Lake Cumberland Regional Hospital Resident Policy/Procedure Manual · 2016-03-10 · 2.3 Re-Appointment . 2.4 Non-Renewal of Contract/Appointment . 2.5 Completion of Training . 2.6

Lake Cumberland Regional Hospital Resident Policy/Procedure Manual

Point of Contact for all business and other correspondence regarding approved programs:

350 Hospital Way Suite 101

Somerset, Ky. 42503 Telephone: 606-451-5092/606-451-5093

Fax: 606-451-5087 Updated 2/6/2015

Lake Cumberland Regional Hospital Resident Manual

Table of Contents Introduction Page 1 Introduction

1.1 Welcome 1.2 Change in Policy 1.3 LCRH Resident Program Recruitment Policy

5 5 5 6

2 Appointment 2.1 Eligibility and Selection 2.2 Resident Contract 2.3 Re-Appointment 2.4 Non-Renewal of Contract/Appointment 2.5 Completion of Training 2.6 Program Closure or Reduction 2.7 Restrictive Covenants 2.8 Visa Policies & Procedures for Foreign/Us Medical School Graduates 2.9 Transfers into the LCRH Residency Program

7 7 8 8 9 9 10 10 10 10

3 Employment Policies 3.1 Equal Employment Opportunity/Diversity 3.2 Employee Background Check 3.3 Pre-Employment Evaluation 3.4 Post Enrollment Requirements: Years 1:4 3.5 Criminal Records 3.6 Controlled Substance (DEA) 3.7 Physician Impairment & Substance Abuse 3.8 Licensure 3.9 Certificates 3.10 Change of Personal Data 3.11 Chain of Communication 3.12 Safety 3.13 Personal Property 3.14 Professional Activities outside the Program 3.15 Visitors in the Workplace 3.16 Weather-related and Emergency-related Closings

11 11 11 11 12 14 14 15 15 16 17 17 17 17 17 17 18

4 Disciplinary Process 4.1 Performance 4.2 Summary Suspension 4.3 Automatic Suspension 4.4 Resident Appeals Process 4.5 Grievance and Due Process Procedure 4.6 Maintaining Discipline among Patients, Nurses and Associates

18 18 20 20 21 22 26

5 Standard of Conduct 5.1 General Guidelines 5.2 Duty Hours & Responsibilities 5.3 On-Call Activities 5.4 Unscheduled Absence 5.5 Harassment Policy 5.6 Sexual Harassment Policy 5.7 Violence in the Workplace

26 26 27 29 30 31 31 31 31

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5.8 Confidential Information and Nondisclosure 5.9 Ethical Standards 5.10 Dress Code 5.11 Use of Equipment 5.12 Use of Computer, Phone, and Mail 5.13 Use of Internet 5.14 Use of Computer Software 5.15 Smoking Policy 5.16 Alcohol and Substance Abuse 5.17 Subpoenas, Claims, & Other Requests 5.18 Disputes between Residents & Medical Supervisors 5.19 Corporate Communication 5.20 Corporate Compliance 5.21 Obligation to Treat 5.22 Moonlighting 5.23 Departing Residents 5.24 Hospital Property

32 32 32 32 33 33 34 34 34 34 35 35 35 36 37 37

6 Responsibilities 6.1 Director of Medical Education 6.2 Program Director 6.3 Academic Council 6.3.1 Academic Council Membership: 6.3.2 Academic Council Charge: 6.3.3 Academic Council Meeting Schedule: 6.3.4 Academic Council Responsibilities: 6.3.5 Academic Council at Risk Definitions 6.3.6 Academic Council Performance Improvement Process Policy 6.4 Graduate Medical Education Committee (GMEC) 6.5 Attending Physician (Resident Preceptor) 6.6 Chief Resident 6.6.1 Overall Responsibilities 6.6.2 Election Process of Chief Resident 6.6.3 Eligibility for Chief Resident Nomination 6.6.4 Chief Resident Specific Responsibilities 6.6.5 Chief Resident Benefits 6.7 Resident Responsibilities 6.7.1 Resident Membership AOA 6.7.2 Resident Attendance at Didactics 6.7.3 Resident Responsibility for Consultation Communication 6.7.4 Hospital Dictations 6.7.4.1 History & Physicals and Consultation Notes 6.7.4.2 Discharge Summary 6.7.4.3 Daily Inpatient Progress Notes 6.7.4.4 Daily Inpatient Progress Notes on Resident’s Continuity Clinic Panel Patients 6.7.4.5 Review of Resident Dictations 6.7.5 Resident Rotation Responsibilities 6.7.5.1 Inpatient Internal Medicine Rotation 6.7.5.2 In Patient Resident Mobile Phone ( In-House ext) 6.7.6 SBAR Transfer of Care 6.7.7 Annual In-service Exams 6.7.8 AOA Clinical Assessment Program (CAP) 6.7.9 Resident Required Advanced Life Support

37 37 38 40 40 40 40 40 41 42 45 45 46 46 46 46 46 48 49 49 49 49 50 50 51 52 53 53 53 54 55 55 56 56 56

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7 Compensation/Insurance Policies 7.1 Payroll/Salary 7.2 Auxiliary Benefits 7.3 Insurance 7.4 Relocation 7.5 Housing 7.6 Malpractice Insurance 7.7 Timekeeping Procedures 7.8 Continuing Medical Education Stipend (CME) 7.9 Resident Professional Exam Cost

56 56 57 58 59 59 59 59 59 60

8 Time-Off Benefits 8.1 Vacation Time 8.2 Family Medical Leave 8.3 Maternity/Paternity Leave 8.4 Extended Leave of Absence 8.5 Bereavement Leave 8.6 Sick Leave 8.7 Military Reserves or National Guard Leaves of Absence 8.8 Jury Duty 8.9 Professional Leave of Absence 8.10 Additional Benefit & Leave Considerations 8.11 International Medicine Rotations

60 60 62 62 63 63 64 64 64 65 65

9 Institutional Policies 9.1 Policy & Procedures 9.2 Communicable Diseases 9.3 Reporting Requirements for Communicable Diseases 9.4 Advocacy Efforts 9.5 Reporting of Patient Care Issues

66 66 66 66 66 67

10 Evaluations 10.1 Evaluation of Faculty 10.2 Evaluation of Resident’s Performance 10.3 Evaluation of Training Programs 10.4 Resident Credentialing for Procedures

67 67 68 69 70

11 Medical Records 11.1 Guidelines for Use of Medical Records 11.2 Guidelines for Documentation in the Medical Record 11.3 Medical Record Completion Guidelines 11.4 Protected Health Information 11.5 Medical Staff Rules & Regulations 11.6 Physician’s Orders 11.7 Service to In-patients

70 70 70 71 71 72 72 72

12 Institutional Resources 12.1 Blood Bank 12.2 Patient Protection Program 12.3 Employee Health Department 12.4 Employee Assistance Program 12.5 Nursing Department 12.6 Nutrition Services 12.7 Pharmacy 12.8 Security 12.9 Rehabilitation Services

73 73 73 74 75 75 76 76 77 77

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12.10 Case Management/Social Work 12.11 Risk Management Program 12.12 Communications/Information Services 12.13 Transport of Patients 12.14 Paging System

78 78 80 79 79

13 Resident Resources 13.1 Conferences, Rounds, Lectures 13.2 Resident Participation on Hospital Committees and in Continuous Quality Improvement 13.3 Computer Use and Support 13.4 Food Services 13.5 Interpreter Services & Notary Services 13.6 Library Facilities 13.7 On-Call Rooms 13.8 Uniforms & Laundry 13.9 Portable Ultrasound Machines

80 81 80 81 83 83 83 84 84 84

14 Universal/Standard Precautions 14.1 Standard Precautions 14.2 Resident & Infection Preventions Role in the Isolation of Patients 14.3 Precautions for Patients with Airborne Diseases 14.4 Needle Sticks 14.5 Other Standardized Procedures

84 85 85 85 86 87

15 Employee Communications 15.1 Open Communication 15.2 House Staff Meeting 15.3 Bulletin Boards 15.4 Suggestions 15.5 Closing Statement

87 88 88 88 88 88

16 Acknowledgement – Resident Manual 89

17 Forms 90

Addendum 90

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INTRODUCTION This document has been developed by Lake Cumberland Regional Hospital (LCRH) Residency Program to familiarize LCRH residents with the expectations of them and the residency program, working conditions, policies, procedures, and employee benefits at LCRH. Information in this Manual does not replace LCRH Human Resources Employee Manual Guidelines, Rules and Regulations. Throughout this Resident Manual (the “Manual”), the terms “Intern”, “Resident,” “House Officer” and “House Staff” refer to any LCRH Post graduate physician enrolled in any of the LCRH Residency Programs. Residents have an obligation to the patient care program of the institution and to the effectiveness of the educational program to which they have been appointed. The most important criterion of the service of the Resident is the proper performance of their professional duties. Professionalism includes honesty, integrity, respect, and compassion, which includes the Resident introducing him/herself to patients, explaining the Resident‘s role in their care, and treating patients with courtesy and respect, as if they were members of their family. The proper discharge of the responsibilities of the Resident requires a full time effort while on duty. All Residents shall remain within the Hospital or clinic when on duty as required by their patient care responsibilities and shall be immediately available if on call. The Residency Program Directors and the Director of Medical Education have the responsibility and authority at all times to assure the Residents’ effectiveness in the programs. The Lake Cumberland Regional Hospital is a long established community hospital with a mission to Provide Healthcare Excellence Close to Home. 1.1 Welcome

Welcome to Lake Cumberland Regional Hospital! Abbreviations used in this Manual: Lake Cumberland Regional Hospital LCRH Director Medical education DME Program Director PD Administrative Director Medical Education ADME Graduate Medical Education Committee GMEC

American Osteopathic Association AOA Osteopathic Graduate Medical Education OGME Osteopathic Postdoctoral Training Institution OPTI 1.2 Changes in Policy This manual supersedes all previous residency manuals and memos. While every effort is made to keep the contents of this document current, Lake Cumberland Regional Hospital at its option, may modify, delete, suspend or discontinue portions of this manual at any time without prior notice. It is the Resident‘s responsibility to obtain the most current version of this manual. A current copy of this manual is available in the LCRH Medical

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Education Department (shared drive) and on the LCRH Internal Website under the Resident Tab. Any changes in this manual shall apply to existing as well as to future Residents. 1.3 LCRH Residency Program Recruitment Policy Appointments to the residency program are made on the recommendations of the Graduate Medical Education Committee, the Program Director and/or the Director of Medical Education. Lake Cumberland Regional Hospital is an equal opportunity employer and does not discriminate on the basis of race, color, religion, sex, national origin or handicapped persons who, with reasonable accommodation, can perform the essential functions of the job. The residency application process at Lake Cumberland Regional Hospital is as follows: a. Interested osteopathic medical school students must apply through the National Match Service (NMS) via ERAS; b. Applicants are considered for interview upon receipt of information requested on the NMS and available on ERAS, and with the following requirements:

• Graduate of a College of Osteopathic Medicine within 3 years of current recruitment

year or upcoming graduate for the current year of a College of Osteopathic Medicine. • Three letters of professional reference, • Letter from your medical school Dean stating you are a student in good standing, • Successful completion of COMLEX 1, COMLEX 2, & PE • Prefer exams passed prior to contract but must pass by Orientation start date • No minimum score • Passing within 3 attempts or less per exam • Medical school transcripts,

c. The Department of Education will contact applicants to arrange an appointment for an interview. The following are provided to each applicant:

• Hotel provided • Lunch provided the day of interview

d. Two days per week will be designated for interviews between November 1 and mid-January of each year. Dates are set annually. e. A max of 4 interviewees per day. f. Resident applicants are interviewed by the Program Director, Director of Medical Education, and members of the Medical Education Committee; g. Applicants are discussed at the January Medical Education Committee Executive Session and either accepted or denied and a rank order list is generated; h. Lake Cumberland Regional Hospital completes the National Intern Registration Match forms that are returned within the appropriate timeframe, usually in January;

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i. Results of the Match are returned, usually in February. Resident contracts are mailed out within the time allotted by the American Osteopathic Association (AOA)/NMS Match regulations. 2 APPOINTMENT Purpose of this manual: The information contained in this Manual is presented for the benefit of the Residents of Lake Cumberland Regional Hospital. The intent of this Manual is to provide and to direct the Resident to necessary information concerning the expectations, policies, procedures and practices of LCRH. Lake Cumberland Regional Hospital reserves the right to revise, withdraw, suspend or discontinue its policies, procedures and practices at any time. Except as may be set forth in the sections below, referred to as Grievance Procedures, Corrective Action/Appeal Process, Summary Suspension, Automatic Suspension and Resident Appeals Process and the contract of employment between LCRH and the Resident. This Manual is not intended to and does not enlarge or create any additional rights of employment. It does, however, set forth and direct the Resident to many matters that the Resident is obligated to obey or observe. In no way should this Manual be considered as the only, or final, source of information on the policies, procedures and practices of LCRH. Residents are to refer to the specific LCRH Medical Staff Bylaws and Rules, LCRH Policies and Procedures for issues concerning employment or patient care, and are encouraged to ask the DME/ADME for additional information or clarification on any such matters. 2.1 Eligibility and Selection The following is the policy of LCRH regarding the recruitment, eligibility and selection of Residents. Each applicant must file an application through the training program‘s respective match process, provide three reference letters, a Dean's letter, board scores, medical school transcripts, medical school diploma; and, finally, appear for a series of interviews. A. Eligibility. Applicants must meet the following qualifications to be eligible for

appointment to an AOA residency program: 1. Graduate of an AOA accredited College of Osteopathic Medicine. 2. Have successfully passed all examinations as deemed required by each training program. 3. Have a full and unrestricted license (training certificate) to practice medicine in a U.S. licensing jurisdiction.

B. Selection. 1. Programs at LCRH select from among eligible applicants on the basis of their preparedness, ability, aptitude, academic credentials, communication skills, and personal qualities such as motivation and integrity and other relevant qualities pertaining to Osteopathic Graduate Medical Education (OGME). 2. Programs shall not discriminate with regard to gender, race, age, religion, color, national origin, disability, sexual orientation or veteran status.

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In selecting from qualified applicants, programs participate in an organized matching program, where available, such as the Resident and Resident Matching Program (NRMP).

2.2 Resident Contract Upon completion of the ―match LCRH‘s Department of Medical Education will send to the matched Residents, the institutional Resident contract. The Resident must return this contract within specified date given at issuance for the contract to become valid. A Resident who breaches the Resident contract may not serve an AOA-approved residency, residency or fellowship program for a period of twelve (12) months following the date of the breach. Contract requirements must be met in full. Resident‘s failing to pass COMLEX Part II (both CE and PE) prior to the start of residency will result in a breach of the contract and immediate termination of the Resident. Violation of the contract by a Resident may result in the loss of credit for time served in the program. All appointments (contracts) are for one year or less, and may be renewed at the discretion of the institution, upon continued evidence of satisfactory performance. The Resident contract shall reference: (these items shall be outlined in detail in the Resident Manual)

1. Resident responsibilities 2. Duration of appointment 3. Financial support 4. Conditions under which living quarters, meals, laundry are provided 5. Conditions for reappointment and promotion 6. Grievance and due process procedures 7. Professional liability insurance 8. Liability coverage for claims filed after program completion 9. Health and disability insurance 10. Leave of absence policy 11. Sick leave policy 12. Policy on effects of leaves on satisfying criteria for program completion 13. Duty hour’s policies and procedures 14. Policy on moonlighting 15. Policy on other professional activities outside the Program Director Counseling, medical, psychological support services 16. Policy on physician impairment and substance abuse 17. Policy on sexual harassment 18. Policy closure of hospital/training programs or reduction in approved Resident positions The contract will be maintained in the individual trainee‘s personnel file. All institutional human resource policies may be applicable to Residents at the discretion of the training program.

2.3 Re-Appointment

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All Residency reappointment contracts carry the condition that Residents must complete their present year of training in a satisfactory manner for the reappointment to be valid at the beginning of the new academic year beginning July 1 (or other pending an off-cycle start). Advancement to the next OGME level is based upon the recommendation of the Program Director/Director of Medical Education (DME) of each training program. The following are perquisites for promotion of the Resident to the following year of training:

1. Complete all rotations with a passing grade as per rotation schedule. 2. Copies of ALL activity (didactic) summaries, case logs, monthly and concurrent summaries, evaluations, time logs are completed and turned in to the appropriate Director(s) of the AOA. 3. Evaluations demonstrate an acceptable performance for Residents at his/her academic level for advancement. 4. Successful completion of the COMLEX Step III exam prior to the start of the OGME II is strongly suggested. But no contract for OGME III will be offered without proof of satisfactorily passing of the COMLEX Step III exam. 5. Evaluations demonstrate no disciplinary or professional behavioral problems. 6. Complies with didactic program per program requirements.

2.4 Non-Renewal of Contract/Appointment If at any time a Program Director determines that a Resident is not meeting the standards of the program, he/she may recommend non-renewal of the Resident‘s appointment or contract. Circumstances which might result in non-renewal of appointment are outlined in the Corrective Action section of this Manual. The Program Director must submit the recommendation for non-renewal in writing to the Director of Medical Education, and will include the basis on which the action is being taken. If the Director of Medical Education determines that there is sufficient reason not to renew the contract, he/she will notify the Program Director, who will so inform the Resident in writing. When possible, the resident will be given no less than four months’ notice of intent to not renew their contract. Resident receiving notice of non-renewal of contract/appointment may implement his/her right to due process through the Appeals Process, as presented in this Manual. 2.5 Completion of Training When a resident is absent from the program for more than the allowed 20 days, the additional time will have to be added onto the end of their training. The sponsoring institution and the program director will have to make a decision as to the appropriateness of the absence. If the absence is approved then the contract must be extended to make up for the additional time away from the program. In order to receive a certificate of residency completion the last 12 months of training must occur in the LCRH Residency program. Before departing LCRH at the conclusion of your residency training, you must complete obligations to your Program Director and also to the institution. An official LCRH Residency Program Clearance Sheet must be completed and turned into the Department of Medical Education Director along with your ID badge. This form can be obtained from the Medical Education office. It will show evidence of your completed medical records, and that you have returned all hospital property such as keys, equipment, parking pass, radiation dosimeter, keys, scrubs, etc. The sheet also requests a

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forwarding address, and reminds you of your right to continuing health insurance coverage through COBRA. In the event that a resident leaves the program prior to completion, a letter verifying the successfully completed rotations during their training at LCRH will be provided the resident and will be maintained in the resident's LCRH resident file. 2.6 Program Closure or Reduction If LCRH intends to reduce the size of, or close a residency program, the institution will inform the Residents as soon as possible. In the event of such a reduction or closure, the institution will make every effort to allow Residents already in the program to complete their education. If any Residents are displaced by the closure of a program or a reduction in the number of Residents, the institution will make every effort to assist the Residents in identifying a program in which they can continue their education.

1. The training institution will immediately notify the AOA, its Osteopathic Postdoctoral Training Institution (OPTI) and its trainees of a program closure or reduction in positions, which would impact trainees prior to program completion. 2. If LCRH reduces in size or closes a program, every attempt will be made to permit the current Residents enrolled in the program to complete their training prior to such an action. 3. In the event of the hospital or program closure or reduction in positions which, would impact trainees prior to program completion. LCRH will immediately notify the OPTI to aid in placement of the enrolled Residents in other AOA approved programs within that OPTI structure. Severance pay shall be provided for two months if the LCRH Residency Program closes or reduction decisions prevent Residents from program completion in that or another geographically proximate program arranged by the LCRH Residency Program and/or the OPTI.

2.7 Restrictive Covenants LCRH strictly prohibits the request for any Resident to sign non-competition guarantees. 2.8 Visa Policies & Procedures for Foreign/US Medical School Graduates It is policy of LCRH to comply with the immigration laws of the United States, and all Residents must obtain and maintain an immigration status that permits employment by the Hospital in a clinical capacity if applicable prior to the time their employment begins. The resident is responsible to acquire and maintain their own visa and provide evidence of same to the program. All offers of employment are contingent on verification of the candidate‘s right to work in the United States. On the first day of work, every new associate will be asked to provide original documents verifying his or her right to work and, as required by federal law, to sign Federal Form I-9, Employment Eligibility Verification Form.

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2.9 Transfers into the LCRH Residency Program Residents wishing to transfer into a LCRH Osteopathic Residency must provide a written verification of previous educational experiences and a statement regarding the performance evaluation of a transferring resident prior to acceptance into the program. This letter must come from the Program Director or Director of Medical Education of the previous residency program. For residents applying for advanced standing with a LCRH Residency for non-AOA approved internal medicine training or for non-internal medicine training must be approved by the Program Director, Director of Medical Education, and the ACOI‘s Council on Education and Evaluation upon request of the Program Director and Resident.

3 EMPLOYMENT POLICIES 3.1 Equal Employment Opportunity/Diversity We are committed to a work setting which treats all employees with fairness, dignity, and respect and affords them an opportunity to grow, to develop professionally, and to work in a team environment that values the diverse background of each employee.

Persons believing they have been discriminated against should feel free to report their concerns to their supervisor or to the Human Resources Department. Refer to the Complaint filing and Investigative Procedures policy for additional information.

Each member of management is responsible for creating an atmosphere free of discrimination and harassment, sexual or otherwise. Further, employees are responsible for respecting the rights and diverse backgrounds of their coworkers.

3.2 Employee Background Check Prior to making an offer of employment, LCRH may request an application for employment through its electronic applicant tracking system. This will generate a job-related background check. A comprehensive background check may consist of prior employment verification, professional reference checks, education confirmation, and criminal check. Refer to LCRH Human Resource Policy & Procedure Manual. 3.3 Pre-Employment Evaluation All associates of LCRH are required to pass a pre-employment physical. Arrangements for a pre-employment screening will be scheduled 1 month prior to start date. Record of immunizations and other health information will be maintained in the Employee Health Record. LCRH is committed to the health and safety of its associates, as well as its patients. This includes the assurance of a drug and alcohol-free work environment. The Hospital has,

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therefore, implemented a substance abuse policy that applies to all LCRH associates, making mandatory drug screening a regular part of the pre-employment screening. Any refusal of a Resident to undergo the test or a positive test result will be denied employment. The pre-employment examination will include a urine drug screen. Residents are required to take an annual Tuberculosis screening. Prior to starting residency training, residents are required to provide evidence of vaccination, immunity, or proof of medical/religious exemption. In addition to the health history, the following tests / procedures are also included: Laboratory Studies: Urine Drug Screen, Rubella Titer, Rubeola Titer, Mumps IGG and Varicella Titer, and Hepatitis B titer (if previous Hepatitis B vaccination series has been completed).

Any employee with a Rubella Titer of less than 1.1 is notified. The employee will be advised to consult his/her physician for immunization.

All prospective employees without proof of immunity will have a Rubeola Virus Antibody test (ELISA) at the time of pre-placement lab studies. Employees, who cannot demonstrate evidence of measles/mumps immunity, will be advised to consult his/her physician for immunization.

Tuberculin skin test or chest x-ray (for those employees with a history of previous positive reaction)

All employees will be given an in-service on Hepatitis B vaccine and will be offered the vaccine, with the hospital bearing the cost of the vaccine. If the employees Hepatitis B titer reflects no immunity, we will offer a booster Hepatitis B vaccination and repeat titer one month after vaccination.

Every new associate is required to have a screening examination provided by the hospital. Employment will be conditional dependent on the results of this screening. Physician trainees may be required to submit to periodic medical tests when warranted by the hospital during employment. 3.4 Post Enrollment Requirements: Years 1:4

• Hepatitis B: All physicians in training should be immunized (series of three {3} injections against hepatitis B virus or provide serologic proof of immunity (titer) as part of their preparation for clinical work.) Anyone electing not to take the hepatitis B vaccine will be required to sign an informed denial form on a yearly basis.

