X

X

UWHCA Board of Directors

February 23, 2017, 1:30 - 4:30 PM, Room H6/215

Meeting Minutes

Medical Staff Membership and Clinical Privileges

Resolution - UW Health ACO, Inc. Nomination of Officers

Attachment - Minutes from January 26, 2017

Attachment - Medical Staff Membership and Clinical Privileges

1:30 PM IIIIII. . Consent AgendaConsent AgendaDr. Thomas Grist

Approval

Presentation - GME Medical Education Annual Institutional Review

1:35 PM IVIV. . Graduate Medical Education Annual Institutional Report (AIR)Graduate Medical Education Annual Institutional Report (AIR)Dr. Susan Goelzer

Report/Discussion

1:45 PM VV. . UW Health FY17 Consolidated Financial ReviewUW Health FY17 Consolidated Financial ReviewMr. Robert Flannery

Update

1:30 PM II. . Call to Order of Board MeetingCall to Order of Board MeetingDr. Thomas Grist

1:30 PM IIII. . Welcome and IntroductionsWelcome and IntroductionsDr. Thomas Grist

Attachment - Resolution UW Health ACO, Inc. Nomination ofOfficers

Attachment - GME Annual Institutional Review

Presentation - UW Health Consolidated Financials Report (YTDDecember 31, 2016)

VIVI. . Closed SessionClosed Session Motion to enter into closed session pursuant to Section 19.85(1)(e),Wisconsin Statutes, for the discussion of confidential strategic matters,which for competitive reasons require a closed session including but notlimited to confidential transaction update with UnityPoint Health/UnityPointHealth-Meriter, considerations of the state's Group Insurance Board (GIB)shifting the state employees' health plan to a self-funded plan, and for thediscussion of financial and other matters including budgetary matters;pursuant to Section 146.38, Wisconsin Statutes, for the review of thePatient Safety and Quality Committee report; and, pursuant to Section19.85(1)(g), Wisconsin Statutes, to confer with legal counsel regardingthese and other matters.

4:30 PM VIIVII. . AdjournAdjourn

UWHCA Board of Directors - February 23, 2017UWHCA Board of Directors - February 23, 2017

AgendaAgenda

Page 3

Page 6

Page 12

Page 14

Page 31

Page 91

Page 2 of 102

Attachment

Open Session Minutesfrom January 26, 2017

Page 3 of 102

1

UNIVERSITY OF WISCONSIN HOSPITALS AND CLINICS AUTHORITY Minutes of Board of Directors Meeting

Open Session

January 26, 2017, 1:30 PM H6/215

UWHCA BOARD MEMBERS PRESENT: Dean Robert Golden (Chair), David Ward (Vice Chair) (via phone),

Chancellor Rebecca Blank, Dr. Thomas Grist, Michael Heifetz, Regent Tim Higgins, Regent Janice Mueller, Senator Luther Olsen, Lisa Reardon, Pablo Sanchez, Dean Linda Scott, Gary Wolter

UWHCA BOARD MEMBERS EXCUSED: Andrew Hitt, John Litscher, Regent Drew Petersen BOARD EXECUTIVE COMMITTEE (Non-Voting): Dr. Alan Kaplan, Dr. Jon Matsumura, Dr. Richard Page UW HEALTH STAFF: PRESENT: Mike Dallman, Bob Flannery, Troy Lepien, Patti Meyer, Dr. Pete Newcomer, Ron

Sliwinski (via phone), Tina Whitehorse, Kelly Wilson (Secretary) 1. Call to Order

Chair Robert Golden called the open session of the Board of Directors meeting to order at 1:30 p.m. Roll call was taken and a quorum was present.

2. ACTION: Approval of UWHCA Consent Agenda

Dr. Grist moved approval of the items on the consent agenda, including: UWHCA December 22, 2016 Open Session Minutes; Medical Staff Membership and Clinical Privileges; Resolution approving the transfer of UWMF Department of Surgery reserve funds over R&D [Resolution 17-016]; Resolution approving UW Health ACO, Inc. Board Membership and Amended Bylaws [Resolution 17-017]; Chancellor Blank seconded the motion; it passed unanimously.

