, and in accordance with the SIU Policy on Patient
Care Activities and Supervision Responsibilities for GME Trainees and Attending Physicians. It
shall be the Residency Program Director’s responsibility to see that such supervision is adequate
and appropriate to maintain both the optimal education environment and excellent quality of
patient care. Residents will be supervised by teaching faculty in a way that gives residents
progressively increasing responsibility according to their level of education, ability and
experience. Availability of the teaching staff will be structured in a way to ensure appropriate
supervision. Determining the level of responsibility for each resident will be the responsibility
of the Residency Program Director with input from the teaching staff.
EVALUATION PROCESS AND PROCEDURES

Section 9

SUBJECT
Selection, Evaluation, Supervision, Graded Responsibility, Promotion/Non-Promotion
and Dismissal of Residents Policy re: Evaluation
Evaluation of SIU Residency Program and Faculty
Final/Summative Evaluation
Final/Summative Evaluation Template
EXCERPT FROM

SELECTION, EVALUATION, SUPERVISION, GRADED RESPONSIBILITY,
PROMOTION/NON-PROMOTION AND DISMISSAL OF RESIDENTS POLICY

EVALUATION
Each residency program must demonstrate that it has an effective plan for assessing resident
performance throughout the program and for utilizing the results to improve resident
performance. This plan should include

1. The use of methods that produce an accurate assessment of residents’ competence in
patient care, medical knowledge, practice-based learning and improvement, interpersonal
and communication skills, professionalism, and systems-based practice.
2. Mechanisms for providing regular and timely performance feedback to residents that
includes at least
• Written semiannual evaluation that is communicated to each resident in a timely
manner
• The maintenance of a record of evaluation for each resident that is accessible to
the resident.
3. A process involving use of assessment results to achieve progressive improvements in
residents’ competence and performance. Appropriate sources of evaluation include
faculty, patients, peers, self, and other professional staff.

The program director must provide a final evaluation for each resident who completes the
program. The evaluation must include a review of the resident’s performance during the final
period of education and should verify that the resident has demonstrated sufficient professional
ability to practice competently without direct supervision. The final evaluation must be part of
the resident’s permanent record maintained by the institution.
EVALUATION OF SIU RESIDENCY PROGRAM
In April of each year the Office of Residency Affairs distributes the end-of-year evaluation of the
residency experience to all residents and fellows. Included in the questionnaire are an evaluation
of the Program Director, the Institution, the Hospitals, the educational experience, patient care,
and facilities. Evaluations are shared in summary with the Program Directors, Department
Chairs, the Dean of the Medical School, and the two Affiliated Hospitals. The questionnaires are
coded to enable tracking return rate. Program Directors, etc., do not see specific resident
evaluations.

FACULTY AND PROGRAM EVALUATION

FACULTY EVALUATION
The performance of the faculty must be evaluated by the program at least annually. The
evaluations should include a review of their teaching abilities, commitment to the educational
program, clinical knowledge, and scholarly activities. Annual written confidential evaluations
by residents must be included in this process.

PROGRAM EVALUATION
The program must document formal, systematic evaluation of the curriculum at least annually.
The program must monitor and track each of the following areas:

1. resident performance;
2. faculty development;
3. graduate performance, including performance of program graduates on the certification
examination; and,
4. program quality. Specifically:
a) Residents and faculty must have the opportunity to evaluate the program
confidentially and in writing at least annually; and,
b) The program must use the results of the residents’ assessments of the program
together with other program evaluation results to improve the program.

If deficiencies are found, the program should prepare a written plan of action to document
initiatives to improve performance in the areas listed in section V.C.1. (of the ACGME Common
Program Requirements). The action plan should be reviewed and approved by the teaching
faculty and documented in meeting minutes.