• Tuberculosis: Yearly results of tuberculin skin test. Monitoring Requirement: 1. Written proof of required immunizations must be documented through the use of health care monitoring form prior to or at the time of enrollment of new, transferring or visiting trainees. A copy of the official immunization records that document certain immunizations may be attached to the form. Please do not send originals.

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2. A yearly statement of results of the tuberculin skin test signed by a physician or other appropriate health care provider only, will be accepted. 3. Any trainee electing not to receive Hepatitis B vaccine must sign a Hepatitis B informed denial statement. 4. Immunization requirements will be waived if medical or other appropriate documentation prohibits vaccination. 5. The immunization status of all physicians in training will be confidentially stored and monitored. Release of information will be at the individual‘s consent and/or as required by the community corporation and clinical teaching hospitals/sites. 6. It shall be the responsibility of the trainee to notify the Director of Medical Education in the event of exposure to or having been diagnosed with a communicable disease, which could pose risks to patients. Failure to Comply with this policy will result in the individual being withheld from clinical activity. Drug and Alcohol Testing It is the policy of LCRH to promote a workplace that is free from the influence of drugs and alcohol. LCRH believes that such a policy is in the best interest of all our employees and the patients whom we serve. LCRH has selected a laboratory with the technological sophistication to conduct Zero Tolerance Drug Testing on all samples submitted for testing. This policy supersedes all previous drug and alcohol policies of LCRH, whether found in an Employee Handbook, Policy and Procedure Manual, or in any other document or communications. All positive test results will be reported to the applicable licensing board/agency as required by law.

B. Definition:

As used in this Policy, the term “drug” means any illegal or illicit drug, any substance or drug producing effects on the central nervous system, or any controlled substance; and the term “alcohol” means the intoxicating agency in beverage alcohol, ethyl alcohol (e.g., beer, wine, liquor), or other low molecular weight alcohols including, but not limited to, methyl and isopropyl alcohol. In addition, the term “drug” will include legal prescription drugs for which the employee does not have a prescription.

C. Prohibited Conduct: The following shall be grounds for disciplinary action up to and including discharge:

1) possessing, using, selling, manufacturing, distributing, dispensing, transferring, offering, furnishing (except as required by your employment or contract) drugs (illegal or illicit) or alcohol;

2) being under the influence of illegal or non-prescription drugs or alcohol, or having drugs or alcohol:

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a. in one’s system, or b. on any LCRH premises or worksites, or c. in any area under the control of LCRH, (including, but not limited to, the

parking area), or d. during LCRH time, or e. in or occupying LCRH property (including, but not limited to, LCRH vehicles) or

property under the control of LCRH.

D. Legal Medications/Drugs This Policy does not prohibit the legal (prescription or non-prescription) use of medications containing alcohol, or the legal (prescription or non-prescription) use of drugs, but LCRH requires that all employees disclose to LCRH, in advance of working, when taking medication containing alcohol or any drug that poses a significant risk of substantial harm to the health or safety of the individual or others, or when taking any medication containing alcohol or any drug that renders the employee unable to perform the essential functions of the job safely. Where required, LCRH will make reasonable accommodations, if appropriate. It is the employee’s responsibility to consult with the employee’s licensed healthcare professional to determine if any medication or drug would adversely affect the employee’s ability to perform the essential functions of the job safely and requires disclosure to their employer.

Residents with chemical dependency problems will be encouraged to seek appropriate treatment for these problems, and the appropriate leave will be provided. Residents returning to duty from a leave of absence related to chemical dependency problem will be required to sign a return-to-work agreement providing for random drug and/or alcohol tests. 3.5 Criminal Records Criminal record check is performed to protect LCRH‘s interest and that of its associates and clients.

• All LCRH entities conduct criminal background checks on all final candidates for employment. The results of criminal background checks may take several weeks to be processed. Residents are not permitted to begin work before the results are received. In the event that a disqualifying conviction is returned on a Resident, he/she will be subject to separation from the Hospital and terminated from the Residency Program. This separation will occur even if the Resident has successfully completed some period of the residency program before the results are received. The Resident‘s contract will then become Null and Void.

Criminal Records

Documents

3.6 Controlled Substance (DEA)

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To obtain a permanent DEA number, contact the Drug Enforcement Administration in Washington D.C., at (202) 633-1000 . Prescribing Controlled Substances over the Telephone: Under no circumstances should Residents prescribe controlled substances over the telephone for any patient, unless the Resident personally knows the patient as a result of providing medical treatment to him/her as part of the Resident's training program. In addition, prior to prescribing any controlled substance over the telephone, the Resident should first review the patient's medical record to verify any pharmacies, patients, or other individual's request for the prescription also use the guidelines for prescribing controlled drugs from House Bill 1(Physicians link to e-Kasper on LCRH home page) The appropriate response to a telephone request for controlled substances from anyone claiming to be the patient of a LCRH attending physician is as follows:

1. Take the patient‘s name and phone number, and the name of the patient‘s attending physician; 2. Call the attending physician with the information; and

Let the attending physician instruct you on how to respond to the request. The resident must keep a record of any and all patient calls, and see that these notes are placed in the patient‘s medical records. 3.7 Physician Impairment & Substance Abuse To provide a safe environment, LCRH Residents have a responsibility to report to work in a fit condition. In keeping with federal drug-free regulations, LCRH is committed to a drug and alcohol free work environment. As a health care provider, we are aware of our responsibility to our patients, visitors, associates, and medical staff to ensure that our facilities are drug and alcohol free. Therefore, the use, sale, purchases, negotiation of sale, manufacture, distribution, dispensation or possession of illegal drugs or the miss use of legal drugs and alcohol is prohibited. This policy is designed to ensure a drug and alcohol free work environment while protecting the privacy of associates and applicants with respect to personal health information. Residents are required to meet the Hospital‘s requirements as defined in Human Resources Policy and Procedure Fitness for Duty – A confidential and mandatory referral process, which evaluates an associate‘s ability to perform his/her job functions when pronounced changes, which negatively impact his/her work performance, are demonstrated. Fit associates are those physically and mentally able to perform the standards required of his/her position. Types of impairment covered by Fitness for Duty include:

1. Psychological Impairment. Significant changes in behaviors and/or psychological state. This may include but not be limited to: threats of harm against self or others, destruction of property or threats of destruction, dramatic mood swings, explosive anger or acting-out behaviors, extreme disclosure of personal information, and disorganized thoughts. 2. Physical Impairment. Significant changes in physical ability to perform job duties and meet the physical standards that impact current job responsibilities. They may include, but are not limited to, diminished ability to walk, lift, climb, operate

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equipment, see, hear, or any physical deterioration that compromises and Resident‘s ability to perform his/her job.

3.8 Licensure

An individual pursuing a residency in the State of Kentucky must be licensed by the State of Kentucky Medical Board. Physicians in their first year of post graduate training (PGY1) are exempt from licensure pursuant to KRS 311.560, section 2(c). After completion of one year of training, a physician is required to obtain an Institutional Practice Limited License or a Residency Training License to practice in Kentucky.

A Residency Training License (R) is issued to a physician entering residency training in Kentucky. This license allows a physician to practice within the parameters of the training program, as well as moonlight at locations designated by the Program Director. This license allows a physician to apply for a DEA license. This license is issued on an academic year, July 1 to June 30, and is renewable annually while in training. An applicant must have completed one year of ACGME accredited postgraduate training and all parts of the USMLE or COMLEX. Please refer to 311.571

The Medical Education office will provide the necessary application forms for the Training Certificate, but responsibility for timely completion lies with the applicant. A Training Certificate is valid only for a period of one year, but may be renewed annually for a maximum of five years. This Learning Certificate allows the resident to practice medicine ONLY within the scope of their residency training program. The Training Certificate allows Residents to follow the schedule of prescribed services, rotations, and clinical activities that have been issued by their Program Directors. Please be advised of the following limitations regarding temporary licensure:

A Resident without a permanent license cannot “moonlight.” Moonlighting – Any circumstance of working as a physician or healthcare provider outside the Resident’s authorized training program. Permanent licensure can be initiated by contacting the Kentucky Board of Medicine (502-429-7150 ext. 222/223.) The Office of Medical Education must be kept informed of any change in licensure status. 3.9 Certificates Each Resident, at the successful completion of their residency training program, will receive a certificate certifying that the Resident has performed all the requirements set forth by the American Osteopathic Association, the attending staff, administration of LCRH, and the appropriate college of each specialty training program. The Hospital is justified in holding such a certificate back only if the Resident fails to complete the internship, residency, or fellowship program, including all required paperwork; or if the Resident‘s performance has been such as to indicate that the Resident is not yet adequately prepared for the practice of osteopathic medicine. Under no circumstances will the hospital arbitrarily refuse to issue such a certificate for relatively minor reasons. In the event of illness necessitating the Resident‘s withdrawal from training, the hospital may properly issue a

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http://www.lrc.state.ky.us/krs/311-00/560.pdf

http://www.lrc.state.ky.us/krs/311-00/571.pdf


certificate to include the period of training completed or arrange for additional training at a later date to complete the training. The certificate of completion will include:

Name of Institution Name of OPTI Resident‘s Name Dates of Completion (start/end) Type of program Signatures of Institution, OPTI, Program Director & DME

3.10 Change of Personal Data It is the responsibility of each Resident to report any changes in name, address, phone number, or email address to the Department of Medical Education and to the LCRH Department of Human Resources, Efficient distribution of W-2 forms, benefits information, and other important hospital mailings is dependent upon the data an associate has provided and timely submission of reimbursement items as well as end-of-year tax information. 3.11 Chain of Communication Residents shall follow the ― Chain of Communication policy of Lake Cumberland Regional Hospital (Hospital‘s Policy and Procedure Manual). When necessary the DME presides over all areas concerning Medical Education and is the final step in the Resident/Intern chain of command. When issues/problems occur, the Resident/Intern should contact/speak with:

1. Chief Residents 2. Attending Physician 3. Residency Program Director 4. Director of Medical Education

3.12 Safety LCRH strives to provide its associates, patients, and visitors with a safe and healthy environment. Should conditions or hazards be identified that pose an immediate threat to life, health or safety, the situation must be immediately and appropriately addressed and reported to the Safety Officer at extension 3920. 3.13 Personal Property

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LCRH assumes no risk for any loss or damage to personal property and recommends that all associates have personal insurance policies covering the loss of personal property left in the Department of Medical Education or LCRH. 3.14 Professional Activities outside the Program Residents may be required to attend educational programs based on the Residency Program‘s requirements. Refer to Residency Training Program Manual for details. 3.15 Visitors in the Workplace For safety, insurance, and other business considerations, only authorized visitors are allowed in the workplace. When making arrangements for visitors, associates should request that visitors enter through the main reception area and sign in. The hours and regulations for visiting are published and given to all patients. Recommendations for individual exceptions to the regulations should be made to the Security Guard or Nursing supervisor. Residents have the obligation to discuss and answer questions about a patient‘s condition with those who have a legal right to know. Information concerning a patient is privileged and confidential and should not be divulged to anyone except individuals specifically designated by the patient. Non-designated friends, relatives and visitors are not entitled to such information, but their inquiries must be handled in a friendly and tactful manner. 3.16 Weather-related and Emergency-related Closings At times, emergencies such as severe weather, fires, or power failures can disrupt company operations. In such instances, Executive Staff “Incident Commander” will decide on the closure and will inform the Medical Director or designee the official notification to the Residents/Staff.

4 DISCIPLINARY PROCESS

(This process will supersede the Problem Solving and Corrective Action Process in the LCRH employee manual.)

4.1 Performance

At any time during the Residency Training Program, the Residency Program Director, or Director of Medical Education may determine that the Resident is not meeting the standards of the program or the profession, for reasons that may include, but are not limited to:

1. Lack of professional competence, insufficient medical knowledge, or technical skills needed to carry out their duties and responsibilities;

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2. Any conduct that is detrimental or potentially detrimental to patients or associates;

3. Demonstrated inability to work with others or behavior that is reasonably likely to be disruptive to Hospital operations;

4. Any demonstrated lack of personal/professional integrity (honesty, reliability, and accountability).

5. Activities or professional conduct that are reasonably likely to be in violation of the Medical Staff Bylaws, Medical Staff Rules and Regulations, or any other Hospital policies and procedures; and,

If the Residency Program Director or Director of Medical Education believes that corrective action is warranted, he/she may do one or more of the following: 1. A written reprimand will either be given to the resident with a signed confirmation of receipt or sent by certified mailed to the Resident, and a copy will be placed in the Resident's file.

2. If a remedial program is required, the Resident shall be so informed in a meeting with the Residency Program Director and the Director of Medical Education. At that meeting, the Resident's deficiencies will be identified, a remedial program will be established, and a time frame for completion of the remedial program will be discussed and documented.

A copy of this document will be given to the Resident, and a copy will be placed in the Resident's file. The remedial plan may include limitations or restrictions on the amount and level of the Resident's patient care activities. Such action may necessitate extension of the Resident's educational program. At the end of the remedial period, the Resident will receive an evaluation. At that time, the Residency Program Director and/or Director of Medical Education may or may not take further corrective action.

3. Recommended Leave of Absence, Suspension or Dismissal of the Resident. The Residency Program Director and/or Director of Medical Education may recommend a Leave of Absence, Suspension, or Dismissal of the Resident. The Leave of Absence or Suspension may be with or without pay. Suspension shall be without pay. Such recommendation will be made in writing, accompanied by any written documents necessary to support the recommendation, and will be filed with the Director of Medical Education. The recommendation will include a time frame for a Leave of Absence or Suspension. The Director of Medical Education, or their designee, will convene an Initial Review Panel within 10 calendar days of the recommended action, which will include the Director of Medical Education (who will chair the Panel), the Residency Program Director (or representative), and representatives of the Risk/Legal Department and Human Resources. Prior to the meeting, the Panel Chair will review the submitted documents, and determine a list of individuals who the Panel may wish to interview. These individuals will be notified to be available in the event the Panel wants to interview them. The Panel will present its findings to the Director of Medical Education,

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who will promptly issue a decision on the recommendation for Leave of Absence, Suspension or Dismissal of the Resident. In the event the Director of Medical Education upholds such recommendation, the action shall become effective immediately. During the period of Suspension without pay, or Leave of Absence without pay, the Resident will not receive any cash, or other compensation. Health-related benefits will continue if the Resident elects to pay for them directly. In all cases of Suspension or Leave of Absence, the Resident will not be permitted any Hospital privileges, nor be permitted to attend Conferences or Rounds. The period of Leave of Absence or Suspension will result in an extension of the Resident‘s educational program. In the event the Director of Medical Education rejects the recommendation, and the Director of Medical Education imposes no other sanction or action, the record of the event will be expunged from the Resident‘s file. 4. Recommend non-renewal of the Resident‘s contract. If a Residency Program Director determines that a Resident is not meeting the standards of the program, he/she may make a recommendation for non-renewal of the Resident‘s contract. The recommendation must be submitted in writing to the Director of Medical Education, and will include the basis on which the action is being taken, along with any written documents necessary to support the recommendation. All written information regarding the recommendation will become part of the Resident‘s file. If the Director of Medical Education/ determines that there is sufficient reason not to renew the contract, he/she will notify the Program Director, who will so inform the Resident in writing. Recommendations for non-renewal should be made no later than four months prior to the end of the Resident‘s current contract (when possible). If the primary reason(s) for non-renewal occur(s) within the four months prior to the end of the current contract, every effort will be made to ensure that the program provides its Resident as much written notice of the intent not to renew as circumstances will reasonably allow. A Resident receiving notice of non-renewal of contract may implement his/her right to due process through the Appeals Process presented in this Manual. In the event the Director of Medical Education rejects a recommendation for non-renewal of contract, the Resident‘s contract will be renewed for the following year. 5. No appeal is available when the action is to reprimand or to institute a remedial program for the Resident. A decision to impose a leave of absence, suspend, dismiss, or fail to renew the Resident‘s contract shall entitle the affected Resident to the Appeals Process in this Manual. Where a Resident receives notice of a corrective action under the terms in this Resident Manual, inclusive of any amendments to this Manual that are in effect on the date of receipt of the notice, this Manual shall govern, irrespective of any later amendments or revisions to the Manual.

4.2 Summary Suspension The Residency Program Director, Medical Education Committee or Director of Medical Education shall have the authority, whenever action must be taken immediately in the best interest of patient care or the Hospital, to summarily suspend all or any portion of the privileges of a Resident, and such summary suspension shall become effective immediately upon imposition. At the discretion of the Director of Medical Education, such suspensions may be with or without pay depending on the allegations and the facts and status of any applicable

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investigation. The Director of Medical Education will convene an Initial Review Panel within 10 calendar days of the suspension. The Panel will include the Director of Medical Education (who will Chair the Panel); the Director of Human Resources, the Residency Program Director (or representative); the Clinical Department Chairman (or representative). The Panel may request an interview with the suspended Resident. Whoever summarily suspended the Resident will provide written documents necessary to support the recommendation. The panel will decide whether to reverse, modify, or sustain the Summary Suspension. A Resident who has been summarily suspended shall be entitled to all of the rights provided in the Appeals Process in this Manual. 4.3 Automatic Suspension A suspension of a Resident shall be imposed automatically if action by the Kentucky Board of Medicine results in revocation or suspension of the Resident‘s license or temporary certificate. Such automatic suspension shall become effective immediately upon notice of action by the Kentucky Board of Medicine. During the suspension, the Resident will be on ―”unpaid leave status” and, in order to continue health benefits, will need to pay the premium directly since, in the absence of a paycheck, deduction of that premium is not possible. If the license or temporary certificate is reinstated, the Resident may apply for readmission into the program. If readmission into the program is denied, the Resident is entitled to all the rights provided in the Appeals Process contained in this Manual. 4.4 Resident Appeals Process A. Whenever a Corrective Action that can be appealed (Leave of Absence, Suspension, Summary Suspension, Dismissal, Failure to Renew Contract, Failure to be Re-accepted into Program after Termination of Automatic Suspension) is imposed on a Resident, the Residency Training Director or Director of Medical Education shall provide written notification to the Resident, either in person or by certified mail, return receipt requested, of the Corrective Action. Such notice shall contain a specific statement of the grounds for such Corrective Action and shall refer to the Resident‘s right of appeal as set forth below. B. To appeal a Corrective Action, the Resident must submit, within ten (10) calendar days after receiving such notice, a written request either in person or by certified mail, return receipt requested to the Director of Medical Education/ for a hearing before an Appeals Committee. No electronic requests will be accepted. C. Upon receipt of a written request for a hearing, the Director of Medical Education shall appoint an Appeals Committee consisting of seven individuals, five of whom will have a vote. The Director of Medical Education will Chair the committee. The voting members will include:

a. A Resident who is a member of the Medical Education Committee or a Chief Resident. b. Two Residency Program Directors/faculty members. A representative from Human Resources; and c. A Medical Staff Member from a different Clinical Department than that of the Resident requesting the Appeal Hearing and that of the two Program Directors on the Committee.

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The non-voting members will be:

a. The Director of Medical Education; and, b. A Resident, from a different Department, at a similar level of training as the Resident who filed the Appeal. The non-voting Resident member may participate in all aspects of the deliberations prior to the vote.

D. The Director of Medical Education will appoint the Administrative Director or Coordinator of the Office of Medical Education to serve as Secretary, who will keep minutes of the meeting. The Director of Medical Education, or his/her designee, will determine the date, time, and place of the meeting. E. No later than ten (10) business days after receipt of the Resident's request for a hearing, the Director of Medical Education or his/her designee, shall notify the Resident by certified mail, return receipt requested, of the date, time, and place of the hearing. F. The hearing shall be held no fewer than thirty (30) and no more than forty-five (45) business days after receipt of the Resident's request for a hearing. A hearing for a Resident who is under suspension shall be held as soon as the arrangements may reasonably be made, but not later than thirty (30) calendar days from the date of receipt of the request for a hearing, unless extended by mutual consent. G. From the date upon which the Director of Medical Education receives the Resident's request for a hearing until the date of the hearing, the Residency Program Director or Director of Medical Education, or his/her shall permit the Resident, upon his/her request, to examine and duplicate any written materials that relate in any way to the suspension, termination, or corrective action. No later than ten (10) business days prior to the scheduled hearing date, the parties shall provide each other with a list of witnesses that each intends to call at the hearing. A maximum of 3 witnesses each may be called by the Resident and by the Program Director to appear in person. An unlimited number of witnesses, however, may submit written testimonials for review by the Appeals Committee. H. At the hearing, the resident's personal presence is required. The Resident may be aided or represented by another Resident in the Hospital's graduate Medical Education program or by a member of the Hospital's Medical Staff. None of the parties to the appeal shall be aided or represented at this hearing by an attorney. I. At the hearing, both the Residency program Director and the Resident may make opening statements. The Residency Program Director shall then present his/her case supporting the corrective action. The Resident shall then present his/her case opposing such suspension, termination, or corrective action. Both the Residency Program Director or Director of Medical Education and the Residents may make closing arguments. J. At the hearing, both the Residency Program Director and the Resident may present written evidence, examine witnesses, and cross-examine witnesses. The Rules of Evidence that govern proceedings in a court of law shall not apply. K. Within five (5) business days after the hearing, the Committee Chair (i.e., the Director of Medical Education) shall prepare and send to both the Residency Training Director or Director of Medical Education and the Resident, by certified mail, return, receipt requested; a written decision which shall affirm, modify or reverse the Resident's corrective action. This decision shall be by a majority vote of the Committee's members and shall be based solely upon the

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written and oral evidence presented by the Residency Training Director and the Resident at the hearing. The Director of Medical Education shall receive a copy of the written decision. L. The decision of the Committee shall be final and binding upon both the Residency Program Director or Director of Medical Education and the Resident. M. A Resident who has been suspended or dismissed from the Hospital's Medical Education Program, and who has instituted an appeal as provided herein, may resume clinical practice only if recommended in writing by the Appeals Committee. N. The Resident's failure to exercise any right provided by the Appeals Process shall constitute an irrevocable waiver of such right. 4.5 Grievance and Due Process Procedure The following Grievance Procedure is available to all Residents who are members of the Resident Staff of LCRH. It is not applicable to Residents from other affiliated institutions that are on rotation at LCRH. A. Complaint procedures are established to protect the integrity and the maintenance of educational standards as they relate to approved OTPIs. B. To provide a mechanism for concerned individuals or organizations to bring to the attention of the accrediting agency information concerning specific actions and programs that may be in noncompliance with the AOA‘s educational standards. C. To recognize the responsibility of the AOA to provide responsible complainants the opportunity to use the AOA as a vehicle to address specific grievances. 1. Grievances. If a Resident has reason to believe that established Hospital policies and procedures including applicable personnel policies (with the exception of any action, policy, practice or procedure connected with the periodic evaluation of Resident, corrective action or appeals, as set forth in this Resident Manual) have been denied him/her or have been erroneously applied to him/her, or if a Resident has a problem (collectively, hereinafter a ―Grievance‖) with any associate of the Hospital, any member of the Hospital‘s Medical Staff, or any other individual affiliated or associated with the Resident‘s residency training program, the following procedure has been established for the discussion and resolution of such a Grievance. 2. Meeting with the Administrative Director of Medical Education. Make an appointment to discuss the Grievance with the Administrative Director of Medical Education (ADME). The ADME will explain the established policies and procedures to assist the Resident in determining whether a formal Grievance should be filed. The Resident shall maintain authority over the final decision as to whether a Grievance exists and/or whether a formal Grievance should be filed. 3. Filing Grievance Notice. If, after discussing the Grievance with the ADME, the Resident believes that a Grievance exists, then the Resident must submit a written notice (the Grievance Notice) of the Grievance to the ADME and the Resident‘s respective Program Director. All Grievance Notices must be set forth in reasonable and sufficient detail an explanation of the Resident‘s Grievance. All Grievance Notices must be properly filed by the respective Resident no later than (30) calendar days after the Resident discusses the Grievance with the ADME.