3. Chair Report

Chair Golden deferred to Kelly Wilson. Ms. Wilson introduced Troy Lepien as the new UW Health VP of Business Integrity, Chief Compliance Officer. Mr. Lepien informed the board that UWHCA is required by Joint Commission accreditation standards to track and address Board members’ potential conflicts of interest. As such, he will request a copy of members’ Statement of Economic Interests from the Government Accountability Board. Any questions should be directed to Mr. Lepien or Ms. Wilson. 4. Closed Session

There being no other matters for the open session, Chair Golden proposed to take the meeting into closed session through a motion to enter into closed session pursuant to Section 19.85(1)(e), Wisconsin Statutes, for the discussion of confidential strategic matters, which for competitive reasons require a closed session including but not limited to review of confidential terms of proposed JOA among UW Health and UnityPoint Health/Meriter Health Services, Inc./UnityPoint Health-Meriter/Unity Point Clinic/UnityPoint at Home and the exchange agreement among UPH/PPIC/UHC/GHS/GHP/Unity, to discuss potential drug acquisitions, and for the discussion of financial and other matters including budgetary matters; pursuant to

Page 4 of 102

2

Section 19.85(1)(g), Wisconsin States, to confer with legal counsel regarding these and other matters; and pursuant to Sections 19.85(1)(f), 146.38, and 146.82, Wisconsin Statutes, and other applicable privacy laws to discuss confidential protected health information and to review the services of health care providers related to a patient care concern.

Regent Higgins moved to go into closed session; Dr. Grist seconded the motion; there was a unanimous roll call vote approving entering into closed session. The following members voted for the motion: Chair Golden, Vice Chair Ward, Chancellor Blank, Dr. Grist, Michael Heifetz, Regent Higgins, Regent Mueller, Senator Olsen, Lisa Reardon, Pablo Sanchez, Dean Linda Scott, and Gary Wolter.

5. ACTION: Approval of UW Health/UnityPoint Health-Meriter JOA

After returning to Open Session, Chair Golden presented a resolution for approval to enter into the UW Health/UnityPoint Health-Meriter Joint Operating Agreement as discussed in closed session. A motion was made by Senator Olsen to approve the Resolution, which motion was seconded by Regent Higgins. The motion was unanimously approved by voice vote. [Resolution 17-018] 6. ACTION: Approval of UPH/PPIC/UHC/GHS/GHP/Unity Insurance Transaction

Chair Golden presented a resolution for approval to enter into the UPH/PPIC/UHC/GHS/ GHP/Unity Insurance Exchange Agreement as discussed in closed session. A motion was made by Mr. Sanchez to approve the Resolution, which motion was seconded by Senator Olsen. The motion was unanimously approved by voice vote. [Resolution 17-019] 7. Adjournment

A motion was made and seconded to adjourn the meeting. The meeting was adjourned in Open Session at 4:25 p.m.

Respectfully Submitted,

Kelly Wilson, Secretary

Page 5 of 102

Attachment

Medical Staff Membership

and Clinical Privileges

February 2017

Page 6 of 102

Page 7 of 102

Page 8 of 102

Page 9 of 102

Page 10 of 102

Page 11 of 102

Attachment

ResolutionUW Health ACO, Inc.

Nomination of Officers

Page 12 of 102

RESOLUTION OF THE BOARD OF DIRECTORS OF

UNIVERSITY OF WISCONSIN HOSPITALS AND CLINICS AUTHORITY

Approval of UW Health ACO, Inc. Election of Officers

February 23, 2017

WHEREAS, the Board of Directors of the University of Wisconsin Hospitals and Clinics Authority (the “Authority Board”) approved a restructuring of the UW Health ACO, Inc. (the “Corporation”) on November 17, 2016;

WHEREAS, Section 3.1(b) of the Corporation’s Bylaws requires that the Corporation’s officers be recommended by the Corporation’s Board, subject to approval by the Authority Board;

WHEREAS, the Authority Board has considered candidates for the Corporation’s officers and now wishes to appoint such officers:

BE IT FURTHER RESOLVED, that the Authority Board hereby appoints the following individuals as officers of the Corporation.