Approved by GMEC November 8, 2002
Amended and Approved by the GMEC March 16, 2007
FINAL EVALUATION

The Program Director must provide a final evaluation for each resident who completes the
program. This evaluation must include a review of the residents’ performance during the final
period of education and it should verify that the resident has demonstrated sufficient professional
ability to practice completely and independently. The final evaluation must be part of the
resident’s permanent record maintained by the institution.
FINAL/SUMMATIVE EVALUATION

Southern Illinois University
__________________ Residency Program
Confidential Verification and Reference for:

Name: _______________________________________________________________

This confidential document relating to a former resident is provided by the Southern Illinois University School of
Medicine, Department of ___________________________________ Residency Program. This document has been
submitted in response to a request for verification of ________________________ residency training and reference
information in lieu of other forms. The original notarized signature of the current program director will verify its
authenticity. The contents of this document are provided with the permission of the above named physician and
should not be released to any other party without the consent of that physician.

I. Verification of Training:

⁪ Dr. __________________ successfully completed ___________________ residency training at
Southern Illinois University School of Medicine as follows:

Internship:
Residency:

⁪ See Appendix Item I. (Optional statement of any deviation from standard training sequence)

II. Disciplinary Action

⁪ During the dates of training at this institution, Dr. ___________________ was not subject to
any institutional disciplinary action.

⁪ See Appendix Item II. (Description of disciplinary actions. This would not normally include
corrective actions instituted for education reasons which have been successfully remediated.)

III. Professional Liability:

⁪ To the best of our knowledge, Dr. __________ was not investigated by any government or
other legal body and was not the defendant in any malpractice suit during residency training.

⁪ See Appendix Item III. Description of investigations and malpractice suits)

IV. Ability to Practice Medicine

⁪ Dr. _________________ has demonstrated sufficient competence to enter the practice of
___________________________ without direct supervision.

⁪ Dr. _________________ has not demonstrated sufficient competence to enter the practice of
___________________ without direct supervision.
*See Appendix Items IV if this item is checked

Consult legal counsel about how to complete if this item is checked.
V. Clinical Privileges/Procedures Requested:

⁪ The education Dr. ______________ received from the training program was sufficient for the practice
of __________________________. Dr. __________________ was recommended for the certifying
examination administered by the American board of _________________.

⁪ At the conclusion of Dr. ________________ ___________________ residency training, he or she was
judged capable of performing the following procedures independently:

(LISTING OF PROCEDURES APPROPRIATE BY YOUR SPECIALTY)

⁪_____________________________
⁪_____________________________
⁪_____________________________
⁪_____________________________
⁪_____________________________
⁪_____________________________
⁪_____________________________
⁪_____________________________
⁪_____________________________
⁪_____________________________
⁪_____________________________

The program is unable to comment on requested privileges/procedures outside the scope of a general
____________________________ residency training program.

VI. Evaluation: The following table is based on the demonstrated performance of Dr. ________________
during the residency training, personal observation by members of the Department of _____________
Education Committee and a composite of multiple evaluations by supervisors.

Unsatisfactory Satisfactory Superior No Knowledge

Basic Medical Knowledge
Professional Judgment
Sense of Responsibility
Ethical Conduct
Clinical Competence
Technical skills
Cooperativeness, Ability to work with others
Record Keeping
Patient Management
Physician/Patient Relationship
Ability to Understand and Speak English
VII. Comments:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

VIII. Recommendation:

Based on a composite evaluation by Southern Illinois University School of Medicine, Department of
________________________ Education Committee, Dr. ___________________________ is recommended to you
on this date of _____________________________.

______________________________________
[Name of Program Director]
Program Director

IX. ⁪ I have reviewed this evaluation with the program director or designee. I understand that this form
will, in most cases, be utilized as the confidential verification and reference form in lieu of other forms
when requests for verification of resident training or reference are received by the Department of
______________________.

______________________________________
[Name of Resident]

X. ⁪ Resident refused to sign.
______________________________________
[Name of Program Director]
Program Director

*********************************************************************************************

“I attest that the foregoing information supplied is true in every respect.”