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4. Form of Filing and Disclosure of Grievance. A properly filed Grievance Notice is one that is either: (1) personally delivered by the Resident to each of the appropriate parties and for which the Resident obtained a time stamped copy (reflecting the date and time of delivery of the Grievance Notice) from each party to whom the Resident personally delivered the Grievance Notice; or (2) mailed by certified mail, return receipt requested to each appropriate party. The ADME may provide copies of all Grievance Notices to the following individuals: (1) the Resident‘s Program Director; (2) the DME; and (3) the Director of Human Resources. 5. Filing Grievance Notice with Alternate Parties and Chiefs of Staff. If due to the nature of the Grievance, the Resident reasonably believes that it would be inappropriate to file the Grievance Notice with the Program Director, then the Resident shall so inform the ADME who shall then instruct the Resident to file the Grievance Notice to the Director of Medical Education. In lieu of filing the Grievance Notice with the ADME or Program Director, the Resident may, for good cause, file the Grievance Notice directly to the Director of Medical Education. “Good cause” shall be determined by the Director of Medical Education in his/her sole discretion and he/she reserves the right to redirect the Resident to the file the Grievance with any other party deemed appropriate by the Director of Medical Education. 6. Discussion with the Program Director. If the Resident filed the Grievance Notice with his/her respective Program Director pursuant to Step 3, above, then the Resident and the Program Director shall meet to discuss the Grievance. Unless the Resident otherwise agrees, such meeting shall occur no later than five (5) business days after the Program Director‘s receipt of the Grievance Notice. If the Resident chooses, the ADME may accompany him/her to this meeting to assist in the discussion of the Grievance. The Program Director shall reply in writing to the Resident‘s Grievance within five (5) business days after their meeting. 7. Program Director Grievance Review. At any time before, during or after a Resident meets with his/her respective Program Director, such Program Director may request the Resident to submit the names of two other Residents from his/her service whom the Program Director may want to ask about the Grievance or specific aspects thereof. In addition, the Program Director may ask the Resident‘s respective Chief Resident to answer questions relating to the Grievance and/or to be present at any meeting pertaining to the Resident‘s Grievance. In the event the Grievance concerns an incident that is not directly related to the Resident‘s training program, the Program Director may request the Resident to submit the names of two Hospital associates who witnessed the incident. If a person identified as a witness leaves the employ of the Hospital prior to resolution of the Grievance, that person shall nevertheless be recognized and accorded an opportunity to be heard during the Grievance Process set forth herein, provided that such person left the Hospital in good standing. 8. Follow-Up after Discussion with the Program Director: Filing of Continuation Notice. If the Resident is not satisfied with the Program Director‘s resolution, and desires to follow through on the Grievance to the next step, the Resident shall meet with the ADME. The ADME will help the Resident with a further review of the Grievance to enable the Resident to make an appropriate decision whether to pursue his/her Grievance. If the Resident desires to pursue the Grievance, then he/she shall file a written notice (the “Continuation Notice”) that he or she wishes to continue to pursue the Grievance. This Continuation Notice may include a restatement of the Grievance Notice, but it must also further expand or explain the Resident‘s reasons for continuing to pursue the Grievance. This Continuation Notice must be filed with the ADME within thirty (30) calendar days after the Program Director issues his/her written resolution.

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9. Discussion with the Director of Medical Education. After a Resident meets with his/her respective Program Director, if the Resident desires to pursue the Grievance, then he/she shall meet with the Director of Medical Education. Unless the Resident otherwise agrees, such meeting shall occur no later than five (5) business days after the Director of Medical Education‘s receipt of the Grievance Notice. If the Resident chooses, the ADME may accompany him/her to this meeting to assist in the discussion of the Grievance. The Director of Medical Education shall reply in writing to the Resident‘s Grievance within five (5) business days after their meeting. 10. Director of Medical Education Grievance Review. At any time before, during or after a Resident meets with the Director of Medical Education, the Director of Medical Education shall follow the same process as in Step 7, above, offering only the same individuals an opportunity to be heard who were heard at Step 7. 11. Follow-Up after Discussion with the Director of Medical Education: Filing of Continuation Notice. If the Resident is not satisfied with the Director of Medical Education‘s resolution, and desires to follow through on the Grievance to the next step, the Resident shall meet with the ADME. The ADME will help the Resident with a further review of the Grievance to enable the Resident to make an appropriate decision whether to pursue his/her Grievance. If the Resident desires to pursue the Grievance, then he/she shall file a written notice (the “Continuation Notice”) that he or she wishes to continue to pursue the Grievance. This Continuation Notice may include a restatement of the Grievance Notice, but it must also further expand or explain the Resident‘s reasons for continuing to pursue the Grievance. This Continuation Notice must be filed with the ADME within thirty (30) calendar days after the Director of Medical Education issues his/her written resolution. 12. Establishment of Grievance Review Committee. The ADME will inform the Hospital‘s Director of Human Resources (or his/her designee) in writing of the Resident‘s desire to proceed on the Grievance and will provide him/her with a copy of the Continuation Notice. The Director of Human Resources will then: (1) select three individuals to serve as members of the Grievance Review Committee in accordance with Step 16, below; and (2) arrange a mutually convenient meeting time to hold a hearing on the Grievance. Subject to extenuating circumstances, the hearing shall be held within five (5) business days after the Director of Human Resource‘s receipt of the Continuation Notice. 13. Composition and Administration of Grievance Committee. The Grievance Review Committee shall consist of a combination of three persons: the Director of Medical Education, one who is a General Administrative Officer of the Hospital, and one who is a Residency Program Director. The Grievance Review Committee will not include anyone who has been involved in the Grievance. The Director of Human Resources will be the chairperson of the meeting, and shall conduct the meeting pursuant to this Grievance Procedure and all applicable policies and procedures of LCRH to ensure an orderly and fair opportunity for all parties to present their positions. 14. Witnesses. The Resident may, at any time prior to one (1) day before the hearing, submit to the Director of Human Resources the names of two Hospital associates who have information relating to the Grievance. These associates may be asked to appear before the Grievance Committee either by the Resident, the Director of Human Resources or by any member of the Committee. The Director of Medical Education may also request not more than two people to appear before the Committee. The Resident‘s appearance before the Committee shall be limited to: (1) making a presentation not to exceed ten (10) minutes (unless a longer

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period of time is permitted by unanimous approval of the Committee); and (2) responding to questions posed by the Committee. Unless otherwise permitted by unanimous approval of the Committee, neither the Resident nor any witness shall be permitted to sit through, attend or participate in the entire hearing. The Committee shall have sole discretion to determine which portion(s), if any, of the hearing the Resident and/or any witnesses shall attend. 15. Additional Information Relating to Grievance. The Committee may, in its sole discretion, interview additional individuals and/or seek additional information from other persons, organizations or entities if the Committee believes that such actions would facilitate resolution of the Grievance. 16. Providing Copies of Grievance. The Director of Human Resources may, in his/her sole discretion, forward copies of the Grievance Continuation Notice to all persons (including any witnesses) scheduled to attend all or any portion of the hearing. 17. Final Decision of Committee. The Committee must use its best efforts to give its decision in writing to the Resident within three (3) business days after the hearing. The Committee‘s decision shall be final, except in the event such decision results in the full and final termination of the Resident‘s participation in his/her residency training program. 18. Appeals. A Resident may appeal only a final decision hereunder. Any such appeal may be brought by the Resident only if: (1) the Resident has complied with and exhausted all remedies pursuant to the Grievance Procedure set forth herein; and (2) the final decision rendered hereunder expressly imposes a Leave of Absence, Suspension, or Dismissal of the Resident or Termination of the Resident‘s participation in his/her respective training program at the Hospital. Any appeal hereunder shall follow and be in accordance with the procedures set forth in the “Resident Appeal Process” section of the Resident Manual. 19. Waiver of Grievance. The Resident shall waive any and all rights under this Grievance Procedure in the event such Resident materially fails, without good cause, to comply with any of the requirements set forth herein, including, without limitation, missing any: (1) deadline for filing a Grievance Notice or Continuation Notice; or (2) any meeting or hearing with any party hereunder. “Good cause” shall be determined by the Director of Medical Education in his sole discretion, acting reasonably. 20. Confidentiality. All Grievances shall be kept confidential. The Resident, ADME, Chief Resident, Program Director, Department Chair, Director of Medical Education and any other Hospital associates, agents or representatives that receive a Grievance Notice or otherwise receive or initiate information pertaining to a Grievance shall keep all such information strictly confidential and shall disclose the same only to those other associates or agents of the Hospital or other third parties or government agencies having a reasonable need to know the Grievance and information pertaining thereto.

21. Modification of Time Limits. All Grievance Procedure time limits may be modified by mutual agreement of the parties based on the absence of one or more of the parties for good reason, such as scheduled vacation, previously determined work schedule, illness or similar absence.

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4.6 Maintaining Discipline among Patients, Nurses and Associates

Members of the Resident staff may not attempt to discipline a patient, medical staff member, nurse or other LCRH Associate. If a patient refuses to observe regulations or obey orders for treatment, the facts must be reported to the attending physician, the Director of Medical Education and the Program Director. The manner of the Resident with the patient should be gentle, polite and serious at all times in keeping with the dignity of the profession. Situations arising with nurses or other hospital associates that would require disciplinary action should be reported to the Director of Medical Education, or in his absence, to the Director of Human Resources and CEO. Under no circumstances are Residents to engage in arguments with the patient and associate.

5 STANDARDS OF CONDUCT 5.1 General Guidelines All Residents are expected to become familiar with LCRH rules and standards of conduct and are expected to follow these rules and standards faithfully in doing their own jobs and conducting the company‘s business. In addition all residents are expected to review and follow all medical staff rules and regulations. Resident rotations are developed on an annual basis based on the AOA requirements for each Program. Electives/selective must be requested by between June 15 and June 30 of for the coming academic year beginning July 1. (See Section 17 Elective/Selective Request Form)

Requests to change an assigned rotation must be submitted to the Residency Coordinator using the Rotation Change Request Form. (See Section 17 Rotation Change Request Form). Changes in rotations cannot be guaranteed since such changes depend on Program requirements and rotation availability. 5.2 Duty Hours & Responsibilities This section supersedes the section on Job Duty Hours, and the section on attendance and Hours of Work in the LCRH Employee Manual LCRH strives to meet institutional and program requirements of the American Osteopathic Association (AOA) to ensure that the learning objectives of its residency programs are not compromised by excessive reliance on Residents to fulfill service obligations. Providing Residents with a sound academic and clinical education must be carefully planned and balanced with concerns for patient safety and resident well-being. Didactic and clinical education has priority in the allotment of residents’ time and energies. Duty hour assignments recognize that faculty and residents collectively have responsibility for the safety and welfare of patients. Hours in excess of the average 80 hour work week (averaged over a four week period) will not be allowed by the Residency Program Director and/or the Director of Medical

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Education. When a violation does occur, the Program will either grant an exception in writing and/or make alter the resident rotations such that there will not be any likely further work duty hour violations.

• Residents are personally RESPONSIBLE for all patients assigned to them. Resident must show for and complete all call assignment. They are expected to report on time and begin the work assigned.

• Duty hours are defined as all clinical and academic activities related to the residency

program, i.e., patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time done away from the training site. 1. Duty hours are limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities, time spent returning to hospital while on home-call, and any time spent in approved “moonlighting” (see section 5.22). 2. The Resident shall not work in excess of 24 consecutive hours including scheduled didactics. Residents may not assume management responsibility for a new or established patient after working 24 hours. Interns may only work a 24 hour shift total. Seniors may work an additional 6 hours to complete documentation, transfers of care. (30 hours maximum continuous duty hours allowed by the AOA) 3. If moonlighting is permitted, all moonlighting (at any and all institutions) will be included within the eighty (80) hour per week maximum work limit and must be reported. 4. The resident shall have on alternate weeks, a 48-hour period off, or at least one 24-hour period off each week free from all educational and clinical responsibilities, averaged over a 2 week period, inclusive of call. 5. One day (off) is defined as one continuous 24-hour period free from all clinical, educational, and administrative activities. Residents may not be on home-call during a “day off”. 6. Upon conclusion of a 24-hour duty shift, residents must have a minimum of 16 hours off before being required to be on duty again 7. A 10-hour time period for rest and personal activities must be provided between all daily duty periods, and after in-house call. 8. All off-duty time must be totally free from assignment to clinical or educational activity. 9. Residents assigned to the Emergency Department rotation cannot work any longer than a 12 hour shift. This includes any assigned Hospital Medicine call shifts (hours). 10. The resident and the hospital must always remember the patient care responsibility is not precluded by the work hour policy. In cases where a resident is engaged in patient responsibility which cannot be interrupted, additional coverage should be provided as soon as possible to relieve the resident involved. And the resulting violation of the work duty hour law must be reported to the residency office as soon as possible. 11. The resident may not be assigned to a 24-hour call shift more often than every third night averaged over any consecutive 4 week period ( 1 in 3). 12. Senior residents (OGME 2 and 3) are expected to supervise and to assist the clinical and overall medical education activities of interns (OGME 1) and medical students assigned one each rotation. 13. OGME-2 Seniors are to always be IN-HOSPITAL during their assigned shifts (NO EXCEPTIONS). 14. OGME-3 senior residents may be assigned ―home call‖ by Program when appropriate.

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15. If an intern or resident has completed all direct care responsibilities, they must remain in hospital for non-patient care activities (such as medical records completion, New Innovations logs, approved research activities, reading, etc.) 16. If for some necessary reason, such as continuity clinic, a personal doctor appointment or administrative activity, a resident must leave their primary rotational location, they must formally (S-BAR - Situation-Background-Assessment-Recommendation) check out to comparable rotation team member. This includes transfer of dedicated residency phones and beepers (such as code beeper, etc). The senior would sign out to either his/her Chief Resident or the Rotational Attending.

The GMEC is committed to assuring that Residents are able to report concerns regarding duty hours without retribution. Residents may report issues by:

1. Scheduling an appointment with the Administrative Director of Medical Education. 2. Scheduling an appointment with the Director of Medical Education. 3. Contacting the resident representative of the Medical Education Committee who will supply a report to the MEC.

MONITORING OF DUTY HOURS: The Department of Medical Education requires residents to log daily activities into New Innovations. Weekly resident hourly reports are run each Monday morning so all hourly logging activities should be completed prior to 7am each Monday morning. Hours above 80 are reported to the Director of Medical Education who will investigate each occurrence. Any week that is close to an 80 hour violation is to be reported by the resident immediately to the DME for immediate action. Duty hours will be reviewed by the GMEC meeting at least quarterly. 5.3 On-Call Activities The objective of on-call activities is to provide Residents with continuity of patient care experiences throughout a 24-hour period. In-house call is defined as those duty hours beyond the normal workday when Residents are required to be immediately available in the assigned institution. Please understand the following:

• Residents are expected to work all assigned shifts or rotation even if a rotational attending is away. In such cases, the resident is to report into the Program Coordinator.

• If a resident has been approved to Moonlight, the Moonlighting cannot interfere with the call schedule. The call schedule takes precedence.

• Vacations must be approved by Chief Residents and the Program at least one month ahead.

1. In-house call must occur no more frequently than every third night, (or no more than one in three) averaged over a four-week period. 2. The Resident shall not work in excess of 24 consecutive hours including scheduled didactics. Residents may not assume management responsibility for a new or established patient after working 24 hours. Interns may only work a 24 hour shift total. Seniors may work an additional 6 hours to complete documentation, transfers of care. (30 hours maximum continuous duty hours allowed by the AOA)

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3. No new patient(s) may be accepted by a resident for care after 24 hours of his/her continuous duty. 4. At-home call (pager call) is defined as call taken from outside the assigned institution.

a. The frequency of at-home call is not subject to the every third night limitation. However, at-home call must not be so frequent as to preclude rest and reasonable personal time for each Resident. Residents taking at-home call must be provided with 1 day in 7 completely free from all educational and clinical responsibilities, averaged over a 4-week period. b. When Residents are called into the hospital from home, the hours Residents spend in-house are counted toward the 80-hour limit. c. The program director and the faculty must monitor the demands of at-home call in their programs and make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.

5. Call shifts should be approximately equal within the OGME1 class and the OGME2 & OGME3 classes. 6. Night Block service cover call for the services that have been formally signed out to them with a complete SBAR sign-out process.(All residents classes share equally within the class in Night Block rotations) 7. Residents on General Surgery, Hospital Medicine and ICU are expected to work with their Attendings‘call schedule and generally residents rotating OB/GYN will follow their Attendings‘call except in an extreme need for the resident to fulfill his/her monthly call schedule. Residents on General Surgery, ICU and Ob/Gyn are not part of the rotating call pool for the emergency “additional nights”. These residents may take home call with the approval and in cooperation with their attending physician. They are also expected to take one day a weekend on call with their attending. 8. Switches in Call A resident may occasionally request to switch call assignments with another resident; however, the switch must be an “equal” (meaning that the other resident is of the resident level of training as you in order to switch), and it must be approved by the Chief Resident and Residency office (PD/DME) before the scheduled shift occurs. A switch must not create a violation of the Work Hour Law for the accepting resident. Please refer to Section17 (Form 1 Switch Request Form) 9. All resident classes (OGME 1, 2, 3) must participant in call. While OGME 1‘s are expected to take more call than seniors, all residents within a class level (OGME) should take approximately the same number of call nights as the others in their respective class. No class or resident is exempt from call duties. 10. There must be an In-house senior resident (senior resident that has been evaluated by their PD as being able and ready to supervise the interns and medical students) at all times. This senior resident‘s duty is to oversee all of the interns and medical students. The senior is in charge of the in-patient team which is under the authority of the in-patient attending. When the Block Night service is not busy, the senior is expected to conduct a mini-didactic programs on a topic listed in the Block Night Curriculum Chapter based on a patient on the service whenever possible. 11. The Chief Residents develop and administer all call schedules. Chief residents must approve any change in resident call assignments. (Please see Section 17 Switch Request Form) 12. Once the Chief “posts” the call schedule as “final”, it is final. Any assigned call or shift becomes the assigned resident‘s personal professional obligation to fulfill it completely. If a resident wants to switch an assigned call, it is the Resident‘s responsibility to obtain alternative Resident to cover, complete a Switch Request Form (see Section 17, Form1), and submit it to the Resident‘s Chief Resident. Remember, a change in call responsibility is not approved until the Chief Resident/PD/and DME signatures are complete.

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13. Any missed scheduled shift/rotation will be referred to the Academic Council for review and possible disciplinary action. The resident missing the originally assigned shift will be assigned additional future call to make up for the missed shift(s). 14. It is recognized that emergencies can occur, but these should be extremely rare. When an emergency occurs that prevents a resident from working his/her assigned shift, the Resident must contact the Chief Resident and Program Coordinator of their program. If these individuals are not available, the PD may be contacted. Cell numbers for all Residency Leadership are posted on the LCRH internal web site under the Resident Tab. In addition the Resident must notify his/her attending physician as a professional courtesy prior to the scheduled shift. 15. The Chief Residents maintain an on-going emergency call list of residents to cover an unexpected emergency shift or call. The Chief will contact the next resident on the Emergency Call list and arrange coverage. Preference will be made by the Chief Residents to provide a makeup call coverage for the resident that work the emergency replacement shift or call. 16. If a resident feels he or she is “impaired” at the beginning of an assigned call or shift, the resident must not work. The resident should not allow this to happen. If it does, the resident must notify their Chief Resident with a truthful explanation of the problem. The Chief Resident will arrange for a replacement. Being “impaired” when a resident is to be on, or to soon be on, call or at work is a violation of professional responsibilities and behavior. It is better for the resident to call in if impaired, than to attempt to work and provide suboptimal care and possibly endanger patients. Such events will be dealt with through the LCRH Medical Staff Guidelines for impaired physicians. The resident will likely be asked to immediately come in for a drug and/or alcohol screen. 5.4 Unscheduled Absence Absence from work for two (2) consecutive days without notifying the Department of Medical Education or the Human Resources Department will be considered a voluntary resignation. If your preceptor (attending physician) is taking time off, you are still considered on duty. You must report / notify the Residency Office of your attending physician‘s absence and your availability for didactics and other activities of the program. If you do not notify the residency office before such a situation, you will be considered as a NO SHOW-NO CALL. In such situations, the resident will lose vacation time at the rate of one and one half days per day of NO SHOW-NO CALL. 5.5 Harassment Policy LCRH does not tolerate workplace harassment. Workplace harassment can take many forms. It may be, but is not limited to, words, signs, offensive jokes, cartoons, pictures, posters, e-mail jokes or statements, pranks, intimidation, physical assaults or contact, or violence. Refer to Human Resources Policies on the LCRH Internal Web. 5.6 Sexual Harassment Policy It is the policy of LCRH to provide an employment environment free of sexual harassment. Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature are violations of our policy. If you believe you have been subjected to sexual

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harassment, you should report it immediately in writing to your Program Director and the director of human resources. All complaints of sexual harassment will be promptly and confidentially investigated. Any Resident who violates this policy will be subject to corrective action, based on the severity of the violation, up to and including termination. Any other form of repeated behavior, which the Resident perceives as harassment, should be reported to the Director of Medical Education. Refer to Human Resources Policies on the LCRH Internal Web. 5.7 Violence in the Workplace LCRH has adopted a policy prohibiting workplace violence. Consistent with this policy, acts or threats of physical violence, including intimidation, harassment, and/or coercion, which involve or affect LCRH or which occur on LCRH or client property, will not be tolerated. Refer to Human Resources Policies on the LCRH Internal Web. 5.8 Confidential Information and Nondisclosure The confidential nature of medical information and the patient's right to privacy are well established. All hospital personnel are expected to treat patient-related information in a confidential manner, sharing it only with those who have a need to know, whether in written, oral, electronic, or any other format. Hospitals and physicians can be held liable for the improper or unauthorized disclosure of medical information. As such, discussion of patient-related information should be conducted only in appropriate settings, and especially not in elevators or other public areas. At the start of your residency at LCRH, you will be asked to sign a confidentiality & non-disclosure agreement, documenting your acceptance of this policy. The Health Insurance Portability and Accountability Act (HIPAA), passed by Congress in 1996, required Lake Cumberland Regional Hospital and its associates and business associates to protect the privacy and security of patient health information. As all Lake Cumberland Regional Hospital associates are affected by HIPAA and subject to its penalties for non-compliance, it is important that everyone keep abreast of new developments and understands the overall impact and intent of the legislation. Refer to Human Resources Policy and Procedures on the Internal Web. 5.9 Ethical Standards Residents are required to comply with the LCRH Code of Conduct. Lake Cumberland Regional Hospital insists on the highest ethical standards in conducting its business. Doing the right thing and acting with integrity are two of the driving forces behind LCRH‘s great success story. When faced with ethical issues, associates are expected to make the right professional decision consistent with LCRH‘s principles and standards. If a Resident cannot determine the correct decision, the Resident should contact their respective program director and/or the Department of Medical Education. 5.10 Dress Code

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1. Dress, grooming, and an overall professional appearance are important aspects of patients' expectations, and project an image of quality healthcare. LCRH surgical scrubs may be worn only while on the General Surgery Rotation or when in the OR or Labor & Delivery areas. When scrubs are worn outside of the OR, Labor, and Delivery, a white coat or similar cover-up should be worn. Residents may also wear scrubs during night call. Residents must appear neat, clean, and professionally dressed at all times. The uniform for floor duty during the day is long white clinical coats. Coats must be worn at all times. Socks must be worn. Male Residents are to wear a shirt with a collar or a LCRH polo shirt under the white clinical coat and khaki pants or dress slacks. Female Residents are required to wear professional attire; dress slacks with blouse/appropriate dresses or LCRH polo shirt under the white clinical coat and khaki pants. (3 LCRH polo shirts will be provided the beginning of your residency training) No open-toed shoes or sandals are to be worn in any patient area. Limited amount of jewelry; simple necklace and earrings, no large rings. Haircuts must be neat and hair growth not overly excessive. Mustaches and well-trimmed beards are permitted. Fingernails must be clean and trimmed. Artificial nails prohibited. Refer to LCRH Dress Code Policy on the LCRH Internal Web. 5.11 Use of Equipment LCRH will provide associates with the equipment needed to do their job. None of this equipment should be used for personal use, nor removed from the physical confines of LCRH-unless it is approved for a job that specifically requires use of company equipment outside the physical facility. 5.12 Use of Computer, Phone, and Mail LCRH property, including computers, phones, electronic mail, and voice mail, should be used only for conducting company business. Incidental and occasional personal use of company computers, phones, or electronic mail and voice mail systems is permitted, but information and messages stored in these systems will be treated no differently from other business-related information and messages. The Residency Program uses email almost exclusively for communications between and to residents. All resident email will be done through the residents LCRH email address (@LPNT.net). Personal emails addresses will not be used for Program purposes. Residents must check their LCRH email several times during each day to remain current with resident emails. 5.13 Use of Internet Associates are responsible for using the internet in a manner that is ethical and lawful. Use of the internet must solely be for business purposes and must not interfere with associate productivity. LCRH encourages associate use of electronic mail, the LCRH Intranet and the internet when it creates a more efficient work environment. However, it should be clear that: 1. Sending and receiving E-mail, Intranet or Internet messages regarding personal matters is not permitted.