President Jonathan Jaffery, MD Vice President Stephanie Berkson Treasurer Robert Flannery Secretary Dan Brzozowski Compliance Officer Troy Lepien

Page 13 of 102

Graduate Medical Education

Annual Institutional Review

2015-2016

Susan Goelzer, MD, MSDesignated Institutional Official (DIO)

Associate Dean of Graduate Medical Education

Page 14 of 102

2

UW Health Institutional Oversight

69 ACGME Accredited Residency and Fellowship Programs

More than 640 trainees Full Accreditation without significant

citation Aggregate Institutional Overall

Evaluation is 4.7/5.0 with a national mean of 4.4

Page 15 of 102

ACGME Institutional Survey

3Page 16 of 102

ACGME Resident Survey Dashboard

4Page 17 of 102

National Mean Survey Dashboard

5Page 18 of 102

6Page 19 of 102

7

454 463 473 492 498

102 101 104107 112

0

100

200

300

400

500

600

700

2012 2013 2014 2015 2016

Fellows

Residents

GME TraineesResidents vs. Fellows

Page 20 of 102

Newest ACGME Accredited Programs

Pediatric Anesthesiology Colorectal Surgery Surgical Oncology Gynecology Oncology Maternal Fetal Medicine Cardiothoracic Anesthesiology Pain medicine (application soon to

be submitted)

8Page 21 of 102

Putting Growth in Context

Wisconsin has 1,888 residency positions, or 32.8 per 100 thousand population.

This compares to the U.S. average of 36.9.

WI Council on Medical Education & Workforce projects a deficit of 2,196 physicians by the year 2030.

9Page 22 of 102

2015-2016 Financial Statement

Stipends/Admin $45,071,872 Affiliation Agreement $ 2,565,625 Total UWHC GME Costs $47,637,497

Hospitals Reimbursements ($12,301,560) Medicare Direct GME ($10,248,767)

Total UWHC GME Expenditure $25,087,170

In addition, Medicare IME reimburses teaching hospitals for higher cost of care associated with training residents.

10Page 23 of 102

Proposed UW Health GME Funding Committee Charge

Understand GME Financing Review Annual GME Budget Establish a vision for GME growth

with the UW Health Strategic Mission and Vision

Conduct a quarterly review of new program and position requests

Approve positions quarterly

11Page 24 of 102

GME Funding Criteria

Strategic Priorities and Alignment Source of Funding Program Quality Academic Merit Recruitment and Retention Clinical Coverage Clinical Service Replacement Costs State and National Needs Budget More….

12Page 25 of 102

ACGME Institutional Oversight

Self Study And Accreditation Visit– Last site visit April 2009– Anticipate next visit in 2023 or later

Clinical Learning Environment Review– CLER Visit every 18-24 months– 6 Focus Areas: Quality, Patient Safety, Care

Transitions, Supervision, Professionalism, and Clinical Experiences/Education and Fatigue Management and Mitigation

– Next visit: April – October 2017

13Page 26 of 102

14

Clinical Learning Environment Improvements

Patient Safety Orientation III Health Disparities and Cultural Competency training Program specific supervision and handoff policies Improved central line training and supervision Maslach Burnout Inventory measurements of PG1s Integration of Residents in Quality and Patient

Safety

– Continued support of Resident Quality and Patient Safety Council and Resident Quality Improvement Symposium

– Resident on every Root Cause Analysis– Increased PSN Reporting– Updating Quality Improvement Curriculum

Page 27 of 102

Faculty and Resident Well-Being

Medical students begin their education more psychologically healthy than their college graduate counterparts.

By residency– 1/3 of trainees may be clinically depressed – 50-70% describe burnout symptoms– 6-12% report suicidal ideation

National physician burnout rate is 50%. Suicide rates for physicians are 2x higher

than those for the general population.