_____________________________________________________________________________________________
Date [Name of Program Director]
Residency Program Director

_____________________________________________________________________________________________
Residency Program Director Name (Typed or printed):

_____________________________________________________________________________________________
Address of Signing Program Director:

_____________________________________________________________________________________________

State of: Illinois Country: United States
Notary Public Seal ______________________________________________
Subscribed and Sworn Before Me on this Day:

______________________________________________
Notary Public signature:

______________________________________________
Notary Public Name: Commission Expires:
PROMOTION,
DISMISSAL,
AND
GRIEVANCE ISSUES
Section 10
SUBJECT
Selection, Evaluation, Supervision, Graded Responsibility, Promotion/Non-
Promotion and Dismissal of Residents Policy re: Promotion/Non-Promotion
Grievance Procedure for Residents
Academic Deficiencies and Corrective Action Policy
Academic Deficiencies and Corrective Action Sample Probation Letter
Selection, Evaluation, Supervision, Graded Responsibility, Promotion/Non-
Promotion and Dismissal of Residents Policy re: Dismissal
EXCERPT FROM
SELECTION, EVALUATION, SUPERVISION, GRADED RESPONSIBILITY,
PROMOTION/NON-PROMOTION AND DISMISSAL OF RESIDENTS POLICY
PROMOTION / NON-PROMOTION
The criteria for advancement shall be based upon the following parameters, all of which need to
be judged as competent for each level of advancement:

A. Medical Knowledge
B. Clinical Competence in Patient Care
C. Interpersonal and Communication Skills
D. Professionalism (includes absence of impairment)
E. Attitudes
F. Practice-Based Learning and Improvement
G. Systems-Based Practice

Specific criteria and requirements for advancement from one year to the next will be set by each
individual program. In general, the following will be required for promotion from one training
level to the next:
PGY1 to PGY2:
Acceptable progress in areas A through G
Ability to supervise PGY1’s and students
Ability to act with limited independence
PGY 2 to PGY X:
Acceptable progress in areas A through G
Ability to supervise/teach
Ability to act with increasing independence
PGY X to Graduation:
Competence in areas A through G
Ability to act independently
Policies with respect to promotion/non-promotion to the subsequent year of training shall comply
with the General and Special Essentials pertaining to that program. The decision for promotion
or non-promotion shall be made by the Residency Program Director with consultation from the
teaching faculty. A decision to withhold advancement or deny reappointment shall be taken only
after documented counseling of the resident apprising him/her of the reason for such potential
action, and documentation that the deficiencies have not been sufficiently corrected within a
reasonable time. Notice to the resident that he/she will not be retained or promoted in the
program for the upcoming contract year should occur four months prior to the expiration of the
current contract whenever possible. If a resident believes that he/she has been dealt with unfairly
in the above process, redress may be sought through the Resident Grievance Procedure
Written Warning or Academic Probation Letter Template
Items in italics are for direction or examples only. Any italicized items should be removed
before letter is printed.

Date:

Dear Doctor ____________________:

This letter is to notify you that you are being placed on academic probation/ being given a
written warning (choose one) effective __(date)__,due to insufficient progress in the competency
areas of:
(examples: Medical Knowledge; Patient Care; Interpersonal Communications skills;
Professionalism; Attitudes; Practice Based Learning and Improvement; Systems Based
practice; Adherence to departmental and institutional policies and procedures.)

These concerns have been previously discussed with you on _____(dates)_____. (If previous
verbal or written warnings have been given, include here) This assessment of your progress is
based on the following:

Observations, Concerns, Events, etc. Examples listed below:

Deficiencies in clinical knowledge base.
Difficulty reaching conclusions without input from a supervisor.
Complaints from patients regarding your interpersonal interactions.
Medical knowledge below the level expected for a PGY______.
Poor performance on the in-training examination with a score of ______.