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2. Under no circumstances will the E-mail system, the Intranet or the Internet be used as a forum for inappropriate, offensive or discriminatory comments. 3. An associate should not consider the contents of his or her E-mail account (LCRH or residence) private. 4. The password used to restrict access to associates’ E-mail accounts is a mechanism for preventing an unauthorized person from gaining access to LCRH‘s information rather than maintaining the privacy of associates’ messages. 5. The E-mail system, including the contents of messages and accounts, can be monitored to:

a. Evaluate the effectiveness and operation of the E-mail system. b. Find lost messages. c. Recover after system failure. d. Investigate suspected criminal acts or suspected breach of security. e. Enforce other LCRH policies.

Associates, including Residents, who use email and Intranet improperly, will be subject to disciplinary action according to policy the Human Resources Policy and Procedure Manual.

• No downloading no installing on a LCRH computer of any software may be done.

• Streaming of ANY web based materials is not allowed to LCRH computers due the limited bandwidth of the system.

All LCRH associates must sign a form documenting that they understand the conditions under which an email account may be used and what conduct is permitted. 5.14 Use of Computer Software LCRH does not condone the illegal duplication of software. The copyright law is clear. The copyright holder is given certain exclusive rights, including the right to make and distribute copies. Title 17 of the U.S. Code states that, “it is illegal to make or distribute copies of copyrighted material without authorization” (Section 106). The only exception is the user‘s right to make a backup copy for archival purposes (Section 117). 5.15 Smoking Policy To provide a healthier and safer environment for patients, visitors, staff, and associates, the hospital prohibits smoking and the use of tobacco products on the hospital campus and in all LCRH medical offices. All associates are required to adhere to this policy to ensure that LCRH is a healthier and safer place in which to work. To protect the health of our patients, medical staff, hospital associates, visitors and volunteers, LCRH has a Zero Tolerance Policy on smoking and the use of tobacco products within the hospital. 5.16 Alcohol and Substance Abuse It is the policy of LCRH that the workplace be free of illicit drugs and alcoholic beverages, and free of their use. In addition to damage to respiratory and immune systems, malnutrition,

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seizures, loss of brain function, liver damage, and kidney damage, the abuse of drugs and alcohol has been proven to impair the coordination, reaction time, emotional stability, and judgment of the user. This could have tragic consequences where demanding or stressful work situations call for quick and sound decisions to be made. 5.17 Subpoenas, Claims, & Other Requests Residents may periodically receive requests for information regarding a legal claim, or potential claim, involving a patient and the Hospital. Whenever a Resident receives such a request he/she should immediately contact the Department of Medical Education who will notify Risk Management. The Resident is not to provide any written or verbal response to such a request without authorization. This will ensure compliance with the Hospital's procedures for release of information only to authorized persons. Residents may not witness wills, advanced directives, or other legal documents for patients. Requests for such assistance should be referred to the Case Manager or the Nursing Supervisor/Administrative Director in charge. 5.18 Disputes between Residents & Medical Supervisors LCRH adheres to the AMA Council of Ethical and Judicial Affairs, Ethical Opinion 9.055, which states, in part, “Residents should refuse to participate in patient care ordered by their superiors in cases in which the orders reflect serious errors in clinical or ethical judgment, or physical impairment, that could result in a threat of imminent harm to the patient or to others.” In such a circumstance, the Resident may refuse to provide the care ordered by the supervisor, provided the omission will not threaten the patient‘s immediate welfare. Residents should communicate their concerns, immediately, to the physician issuing the orders, and to the Program Director and Director of Medical Education. Residents who raise such a complaint will not be subject to retaliatory or punitive actions, if the complaint was made in good faith, in the interest of patient care.

The Program Director or Director of Medical Education shall immediately notify the Chief Medical Officer regarding the Resident‘s concerns. The Chief Medical Officer may take such action as he deems reasonable, in his sole discretion, to investigate and resolve the situation, subject to the rights and obligations of the parties as set forth in the LCRH and Medical Staff Policies and Procedures. 5.19 Corporate Communications Because of your constant relationship with patients and their visitors, your role in establishing a positive reputation for the LCRH is important. Patients are seldom qualified to judge the technical quality of medical care they receive. To patients, the most important thing is usually the personal concern of each individual they contact in the Hospital. The patients are extremely conscious of the many little things that add up to kindness, sympathy and understanding. Lake Cumberland Regional Hospital, through the compassion and caring of its physicians, nurses, and support staff, strives to achieve excellent patient satisfaction ratings.

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LCRH‘s Marketing/Community Relations is responsible for handling inquiries and requests from newspapers, magazines, and radio and television stations. Refer any such request to the Director of the Marketing/Community Relations Department. During evening and night shifts, refer such inquiries and requests to the Nursing Supervisor on duty.

5.20 Corporate Compliance The compliance program at LCRH is a comprehensive strategy to ensure associates and medical staff complies with applicable rules, regulations, and laws.

• The LifePoint Corporate Compliance Line

1-877-508-LIFE (5433) o Callers remain anonymous.

o There is no retribution to callers.

5.21 Obligation to Treat A primary mission of the hospital is to serve and heal all persons who need its help. In addition to general legal and ethical requirements, hospitals participating in the Medicare program are required to provide examinations and treatment to individuals with emergency medical conditions, or women in labor, regardless of their ability to pay. This is the Emergency Medical Treatment and Active Labor Act (EMTALA). EMTALA was passed as part of the Consolidated Omnibus Budget Reconciliation Act of 1986, and it is sometimes referred to as “the COBRA law.” This law requires hospitals with emergency departments to provide a medical screening examination “within the capabilities of the Emergency Department‖ to any person requiring one without regard to the ability to pay. We must determine whether the person has a “emergency medical condition” or is in “active labor.” If so, the law requires the hospital to either:

1. Provide treatment “within the capabilities of the staff and facilities of the hospital” as may be necessary to stabilize the emergency medical condition; or, 2. Arrange for a transfer of that person as set forth by the law. An emergency patient who is not stabilized can generally only be transferred if the individual requires the transfer or if a physician certifies that the medical benefits of transfer outweigh the risk of affecting the transfer.

Substantial penalties for violation of this law exist for both the Hospital and the physician and the statute may be enforced by the government or an aggrieved individual. 5.22 Moonlighting (This section supersedes the section on outside employment in the employee manual for LCRH.)

• Moonlighting privileges are granted only by the Residency Program.

• Residents/Interns (OGME 1‘s) are not permitted to moonlight. 36


• Senior residents (OGME 2 & 3) must obtain approval from their Program Director and the Director of Medical Education prior to moonlighting (see Section 17 Form 3 Moonlighting Request Form.

• All resident applications for moonlighting must be submitted prior to beginning the moonlighting. Violation of the rules for moonlighting will result in disciplinary action up to and including possible suspension from the program

• Application to Moonlight must include

O LCRH Residency Moonlighting Request Form

O Successful completion of COMLEX III

o Copy of the resident‘s active license to practice medicine within the state in which he/she will be moonlighting (not training license)

o Copy resident‘s DEA license and number

O Copy of Certificate of Insurance for the moonlighting site.

(The Residency Program professional malpractice covers the resident only when he/she is working in a LCRH clinical facility within the scope of the Residency Program only.)

o Completed applications for Moonlighting are reviewed by the Academic Council which will make a recommendation for approval or denial.

o Moonlighting privileges can be rescinded at any time by the Academic Council if

the resident fails to meet the Program requirements to Moonlight.

o All moonlighting activities will be included in resident‘s duty hour New Innovations log. Moonlighting activities count towards the 80 weekly hour limit on resident hours.

o Malpractice coverage for Moonlighting activities is the resident‘s responsibility. It

is the resident‘s responsibility to arrange this within each individual Moonlighting contract and notify the residency program of coverage.

o Each resident will have a section within their personnel folder titled “Moonlighting”. All documents related to requesting of moonlighting privileges will be kept in this section. The original completed Moonlighting Request Form will be kept here.

5.23 Departing Residents

Upon the completion of residency training, the Resident is required to complete the LCRH Clearance Sheet to ensure that all items are returned, that required documents are completed

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and that all patient record information is fulfilled prior to the Resident‘s departure from their training program. All residents must obtain a signature from the Director of Health Information Maintenance (HIM/ medical records) attesting to their completion of all medical records. Once all items are completed, the Resident will be issued their training certificate indicating satisfactory completing the program, if so warranted.

Prior to the Resident‘s departure, an “exit interview” will be conducted with the Resident to obtain information regarding their training experience as well as their thoughts of LCRH. This process will help to enhance future trainees experience with LCRH. This interview is a required part of the residency program and must be completed prior to issuance of the training certificate. 5.24 Hospital Property No x-ray films, patient records, instruments, equipment, drugs, scrub suits or other hospital property shall be taken from the hospital unless permission has been granted by the Director of Medical Education. 6 RESPONSIBILITIES 6.1 Director of Medical Education Position Description: The Director of Medical Education (DME) is responsible for assuring the development of high quality post graduate education programs providing high quality residency training. The DME is responsible for assuring the development of a high quality curriculum as well as assuring the highest quality clinical experiences for the residents. Assuring the development of post-graduate programs is a major priority. The DME will also serve as an advisor to students and residents regarding their career choices. The DME will participate in the clinical training of the residents. The DME must be qualified to manage and direct PDs and residents in a graduate medical education program within the residency training requirements of the American Osteopathic Association and all applicable laws and regulations. The DME is directly responsible for the overall program administration of all Residency Programs within the Institution. Responsibilities: 1. Ensuring a high quality curriculum. 2. Authorized point of contact regarding all official residency related communication from the AOA. 3. Prepare annual medical education report. 4. Develops and monitors house staff training programs. Establishes resident schedules in conjunction with Chairpersons of clinical departments, the Graduate Medical Education Committee and attending physicians. 5. Develops resident curriculum in conjunction with program directors, residency staff, teaching faculty, hospital staff, and house staff. 6. In cases where requirements of internship conflict with the desires of the Residency Program Director, the Director of Medical Education will be responsible for the intern program.

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7. Evaluates resident‘s performance and Residency Program Faculty 8. Counsels residents concerning their performance and takes appropriate disciplinary action if warranted subject to compliance with the Residency Program, LCRH, and/or LCRH Medical Staff Bylaws, rules and regulations. 9. Responsible for implementation and monitoring of the Residency Program budget and for submitting budgets to the Chief Medical Officer and Chief Financial Officer for review and approval. Maintains awareness of outside financial resources for programs and utilizes them as appropriate. Strives to achieve financial targets associated with Graduate Medical Education reimbursement and expense management. 10. Directs recruitment activities for medical students and residents. 11. Enforces the educational standards of AOA, the various residency boards and the institution regarding intern and residency training. 12. Prepares annual reports to the AOA on the status of the graduate medical education program and coordinates surveys required to maintain accreditation of all affiliated graduate and postdoctoral medical education training programs. Responsible for ensuring that, individuals are adequately prepared for program inspections and that required accreditations are achieved and maintained. 13. Oversees lecture schedule and frequently serves as faculty and attends didactic sessions. 14. Maintains attendance records and evaluates quality of didactic presentations, taking action as appropriate. 15. Determines the schedule of rotations for all interns and residents, within the curriculum requirements outlined by the AOA. Coordinates with Residency Directors on the schedule of rotations for residents, within the curriculum requirements outlined by the AOA and specialty boards. 16. Review all interns and residents evaluations at least every six months and meets with residents when needed to insure that the Program‘s objectives are met. 17. Responds to communications form the AOA, arranges institutional payment of required fees, and cooperates in the arrangement of Program inspections. 18.Collaborates with the OPTI and its sponsoring College of Osteopathic Medicine and attends meetings as scheduled. 19. Upon satisfactory completion of the OGME-1R year the institution shall issue a letter of completion to each trainee in the appropriate specialty, for licensing purposes, and with a copy to the OPTI. 6.2 Program Director Position Description: The Program Director is responsible for assuring the development of high quality education programs providing high quality residency training. The Program Director is responsible for assuring the development of a high quality curriculum as well as assuring quality clinical experiences for the residents. The DME will participate in the clinical training of the residents. The Program Director must be qualified to manage, teach, and administer an Osteopathic Residency Program in a graduate medical education program within the residency training requirements of the American Osteopathic Association and applicable laws and regulations. The Program Director of each residency will report to and be responsible to the Director of Medical Education for all aspects of his/her residency. Qualifications:

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1. Graduate of an AOA-approved college of osteopathic medicine. Responsibilities: The Program Director: 1. Has the overall responsibility for the content, administration, and conduct of the Program Director’s residency. 2. Serves as the authorized point of contact regarding all official communication from the AOCI 3. Prepares annual reports to the ACOI. 4. Develops and monitors the Internal Medicine residency program 5. Establishes schedules in conjunction with Chairpersons of clinical departments, the Medical Education Committee and attending physicians. 6. Develops Internal Medicine curriculum. 7. Evaluates performance of residents, counsels residents concerning performance and takes appropriate disciplinary action if warranted subject to compliance with medical staff bylaws, rules and regulations and prior consultation with President or the Medical Staff and/or his designee(s). 8. Develops budget for educational programs as directed by the DME 9. Assists the DME with recruitment activities for medical students, interns and residents. 10. Enforces the educational standards of AOA, the various residency boards and the institution regarding intern and residency training. 11. Prepares annual reports to the AOA on the status of the graduate medical education program and coordinates surveys required to maintain accreditation of all affiliated graduate and postdoctoral medical education training programs. 12. Responsible for ensuring that individuals are adequately prepared for program inspections and that required accreditations are achieved and maintained. 13. Oversees IM lecture schedule and frequently attends morning report and noon lectures, participating as a speaker periodically. 14. Maintains IM residency attendance records and evaluates quality of presentations, taking action as appropriate. 15. Determines the schedule of rotations for Internal Medicine residents, within the curriculum requirements outlined by the AOA. . 16. Meets with interns and residents on a periodic basis and as required insuring that Program objectives are met. 17. Responds to communications from the AOCI. 18. Collaborates with the sponsoring College of Osteopathic Medicine and attend meetings as scheduled. 19. Attends the annual ACOI Congress on Medical Education for Resident Trainers. 20. Proctors the annual internal medicine resident‘s in-service examination. 21. Completes the AOA Program Complete Summary – Final Resident Assessment (CCCP Part III) Copy to be placed in the resident‘s file and a copy sent to Osteopathic Medical Network of Excellence in Education (OMNEE). 6.3. Academic Council 6.3.1. Academic Council Membership: Director Medical Education (DME), all Residency Program Directors, Directors of Continuity Clinics if Different from the Program Director. The DME can appoint additional individuals to the Council. The Residency Program Administrator will serve as staff for the Council. The DME will chair the Council.

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6.3.2. Academic Council Charge: The Academic Council is charged with monitoring and maintaining the academic and clinical care standards of excellence for the overall Residency Program. The Council will serve as the Peer Review body for the LCRH Residency Program. 6.3.3. Academic Council Meeting Schedule: No less than quarterly but more frequently as needed by the Residency Program. Minutes will be maintained by the Residency Program Administrator. 6.3.4. Academic Council Responsibilities: The Council 1. Reviews any resident issue or concerns arising under Section 4.1 of the Residency Manual Residency Performance A. At any time during the Residency Training Program, the Residency Program Director, or Director of Medical Education may determine that the Resident is not meeting the standards of the program or the profession, for reasons that may include, but are not limited to

1. Lack of professional competence, insufficient medical knowledge, or technical skills needed to carry out their duties and responsibilities; 2. Any conduct that is detrimental or potentially detrimental to patients or associates; 3. Demonstrated inability to work with others or behavior that is reasonably likely to be disruptive to Hospital operations; 4. Any demonstrated lack of personal/professional integrity (honesty, reliability, and accountability). 5. Activities or professional conduct that are reasonably likely to be in violation of the Medical Staff Bylaws, Medical Staff Rules and Regulations, or any other Hospital policies and procedures; and,

B. Reviews the results of the annual in-service examinations C. Reviews and must approve all Process Improvement Plans (PIP) for residents in order to maintain the highest possible academic and clinical care standards. D. Monitors compliance with resident PIPs. E. Defines for the Residency Program the guidelines for the following resident processes:

Promotion to the Next Residency year including confirmation of completed rotations (months) as recommended by each Program Director. (From Section 4.4 Resident Manual) 4. Recommend non-renewal of the Resident’s contract. If a Residency Program Director determines that a Resident is not meeting the standards of the program, he/she may make a recommendation for non-renewal of the Resident‘s contract. The recommendation must be submitted in writing to the Director of Medical Education, and will include the basis on which the action is being taken, along with any written documents necessary to support the recommendation. All written information regarding the recommendation will become part of the Resident‘s file. If the Director of Medical Education/ determines that there is sufficient reason not

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to renew the contract, he/she will notify the Program Director, who will so inform the Resident in writing. Recommendations for non-renewal should be made no later than four months prior to the end of the Resident‘s current contract (when possible). If the primary reason(s) for non-renewal occur(s) within the four months prior to the end of the current contract, every effort will be made to ensure that the program provides its Resident as much written notice of the intent not to renew as circumstances will reasonably allow. A Resident receiving notice of non-renewal of contract may implement his/her right to due process through the Appeals Process presented in this Manual. In the event the Director of Medical Education rejects a recommendation for non-renewal of contract, the Resident‘s contract will be renewed for the following year.

• Residents Requiring an Advisory action • Resident At Risk (Academically and/or clinically) for not successfully

completing the residency. • Probation • Termination

F. Reports to the Graduate Medical Education Committee 6.3.5. Academic Council at Risk Definitions

1. Resident Advisory a. Shall be given in writing to the resident with a signed receipt the resident of the Advisory for any academic, professional, or clinical concern.

2. At Academic Risk a. Shall be given in writing with a signed receipt by the resident being at Academic Risk. This is to identify residents for whom there is concern as to the resident having sufficient medical knowledge; including but not limited to

• Scoring in the 30% or less overall percentile on the annual in-service exam

• Attending less than 85% of didactic sessions on a monthly basis 3. At Clinical Care Risk

• When 2 or more Attending physicians during one or more rotations identify issues with the resident‘s clinical performance that effect patient care or safety;

• Resident non-professional actions or performance; • Resident does not possess adequate and appropriate technical skills; • Resident is not able to use medical knowledge and/or technical skills effectively

in providing medical care; • Resident has not abided by LCRH Hospital Policies and LCRH Medical Staff

Bylaws and Policies; • Resident demonstrates inability to work cooperatively with others; • Resident has not abided by the LCRH Corporate Code of Conduct and applicable

standards of professional responsibility. 6.3.6. Academic Council Performance Improvement Process Policy

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Performance Improvement Process Policy The Performance Improvement Process applies to all residents at the Lake Cumberland Regional Hospital (LCRH). The Policy is designed to provide Resident Program Directors and teaching faculty a consistent way of addressing and documenting substandard academic, clinical, and professional performance; while protecting the institution from claims, discrimination, and/or wrongful discharge. These are guidelines only. There are circumstances in which deviation from these guidelines include immediate termination. This Policy is subservient to all LCRH policies. PROCEDURE This process pertains to matters of resident conduct and competence. Any resident who does not display satisfactory performance in his or her position may, in certain cases without resorting to the steps set forth in this process, be subject to corrective action. More serious violations of conduct may result in immediate suspension or termination. Such violations include but are not limited to “willful, malicious, deliberate, negligent, illegal or other serious acts”. The LCRH requires that residents comply with certain standards of patient care, productivity, customer service, conduct and work performance in accordance with defined administrative practices and procedures (set out in the resident manual, resident employment agreement, and LCRH hospital and Medical Staff Bylaws and Policies). When a resident‘s performance falls below the expected standard, the Program Director will inform the Academic Council which will develop a Performance Improvement Plan. The following process will be used. Note: Any resident may file a grievance at any time during the Performance Improvement Process. Please refer to the LCRH Resident‘s Manual. Level One: Advisory

1. The Program Director or designee will meet with the resident to clarify and to explain, while seeking to understand, the nature of the problem and the proposed remediation.

2. The purpose of this discussion is to remind the resident of the academic or behavioral expectations and responsibilities, to set measurable remedial goals, and a timeline for achieving them.

3. The resident will be informed that this is the first step of the Performance Improvement Plan (PIP) and process. 4. The Program Director will document using the “Performance Improvement Plan” document. This document should include the specific issues being addressed; the specific remedial steps to be taken, a specific time for completion, and the metrics to be used for determination of completion. The proposed Advisory PIP is submitted to the Academic Council for review and approval.

5. The Program Director will review with the resident the Academic Council‘s approved Advisory PIP. The resident will sign the Advisory PIP indicating his/her agreement to the Plan

6. Based on the prescribed improvements and timeline for the same, the Program Director will meet with the resident to assess progress and report this back to the Academic Council

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7. The Academic Council will determine if the PIP has been completed satisfactorily

8. This Advisory to the resident will not be reported to licensing and credentialing agencies unless there are repeated events which result in Level Two, Three, or Four Performance Plans.

9. The PIP will be reported to the Director of Medical Education (DME), remain confidential to the resident and the Academic Council, and filed in the Residency Office

Level Two: Warning If the resident‘s performance does not improve in the time set forth in Advisory PIP or if there is another “incident”, the Program Director or designee will discuss the issue with the resident. During the discussion the Program Director will:

1. Document the behavioral or academic issues (specifics relating to the issue including date, time, and persons involved)

2. The Program Director will document using the ―Performance Improvement Plan ―document. This document should include the specific issues being addressed; the specific remedial steps to be taken, a specific time for completion, and the metrics to be used for determination of completion. The resident will sign the PIP indicating his/her agreement to the Plan

3. Document that the resident receives a copy of the MEC Grievance Policy

4. Ensure that the resident understands that if a Warning PIP is not completed satisfactorily that this will lead to a Probation Performance Improvement Plan.

5. The proposed Warning PIP is submitted to the Academic Council for review and approval.

6. The Program Director will review with the resident the Academic Council‘s approved Warning PIP. The resident will sign the PIP indicating his/her agreement to the Plan

7. Based on the prescribed improvements and timeline for the same, the Program Director will meet with the resident to assess progress and report this back to the

8. The Academic Council will determine if the Warning PIP has been completed satisfactorily

9. The Program Director will document that the resident has been informed the resident that this PIP will be placed in his/her permanent Residency Program file and may be reportable to licensing and credentialing agencies.

10. The Warning PIP will be reported to the Director of Medical Education (DME), remain confidential to the resident and the Academic Council, and filed in the Residency Office.

Level Three: Probation

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If the resident‘s performance does not improve or if there are repeated academic, clinical or professional issues, the resident may be placed on Probation with a Probation PIP. The Program Director will:

1. Document the academic, clinical or professional issue(s) (specifics relating to the issue including all previous PIPs and the results of the PIPs, occurrence date(s), time(s), and persons involved). The program Director will develop a Probation PIP and submit it with all previous documentation to the Academic Council for review and recommendation.