15Page 28 of 102

ACGME Initiatives to Improve Resident Well Being

Surveys assess the problem Access to Counselling/Coaching for

all physicians Wellness Resources

– Fitness Facility– Access to Good Food– Resilience Training– Mindfulness Based Stress Reduction– Social Activities– Mentorship and Support

16Page 29 of 102

2016-17 Action Plan Work with UW Health Leadership to

expand Faculty and Resident Wellness Initiatives

Continued Clinical Learning Environment (CLE) Improvements

Host CLER Visit Consider GME Sponsoring Institution

options Assist in formalizing an approach to GME

Growth Prepare Programs for NAS Site Visits

17Page 30 of 102

Graduate Medical Education2015-2016 Annual Institutional Review

Page 31 of 102

Graduate Medical Education 2639 University Avenue, Suite 201

Madison, WI 53705 Phone: 608-263-0572

E-mail: uwgme@uwhealth.orgUWHealth.org

Page 32 of 102

Executive Summary from Designated Institutional Official

As the UW Health Designated Institutional Official and UW School of Medicine and Public Health Associate Dean for Graduate Medical Education, it is my pleasure to provide this year’s review of our institution’s Graduate Medical Education enterprise. The Accreditation Council of Graduate Medical Education (ACGME) requires that we conduct an Annual Institutional Review (AIR) and provide a written report of this activity to the Medical Staff and the University of Wisconsin Hospitals and Clinics Authority (UWHCA) Board. This report covers activities between July 1, 2015 and June 30, 2016.

The ACGME Next Accreditation System (NAS) extended the period of time between site visits to 10 years but added an institutional Clinical Learning Environment Review (CLER) visit every 18‐24 months and an annual data review of each program. Programs are provided with annual notification of continued accreditation with any concerning trends and citations. The institution and all its programs will undergo a self‐study and site visit every 10 years. We successfully conducted our second CLER visit for the fall of 2015. Our last ACGME institutional site visit was in 2009. At this time we anticipate an institutional site visit sometime after 2022.

The UWHCA, as the sponsoring institution, prides itself on its history of high quality in all of its residency and fellowship programs. The UWHCA sponsors 64 ACGME accredited programs with more than 640 trainees. The 2015‐16 academic year once again presented new and exciting challenges in graduate medical education (GME). Our growth trend continues as UW Health continues to increase in size and scope. Over the past decade the number of trainees in our programs has grown by more than 20%. The requests for new GME programs and positions continue such that we predict an increasing growth trend in GME.

I am delighted to report that the institution and all of our programs have full accreditation in the new ACGME NAS. There are no programs with significant new citations and no programs on probation. Our institutional oversight includes Annual DIO meetings with all core program directors and program coordinators in addition to the Focused and Special Reviews conducted through the Graduate Medical Education Committee (GMEC).

In closing, I would like to thank each and every member of our extended GME community for their hard work and dedication to providing an excellent clinical learning environment for all of our residents and fellows. Our training programs touch the lives of thousands of patients and families each year and our educational mission reaches beyond our hospital to the communities we serve. We are delighted to train outstanding physicians, many of whom will graduate and pursue careers here at UW Health and throughout the State of Wisconsin.

Susan L. Goelzer, M.D., M.S. Professor of Anesthesiology, Internal Medicine and Population Health Sciences Senior Medical Director for GME/Designated Institutional Official Associate Dean for Graduate Medical Education

1

Page 33 of 102

Table of Contents

Executive Summary from Designated Institutional Official.......................................................................... 1

Introduction and Purpose ............................................................................................................................. 3

Summary of 2015-16 Key Institutional Accomplishments ........................................................................... 3

Enrollment Data, Growth Trends, and Financial Statement ........................................................................ 3

GME Office Highlights ................................................................................................................................... 5 GME Office Organizational Chart ..................................................................................................... 7

GME Committees and Subcommittees ........................................................................................................ 8 GMEC ............................................................................................................................................... 8 Strategic Planning Subcommittee ................................................................................................... 9 Program Review Subcommittee ...................................................................................................... 9 Curriculum Review Subcommittee ................................................................................................ 10 Global Health Subcommittee ........................................................................................................ 13 Coordinator Subcommittee ........................................................................................................... 14

Resident Wellness Workgroup ................................................................................................................... 14

Resident Quality Safety Council (RQSC) ...................................................................................................... 15