The expected standard for your level of training is that you should:

(examples listed below)
Be able formulate an appropriate and complete differential diagnosis.
Score of at least in the 50% percentile on the in-training examination.
Be able to formulate an initial treatment plan.
Independently be able to interact with patients without receiving
complaints.

To assist you in meeting the expectations, the following will be organized.

(examples listed below, if applicable)
• You will repeat the following rotations
• You will be assigned a mentor.
• The chief resident will meet with you weekly to go over board prep
questions.

You will remain on probation for ___(how long)___. You will be reassessed on
____(when)_______. During this time your progress will be assessed via the following
parameters:
(examples listed below)
• You must obtain at least satisfactory ratings on all rotations.
• You must score in the ________ percentile or above on your in-training exam.
• There must be no episodes of patient complaints
• There must be no notices of medical record delinquencies.

If you are either making substantive progress or meeting standards, you will either be
continued on probation/written warning (choose one), restored to good standing or promoted to
the PGY______ year. If you are not achieving these standards you may be required to remediate
all or part of your PGY______ year or you may be terminated from the program.

(Please note that if a resident’s contract will not be renewed or if a resident will not be
promoted to the next level of training, the resident must be notified of this in writing 4 months
prior to the end of the current contract. Assessment of resident progress and decisions re
advancement must be made with this standard in mind.)

_______________________________
Program Director

________________________________
Karen Broquet, MD
Chair, GMEC

By signing the below, I acknowledge receipt of this letter and a copy of the current SIU
Grievance Policy.

________________________________
Resident
EXCERPT FROM

SELECTION, EVALUATION, SUPERVISION, GRADED RESPONSIBILITY,
PROMOTION/NON-PROMOTION AND DISMISSAL OF RESIDENTS POLICY

DISMISSAL
Dismissal or non-promotion of a resident whose performance is unsatisfactory will be
communicated in writing to the resident in accordance with GMEC policies on academic
deficiencies and corrective action. Appeals of dismissal actions shall be handled through the
Resident Grievance Procedure.
ACCREDITATION RESOURCES
Section 11