2. The Academic Council will determine if the resident is to be placed on Probation and define the conditions, timeline, and assessment process for resolution of the Probation PIP.

3. Document that the resident receives a copy of the MEC Grievance Policy

4. Inform the resident that this will be placed in their permanent Resident Program file and reportable to licensing and credentialing agencies

5. The PIP will be reported to the Director of Medical Education (DME), remain confidential to the resident and the Academic Council, and filed in the Residency Office.

6. Notify the Chief Medical Officer and DRMC Human Resources

7. The Program Director will review with the resident the Academic Council‘s approved Probation PIP. The resident will sign the PIP indicating his/her agreement to the Plan

8. Based on the prescribed improvements and timeline for the same, the Program Director will meet with the resident to assess progress and report this back to the Academic Council.

9. The Academic Council will determine if the Probation PIP has been completed satisfactorily Level Four: Termination

If the resident‘s , academic, clinical, or professional behavioral, does not meet the terms of the Probation PIP or if there are repeat issues, the resident will be given a written notice by the Program Director/Director of Medical Education of dismissal from the residency training program. The resident will receive a copy of the Appeal/Grievance Process for Probation, Disciplinary Action and Termination (Policy 106). This information will be placed in their permanent file and reportable to licensing and credentialing agents. The DME will notify the Chief Medical Officer and LCRH Human Resources of the termination

The LCRH Residency Program does not endorse arbitrarily the renewal of a resident‘s appointment or contract. The Program Director must give the resident a four month notice of intent not to renew the LCRH Resident Contract, unless the performance or breach of contract warrants immediate dismissal. 6.4. Graduate Medical Education Committee (GMEC) The Graduate Medical Education Committee (GMEC) shall consist of the DME, all Program Directors, the Resident Advisors, and the Directors of the Continuity Clinics (if other than the Program Directors). The ADME and Chief Residents will be ex-officio (non-voting) members.

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Other voting members will be appointed for one year appointments by the DME. Representatives from major affiliate institutions shall be members of the GMEC and shall be strongly encouraged to attend the education committee meetings when logistically possible. The ADME will serve as staff for the GMEC. The GMEC shall meet at least 10 months of the year for the following purposes:

1. To provide verifiable evidence of communication between the GMEC and those representatives of major affiliate institutions when attendance at the monthly meetings is not feasible.

2. To receive the periodic reports from the Residency Academic Council 3. To report to the Director of Medical Education in writing any inferior function on

the part of the resident, e.g. tardiness, attitude, lack of cooperation, etc. so the Director of Medical Education can become involved early in the service

4. To review compliance of resident duty hours 5. To participate in the selection of residents for each training program 6. To maintain and improve the quality of the Residency Program 7. To approve affiliations within the scope of AOA policies and procedures 8. To assist the DME in developing and implementing the highest possible quality

post-graduate educational program 9. To assist in the development of a curriculum and methods to evaluate the

educational experience of the intern and residents during training 10. To assist in the program, faculty, intern and resident evaluations, as well as

program modification as needed in accordance with evaluation results 11. To maintain minutes using the LCRH meeting format of all GMEC Meetings

6.5. Attending Physician (Resident Preceptor) Each service has one or more attending physicians or preceptor with responsibilities to the Residency Program, the residents, medical students and the GMEC.

a. To meet with residents at the beginning of each rotation to review the rotation curriculum and its goals and objectives.

b. To meet and discuss with the resident midway through the rotation the resident‘s performance: areas of satisfactory performance and suggestions for greater performance; as well as areas needing improvement.

c. To complete a performance evaluation after completion of the rotation. d. To participate regularly in curriculum development. e. To provide didactic teaching for residents and medical students. f. To assign a reading and study program.

(Please see the LCRH Residency faculty Manual

6.6. Chief Residents 6.6.1. Overall Responsibilities

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Chief Residents shall act as an advocate for their Resident group as a whole. Information that the Chief feels is reflective and important for the overall benefit of the residency should be related to the faculty and the Program Director. 1. Chief Residents are given opportunities to participate in the development and management of the Residency Program. 2. Chief Residents will promote the Vision and Mission of the residency. 3. Chiefs will serve as conduit to the faculty for the residents in their program for issues related to the program. 4. Chief Residents will support the faculty by helping Residents understand that decisions are made to facilitate their education and to create a pleasant working environment. 6.6.2. Election Process of Chief Residents 1. Two Chief Residents will be elected for one academic year in late April by their peers from a slate of candidates developed by the Academic Council. Optimally there will be 3, but no more than 5, candidates each year. 2. The Program Director will confidentially speak with the residents nominated for the Program‘s Chief to determine the resident‘s willingness to serve. 3. A secret ballot election is held by the residents within each Program during the first week of May each year. Traditional Rotating Interns will vote and will relate to the Family Medicine‘s Chief Resident‘s group. 4. The winner will be chosen by the nominee receiving the most votes (simple majority) 5. The ADME will manage the secret ballot process. 6. The PDs will announce the results of the election 7. In the case of an inadequate number of nominees being available, the existing Chief Resident can be asked to serve another year by the PD with approval of the DME. In the situation in which there was not a Chief Resident the preceding year and in which there is no resident meets eligibility requirements, the PD with approval of the DME may appoint a Chief Resident. 8. In the case of a tie between nominees, a run-off election may be held. 9. All Chief Resident selections are ultimately subject to the approval of the DME. 6.6.3. Eligibility for Chief Resident Nomination a. Residents who have exemplified the character and work characteristics that identify them as able to perform satisfactorily in the Chief Resident position. b. Cannot be deemed At Risk Academically from their last In-service Exam c. Cannot have a Warning or Probation Performance Improvement Plan in place. d. Must have a mean => 85% attendance at didactics e. Cannot have any clinical care concerns raised by rotational attending evaluations during the past 12 months 6.6.4. Chief Resident Specific Responsibilities a. The overall daily functions of the residency programs including clinical care and didactics. b. Assure that all Program rotations and call assignments are assigned and met on a daily basis.

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c. Complete, with staff and faculty assistance, all resident schedules, including rotational, call, night block, emergency call coverage, continuity clinics, and assignment of residents to Hospital or Medical Staff Committees. d. Receive and make recommendation to the PD on all resident requested changes in published schedules and time off recommendations. e. Attend all Program and Faculty meetings to which they are invited. f. Attend the weekly Chief Resident meeting g. Attend all OMNEE sponsored meetings that include Chief Residents

h. Organizes and supervises with their respective PD‘s assistance the Harrison and Rakel Club‘s (education material). The Chief is personally responsible for the Program didactics each week, although this can be delegated to other senior residents with their agreement.

i. Selects articles for PD approval and supervises presentations at Journal Club. j. Disseminate Program policies and solutions to problems to their residents. k. Serves as Moderator for daily Noon Lecture including but not limited to the following duties 1. Making daily announcements to the Residents and medical students that effect clinical care or the Program 2. Introduce the noon faculty member 3. Collect the resident sign in book for the noon lecture 4. Remind residents to complete faculty evaluation forms l. Orient newly elected Chief Residents to their new responsibilities. m. Serve as a resource person for other Resident physicians regarding functions of the program. n. Responsible for discipline among the Residents, with the Program Director‘s approval. o. Provide assistance to the faculty in the evaluation of other Resident physicians' performance. p. Assist in the orientation of new residents q. Assist the Program Director and DME with any other activities or tasks as requested for the function and improvement of the Resident Program. r. Completes any additional tasks as outlined in the following Chief Resident Duties Summary The following Table summarizes the Chief Resident Duties: Chief Resident Duties Two Chief Residents for each Program that Rotate Duties Periodically (every 6 months) One Chief for Each Program Must Always Be in Town Common / Similar Duties Develops all Resident Rotation, Call, Night Block, Emergency Call Coverage, & Clinic Schedules with staff assistance Attends Chief Resident / Residency Leadership weekly meeting Serves as a Bi-directional Conduit between Residency Program/Staff/Faculty & Residents Supervises/Manages all Change in Scheduled Resident Assignments Participates in Medical Staff Peer Review when requested Attends Faculty / Program meetings Upon Invitation Attends all OMNEE sponsored meetings that include Chief Residents

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Participates in Resident Application Interviews, Scramble, and Selection Process Any other Residency Program Duties as assigned by the PD and/or DME Conducts Resident Only Meetings Participates in Annual New Resident Orientation Services on one of the following Committees: Quality Council, Case Management

Distinct Duties Clinical Chief Resident Academic Chief Resident Backs Up Academic Resident Backs Up Clinical Chief Resident Develops and Maintains the Emergency Call Coverage List

Develops schedule for and content of Harrison or Rakel Club depending on Program

Supervises implementation, unexpected changes, sick resident or other issues that produce changes in any resident assigned schedules including rotations, vacations, and holidays.

Supervises Journal Clubs including selection of articles and assists staff in scheduling presenters

Is on call to the Hospital for daily Clinical Concerns from Seniors Residents, Attending, and /or Hospital staff

Develops and Manages Board Review sessions

Attends any Medical Staff Peer Review Committee when a resident from the Chief’s Program is requested to attend.

Presents as many as 2 noon lectures each month from the Curriculum topic list

Receives weekly summary of delinquent HIM charts from MR and notifies the appropriate residents.

Prepares and finalizes monthly house staff only meeting minutes

Assists Faculty with the monthly Morbidity and Mortality Noon time Conference including suggestion and selection of cases, presentation of the case, delegating and assisting preparation of the presentation to another resident and preparing presentations and discussions of the teaching points within the case.

Supervises Noon Lectures including daily announcements, introduced noon speakers, manages sign in book and noon faulty evaluations

6.6.5. Chief Resident Benefits a. The Chief Resident will receive an annual stipend for serving as Chief Resident. The amount of the stipend will be specified annually. b. Chief Residents will be provided an office with phone and hospital computer access c. Chief Residents may park in the “Resident Program” parking spaces. d. Expense re-imbursement for the Chief Resident to attend OMNEE sponsored Chief Resident meetings will be provided. Chief Residents must arrange their call assigned coverage for such meetings away from LCRH. (See Section 17 LCRH Expense Re- imbursement Form) e. One half day per month as Admin time

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6.7. RESIDENT RESPONSIBILITIES 6.7.1 Resident Membership in AOA AOA Membership All residents are required to be members of the AOA. Family Medicine Residents are required to be members of the American College of Osteopathic Physicians (ACOFP). Internal Medicine residents are required to be members of the American College of Osteopathic Internists (ACOI). If the resident is not a member, please notify your Program Coordinator immediately. The AOA does charge a fee for membership for residents. Resident Attendance at the Annual ACOFP or ACOI Meeting All FM and IM residents must attend one of their colleges (ACOFP or ACOI) fall or spring national meetings during their OGME 2 or 3 year. Funds for this meeting may come from the resident‘s CME funds if available. If the resident does not have CME funds, he/she is still required to attend one of these meetings prior to graduation. Residents must also arrange the needed time away for these meetings with their Chief Resident. 6.7.2. Resident Attendance at Didactics Resident attendance at all didactic sessions is required. The LCRH Residency Program maintains records of resident attendance at all didactic sessions. While it is recognized that occasionally patient care needs can prevent attendance, a minimum mean of 80% attendance to all didactic sessions is required. Resident must sign in for each didactic session. The sign-in attendance sheet will be picked up by the Chief Resident or residency staff members approximately 5 minutes after the scheduled start time for each didactic session. If a resident must be absent or arrives after the sign-in sheet has been picked up, the resident may e-mail his/her residency coordinator to explain the absence or tardiness. Absences may be excused, but may not always be, based on a review by the residency coordinator and PD based on the circumstance of the absence. Excused absences are not counted against the resident’s attendance. Attendance is tracked by the residency coordinator and placed in each quarterly resident evaluation. If a resident falls below the 80% attendance, the resident will be made aware of the deficiency by the program coordinator. If the resident fails to bring their attendance up to the 80% during the next quarter, he/she will be referred to the Academic Council for an appropriate Process Improvement Plan. Residents should be aware that if they cannot get to the noon didactic by 10 minutes before the schedule start time, they should defer lunch till after the noon didactic session. 6.7.3. Resident Responsibility for Consultation Communication Resident requesting an in-patient or outpatient consultation should call the consulting physician, in addition to entering an electronic order for the in-patient consultation. The requesting resident should explain the patient‘s clinical situation and the reason for the consult. If the consult is not urgent, or the time is such that the consultant is likely asleep or not available, then the call may be made by the ordering resident at 6 AM the following morning. If the consultant has a resident with them, the ordering resident may call the consultant‘s resident for the consultation. If, for some reason, the ordering resident cannot call at 6 AM, the

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consulting resident must make it clear at his/her SBAR check-out that the resident coming on must make the call to the consultant as soon as possible. Nurse or ward/unit clerks are not be asked to make the call to the consultant, unless the resident cannot leave a critically ill patient. In this case the nurse can be asked to make the call to the consultant. 6.7.4. Hospital Dictations The LCRH Medical Staff Bylaws require specific elements to be included in each History & Physical (H&P), Discharge Summary, and Operative Note for a patient at LCRH. All typed notes are reviewed by the resident‘s attending physician. In addition, a sample of resident typed notes randomly selected by Medical Records will be reviewed by the Residency Program at last twice a year to assess inclusion of all required elements and the completeness of the notes. These reviews will be reviewed with the resident doing the typed notes. 6.7.4.1. History & Physicals and Consultation Notes The Residency Program requires that H&Ps, Consult Notes, and Procedure Notes should be done as soon as possible following the clinical visit or procedure (required within 24 hours of arrival). Progress notes must be entered daily. Delay can and often does create major problems in documentation accuracy the facilitation of patient care. It is not appropriate to wait until the end of a day or shift or take notes home to be done. Delay in typed notes such as H&Ps can delay surgical procedures since the H&P must be in the electronic record before the patient can go to an OR. Discharge Summaries should be done before the patient is discharged. The LCRH Medical Staff Bylaws require the following 17 elements in the H&P: a. chief complaint b. history of present illness, reason for hospitalization c. past medical and surgical history d. social history e. family history f. allergies g. medications h. a review of anatomical systems, vital signs, and current level of function i. physical examination

j. general assessment of mental status, debilities and emotional behavior

k. Diagnosis, reason for admission l. plan of care m. immunizations (as appropriate) n. date, time and signature of the physician The Review of Systems must contain the following 13 elements with each preceded by a capitalized heading: Resident Review of Systems Elements

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1. General 2. HEENT (Head, Eyes, Ears, Nose, Throat) 3. Neck 4. Heart 5. Lungs 6. GI 7. GU (Genito-Urinary) 8. Extremities 9. Neuro 10. Endocrine 11. Skin 12. Musculoskeletal 13. Psychiatric 6.7.4.2. Discharge Summary All patient medical records must contain a discharge summary. A discharge summary shall

be dictated/typed into electronic notes within thirty (30) days of discharge on all medical records of patients hospitalized over twenty-four (24) hours. The report shall include at least the following:

The LCRH Medical Staff Bylaws require the following 7 elements in a Discharge Summary 1. Reason for hospitalization 2. Final diagnosis 3. Significant findings 4. Procedures performed and care, treatment, and service provided 5. Condition of the patient at discharge 6. Follow up care instructions including diet, activity, timed follow-up and medications 7. Date of discharge a. A final progress note may be substituted for the discharge summary in the case of patients with problems of a minor nature who require less than a 48-hour hospitalization, and in the case of normal newborn infants, and uncomplicated obstetrical deliveries. In the event of death, a summation statement in the form of a final progress note or a dictated summary is to indicate the reason for admission, the findings and course in the hospital, and the events leading to death. Include autopsy findings, if performed; and an indication that the patient was evaluated for organ donation in accordance with hospital protocol. The LCRH Residency Program requires these 7additional elements for all Discharge Summaries All 14 are listed below. The bolded items are the added items required by the Residency Program. 1. Admitting Diagnosis 2. Final Diagnosis(es) 3. Reason for hospitalization 4. Significant Findings 5. Hospital Course including care/ treatment provided, procedures performed and services provided 6. Patient’s Condition at Discharge 7. Patient’s Activity after Discharge

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8. Diet 9. Medications 10. Specific Follow-up care including date and time with whom 11. A list of any specific Follow-up labs that should be done by the physician who sees the patient in follow up 12. Code Status 13. Documentation that a call was made by the discharging resident to the outpatient physician who will be seeing the patient at the first follow up visit to summarizes the patients hospitalization and discharge instructions. In the case of a patient returning to a nursing home, the physician that will be providing care at the nursing home must be called. 14. Cause of Death when the patient died in hospital 6.7.4.3. Daily Inpatient Progress Notes Each resident is expected to dictate/type a formal daily Progress Note on each of their patients. Additional typed progress notes are appropriate based on the patient‘s clinical course. The following elements must be included:

• History Present Illness (HPI): This must contain the patient Chief Complaint. This must include what the “patient tells you” described in four ways a. Location b. Duration c. Timing d. Factors that exacerbate or alleviate the symptom

• Physical Exam (PE): A Minimum of eight of the following examinations chosen relative to the patient‘s disorder(s) must be included a. Vital signs b. General appearance c. HEENT d. Neck e. Lungs f. Heart g. Abdomen /GI h. GU i. Extremities j. Neurological k. Musculoskeletal including OMM l. Skin

• Diagnostic Data: This must include all labs, radiology studies, EKG or results from procedures since the previous daily Program Note. In the case of EKGs and radiologic procedures, these must be personally reviewed by the resident.

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• Assessment & Plan

The diagnoses must be listed in decreasing order of importance with the plan for each including what is planned for the next 24 hours. 6.7.4.4. Daily Inpatient Progress Notes on Resident’s Continuity Clinic Panel Patients When resident‘s panel patient from the resident‘s Continuity Clinic is admitted to the hospital, the resident is expected to follow the patient‘s course while in the hospital even though the resident is not a member of the inpatient team caring for the patient. The resident is expected to see and make notes on all of their patients who are admitted to the hospital. If the clinic resident is not on the in-patient team he/she is expected to see your patient once you are notified of their admission and at least every other day after admission. The clinic resident should place a note in the electronic record to document the time he/she was with your patient. The clinic resident should communicate with the team that is caring for your patient to give them your insight into the patient‘s medical background and current needs. The clinic resident is not to assume management of the patient, but rather to participate in the care with the team. 6.7.4.5. Review of Resident Dictations The Attending physician is expected to read and to suggest revisions of all supervised resident dictations/typed notes. Resident Advisors are expected to review the dictations/typed notes submitted by the resident for the resident’s portfolio. In addition, a sample of the resident‘s dictation/typed notes will be reviewed at least twice a year by Program Faculty and that analysis will be reviewed with the resident. This random review will be based on 3 H&Ps, 3 Consultation Notes, 3 Discharge Summaries and 3 Procedure Notes from each resident that are randomly selected by the Health Information Management Department 6.7.5 Resident Rotation Responsibilities The Resident assigned to an attending physician will be expected to participate in the management of patients assigned to the attending physician, under his/her direct supervision. This will involve rounds with the attending physician on patients in the hospital, as well as participating in office practice under supervision. The Resident will keep a complete log of patients seen and procedures performed.

• Specific overall rotation requirements for each type rotation are detailed in the Residency Curriculum Manual which should be reviewed. The Curriculum Manual Chapter for each Rotation should be reviewed before the beginning of the rotation for the goals and expectation of the Rotation. A copy of the Curriculum Manual Chapter on the Rotation is emailed to the attending on the first day of the Rotation by the residency coordinators.

• The Resident shall obtain and write or dictate the history, perform and record the results

of the physical examinations, and state the diagnosis on all patients assigned. The non-operative and non-specialized treatment of each patient under his/her care is the resident‘s responsibility under the supervision of the attending physician. (See Sections 6.7.5 Hospital Dictations)

• The Resident shall make rounds with the Attending physician and clinical team daily as

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well as other suitable intervals. The resident shall receive instructions, information, criticisms, advice, suggestions and assistance from his/her superiors who thus contribute to the Resident‘s education. The resident will be responsible for the management of the attending physician‘s patients under direct supervision.

• The Resident will make daily progress notes on the record describing the patient‘s clinical

course and should record all treatment or special diagnostic procedures, or make certain they are recorded.

• When a patient is discharged, the resident shall write a concluding note and dictate a

Discharge Summary. (See Sections 6.7.5 Hospital Dictations ) Resident Log: The Resident should consider keeping a personal log of each day‘s activities. This can be very helpful when updating the resident‘s activities in New Innovations each week

6.7.5.1. Inpatient Internal Medicine Rotation LCRH has multiple inpatient Internal Medicine teaching services. These inpatient care groups are managed by the Hospitalist service and led by a Hospitalist Teaching Attending. The number of patients on each service may vary. Each teaching service consists of the Hospitalist attending, a senior (Internal Medicine or Family Medicine OGME 1 or 2) and 2-3 FM or IM OGME 1s. Rotations are 4 weeks in duration. In general, vacation time should not be requested while assigned to an Internal Medicine or ICU teaching service. Inpatient IM Shift Definitions: Day Hospitalist Shift and Day Call Overall Work Schedule: 6 a.m. to 7 p.m. 6:00 a.m. – Begin shift with SBAR Check-out Report from Night Block for resident patients 6:30 a.m. – Arrive on ward and begin initial round 7:30 a. m.—Round with your Senior (pre-attending) (time depend on attending preference)

8:00 a.m. –Round with attending (time depends on attending preference)

12 noon – Noon lecture

5:45 p.m. --SBAR Check-out Report with Night Block and cover until 7 p.m.

7:15 p.m. – End of Day shift & Day shift team leaves the building

Block Night & Night Call Shifts: 5:45 p.m. to 6:30 a.m.

5:45 p.m. –SBAR Check-out Report from Day shift

6:00 p.m. –Shift begin – Meet with Hospitalist Attending for patient assignments or special needs.

6:45 a.m.—7:15 a.m. – SBAR Check-out with day shift

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6:30 a.m. End of Night Shift

Residents on the Night Block service are to be involved in didactic sessions during each shift whenever patient care allows. The senior resident(s), OGME-2 & 3 are to lead didactic sessions during each shift on one or more of the topics listed in the Curriculum Manual Block Night Chapter. Other clinical topics can be chosen by the senior resident depending on patient case material on the service that night. The most senior resident on the rotation is responsible for reporting the date, topic, session leader, and the names of all residents, students and Attendings that attended or participated to the resident coordinator at the end of the rotation. Whenever possible, the didactic topic should reflect a case on the service (inpatient IM care will include ICU care).