Review of Institutional and Program Performance Indicators ................................................................... 17 Accreditation Information ............................................................................................................. 18 2016 ACGME Survey Results.......................................................................................................... 22 2016 Recruitment Information ...................................................................................................... 27 Program Director Years of Service ................................................................................................. 28 CLER Performance ......................................................................................................................... 28 Duty Hours Review......................................................................................................................... 30

2015-16 AIR Meeting .................................................................................................................................. 32

2016-17 Action Plan .................................................................................................................................... 33

Appendix A: GME Program Overview Table ............................................................................................... 34 Appendix B: GME Program Directors ......................................................................................................... 35 Appendix C: Scholarly Activity .................................................................................................................... 37 Appendix D: GME Supervision Policy .......................................................................................................... 48 Appendix E: GME Transitions of Care/Handoff Policy ................................................................................ 52 Appendix F: UW Health GME Policies and Statements .............................................................................. 56

Page 34 of 102

Introduction and Purpose

Every fall, the UW Health Graduate Medical Education (GME) Office publishes an Annual Institutional Review (AIR), summarizing the past academic year in graduate medical education. The AIR documents how well programs are performing from an accreditation standpoint and provides a summary of key performance data. It also identifies opportunities for improvement and memorializes an action plan for the upcoming year.

Summary of 2015-16 Key Institutional Accomplishments

The UW Health GME community completed another successful year, during a time of continued accelerated growth and ever evolving ACGME requirements and expectations. Some of this year’s achievements include:

• Continued favorable accreditation status for all 64 programs;• Overall positive ACGME survey results with institutional scores above the national means;• A second successful ACGME Clinical Learning Environment Review (CLER) site visit;• Development and GME Office review of program specific supervision and handoff policies;• Increased resident and fellow reporting into Patient Safety Net (PSN) and participation in

institutional Root Cause Analyses (RCAs);• Two programs, Pediatrics and Radiology, volunteering to participate in the ACMGE’s self‐study

pilot, providing our Institution with early insights to this new process;• Continued development of institutional and program specific metrics and goals, allowing for data

driven identification of improvement opportunities;• Development of policy and process for GMEC approval of new programs and positions, providing

clarity to the process and more rigorous review of such requests;• Baseline measuring of incoming PG1s using the Maslach Burnout Inventory and the creation of a

Resident Wellness workgroup;• Increased sharing of program notable practices across our institution;• March 2016 GME Retreat on how to help an underperforming resident or fellow;• Successful managing of five different orientations to accommodate staggered start dates for

fellowships; and• Continued improvement of our AIR process and institutional action plan development.

Enrollment Data, Growth Trends, and Financial Statement

As an institution, we continue to experience tremendous growth both in terms of size and scope. We now have more than 600 residents and fellows, representing a 20% increase in growth over the past decade.

3

Page 35 of 102

Currently, we have 64 accredited programs, 22 residency and 42 fellowships, with several new program applications and requests for complement increases on the horizon. Additionally, two of our programs participated in the state of Wisconsin’s rural residency multi‐year grant program. For this academic year, state grants funded one General Surgery position and two Psychiatry positions in underserved Wisconsin communities.

Residency Fellowship Total ACGME Accredited Programs 22 42 64 Trainees in ACGME Accredited Programs 498 112 610

0

100

200

300

400

500

600

700

'06 '07 '08 '09 '10 '11 '12 '13 '14 '15 '16

FTEs

Fiscal Year

FY06 - FY16 GME FTEs

UWHCAFunded

Total Funded

454 463 473 492 498

102 101 104 107 112

0

100

200

300

400

500

600

700

2012 2013 2014 2015 2016

GME Trainees - Residents vs. Fellows

Fellows

Residents

4

Page 36 of 102

The training provided to our residents and fellows is rich and varied, serving diverse populations in both urban and rural settings. Nearly thirty percent of our residents’ and fellows’ training occurs at locations outside of the UW Health system, including the William S. Middleton Memorial Veterans Hospital, Beloit Memorial Hospital, and numerous community access and rural health centers, many of which are outside of Dane county.