SUBJECT
Frequently Asked Questions Related to Master Affiliation Agreements and
Program Letters of Agreement
The Behavioral Interview, A Method to Evaluate ACGME Competencies in
Resident Selection: A Pilot Project
Preparing for the Accreditation Site Visit: Advice for New and Seasoned
Program Directors
Site Visit, FAQ’s
INSTITUTIONAL POLICIES AND TEMPLATES
Section 12
SUBJECT
Americans with Disabilities Act Policy
Academic Deficiencies and Corrective Action Policy
Academic Probation Letter Template
Closure Reduction Policy
Disaster Plan Procedure Policy
Drug Screening Policy and Protocol
Duty Hour Policy
Evaluation of SIU Residency Program and Faculty Policy
Final/Summative Resident Evaluation Template
Grievance Procedure for Residents
Harassment Policy
Impairment Policy
Industrial Sales Rep Policy
Internal Review Protocol
Leave Policies
Licensing Exam (USLME and COMLEX) Policy
Maintenance of Records and Disclosure of Information about Residents and Fellows
Guidelines
Medical License Policy
Medical Record Completion and Suspension Protocol
Military Leave Policy
Moonlighting (Professional Activities Outside Scope of Residency Training)
Non-Accredited Fellowship Policy
Off-Site Required Rotations and Off-Site Electives Policy
Off-Site Rotations Which are Established as an Integral and Recurring Component of a
Residency Training Program
Prescription Writing Policy and Controlled Substance Schedule
Procedure for Post Graduate Medical Observership
Professional Conduct Policy
Program Letter of Agreement Template
Recruitment of Unfilled Positions Policy
Resident Transfer Policy
Resident Credentialing Policy
Residents from Outside Programs Coming to SIU for Elective or Required Rotations
Residents Who Start Late
Selecting a Program Director Policy
Selection, Evaluation, Supervision, Graded Responsibility, Promotion/Non-Promotion
and Dismissal Policy
Serving Legal Papers in Clinic Setting
Stipend Policy
Supervision of Resident Physicians and Fellows
Support for GME in Event of Disaster Policy
Suspension for Medical Records and/or Duty Hour
Time Record Completion and Suspension Protocol
Index
Section 13
Index
Topic Section
AAMC Immigration Primer 5
Accreditation by ACGME 2
Accumulation of Leave Time 4
ACGME Common Program Requirements 2
ACLS 6
Administrative Organizational Chart 1
Adoption Leave 4
Americans with Disabilities Act 4
Autopsy Policy for SJH 2
Bereavement Leave 4
Brochure for Residency Programs 2
Calendar of Events 1
Certificates of Completion 6
Closure / Reduction Policy 1
Completion of Work 4
Computerized Data Collection by Others 2
Contract Completion 4
Contract Sample, with instructions 4
Contract Sample, current year 4
Controlled Substances, Schedule 4
CPR 6
Credentialing 3
DEA Numbers 4
Deficiencies in Performance 10
Delinquent Medical Records and Duty Hours 4
Directory, House Staff 2
Directory, Program 1
Disaster Plan Procedure 2
Dismissal 10
Dress and Decorum 7
Drug Representative Guidelines 2
Drug Screening 4
Duty Hours, Institutional 4
Duty Hours, ACGME 4
ECFMG 5
Educational Leave 4
Educational Resources at SIU 6
Employee Assistance Program 4
Employment Eligibility Requirements 4
Evaluation of Faculty 9
Evaluation of Program 9
Evaluation of Residents 9
Evaluation, End-of-Year 9
Evaluation, Final/Summative 9
Evaluation, Final/Summative Template 9
Fact Sheet 2
Family and Medical Leave 4
Fellowships, Unapproved 3
Financial Assistance 2
GMEC Mission Statement 1
GMEC Responsibilities 1
Graded Responsibility 4
Grievance Procedure 10
Harassment 7
Identification Badges 4
Impairment Policy, Signs and Symptoms 4
Institutional Accreditation Letter 2
Institutional Requirements 2
Internal Review Guidelines 2
J-1 Issues 5
Job Search Leave 4
Lab Coats 4
Legal Papers being served 2
Letter of Offer Templates 4
Liability Insurance Coverage 4
Licensing Examinations 6
Licensure 4
Match 3
Maternity Leave 4
Medical Information Release 7
Medical Records Completion 4
Medicare Teaching Guidelines 6
Military Leave 4
Moonlighting 4
NPI Numbers 4
NRMP 3
Observerships 6
Off-Site Required and Elective Rotations 6
Off-Site Rotation and Off-Site Elective Requirements 6
Orientation 4
Parental/Paternity Leave 4
Parking Cards / Stickers 4
Patient Information / Records 7
Policy Organizational Chart 1
Prescription Writing 4
Probation Letter - Sample 10
Probation Policy 10
Professional Conduct Policy 7
Program Coordinator Responsibilities 2
Program Director Job Description 2
Program Director Responsibilities 2
Program Director Selection 2
Promotion / Non-Promotion 10
Program Letters of Agreement 1
Program Letters of Agreement, FAQ’s 1 and 11
Recruitment, “The Behavioral Interview” 11
Recruitment for Unfilled Positions 4
Recruitment Reimbursement 2
Resident Wellness 4
Resident’s Information and Records 7
Rotations by non-SIU Residents 6
Selection of Residents 3
Selection, Evaluation, Supervision, Graded Responsibility, 4
Promotion / Non-Promotion and Dismissal of Residents Policy
Sick Leave 4
Site Visit, ACGME FAQ’s 11
Site Visit Preparation 11
Speaking Skills 4
Starting Late 4
Stipend Policy 4
Supervision Policy 8
Time Records Completion 4
Transfer of Residents 3
Vacation Leave 4