6.7.5.2 Inpatient Resident Mobile Phone (In-house ext ) An OGME-1 on the inpatient medicine service and one on the Night Block will be assigned each day to carry the Inpatient Resident Phone. The phone is handed off from OGME-1 to OGME-1 with each shift change. After hours calls from pharmacies to the hospital operator seeking clarification of any resident‘s prescription will be forwarded to this phone. The resident carrying the phone may be able to clarify the pharmacists need; however, in most case he/she will not be able to do so. The phone resident can provide a cell phone number to the pharmacy (these are posted on the LCRH Internal Web site under the Residency Tab) or take the information needed and contact the responsible resident in the morning. In all cases the phone resident will contact the resident being source to provide complete information concerning the call by 8 am the next morning. A fresh battery should be placed in the phone at every change of shift by the team going off service 6.7.6. SBAR Transfer of Care Properly done patient hand offs between healthcare providers must be done carefully and completely in order to provide optimal care. The Joint Commission endorsed SBAR process is to be used for all resident patient hand-offs. SBAR is an acronym for: Situation, Background, Assessment, and Recommendation. Situation

• Identify the patient by name, medical record number, age, sex, & room number

Background

• Give the patient's presenting complaint, primary diagnoses, relevant past medical history including any allergies and brief summary of hospital course to date

Assessment:

• Give most recent vital signs, pain control scale, level of consciousness, 56


todays overall conditions, severity status and any current concerns for the coming shift

Plan

• What can be expected during the coming shift and any specific needs or thing that should be done such as pending lab or x-ray results and what to do if any predictable things occur (the what ifs for the next shift)

SBAR handoffs must be done face-face to allow the receiving physician the opportunity to ask the leaving physician questions. A written list of patients with needs is never a substitute for a formal face-to-face SBAR handoff Please note: A resident cannot leave the service or building without securely handing off the care and responsibility of his/her patients to someone present and able to assume that duty using a formal face-to-face SBAR process. If after a reasonable time (30-45 min) a resident who is appropriate to whom you would hand off a patient such as a clinical team member, the resident can formally hand-off the patient to the resident‘s attending physician. It is never acceptable for a resident to simply leave his or her service before a face-to-face SBAR hand-off of all patients for whom the resident is responsible. 6.7.7. Annual In-service Exams All residents will take the annual national AOA In-service exam from their respective program. Residents will not be on call the night before the exam. The Program Director will meet with each resident within their program to review the resident‘s In-service Exam results and develop a Performance Improvement Plan when needed with the resident. Documentation of the exam review will be made in the resident‘s program file. The program will be responsible for the cost of this exam. 6.7.8. AOA Clinical Assessment Program (CAP) All Family Medicine and Internal Medicine residents are expected to take part in the AOA‘s on-line Clinical Assessment Program (CAP). Residents will choose one of the available AOA CAP disease state modules and enter the required number of their panel patients into the CAP program. It is expected that residents will do at least one module each year. Additional modules are encouraged. 6.7.9. Residency Required Advanced Life Support Certification

• All residents must maintain Advanced Life Support Certification (ACLS) throughout the residency.

• Family Medicine residents must also maintain Pediatric Advanced Life (PALS) Support Certification.

7 COMPENSATION/INSURANCE POLICIES

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7.1 Payroll/Salary After registration through the Medical Education office, all Residents are on the LCRH payroll and commence with being paid an annual salary. The salary amount appropriate to a Resident's contracted Post-Graduate Year (OGME) level will be stated in his/her contract. These established salary amounts are reviewed annually and amended from time to time. For information on the compensation schedule, please consult the Medical Education Office. Payrolls are prepared for a bi-weekly period ending Saturday. Pay is dispersed through Direct Deposit on the following Friday with the exception of a holiday week-end. The first time you get paid you will receive a paper check with check stub After that first pay check you should register for an electronic pay stub. Information will be provided at a later date for this process. At the time of registration, each Resident must complete a Withholding Allowance Certificate (W-4) for the purpose of withholding Federal Income Tax and State of Kentucky Withholding Exemption Certificate for the purpose of withholding State Income Tax. A new W-4 and state tax form must be filed when there is a change in family status. A Social Security number and/or immigrant visa number is required. Residents must also complete an I-9 form, and submit supporting documentation. DIRECT DEPOSIT: LCRH requires all associates to either use direct deposit or the payroll debit card for payment of wages. Residents will meet with Human Resources during the orientation process to complete necessary forms. TAX/SOCIAL SECURITY DEDUCTIONS: LCRH is required by law to withhold federal and state income taxes from your pay. The Hospital pays its social security tax assessed by the federal government on your wages. You pay a matching amount through payroll deduction. The amount of your contribution to social security as well as amounts withheld for federal, state and city income taxes appear on your paycheck stub or electronic pay stub. 7.2 Auxiliary Benefits Parking: Parking is available free of charge to all LCRH associates. When you hold a LCRH parking permit, you assume responsibility for observing all parking regulations. All associates will park in designated associate lots. Residents are allowed to park in the “physician” lot. Upon graduation or termination from the Residency Training Program, the parking permit must be returned to Medical Education Office in order to cancel your parking assignment.

Holidays: Holidays are granted and scheduled at the discretion of the Medical Education Department. The Hospital recognizes the following holidays: New Year‘s Day, Independence Day, Thanksgiving Day, Memorial Day, Labor Day, and Christmas Day. I.D. Badges: Photo identification badges are issued to all LCRH Residents by Human Resources. You are expected to wear your I.D. badge at all times while on duty. The proper way to wear your badge is above your waist with the photo/name side showing. Contact Human Resource for replacement I.D. badges. The hours of operation are: 8:00 a.m. to 5:00 p.m., Monday through Friday. Flexible Spending Accounts: Flexible spending accounts are available for pre-tax payment of associate‘s health and dental deductibles and copayments, and certain un-reimbursed medical and/or dependent care expenses. Enrollment in the flexible spending benefit must be within the first 30 days of employment or during the annual election period. You are able to designate the amount of money that you wish to have placed in a flexible spending account up to the legal

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limit. Note: IRS rules require that any money left in your account at the end of the plan year will be forfeited. Please plan carefully so that you will be able to use all the funds you set aside. 401K Matched Retirement Savings Plan: All Residents are eligible to contribute to the 401K Matched Retirement Savings Plan. LifePoint’s 401k match is provided each year at the company’s discretion. You will be vested to your matching contributions after you have completed 2 years of service with at least 1000 hours in each year. You are always vested in your contributions. LCRH has automatic enrollment in the 401K at 2% of your salary. You must make an active election to change this amount. 7.3 Insurance LCRH offers Residents a flexible benefits program which offers a wide selection of benefits and allows you the flexibility to select the benefits that best meet your individual needs. From time-to-time, the specifics of the benefit programs change. For this reason, Summary Plan Descriptions (SPD) are available electronically on the Lifepoint benefits website. HEALTH INSURANCE: Residents are eligible to enroll in the Health Insurance Program. All benefits take effect on the first of the month following 30-days of employment. Residents who enroll in one of the plans pay pre-tax premiums through payroll deduction. CONTINUATION OF MEDICAL COVERAGE: COBRA: On termination of your contract with LCRH, you may arrange for continued coverage under the Consolidated Omnibus Budgeted Reconciliation Act, which guarantees an associate the right to uninterrupted coverage by his/her employer‘s medical insurance for up to 18 months after termination. Regular coverage ends on the last day of the month in which you leave the employ of LCRH. If you elect to continue coverage, you must pay the entire cost. Information on COBRA is available through the LCRH’s Human Resources Department. DENTAL INSURANCE: Dental coverage is available for purchase for you and your family. You are able to choose from two dental plans, basic and comprehensive. Your semi-monthly contribution is payroll deducted on a pre-tax basis. Coverage is effective the first of the month following 30 days of employment. PROFESSIONAL LIABILITY INSURANCE: The Hospital furnishes professional liability insurance to Residents without cost to them. This insurance covers Residents during the time they are within and acting on behalf of LCRH, following schedules that have been issued by their Program Directors. Residents are also covered for legal actions relating to their residency training, which are initiated after they leave the program. LIFE INSURANCE: The Hospital provides one time your annual salary in life insurance and accidental death insurance at no charge. Additional coverage up to five times your annual base salary is available for purchase, as well as dependent coverage for your spouse and children. You become eligible for coverage the first of the month following 30 days of employment. You can also purchase Voluntary AD&D Insurance coverage at up to five times your annual salary. SHORT-TERM DISABILITY (STD): You are eligible for this benefit on the first of the month following 30 days of employment. Associates have two choices regarding waiting periods for Short Term Disability, which include a 14 day or, 60 day, waiting period. Premiums are calculated based on the waiting period and age of the associate. This benefit is purchased with after-tax dollars.

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LONG-TERM DISABILITY (LTD): The first day of the month following 30 days of employment you are eligible to purchase long term disability insurance. There are two options available for long-term disability insurance. Options include benefit payments at either 50% or 60% of your salary. Benefits are purchased with after tax benefits. ADDITIONAL BENEFITS: Residents will receive free meals while on duty at LCRH. Residents will receive an educational stipend as set forth by the Department of Medical Education. Please contact the department for the current stipend amount. 7.4 Relocation Relocation expenses for Residents entering LCRH‘s residency programs are at the expense of the individual Resident. 7.5 Housing Housing, and all its associated fees, utilities, etc. are the responsibility of the Resident. 7.6 Malpractice Insurance Residents are covered under the LCRH malpractice insurance as it relates to residency training. Residents participating in activities outside the scope of the Residency Training Program will not be covered under the Hospitals malpractice coverage. Activities outside the Residency Training are strictly prohibited unless prior approval is obtained from the Program Director and the Director of Medical Education. Participation in activities outside the Residency Training Program without the expressed written consent of the Program Director and Director of Medical Education are grounds for immediate dismissal. Note also that this and any activity that is not expressly part of the training program will not be covered by LCRH malpractice insurance. 7.7 Timekeeping Procedures By law, LCRH is obligated to keep accurate records of the time worked by associates. Each resident must fill out the appropriate time log for their monthly activities. The time logs must be completed in accordance with the LCRH time-reporting guidelines. Please refer to section 5.2 (Monitoring of Duty Hours) in this Resident Manual for the process to record worked hours. 7.8 Continuing Medical Education Stipend (CME) Each OGME year, the resident is provided an amount of money ($ 1000 OGME-1; $ 1500 OGME-2; $ 2,000 OGME-3), that is available to the resident for reimbursement for approved educational items. All CME Stipend payments must be approved by the DME. Approval should be obtained before purchase. In general, the CME Stipend May Be Used for the following: Will be Approved: Will NOT be Approved: Medical Textbooks Digital Camera Medical Journal Subscriptions CD Burner Computer Office Supplies PDA (Palm Pilot) Lab coat altering/dry cleaning

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Medical computer software Clothing including shoes Computer printer Flash drives Computer Scanner Computer/Palm batteries Medical conference registration Phones, I-pad, or similar personal

connectivity devices. * Airfair, hotel, meals, (medical conference related)

State licensing fees Board application fees AOA/ACOI dues American College of Physicians dues Board review audio/video tapes Gas mileage (rotations, meetings) Personal medical examination equipment including; stethoscopes, hand held ophthalmoscope, otoscope, penlight, reflex hammer, neurologic thin fiber examination tool.

****** Educational stipends may be subject to applicable taxation****** Any item not listed above can be requested. Requests may or may not be accepted and reimbursed. If not listed above, you should not plan on reimbursement until it has been considered and approved. Residents may spend more than this amount during any OGME years for professional equipment and/or supplies. Such items may be tax- deductible. Residents should contact your personal tax advisor on such issues. Each osteopathic resident is required to attend one national meeting of their specialty college during their OGME 2-3 years usually either an ACOFP or ACOI meeting. Residents may be reimbursed for their registration, transportation, lodging, and meals upon presentation of all itemized receipts and proof of attendance. The Program will not cover any ―additional person attending such meetings or any alcoholic beverages. 7.9 Resident Professional Exam Costs The Residency Program will pay for (not from your CME funds) the resident to take the Comlex 3 exam either the OGME 1 or 2 year. (See Section 17 LCRH Expense Re-imbursement Form) (The resident must have passed the COMLEX 3 exam an offer for an OGME 3 contract can be made.) One paid day off to take the exam is also provided. No other exam associated costs will be covered by the program. (This paid day is included in PTO hours) One additional paid day to take your Board Certification exam near the end of your OGME 3 will also be provided. The resident is responsible for the overall cost of the Board Examination. (This paid day is included in PTO hours)

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8 TIME-OFF BENEFITS This section supersedes the PTO section of the LCRH Employee Manual. 8.1 Vacation Time Paid time Off (“PTO”) provides interns 20 days (160 hours) paid time off per educational year per the AOA standards, five (5) days maximum in any one rotation. When a resident is absent from the program for more than the allowed 20 days, the additional time will have to be added onto the end of their training. The sponsoring institution and the program director will have to make a decision as to the appropriateness of the absence. If the absence is approved then the contract must be extended to make up for the additional time away from the program As the time off is limited and the rotations are all important, all residents must submit, at the minimum, two weeks (10 days, 80 hours) of requests by the 15th day of their first month of residency (July for most all residents). If these weeks are not submitted, the two weeks of vacation will be assigned by the residency staff with attention made to particular no-vacation rotations and coverage needs of the program. We do not want the days saved and then lost late in the academic year. Maximum length of any period of time away is one week. Requests for PTO must be made two months prior to the date(s) desired. Emergencies will be considered. Every effort will be made to accommodate last minute request for job/residency interviews and family emergencies. PTO includes all time off (including sick days, vacation, conferences, holidays, etc.). There is no provision that allows you to work double shifts or weekends shifts to trad days. In order for PTO to be approved, any and all duties or scheduled call times must be covered. If you are scheduled for a call shift during the time you would like to take PTO, you will be responsible for finding someone to switch call shifts with you. Remember that any call switch is not allowed until after it has been approved by the PD/DME. PTO is not allowed during the rotations specified below as well as certain dates of the program year (first month and last month) per program: Family Medicine:

• Pediatrics (In Patient) • OB/GYN • ICU • Pulmonary • Block Nights • IM inpatient • Any OUT rotations • Any 2-week rotations

Internal Medicine

• Block Nights • IM Inpatient • ICU • Pulmonary • Any OUT rotations • Any 2-week rotations

Traditional Internship

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• Block Nights • IM in-patient • Anesthesia/Surgical Selective • ICU/Pulmonary • Any OUT rotations • Any 2-week rotations

PTO also includes the first five (5) days of an absence due to illness, injury, disability, or maternity/paternity. More specific information is documented below in the Family Medical Leave section. A “PTO” form needs to be completed for all time away from the Medical Center. The form must include approval signature from your Attending for the rotation, signature of the Chief Resident for Call and lecture/club presentations coverage, and the signature from Office Manager for program requirements. Only then will the request be given to your PD/DME for the final approval or your planned time off. You should not make any arrangements that you cannot get out of prior to the PD/DME signature on your form. Only the PD/DME signature gives you permission to be away from the program. Note that all resident contracts are for a one year period unless otherwise written. While it is true that any time off beyond the 20 days in any academic year will necessitate extending the resident’s time to completion, it is not guaranteed that another contract for the next academic year will be offered. There are situations where there will be no position for a resident post an extended leave of absence. Every effort will be made to keep residents on schedule. 8.2 Family Medical Leave In accordance with the “Family and Medical Leave Act,” LCRH‘s unpaid leave-of-absence policy supports up to twelve work weeks of leave during a 12-month period for the following: • Pregnancy/birth of a child • Placement with an associate of a child for adoption or foster care • Caring for a spouse, same-sex domestic partner, child, or parent with a “serious health condition” • Your own “serious health condition” The 12-month period is measured forward from the date your first FMLA leave begins. To be eligible for FMLA, you must first have been employed at LCRH for at least twelve months and have worked 1,250 recorded hours in the 12 months preceding the leave. You must apply for this leave and it must be approved by Human Resources. The forms are available in the Human Resources office. If eligible for FMLA, FMLA must be applied for concurrently with any leave due to maternity or paternity, short or long-term disability, and leave pursuant to “Extended Leave of Absence” in the Resident Manual. Leave under this provision only protects your job, i.e., job security. It does not provide any income guarantee or entitlement. Time taken off for leave may extend the training period as necessary to comply with the appropriate accreditation guidelines. While on FMLA, Residents are entitled to up to twelve weeks of LCRH-subsidized benefits only (see “Benefits While on Leave”). See Human Resources Policy and Procedure Manual.

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Note: Residents are allotted 20-days off per year. Additional training time will be required for time taken off beyond this allotment. 8.3 Maternity/Paternity Leave Time off for Maternity Leave will be subject to the Leave of Absence Policy located in the LCRH Human Resources Policy and Procedure Manual. It is the Resident's responsibility to notify the Program Director as soon as possible (at least 60 days) in advance of anticipated utilization of a maternity/paternity leave. Time taken off for a maternity/paternity leave may extend the training period, as necessary, to comply with appropriate accreditation guidelines. The department to which the Resident is assigned must approve any leave of absence. If eligible for FMLA, FMLA must be applied for at the same time a maternity/paternity leave is requested. Note: Residents are allotted 20-days off per year. Additional training will be required for time approved and taken beyond this allotment. 8.4 Extended Leave of Absence Depends on how many months completed: Residents with extraordinary and long-term personal or family tragedies may be granted extended leave without pay and without loss of previously accepted residency position or status for periods of up to one year in the following circumstances: 1. Terminal illness. 2. Permanent disability 3. Complications of pregnancy that threaten maternal or fetal life. 4. Other ―devastating conditions‖ or personal tragedies from which eventual recovery and/or return to regular employment may be reasonably expected. If extended leave is requested, the residency Program Director will provide the Resident written information regarding its potential impact on: 1. Requirements for successful program completion. 2. Requirements for board eligibility. The Program Director will also provide written information regarding availability of alternative accommodations, such as reduced hours, night-call accommodations, modified rotation schedules and part-time scheduling. Eligibility for extended leave will be determined on a case-by-case basis by the Residency Program Directors and/or Committee for that department. In case of a dispute, a panel consisting of three Program Directors and two Chief Residents of other departments shall be convened by the Director of Medical Education to hear arguments on both sides and make a final determination. If extended leave or other accommodations are granted, the Residency Program Director will prepare written documentation of the circumstances and conditions of these accommodations, as well as the necessary requirements for the Resident to return to full active status. Note: Residents are allotted 20-days off per year. Additional training will be required for time taken beyond this allotment.

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8.5 Bereavement Leave Residents are eligible to receive up to three (3) consecutive scheduled workdays off with pay in the event of the death of an immediate family member. The three days should be scheduled between the dates of the death through the day following the funeral. You must immediately notify your Program Director and the Department of Medical Education of your need for bereavement/funeral leave. Paid bereavement leave is provided for immediate family members who are defined as: spouse, children, stepchildren, parents, stepparents, brothers, stepbrothers, sisters, stepsisters, grandparents, grandchildren, and parents-in-law. You may request time off if additional days of bereavement leave are required or to attend the funeral of other family members or friends. Additional time off, whether paid or unpaid, must be arranged through your Program Director and the Director of Medical Education is based on the ability of your department to staff adequately during your absence. See Bereavement Policy, located in the Human Resources Policy and Procedure Manual. Note: Residents are allotted 20-days off per year. Additional training will be required for time taken beyond this allotment. 8.6 Sick Leave Full-time associates who become incapacitated due to illness, injury or other forms of medial disabilities, may be granted a Medical Leave, not to exceed one (1) year. After one (1) year of Medical Leave of Absence status access to health and other elected insurance plans is terminated. The associate is removed from the active payroll, and Human Resources will notify the associate of his/her post employment rights. The associate requesting medical leave must submit a certification of health care provider, identifying the reason for the medical leave, with prognosis and expected return to work date. This certification must be returned within ten (10) days of LCRH giving notice that certification is required. Going beyond ten (10) days will cause LCRH to make a decision on the leave status without the information on the certification or to even deny the leave request. If circumstances exist where even a diligent, good faith effort on the part of the associate will not produce the certification in that time frame, then the associate should notify his/her Department Director as soon as he/she becomes aware of the delay. LCRH reserves the right to request a second opinion (at no cost to the associate) on any request for Medical Leave. Every effort will be made to retain an associate‘s original position while on Medical Leave. However, it may be necessary to fill the position with a full-time associate before the leave terminates. In these instances, LCRH will make every attempt to place the associate in a similar position on the same shift, with the same rate of pay, as before the leave commenced, and in accordance with any federal or state laws, regulations or statutes that contain return to work compliance requirements. Refer to Human Resources Policy and Procedures for complete details. Note: Residents are allotted 20-days off per year. Additional training will be required for time taken beyond this allotment. 8.7 Military Reserves or National Guard Leaves of Absence

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Associates who serve in U.S. military organizations or state militia groups such as the National Guard may take the necessary time off to fulfill this obligation and will retain all of their legal rights for continued employment under existing laws. 8.8 Jury Duty If you receive a notice that you are to report for jury duty, notify your Program Director and the Department of Medical Education immediately so coverage can be arranged for you. LCRH will pay you your regular salary for the length of time connected with either the selection process or jury duty. Upon returning to work, written proof of your jury duty must be submitted to your Program Director and the Department of Medical Education in order to be reimbursed. 8.9 Professional Leave of Absence Unpaid professional leave of absence is granted at the discretion of the Program Director of each residency program. Time taken off for leave may extend the training periods as necessary to comply with appropriate accreditation guidelines. Note: Residents are allotted 20-days off per year. Additional training will be required for time taken beyond this allotment. 8.10 Additional Benefit & Leave Considerations Effect of Leave for Satisfying Completion of Program: Time taken off for any leave may extend the training period, as necessary, to comply with appropriate accreditation guidelines. Residents should check with their Program Director to make sure they are not in jeopardy of needing to extend their training and, therefore, changing plans for a job or fellowship opportunity. Residents are not automatically guaranteed re-entry into the training program and therefore should discuss future arrangements with their Program Director prior to commencing a leave of absence. An associate remains eligible for health benefits during the time he/she is on unpaid leave. During the time the associate is not receiving pay, the usual payroll deduction obviously cannot be made. The associate, therefore, is responsible for direct payment of benefits costs. A check or the appropriate amount must be received by the benefits office before the 15th of each month to assure uninterrupted coverage. An associate requiring further leave after FMLA has expired, or an associate exercising any of the other forms of unpaid leave, assumes full cost of any insurance coverage. Any leave of any kind must be coordinated through Human Resources and notification to the Department of Medical Education is required.

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Note: Residents are allotted 20-days off per year. Additional training will be required for time taken beyond this allotment 8.11 International Medicine Rotations INTERNATIONAL MEDICINE ROTATIONS The KYCOM program makes available experiences in underdeveloped areas of the world through the OPTI and KYCOM. KYCOM has clinics and international medicine learning experiences in Honduras and the Dominican Republic. Typically, KYCOM covers resident housing costs and business related travel within the country. Airfare to the rotation site and personal expenses are the responsibility of the resident. The resident should check with KYCOM concerning the resident‘s total costs for such a rotation. The resident is responsible for all costs for an international rotation if not covered by the sponsoring organization, i.e. OPTI or VCOM. All international medicine rotations must be approved by the DME. Priority for these rotations will be given to OGME 2 and 3 residents. Once the dates available are released, the senior resident has thirty days to make your interest known. If spaces are still available after the thirty days, OGME 1 will be considered. An international rotation is structured the same as local rotations including rotational attending and resident evaluations. KYCOM defines the goals and objectives for the rotation.

9 INSTITUTIONAL POLICIES 9.1 Policy & Procedures All of LCRH Policies and Procedures are located on the LCRH Internal Website. Select LCRH policies and procedures will be reviewed during Orientation. Residents are held responsible for reviewing and will be expected to conform to all policies and procedures. Each Residency Program is required to adhere to the policy and procedure manual for their respective Residency Program. The manuals will be reviewed with the residents at the start of their training program. The Residency Program Director/DME will review and update manuals on an annual basis. Residents will receive notification, by e-mail and/or verbally, of any policy changes. Program Directors will ensure that a copy of the Residency Program Manual will be on file in the Department of Medical Education Department. Each Resident will annually sign an “Acknowledgement of Review” attesting that they have reviewed their residency program manual. This acknowledgement will be maintained in each Resident‘s personnel file located in the Department of Medical Education. Residents are required to remain current on all policies and procedures as they occur for the hospital and their residency program. All updates are posted and communicated as they occur.

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9.2 Communicable Diseases The Kentucky Reportable Disease Form is provided by the Department for Public Health, Division of Epidemiology and Health Planning. This form and/or disease specific form provided by this government agency is to be completed by the Infection Preventionist in reporting of the diseases listed under sub-section C. A summary report of all findings submitted to the Health Department shall be submitted to the Infection Control Committee on a quarterly basis.

9.3 Reporting Requirements for Communicable Diseases Who shall report?

Laboratory and supervisors having knowledge of a reportable disease are responsible for notifying the Infection Preventionist (Ext. 3235) or the Quality Director (3105) when the Infection Preventionist is unavailable. If the Infection Preventionist is not available and the reporting of the disease is urgent, the Quality Director shall call the proper health authority.