2015 - 2016 Financial Statement

$ 45,071,872 Stipends, benefits, administration

$ 2,565,625 Funding provided to UWSMPH departments per affiliation agreement

$ 47,637,497 Total GME Costs

$ (12,301,560) Less: Reimbursement from affiliated organizations

$ (10,248,767) Less: Preliminary estimated Medicare reimbursement for direct GME

$ 25,087,170 Total UWHC GME Expenditure

GME Office Highlights

The GME Office coordinates the overall residency education efforts and strives to ensure that we are meeting ACGME institutional and program requirements and supporting the educational mission of our programs. In January 2016, a new GME Program Manager was hired, with a focus on issues related to accreditation and education. This past spring, the GME and Medical Staff Affairs (MSA) offices moved to a new shared office space, allowing the Director of GME and MSA to oversee GME and MSA staff from one location.

In March 2016, the GME Office organized a retreat focused on helping programs manage underperforming residents. Programs learned about UW Health resources available to assist with a resident who may be struggling and how best to handle from a GME‐policy and UW Health legal/HR‐standpoint. There was also a program director panel, where programs shared their experiences in handling these difficult situations and how to provide support to such residents.

Also in March, a comprehensive review of the ACGME Institutional and Common Program Requirements was performed in order to ascertain our compliance with required policies and other statements. A table was created providing reference to all ACGME requirements, our institutional policies, GME Departmental policies, and indicating where program policies are required. This document provides a clear reference for

5

Page 37 of 102

programs to know what policies exist and what policies they should have within their programs. The “UW Health GME Policies and Statements” document is included in Appendix F. Next year the GME Office will include all GME Departmental policies in U‐Connect in addition to MedHub for easier reference.

This past summer the GME Office successfully managed five orientations, up from two sessions in past years, to accommodate the later start dates for fellowships. Once again, the GME Office received high marks from new trainees in terms of quality of service and responsiveness to questions. Major enhancements were made to the New Hire Portal to improve communication, data collection, and work flow. We will continue to enhance the New Hire Portal within MedHub and develop solutions to some of the challenges that arose with respect to state licensing requirements.

As the GME trajectory reflects notable increases in both programs and trainees, it is imperative that the GME Office operates efficiently. Goals must be prioritized to ensure resources are aligned to high‐value, broad impact projects and issues. The GME Office recognizes that many programs are also managing increased numbers of trainees and accreditation requirements. Accordingly, the GME Office is looking for ways to streamline communications to programs, simplify procedures, and reduce reporting burdens. Also planned are improved methods for capturing and maintaining program information necessary for timely reporting, analysis and decision making.

Overall, GME Office relations with Program staff are productive and aligned with shared goals and priorities. However, structural differences between program staff and GME Office staff sometimes impede collaboration and create workflow inefficiencies. The GME Office continues to explore ways to reduce these barriers and promote better collaboration between programs and GME Office staff.

Next year, we plan to:

• implement a yearly check in with program coordinators (similar to the annual DIO meeting for coreprogram directors) in an effort to better understand and support each other’s work;

• provide better clarity to roles and responsibilities between the GME Office and program staff toavoid confusion and duplication of efforts; and

• work with UWSMPH to develop a shared drive for storing resident files which can be accessed byboth the GME Office and programs.

6

Page 38 of 102

Chris Green, MDSVP, Associate CMO

Leigh LarsonDirector, GME and MSA

Susan Goelzer, MDDIO for GME

Linda DonoghueSr Admin Sec

Medical Staff Affairs Graduate Medical Education

Krystal La BrecMSA Specialist

Tami ReesonMSA Specialist

Wendy GarciaSr MSA Specialist

VacantMSA Coordinator

Jordan MinickStudent Help

Amy KasperGME Program Mgr

Accreditation & Innovation

Mary Newton-KelloggGME Program Mgr

Business Operations

Cindy FeulingGME Specialist

Jeanne SarbackerGME Coordinator

Amanda PausGME Specialist

Kara WestmasGME Coordinator

MedHub Administrator

Caroline McCormickTeddy HermbergMorgan Scrobel

Student Help

ACGME Accredited Residents and Fellows

Graduate Medical Education and Medical Staff Affairs

Michele KlausManager

Laura ClementMSA Specialist

Page 39 of 102

GME Committees and Subcommittees

The Graduate Medical Education Committee (GMEC) is a Subcommittee of the UWHC Medical Board. It meets monthly and has the authority and responsibility for monitoring and advising on all aspects of graduate medical education in accordance with ACGME requirements. This year the GMEC was chaired by Art Walaszek, MD, Psychiatry Residency Program Director. Its membership includes program directors, Subcommittee chairs, resident representatives, the DIO, GME staff and program coordinators.

The GMEC is responsible for review and approval of GME policies. Several new policies were approved during the 2015‐16 year.

GMEC Approval Date Policy Title July 15, 2015 Stipend Administration for GME Trainees September 16, 2015 Annual Institutional Review (AIR) November 18, 2015 Transitions of Care/Handoff Policy November 18, 2015 Supervision of Residents November 18, 2015 Evaluation of Residents and Faculty December 16, 2015 Academic Improvement and Corrective Action December 16, 2015 Appeals of Resident Corrective Actions April 20, 2016 Promotion of Residents

The GMEC is responsible for review and approval of new programs and complement changes. Below is a summary of new program applications and complement increases that received GMEC approval. Funding decisions for new positions are outside the scope of GMEC and are determined by UW Health leadership.

2015‐2016 GMEC‐approved New Programs and Position Increases

• Adult Cardiothoracic Anesthesiology Fellowship – 2 FTE• Advanced Heart Failure and Transplant Cardiology Fellowship (Internal Medicine) – 1 FTE• Colon and Rectal Surgery Fellowship – 1 FTE• Gynecologic Oncology Fellowship (Obstetrics & Gynecology) – 3 FTE• Maternal‐Fetal Medicine Fellowship (Obstetrics & Gynecology) – 3 FTE• Neurological Surgery Residency – 7 FTE

Additional GMEC Requests on the Horizon

• Transplant Hepatology Fellowship (Medicine) – 1 FTE• Interventional Radiology‐Integrated Residency (Radiology) – 5 FTE• Neuroradiology Fellowship (Radiology) – 1 FTE• Pain Medicine (Physical Medicine & Rehabilitation) – 2 FTE• Emergency Medicine Services Fellowship• Epilepsy Fellowship (Neurology)• Female Pelvic Medicine & Reconstructive Surgery Fellowship (Obstetrics & Gynecology)• Pediatric Cardiology Fellowship• Pediatric Gastroenterology Fellowship

8

Page 40 of 102

• Pediatric Rheumatology Fellowship• Rheumatology Fellowship

The GMEC is responsible for overseeing the quality of the learning and working environment for the institution. The oversight powers of the GMEC are augmented by the below GMEC Subcommittees.

Strategic Planning Subcommittee

The Strategic Planning Subcommittee assists the GMEC with broad vision and strategic direction, including oversight of action plans developed from Annual Institutional Review (AIR) meetings. It provides counsel on prioritizing funding of new positions and programs. This year the Subcommittee served as a sounding board for the DIO and program directors that are members of the UW Health Funds Flow Education Committee, which is charged with bringing greater transparency to the cost of graduate medical education.

Strategic Planning Subcommittee Membership: Dr. Susan Goelzer (Chair), Dr. Eugene Foley, Dr. John Frohna, Amy Kasper, Dr. Paul Kranner, Leigh Larson, Dr. Jessica Robbins, Denise Mussehl, Dr. Bennett Vogelman, Dr. Art Walaszek, and Dr. Mary Westergaard.

Program Review Subcommittee

The Program Review Subcommittee oversees and schedules Focused and Special reviews of programs – two of the main ways the GMEC exercises oversight of programs. Special reviews are in‐depth in nature and include interviews with the program director, coordinator, faculty and residents and an extensive administrative review of program policies and procedures. In contrast, Focused reviews are briefer and only include an interview of the program director and coordinator.

This year the Subcommittee provided clarification to the criteria that triggers a Special versus Focused review and is in the process of updating the Special review checklist. In addition, it is developing a guide for reviewers new to the Focused review process.