9.4 Advocacy Efforts The Ethics Committee of LCRH assists in resolving ethical problems in patient care through its interdisciplinary Ethics Consultation Service (ECS), a subcommittee of the Hospital Ethics Committee (HEC). The ECS is available to all hospital care professionals, patients, patient‘s families, and other patient representative/surrogate. Although primary responsibility for identifying and resolving problems in the clinical setting rests with health care professionals in concert with patients or their representative/surrogate, hospital staff is encouraged to seek timely involvement of the ECS in ethically troublesome situations. The hospital assures that persons requesting ethics consultation may do so without intimidation or fear of reprisal. The recommendation of the ECS is advisory only. The process of ethics consultation is intended to supplement and support – not supplant – existing institutional mechanisms for making decisions and resolving conflicts in clinical practice. 9.5 Reporting of Patient Care Issues Occurrence Reporting (Incident Report): Occurrence reports are completed for any happening out of the ordinary which results in a potential for or actual injury to a patient, visitor, or employee. Occurrence reports are also completed for damage to facility property or equipment. Employees, volunteers, and medical staff members have an affirmative duty to report occurrences. Occurrences are to be reported in the following manner: 1. Complete an online event report with details of the event that occurred 2. If the event that has occurred places the patient, hospital or employee in immediate danger the Chief Nursing Officer must also be notified. Once an online event report has been completed the system will send an email to the Director of

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Risk Management, the Director of Medical Education and Medical Education Program Manager / ADME to alert of the new incident. All incidents will be investigated by the Risk Department, the Department of Education, and the Director of the Area in which the incident occurred within 7 days or less depending on the nature of the incident. 10 EVALUATIONS This section supersedes the Performance Evaluation, Promotion, Transfer, and Reassignment sections of the LCRH Employee Manual. All components of the Resident‘s program will be evaluated and meet the guidelines set forth by the AOA. The evaluation instrument utilized will be the form developed by New Innovations. This evaluation instrument encompasses the seven (7) Core Competencies. It will be sent out on monthly bases at the completion of your rotations. The faculty will be expected to return the form within 10 days following completion of each rotation. 10.1 Evaluation of Faculty All Residents are required to complete monthly evaluations of the faculty with whom they work. The number of faculty evaluations each Resident completes will vary depending on service assignments and/or the size of the attending staff. The Resident will be sent a Faculty Evaluation electronically using the similar format of the New Innovations software. The evaluation is to be returned to the LCRH Department of Medical Education within 10 days following the end of the rotation. 10.2 Evaluation of Resident’s Performance 1. Residents will be evaluated upon the completion of each rotation by the attending on each rotation. This evaluation shall be signed by the assigned faculty member and the Resident; and reviewed by the Program Director and DME. All evaluations from both the faculty members and the Resident shall be returned to the LCRH Department of Education within 10 days following the completion of the rotation end date. 2. The Program Director, DME and the Medical Education Committee shall review the performance of every Resident on a quarterly basis to ensure that educational objectives are being met. 3. Prior to early termination of a Resident contract, the institution shall provide the Resident with appropriate warning and counseling. The assigned faculty member is responsible for documenting deficiencies and attempting to resolve concerns with the Resident. 4. In cases of early termination of a Resident contract, the DME shall provide the Resident with documentation regarding which rotations, if any, were completed satisfactorily. In cases of early termination or unsatisfactory completion of a Resident contract, the AOA Postdoctoral Division must be promptly notified and the terminated contract submitted to the AOA. 5. If the resident is accepted into another resident training program, that program‘s DME has the authority to determine which, if any, rotations from previous AOA- approved programs will be accepted for advanced standing. 6. All Internal Medicine residents will take the ACOI annual in-service examination for

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the year of their training. The results will be reviewed with the resident by the Program Director and or DME. A remedial educational program will be developed for each resident and overall curriculum modification as needed based on the results of the in- service exam. The examination will be administered at LCRH and proctored by the Program Director or his designee. A record of all resident evaluations will be permanently maintained in the Department of Medical Education in accordance with the LCRH Document Retention Policy. A record of all resident evaluations will be permanently maintained in the Department of Medical Education in accordance with the LCRH Document Retention Policy. If a Resident requires an explanation or interpretation of his/her education records, he/she should make such a request directly to the Residency Program Director or to the Director of Medical Education . Resident evaluations will be based, in part, on at least the following: 1. Academic Performance: a. Whether the Resident has sufficient medical knowledge based on the educational objectives of the program; b. Whether the Resident possesses adequate and appropriate technical skills; c. Whether the Resident is able to use medical knowledge and/or technical skills effectively in providing medical care; d. Whether the Resident has progressed in his/her core competency achievement; and e. Whether the Resident has any deficiency that may affect his/her clinical or academic performance. 2. Hospital Standards: a. Whether the Resident has abided by Hospital Policies; b. Whether the Resident demonstrates ability to work cooperatively with others; c. Whether the Resident has followed the established practices, policies and procedures of the Hospital; and d. Whether the Resident has abided by the LCRH /LifePoint Code of Conduct and applicable standards of professional responsibility. At the completion of each rotation, the Resident shall evaluate the rotation. a. The DME shall evaluate each rotation with the resident quarterly. The DME shall determine the amount of work being required of the residents to ensure that they are not overburdened with routine responsibilities and that they have the opportunity to observe a sufficient variety of cases. b. The Graduate Medical Education Committee shall evaluate the Resident training programs quarterly. c. Evidence of these evaluations will be maintained in the Department of Medical Education. d. The Program Director will be ultimately responsible to decide if a resident has or has not passed any and all rotations. The Program Director will use the Attending physicians evaluation and direct contact with the Attending. They will also require the timely completion of the resident evaluation and the resident duty hour logs and procedure logs. e. The resident will be asked to periodically evaluate the Program Director, Director of Medical Education and the overall Residency Program. These will be used by the Graduate Medical

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Education Committee to evaluate the Program. 10.3 Evaluation of Training Programs This process is used to monitor the educational process of each training experience. At the completion of each rotation, the Resident shall evaluate the rotation. a. The DME shall evaluate each rotation with the resident quarterly. The DME shall determine the amount of work being required of the residents to ensure that they are not overburdened with routine responsibilities and that they have the opportunity to observe a sufficient variety of cases. b. The Medical Education Committee shall evaluate the Resident training programs quarterly. When necessary, the committee shall approve affiliations within the scope of the AOA policies and procedures. c. Evidence of these evaluations will be maintained in the Department of Medical Education. d. The Program Director will be ultimately responsible to decide if a resident has or has not passed any and all rotations. The Program Director will use the Attending physicians evaluation and direct contact with the Attending. They will also require the timely completion of the resident evaluation and the resident duty hour logs and procedure logs. 10.4 Resident Credentialing for Procedures Competency in performing clinical procedures is an important part of the Family Medicine and Internal Medicine Curricula. These procedures are listed in the respective Curriculum Manual chapters. Competency is defined by the resident performing five (5) procedures with a faculty attestation to the resident‘s procedural competency recorded in New Innovations for each procedure. The attesting faculty must be privileged by LCRH in the procedure. (Please consult the LCRH Internal Website Medical Staff Tab, Privileges for a list of privileged procedures by medical staff member) (Note: A senior resident who has performed at least 10 (ten) of any one procedure may attest to the resident’s procedure, as long as their attending physician is aware of the senior oversight of the other resident. This attending physician that is ultimately responsible for the procedure being done, and must sign-off (not the senior resident) in New Innovations.) A pocket card is provided for convenience to the resident to record procedures, dates, attending, etc., at the time of the procedure. It is provided to each resident by the resident coordinators. The information on these cards must then be entered into the New Innovations Procedure log page. New Innovations will automatically contact the attending for approval and comment. A list of residents with their individual privileged procedures will be maintained on the LCRH Internal Website under the Residency Tab (under construction) 11 MEDICAL RECORDS The importance of complete and accurate medical records and an orderly and efficient system of medical record control (to assure accessibility) cannot be overemphasized. At the beginning of the Residency, instructions in the use of dictation equipment/documentation in medical records and the policies of the Hospital will be given by Information Services. If a problem arises in connection with medical records, their staff will be glad to assist you. 11.1 Guidelines for Use of Medical Records

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Medical records are privileged and confidential documents and must be safeguarded according to Hospital Medical Records policies and procedures. The handling of medical records shall be governed by the following guidelines: 1. Medical records must be available to Medical Records personnel day or night. They must: a. Remain in specified patient care areas. b. Be readily accessible in case of emergency. 2. Medical records may not be removed from the Hospital except for legal purposes, and then only in the custody of authorized Medical Records personnel. 3. Medical records must be kept intact on in-patient floors and in the clinics, and must not be taken apart or pages removed or rearranged. 11.2 Guidelines for Documentation in the Medical Record Residents are reminded that medical records are legal documents, and the physicians may at some future date be cross-examined in court under oath on the notes he/she has written. Personal opinions, or non-medical judgments, should not be expressed in the medical record on any matters except those that pertain to the medical care of the patient. Rules for Entries into the Medical Record: 1. Entries must be signed, dated, and timed. 2. Entries must be complete and accurate. 3. Entries must be recorded only on officially approved LCRH forms that are provided on the divisions or in the clinics. 4. Entries should be made chronologically with minimal blank spaces left between entries to avoid bulky records. 5. Chemical, abrasive or other erasures or alterations, that delete the original entry, create an impression of a falsified record and render the record valueless to the patient or to the Hospital in the event of litigation. Corrections should be made by drawing a SINGLE LINE through the part to be corrected and the new entry made in proper sequence, or above or below the incorrect entry. The reason for the correction, if not obvious, should be noted in the margin. All corrections must be signed, dated and timed by the individual making the correction. 6. Entries should not contain facetious, libelous, or otherwise inappropriate, subjective remarks. 7. Entries must be signed, not initialed. 8. Only LCRH approved abbreviations can be used in medical records and in orders. These are listed on the LCRH Internal Website. 11.3 Medical Record Completion Guidelines 1. Discharge Summary‘s should be dictated/typed at the time of discharge. Procedure notes must be dictated/typed prior to transfer from post acute care unit(PACU) . History and Physical notes must be done within 24 hours of admission for the medical/surgical floors and within 6 hours for the Intensive Care or Critical Care Units. Admit notes must be entered at the time of admission. Progress Notes must be entered at least daily and at the time the patient is seen. There must be a progress note on all patients that a resident sees as a result of a call to the floor. This does not have to be as detailed as the daily progress note but must speak to the

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reason for the call back to evaluate. Every evaluation and management decision MUST have a note that explains what the evaluation showed and what you did about the situation. The principal diagnosis is the condition established to be chiefly responsible for occasioning the admission of the patient to the hospital for care. Other diagnoses are all conditions that coexist at the time of admission, or develop subsequently, which affect the treatment received and/or length of stay. Diagnoses that relate to an earlier episode which have no bearing on this hospitalization are to be excluded. 2. The Hospital uses a direct-dial dictating system for Operative Reports and Discharge Summaries and can be used on any phone. Operative reports should be dictated immediately following surgery. Clinical records should be completed immediately following discharge. Directions for proper dictating procedures will be given to Residents at the time of their orientation. 3. Incomplete medical records are considered delinquent 30 days following discharge date. Failure to complete records in a timely manner will result in the Resident being placed in suspension status. Suspension status will be lifted once the medical record is complete. While on suspension, a resident will be placed on a leave of absence. This time will be taken from the residents‘ personal PTO. If there is not sufficient PTO, the residents’ time to completion will have to be extended to accommodate this unscheduled suspension. 11.4 Protected Health Information Medical records are considered Protected Health Information and are privileged and confidential documents and the information must be safeguarded against unauthorized release according to Hospital and Medical Records policies and procedures. Information regarding a patient's care and treatment shall not be divulged without the written consent of the patient, parents or guardians of minors, or executors of estates of decreased individuals. The following medical correspondence shall be handled by Medical Records including: 1. All insurance forms. 2. Request for various medical certificates. 3. Request for case summaries and other specified medical record information. 4. Letters to schools, unions, or places of employment. 5. Birth certificates/Proof of Birth letters. No Resident shall give out any information relative to the Hospital or concerning any patient in the Hospital to a representative of the press. Such communications are issued by Public Relations Officer. 11.5 Medical Staff Rules & Regulations In addition to being familiar with the content of the Hospital's “Administrative Policies and Procedure (AP&P)” Manuals, Hospital Policies, and the System Manual, Residents must review the most current copy of the Rules and Regulations of the Medical Staff and the Medical Staff Policies. These are available in the Department of Medical Education and the Medical Staff Department and on the LCRH Internal Web.

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11.6 Physician’s Orders Orders must be written or electronically entered clearly, legibly and completely in black permanent ink and signed by the attending physician or Resident responsible for the patient's care. All orders should include the date and time the order is written. All orders written must be done so on Physician's Order Sheet and must include the date and time written, the Attending physician’s name and the physician‘s or Resident‘s signature. Supplemental verbal review of orders between the physician and nurse or other health care professional involved with the execution of the order is encouraged to provide clarity. Orders must be specific for diagnostic or treatment procedure. Only generic medication names may be used. The time (when appropriate), frequency, duration, and date to be carried out should be included. Medication orders will be in concert with the Pharmacy Policy & Procedures found on the LCRH Internal Web. Only LCRH approved abbreviations can be used in medical records and in orders. Approved abbreviations are listed on the LCRH Internal Web Physician orders must be written on hospital approved physician order forms or LCRH approved order set forms according to medical staff bylaws. Any order discrepancy, or clarification that is required, will be done by clinical staff with ordering physician in accordance with medical staff bylaws and LCRH Policy and Procedures for medical orders. 11.7 Service to In-patients Residents assigned to inpatients units must follow the guidelines of the LCRH Medical Staff Rules and Regulations policy. Specifically, Residents must evaluate admissions or transfers to critical care areas based upon the patient‘s condition. Each patient should be seen as soon as possible upon admission to one of the med/surgical floors. If the admit is to ICU, CCU, L&D, etc. they should be seen immediately. If there are other pressing patient care issues, a decision may be made in consultation with the senior resident and the attending physician, to stabilize new admission and then return soon to finish the work up. Use your team, and cover all of your patients, per their presentation and their needs. Residents must evaluate inpatients and write progress notes at least daily. When a patient is seen with an attending, the Resident should chart that in the progress note. Residents should answer pages as soon as possible, and respond to emergency consultations and Emergency Department requests within 30 minutes. Residents are encouraged to consult with an attending or any time he/she is uncertain about a patient care issue. 12 INSTITUTIONAL RESOURCES 12.1 Blood Bank Blood and/or blood components are administered intravenously upon physician's orders. An informed consent must be signed by the patient or designated caregiver prior to transfusion. The Resident administering blood and blood components shall have knowledge and understanding of immuno-hematology, blood grouping, blood and its components, administration equipment and technique appropriate for each component, indications for use, monitoring parameters, side effects, toxicities, incompatibilities, storage requirements, transfusion reactions, and potential complications. Pre-transfusion testing to ensure compatibility shall be established prior to each transfusion. Positive patient and blood identification per LCRH Blood Product Administration Policy must be performed and documented prior to each transfusion. Collections of blood for type and screen or type and cross match are drawn within three (3) days of the anticipated date

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of need. When ordering blood and blood components; confirm type and cross match, and other pre-transfusion laboratory tests complete blood count [CBC], platelet count; confirm type of blood or components to be transfused; confirm number of units; date of transfusion; pre-medication, if necessary; post-transfusion laboratory orders. Observe Standard Precautions. Obtain blood samples for type and cross match, if necessary. Complete appropriate blood bank request slip and send blood sample and request slip to blood bank. The Blood Bank Sample Collection Procedure must be followed for collection of blood samples for pre-transfusion testing. All possible precautions must be taken to insure the proper identity of patients to be transfused and of the blood selected for transfusion. An error in identification of the patient or donor unit is dangerous and can result in a hemolytic transfusion reaction. The resident is responsible to be aware of and follow the already established laboratory/blood bank policies for administration of blood products. Auto-transfusion system will be used by a registered nurse to safely collect and to re-infuse autologous whole blood to the patient who has had orthopedic surgery such as a total joint replacement (ex: knee, hip). The auto-transfusion system is a self-contained disposable autologous whole blood recovery system designed to collect and re-infuse blood lost following surgery. The hemovac vacuum source is used to aspirate the shed blood. The collection system is then re-infused by using a 40-micron filter and a standard blood infusion set. On the Internal Web, refer to Laboratory Policy and Procedure Transfusion Services, Nursing Policy and Procedures Blood Administration and Post-Operative Orthopedic Transfusion. References (Administrative policies and procedures found on LCRH Internal Web): 1) Blood Product Administration; 2) Guidelines for Blood Bank Sample Collection; 3) Guidelines for Blood Utilization Review. 12.2 Patient Protection Program Child/Adult Abuse and Neglect: State laws require that all health care providers, including Residents, report suspected child/Adult abuse or neglect. It is the responsibility of the person who identified the suspected abuse to notify the appropriate authorities in the locality where the patient resides. Referrals of suspected abuse are made to the appropriate Social Service/Child Protective Services, Cabinet for Health and Family Services and/or Police Department/Sheriff‘s Office.

1. Residents are to immediately notify the House Supervisor or Department Director if abuse/neglect/exploitation is suspected.

a. Provide a safe environment b. Maintain confidentiality c. Ensure that the alleged victim is treated with concern, dignity and

respect. Be nonjudgmental.

2. The department director or house supervisor who receives the report of suspected abuse/neglect/exploitation will ensure the following are notified:

a. Administrator or designee b. Local law enforcement (Somerset Police Department or the Pulaski County Sheriff Department) or the Kentucky State Police

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(after business hours call – 911); c. Cabinet for Health and Family Services/ Department of Social Services, 677-4086 (after-hours call – 911); d. Office of Inspector General (Division of Licensing and Regulation) /Cabinet for Health and Family Services at (606) 330-2030. e. The Commonwealth’s attorney or the county attorney.

3. The Department Director, Manager, or House Supervisor will initiate an internal investigation utilizing the “Investigation Tool for Allegation of Abuse, Neglect, and Misappropriation of Patient Property

For complete details, refer to the Policy & Procedures found on the LCRH Internal Web. 12.3 Employee Health Department The Employee Health Program provides a variety of health-related services, including post-offer pre-placement physical examinations, evaluation and treatment of workplace injuries and illnesses, exposure surveillance and updating immunizations. At various times throughout your employment, you will be asked to report to the Employee Health Nurse for screening such as the annual PPD skin test for Tuberculosis surveillance. You may also, because of your work duties or area, be asked to have other specific screening tests and exams, many of which are mandated by state or federal agencies. The Employee Health Program requires medical evaluations and treatment for work-related injuries, which include exposure to blood and/or body fluids (e.g., sharps injuries, splashes, exposures to communicable disease, falls, etc.). The Employee Health Department will arrange physician appointments for employees to determine:

• When an associate with an injury or infection requires work restriction or work exclusion • When an associate is ready to return to work after an injury or infectious illness

Employee Health Program is a means for evaluating and maintaining the overall good health of its associates. Associates suffering illness, injury, exposure to toxic substances or a curable or incurable blood or air-borne communicable disease while on duty must report it immediately. Employee Health Department must be notified and an Event Report must be completed for any of the above situations within 24-hours of occurrence or knowledge of occurrence. In cases of potential exposure to potential blood borne or air-borne pathogens, an Occurrence Report is completed and followed according to the Infection Control Manual. A verbal report should be made to the House Supervisor’s office who will be responsible for notifying Employee Health and Administration of the occurrence. Diphtheria, tetanus, pertussis and rubella. Employee Health will screen all new employees for the communicable disease listed above and encourages the appropriate vaccine to those with a negative antibody result. All medical staff must participate in the Medical Center‘s annual TB testing program. Refer to Human Resources Policies on the LCRH Internal Web.

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12.4 Employee Assistance Program Eligibility: Applicant must be a current employee of Lake Cumberland Regional Hospital, Lake Cumberland Medical Associates, or Lake Cumberland Surgery Center and have completed six (6) months of service. Contract employees are NOT eligible for this assistance. Eligible employees may receive assistance one time per rolling calendar year. If an employee should need additional assistance, the request should be presented to Administration for approval

Hardships Defined: The hardships that qualify an employee for assistance include:

• Uninsured loss due to fire, flood, tornado, etc. when other compensation is not available or does not exist.

• Extended illness or injury that requires absence from work or results in critical economic hardship after all leave benefits have expired.

• Other unexpected ‘crisis’ needs when other funds are not available and other financial and community resources have been exhausted.

Application and Decision-making:

Written requests may be submitted to the Human Resources office using the attached request form. A review committee will evaluate the request with regard to the eligibility requirements and the nature of the hardship, and will make a determination about the use of available funds. Decisions of the review committee are final. The review committee shall consist of:

• Director of Human Resources • Representative of Administrative Team • Controller or designee • Department Manager Representative

12.5 Nursing Department The goal of the Department of Nursing is three-fold: to give quality care to patients, to provide an exemplary learning climate for students and staff, and to promote a spirit of inquiry in nursing. The nursing staff is committed to the concept of collaboration in the delivery of quality patient services and welcomes opportunities to work together with Residents to achieve this goal. The Department of Nursing at LCRH is decentralized to promote clinical specialization and accountability for nursing care as close to the point of service as possible.

• The Chief Nursing Officer (CNO) directs nursing at LCRH. • Each Nursing Unit is managed by a Nurse Director. • The Chief Nursing Officer (CNO) is the corporate officer responsible for assuring a

consistent standard of nursing care throughout LCRH. LCRH partners with multiple schools of nursing to provide learning experiences for student nurses. 12.6 Nutrition Services

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The Department of Nutritional Services is responsible for the overall nutritional care of all patients. Registered Dietitians provide nutritional care which includes screening patients to identify those at actual or potential nutritional risk, development of nutrition care plans, and to educate patients for home management of prescribed dietary treatment regimes. The Department is also responsible for the preparation and distribution of food to all hospitalized patients. A patient selected menu is utilized and every effort is made to accommodate special requirements. Commonly used normal and therapeutic diets are described in the on-line Nutrition Care Manual by the American Dietetic Association which is accessible to all LCRH associates on the LCRH website. Dietitians are available for consult about individual patient's nutritional status/therapy plan and should be consulted whenever a patient requires dietary modification other than or in addition to those described in the Diet Manual. Orders for discharge patient education should be written at least 36 hours in advance of anticipated discharge of the patient to allow adequate time for full instruction. Inpatient dietitians can be contacted by calling the Nutrition Services office. 12.7 Pharmacy The Department of Pharmacy Services has the responsibility for the procurement, storage, distribution and control of all medications for patients of the LCRH. The Department provides information and assistance on the clinical use, pharmacokinetics, administration, and adverse reactions of medications. Pharmaceutical/drug samples are not permitted to be stored or dispensed anywhere in the In-Patient facility, including Department of Education offices. This does not apply to LCRH clinics. Policies and procedures for pharmaceutical services are developed by the Department of Pharmacy Services, reviewed by the Pharmacy and Therapeutics Committee, approved by the Medical Staff Executive Committee and are located on the LCRH Internal Website. Pharmaceuticals are dispensed only to in-house patients and patients in the Emergency Department The Formulary is maintained, by the Department of Pharmacy Services and the Pharmacy and Therapeutics Committee. It is a continually revised list of drugs that are the most safe and effective for use at LCRH. The Formulary on LCRH website contains a list of available drugs by generic name and an alphabetic cross-reference of trade names. The Department of Pharmacy Services is open 24 hours per day, 7 days per week. The prescription pads can be ordered through your department from Materials Management Department. The pads must be obtained during normal hours and require a signature. Clinical Pharmacy Services provided by the pharmacy include, but are not limited to, dosage adjustment recommendations for patients with renal dysfunction, facilitating the conversion of patients to oral medications as soon as possible after admission, review of culture and sensitivity reports for appropriate antibiotic usage, as well as providing drug information for both staff and patients. 12.8 Security

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Loss of hospital, patient, or personal property under any circumstances should be reported to Security – ext 0 (operator) and the House Supervisor. Although the Hospital can assume no financial responsibility for personal losses, every reasonable safeguard will be provided. Thefts or any other incidents should be reported immediately to Security for investigation. Also, suspicious persons should be reported immediately for investigation. Residents should exert a constant interest in the personal safety of patients and in the proper protection of their property. Please help LCRH provide a safe and secure environment for all patients, visitors, and associates. 12.9 Rehabilitation Services The Department of Rehabilitation Services includes: Occupational Therapy (OT), Physical Therapy (PT), and Speech-Language Pathology (SLP). The Services include comprehensive and individualized assessment and treatment of inpatients, and outpatients. Programs are designed to identify, correct, improve, and/or alleviate acute or chronic dysfunction and to promote optimal health for orthopedic, cardiac, pulmonary, congenital, vestibular and neurological disorders. Functional goals may be short-term at each rehabilitation settings to prepare the patient to move through the continuum of rehabilitation care to another level and setting. Referral Process: 1. Inpatient referrals for PT, OT, and SLP require a physician‘s order in the patient‘s medical record with the dysfunction or impairment for treatment. 2. Outpatient Referrals information should include: a. Patient Name b. Physician Name c. Medical Record Number d. Date of Birth e. Diagnosis f. Description of the problem to be treated/precautions Printed Forms are available. 12.10 Case Management/Social Work The Case Management Department is comprised of Registered Nurse Case Managers and Social Workers. RN Case Managers and Social Workers are unit based and are assigned throughout the hospital to assist patients and their families with personal, emotional, marital, family, or other problems that are often related to illness and their ability to gain maximum benefit from health care services. In addition to counseling, social workers collaborate with physicians, nurses, and other health care workers in medical care plans for patients. With their thorough knowledge of available health and welfare resources in the community, they can help with arrangements for rehabilitation services, care in the home, nursing homes, tutoring, specialized infant and children's services, or other post-hospital assistance. The social worker must be

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notified in cases of suspected child or elder abuse or in cases of domestic violence. The RN Case Managers are responsible for assuring prudent utilization of all resources by evaluating the options available and balancing cost and quality to assure the optimal clinical financial outcomes. The Case managers are responsible for discharge planning, length of stay and Utilization Review of necessity, medical necessity and appropriate level of care. Business Hours: The Case Management Department hours are Monday through Friday, 8 a.m. – 4:30 p.m. During these hours, Case managers and Social Workers can be contacted on their individual Spectra Link phones or by order entry referrals through Meditech or by calling the Case Management main number at (606)678-3126, also LCRH website will have the case manager on call (On call hours are 4:30pm-8:00am). 12.11 Risk Management Program To meet its commitment to provide safe quality health care, Lake Cumberland Regional Hospital shall maintain a comprehensive Risk Management Program in accordance with the provisions of applicable federal regulations, state statutes, the standards of The Joint Commission, and other regulatory agencies. The Risk Management Program will provide an integrated and coordinated effort to control losses related to professional liability, general liability, workers compensation, and property damage. OBJECTIVES The objectives of the Risk Management Program are as follows: To provide ongoing surveillance for potential variances to facility standards or policies in order to reduce or eliminate losses for the facility To investigate, categorize, and analyze all patient events, occurrences or variances, including patients’ complaints, in order to establish trends or patterns involving individuals, locations, or types of incidents and to determine appropriate action to prevent recurrence. To maintain a safe environment for patients, employees, medical staff, and visitors To integrate data received from quality resource management, safety management, infection control, employee health and other programs as appropriate, as it pertains to potential losses to the facility, staff and patients; and to make recommendations toward resolving issues causing losses To communicate findings and analysis of risk management activities to senior management at Lake Cumberland Regional Hospital and appropriate departments, along with suggestions for improvement To orient new employees to their responsibilities in proper reporting of unusual occurrences, patient events or variances from standards and future prevention of such occurrences To provide in-service education and continuing education on risk management and risk prevention to facility employees, senior management, medical staff members, and members of the Board of Trustees To maintain confidentiality of all information pertaining to unusual occurrences within the facility To comply with the requirement of Risk Management in reporting potentially compensable events. To comply with all Federal and State statutes, and regulatory and accreditation agencies governing the internal risk management program

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12.12 Communications/Information Services Telephone System: The Communications/Information Services Department is comprised of a complex network of processor and computer supported telecommunications systems. The system supports direct incoming and direct outgoing dialing from most telephones, bypassing the hospital operator. To access an outside line you must dial 9 first. The Resident‘s quarters are equipped with telephones that Residents may use to conduct their business. The Medical Center‘s operators make a determined effort to direct incoming calls to the correct extension. However, if you customarily cannot be reached at a specific hospital extension, the operators will use the digital paging system. The audible overhead paging system is designed for emergency business and used by the hospital operators only. The hospital operator will not accept messages. If you have a pager problem or need a new battery the hospital operator will be able to assist you. 12.13 Transport of Patients Patients transferred from a patient care area, the mode of transport and necessary equipment will be determined by each patient‘s nurse, based on the patient‘s physical condition, activity restrictions and pre/post procedure care considerations. Residents needing assistance with transporting patients must refer to the nursing staff on each unit for assistance. 12.14 Paging System Signal Calls: The telephone operators at LCRH have been instructed not to call students or Residents from lectures, conferences, or meetings, except when the call is very urgent. Therefore, when such a call is made, it is an urgent call insofar as the operator knows and must be answered at once. If a Resident is unable to answer the page he/she should have one of the personnel in the area call the operator, explain the circumstances and take a message. The emergency codes for the medical center are: Code Black Bomb Threat Code Gray Disturbance Code Blue Resuscitation Code Yellow Emergency Management (disaster) Code Alpha Infant/Child Infant/Child Abduction

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Code Orange Hazard Mat Release/Chemical Spill Plain Language Text Severe Weather Watch (tornado watch) Plain Language Text Severe Weather Warning (tornado warning) Code Green Evacuation Code Red Fire Code 400 ER Overload Plain Language Text Civil Disturbance Active Shooter Weapon Discharged on Premises Specific Utility Loss of Essential Equipment/Utilities Code Golden Patient has wandered off/eloped Code River Water leaks or spills Rapid Response Team Patient has significant change in his/her

condition Resident (by name) STAT (Operator will state what phone or area): The Resident will answer to that STAT page. 13 RESIDENT RESOURCES 13.1 Conferences, Rounds, Lectures There are regularly scheduled Conferences, Seminars, Rounds, Lectures, Demonstrations, etc., presented throughout the year under the auspices of the Hospital, each Residency Training Program, and the Department of Medical Education. Notification of these meetings is published in advance. Refer to Residency Training Program manual for specific didactic programs and attendance requirements. When notified of a medical program either at LCRH, offsite, or out of town, it is a mandatory educational program for all residents. All Morning Reports, Noon Lectures, designated evening CME programs, and daily check-outs (morning and evening) are mandatory. Satisfactory adherence to the educational programs and check-outs is part of the evaluative process for each resident and each program. 13.2 Resident Participation on Hospital Committees and in Continuous Quality Improvement Residents are assigned to various Hospital Committees each year during their residency. The committee assignments are for one year duration. Each year the resident will be assigned to a new committee to gain more experience in hospital policy management. Continuous quality improvement is required for all aspects of patient care at LCRH and is a central component of all physicians’ professional activities. In addition it is required for all physicians to maintain their Board certification. All first year residents and some senior residents will be assigned to one or more LCRH Continuous Quality Improvement projects. Second and Third year residents will be assigned to membership on one or more Hospital Committees. Residents on either a Continuous Quality Improvement project or hospital committee are expected to attend all Committee meetings unless they have urgent patient care. Residents are expected to be able to regularly report their Continuous Quality Improvement Project and/or Committee activities to the resident groups as a whole. 13.3 Computer Use and Support

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LCRH utilizes MEDITECH as the primary information system in the clinical area. MEDITECH applications include Nursing Documentation, PCI (Patient Care Inquiry), Laboratory; Order Entry, Radiology, Admissions, Medical Records, and Pharmacy, among others. There are other departmental specific clinical applications such as PACs for radiology. Additional training will be provided for clinicians required to use departmental systems. All systems are supported twenty-four hours a day. Technical assistance can be accessed by calling the Help Desk at Ext 3383. You will also be assigned an email account and access to the Intranet (Internal Web). Use of email and the Intranet are subject to the LCRH Confidentiality Policy (Refer to LCRH Policy & Procedures). The following information is presented as an overview only. Detailed information is available from Information Services and copies of all policies are available in the Information Services Department. Patient Confidentiality and Security Patients have the right to absolute privacy of their clinical records. All access should be by clinical care providers only and never by curiosity seekers or friends, neighbors, relatives or co-workers not involved in the patient‘s clinical care. You are privileged to access patient records with which you have legitimate clinical links. At the same time your user ID and password are assigned, you will be asked to sign a confidentiality agreement. The agreement verifies your understanding of what constitutes a breach of access and the consequences of such a violation. All computer access is through use of an individually assigned sign-on ID and unique password. For security reasons, your ID or password is never to be shared or borrowed. Use of this user ID establishes user identity and all transactions are tracked and logged to determine appropriateness of those transactions. Information Services constantly runs reports to track users and their access. Audit trails are maintained to allow for periodic audits of clinical transactions, as well as those on the Internet. Some patients are designated as confidential. When one wishes to access the information for these patients, a screen warns the user that the patient is confidential and asks if (s) he wishes to proceed. Extra caution must be exercised in this case. Access to any patient data is subject to the LCRH Confidentiality Policy (Refer to Human Resource Policy & Procedure Manual). Process for Obtaining Access When you arrive at LCRH, the Medical Records Department representative will notify the Information Services Department of your need for access. When you have signed the Confidentiality Agreement, you will be assigned your user ID and password. Meditech training classes will be presented by a representative of Information Services during resident orientation. If for any reason your privileges are suspended or revoked, your computer access will be affected accordingly. Electronic Signature LCRH will create an electronic signature for you, which associates each provider with system/patient activity. Individual PINs for the electronic signature and any other passwords which are created are to be treated as confidential and are NOT to be shared among other individuals. Any violation or inappropriate use of personally issued sign-on or electronic signature codes is considered a breach of confidentiality and is subject to disciplinary action. Immediate notification should be made to the Information Services Department if you suspect that your code or password has been lost, stolen, or used by anyone other than its issued user.

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MEDITECH Clinical Menu Access to multiple clinical menu options is available through MEDITECH after completion of the required security forms and training. Menu options include retrieval of patient clinical results from radiology and laboratory, designated nursing documentation, medication information, visit history and demographics. Security Considerations The security of the LCRH network is of primary concern. For this reason, various processes are in place to protect the network, including:

• Internet use is limited to job-related access only, and non-related sites are blocked. • Mobile computing and storage devices that contain or access information resources at

LCRH are strictly monitored. They must be approved by Information Services prior to connecting to the information systems at LCRH. Mobile computing and storage devices include, but are not limited to: laptop computers, personal digital assistants (PDAs), plug-ins, Universal Serial Bus (USB) port devices, Compact Discs (CDs), Digital Versatile Discs (DVDs), flash drives, modems, handheld wireless devices, wireless networking cards, and any other existing or future mobile computing or storage device. Portable computing devices and portable electronic storage media that contain confidential, personal, or sensitive LCRH information must use encryption or equally strong measures to protect the data while it is being stored.

• No one is allowed to download anything from or install anything on any LCRH computer.

Details of these considerations may be obtained from the Information Services department (HIPAA Security Policy and Departmental Policies). 13.4 Food Services Meals are provided to Resident Physicians free of charge in the Cafeteria and Medical Staff Lounge and in the Resident Pantry while on duty at the hospital. Food is not provided for resident family members; it is not to be taken home; and should only be the amount for a healthy single meal. A limited selection of sandwiches, snacks, salads and beverages are available during evening hours and weekends in the Medical Staff Lounge and Resident Pantry. NOTE: Residents having breakfast and/or lunch are required to obtain their meals prior to the start of morning or noon lectures. Once the lecture has started, Residents are not permitted to leave for meals. This is disruptive and disrespectful to the lecturers. Residents are responsible for their own meals while at other institutions, if that institution does not provide meals free of charge or provide meal tickets. Cafeteria Monday through Friday Breakfast 7:00 a.m. to 10:00 a.m.

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Lunch 11:30 a.m. to 1:30 p.m. Dinner 4:30 p.m. to 6:30 p.m. Weekend / Holiday Breakfast 8:00 a.m. to 10:00 a.m. Lunch 11:30 a.m. to 1:30 p.m. Holiday service hours vary. Please check the LCRH internal web for correct holiday hours. A selective menu that includes sandwiches, snacks, salads, and beverages are available during all open hours. Selections of hot entrees are available during normal meal times. Sub Way Monday through Friday: Hours: 7:00 a.m. to 10:00 p.m. Saturday Hours: 8:00 a.m. to 10:00 p.m. Sunday: Hours: 9:00 a.m. to 10:00p.m. Baxter’s Coffee Monday through Friday: Hours: 7:00 a.m. to 5:00 p.m. Saturday & Sunday – Closed Vending Machines Vending machines are available and open 24 hours per day near the cafeteria. Items available for purchases are snacks, and beverages. 13.5 Interpreter Services & Notary Services For foreign language interpretation, contact Language Services Associates via telephone 24/7. Access LSA by calling 1-877-274-9745, and entering the hospital’s access code 2806312. For Sign Language interpretation, the department manager, house supervisor or bedside caregiver should obtain the designated laptop computer in the house supervisor’s office that is equipped with the video camera capability along with the logbook for that computer. The computer is taken to the bedside and the Language Services Associates (LSA) video remote interpretation (VRI) icon is accessed to connect to the website (https://interpretrac.lsaweb.com/). Notary services are usually available in the Administration office. Please call 3232 for availability. 13.6 Library Facilities Residents are given access to the Pikeville College of Osteopathic Medicine (KYCOM) electronic library during residency. 13.7 On-Call Rooms

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https://interpretrac.lsaweb.com/


On-Call Rooms are provided at LCRH for residents/interns during Block Night Rotations and other rotations requiring night call and are located _______________________________. 13.8 Uniforms & Laundry Lake Cumberland Regional Hospital will furnish each Resident with two lab coats on the day of orientation and two new coats every year thereafter. Residents requiring scrubs must consult their individual training departments for instructions on obtaining them. Lab coats should be changed at least weekly and any time that they become soiled. It is the residents’ responsibility to see that they have clean, professional coats at all times. 13.9 Portable Ultrasound Machines A unit specific portable ultrasound machine is available for resident use in placing central lines and other appropriate clinical uses in the Emergency Department and the Intensive Care Unit. The Operating Room portable ultrasound machine can never be taken from the Operating Room. The Resident ultrasound machine is located in the ICU. It should be used for residency clinical needs. 14 UNIVERSAL/STANDARD PRECAUTIONS Universal/Standard precautions exist to provide the same high level of infection precaution for all patients. 14.1 Standard Precautions Standard Precautions are consistent with recommendations from the Centers for Disease Control to consider all blood and body fluids as potentially infectious, regardless of the patient‘s diagnosis. In order to follow these recommendations, use of personal protective equipment (PPE) must focus on the care provider‘s interaction with the patient at the time. Transmission based precautions, which focus on the diagnosis of the patient, are used in conjunction with standard precautions to prevent the transmission of disease. It makes more sense to consider all blood and body substances as potentially infectious, rather than to practice precautions only on patients diagnosed with certain infectious diseases, because the infection status of all patients ‘blood cannot be known for most infectious diseases. Standard precautions include the following elements and shall be followed by all personnel at all times, regardless of the patient‘s diagnosis. Use individual judgment based on the risk of splash and/or splatter of body fluids in determining when PPE are needed. Each individual must establish his/her own standards for consistent use of PPE. These personal standards should be based on the individual‘s skills and interactions with the patient‘s body substances, non-intact skin, and mucous membranes. 1. Wear gloves when it is likely that hands will be in contact with body substances, e.g. blood, urine, feces, wound drainage, oral secretions, sputum, and vomit. 2. Protect clothing with a disposable isolation gown when it is likely that eyes and/or mucous membranes or the body will be splashed with body substances (e.g., when suctioning a patient with copious secretions). 3. Wear masks and/or eye protection when it is likely that eyes and/or mucous membranes will be splashed with body substances (e.g., when suctioning a patient with

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copious secretions). 4. Each physician needs to evaluate his/her own interactions with the patient and use PPE as appropriate, based on anticipated contact with body substances, not the patient‘s diagnosis of infection. All physicians who have frequent contact with blood or body fluids should be immunized against hepatitis B. 14.2 Resident & Infection Preventions Role in the Isolation of Patients If the patient has a disease that is transmitted in whole or in part by the airborne, droplet or contact route, the Resident is responsible for placing the patient in the appropriate transmission based precautions according to policy. The Infection Preventionist is available for consultation to assist in this process. If the patient is ambulatory and is soiling the environment with body substances, the patient should be placed in a single room, even if he or she does not have a diagnosis which requires transmission based precautions by policy. All direct care providers need to know their own immune status. Screening and vaccinations are available in Employee Health. 14.3 Precautions for Patients with Airborne Diseases a. Private Room with negative air pressure b. Airborne Precautions sign on door c. Door Closed When a patient is suspected of or known to have a disease transmitted in whole or in part by the airborne route, the physician should request a private, negative air pressure room and write the diagnosis or “rule out” diagnosis on the order sheet. This will prompt the nurse to have the patient placed in an appropriate room. The nurse will place an Airborne Precautions sign on the door to the patient‘s room. The Airborne Precautions sign instructs anyone about to enter the room to wear an N95 PRF mask when entering. If the patient has chickenpox (varicella) and the person wishing to enter the room has had chickenpox, he/she may enter the room without an N95 PFR mask to provide care. The airborne route transmits the following diseases in whole or in part. Patients with these diseases need to be placed in Airborne Precautions. Note: When a patient leaves the hospital room to go to any other area, the patient must wear a surgical mask.

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Disease Duration of Airborne Precautions Comments

Chickenpox (Varicella) Until all lesions are crusted. Persons who are not susceptible do not need to wear a N95 PFR mask. Exposed susceptible patients should be isolated beginning 10 days after exposure until 21 days after 1st

exposure. Call Infection Preventionlist.

**Herpes – zoster/varicella localized in immuno-compromised patient, or disseminated

Duration of illness Localized lesions in immuno-compromised patients frequently become disseminated. Because such dissemination is unpredictable, use the same precautions as for chickenpox. Call Infection Preventionlist.

**Measles (rubeola) For 4 days after start of rash, except in immuno-compromised patients, for whom precautions should be maintained for duration of illness

Persons who are not susceptible do not need to wear a N95 PFR mask. Promptly report to Infection Preventionlist.

** Mumps (Infectious parotitis) For 9 days after onset of swelling. Persons who are not susceptible do not need to wear a mask. Call Infection Preventionist.

Pertussis (Whooping cough) For 7 days after start of effective antibiotic therapy.

Call Infection Preventionist.

Tuberculosis – Pulmonary confirmed or suspect

In most instances, duration can be guided by clinical response and a reduction in numbers of TB organism on sputum smear. Usually this occurs within 2-3 weeks after chemotherapy has begun. Apply precautions until patient is improving and sputum smear X 3 is negative to for TB organism.

Prompt use of effective antitubercular drugs in the most effective means of limiting transmission. Call Infection Preventionist

(All other Isolation Protocol see LCRH Internal Web policy/procedure) 14.4 Needle Sticks Any needle stick of a resident or a medical student should be managed according to the LCRH Needle Stick Protocol found on the LCRH Internal Website policy, enter an event report under the Infection Control. Notify House Supervisor and Employee Health immediately. If a needle stick or blood/body fluid exposure occurs after Employee Health‘s normal business hours, or during the weekend,

• Report the incident to the house supervisor and to the Residency Office immediately.

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• Notify House Supervisor and Employee Health immediately to initiate needle stick protocol to complete documentation that is required, and then follow up with Infection Preventionlist.

14.5 Other Standardized Procedures Soiled linen: All soiled linen is to be put into individual clear laundry bags, closed securely, and transported in carts to the laundry.

Central Processing Reusable Items: All miscellaneous reusable equipment to be returned to Central Processing is to be placed in a marked basin on shelf located in soiled utility room.

NOTE: Any fluid filled container that is not disposable should be emptied into hopper on unit prior to returning to Central Processing. All special trays are to be left in soiled utility room. Disposal of regulated medical waste from patient rooms and ICU: Follow regulated medical waste management policy which can be found on the LCRH Internal Web Page. Communicable Diseases FURTHER QUESTIONS OR CONCERNS REGARDING INFECTION PREVENTION AND CONTROL SHOULD BE REFERRED TO THE INFECTION PREVENTION AND CONTROL POLICIES ON THE INTERNAL WEB AND/OR INFECTION PREVENTIONIST. 15 EMPLOYEE COMMUNICATIONS 15.1 Open Communication LCRH encourages associates to discuss any issues they may have with a co-worker directly with that person. If a resolution is not reached, associates should arrange a meeting with their direct supervisor. If the concern, problem, or issue is not properly addressed, associates should contact the Human Resources Department. Any information discussed in an Open Communication meeting is considered confidential, to the extent possible while still allowing management to respond to the problem. Retaliation against any associate for appropriate usage of Open Communication channels is unacceptable. 15.2 House Staff Meetings In order to keep the communication channels open, the Department of Medical Education will have at last once-a-month house staff meeting. Residents receive communications from the Department about the agenda and discussion topics every month. 15.3 Bulletin Boards The Department of Medical Education provides Residents with a bulletin board in the Medical Education Department where Residents can find organizational announcements, news/events, and discussions about specific topics. The Residents are responsible for reading necessary information posted on the bulletin board. E-MAIL: All residents will be provided a LPNT email address to use while employed by LCRH.

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LPNT Emails can be set up to be accessed from I-phones and DROID phones. All communication from the DME/Program Directors or Residency Program staff will be done using the LPNT email. Remember any information that comes through the e-mail is important. Residents are responsible to know what has been sent to them by e-mail. 15.4 Suggestions The Department of Medical Education encourages all Residents to bring forward their suggestions and good ideas about making LCRH a better place to work and enhancing service to LCRH customers. Any associate who sees an opportunity for improvement is encouraged to talk it over with their Program Director and Director of Medical Education. The Department of Medical Education can help bring ideas to the attention of the people in the organization that will be responsible for possibly implementing them. All suggestions are valued. 15.5 Closing Statement Successful working conditions and relationships depend upon successful communication. It is important that Residents stay aware of changes in procedures, policies, and general information. It is also important to communicate ideas, suggestions, personal goals, or problems as they affect work at Lake Cumberland Regional Hospital to the Department of Medical Education.

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16 ACKNOWLEDGMENT - Resident Manual I acknowledge that I have been given access to the Lake Cumberland Regional Hospital Resident Manual and agree to abide by the Manual. I am aware that if, at any time, I have questions regarding the Resident Manual, I should direct them to the Administrative Director of Medical Education or the Director of Medical Education. I know that Lake Cumberland Regional Hospital policies and other related documents do not form a contract of employment and are not a guarantee by Lake Cumberland Regional Hospital of the conditions and benefits that are described within them. Nevertheless, the provisions of such Lake Cumberland Regional Hospital company policies are incorporated into the acknowledgment, and I agree that I shall abide by its provisions. I also am aware that Lake Cumberland Regional Hospital, at any time, may on reasonable notice, change, add to, or delete from the provisions of this Manual or other company policies. ____________________________________ ___________________________ Resident‘s Printed Name OGME Level ____________________________________ ___________________________ Resident‘s Signature Date

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.

17. FORMS

1. Switch Request Form(Call, Didactics, Presentations)

2. Personal Time Off (PTO) Request Form

3. Moonlighting Request Form

4. LCRH Expense Form

5. Elective/Selective Request Form

6. Rotation Change Request Form

18. ADDENDUM

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