The Program Review Subcommittee updated the Annual Program Evaluation (APE) template, in an effort to make the template clearer and remove reporting redundancies. APEs are a requirement of the ACGME and require programs to monitor and track: (1) resident performance, (2) faculty development, (3) graduate performance, and (4) program quality.

2015-2016 Focused and Special Reviews Rationale for Review

Emergency Medicine Focused Review New Program Director Infectious Disease (Medicine Fellowship) Focused Review

New Program Director

Orthopedic Surgery Focused Review New Program Director Otolaryngology Focused Review New Program Director Pathology Focused Review New Program Director Pediatrics Special Review Completion of a Self‐Study Psychiatry/Addiction Focused Review New Program Director Psychiatry/Geriatric Focused Review New Program Director Vascular Neurology Focused Review New Program Director

9

Page 41 of 102

The Program Review Subcommittee provided input on new program application requirements, in order to provide clarity to roles and responsibilities for review of draft applications, including review of subspecialty applications by the core program director and core program coordinator.

One important new element of the ACGME Next Accreditation System (NAS) is the self‐study visit, which is intended to foster a climate of continuous quality improvement. Two of our programs, Pediatrics and Radiology, volunteered to participate in ACGME’s pilot of this new process. A goal for the Program Review Subcommittee in the coming year will be to learn from Pediatrics’ and Radiology’s experience and assess how best to assist programs with upcoming self‐studies and 10‐year site visits.

Program Review Subcommittee Membership: Dr. Jessica Robbins (Co‐Chair), Amy Kasper (Co‐Chair), Robert McDonald, Dr. John Frohna, Jeanne Sarbacker, Dr. Holly Caretta‐Weyer (Resident), Dr. Paul Kranner, Denise Mussehl, Ian Todaro, Dr. Art Walaszek, and Kara Westmas.

Curriculum Subcommittee

The Curriculum Subcommittee oversees the development of centralized curriculum to meet ACGME requirements and programs’ educational needs. It is also responsible for serving as an information hub of notable education practices across programs. This year the GMEC began dedicating time during monthly meetings for program faculty and education professionals to share best practices. The Curriculum Subcommittee then compiles the information shared at GMEC into a newsletter for later distribution to the entire UW Health GME community. The first issue was distributed this past summer and highlighted notable practices from Ophthalmology, Internal Medicine, Obstetrics and Gynecology, Nephrology, and Pulmonary Critical Care Medicine. The initial feedback of this bi‐yearly newsletter was positive and serves as another way to increase knowledge sharing across programs.

The Subcommittee assists in leveraging institutional resources to meet program aims. For example, this year the Subcommittee focused on how to deliver more data to residents about their practice habits and clinical effectiveness. The Subcommittee also provides broad oversight and input to the below educational curriculums.

GME Orientation

Professional organizations now recommend that institutions delay start dates of subspecialty programs to allow more time for fellows to transition from their previous residency. To accommodate this change, five different orientations were scheduled over the summer of 2016, placing an extraordinary new burden on the GME Office and the demands of in‐person presentations at orientation. In all, there were 47 in–person presentations given to 198 new trainees.

This year, for the first time, we had a presentation dedicated to the topic of healthcare disparities, which was extremely well received. Additionally, the Patient Safety, Quality Improvement and Infection Control departments worked together to create a case‐based presentation that incorporated the use of an Audience Response System, an application used to engage a large audience.

One benefit to having multiple orientations for the subspecialties is that presenters were able to tailor information specifically to the audience, providing a richer learning experience. Overall feedback from GME

10

Page 42 of 102

Orientation was overwhelmingly positive. We are fortunate to have dedicated representatives from across UW Health devoting energy towards thoughtfully orienting new residents and fellows.

Patient Safety Orientation

In January 2016, a workgroup of the Curriculum Subcommittee executed the second annual Patient Safety Orientation for first year residents, led by Dr. Tosha Wetterneck, Medical Director of Patient Safety. The half‐day orientation included a large group didactic session with a focus on near misses and other important terminology, patient safety from a systems perspective, a brief demo of the Patient Safety Net (PSN), and an opportunity for residents to enter an actual safety event. Afterward, residents were broken into small groups to conduct a Root Cause Analysis (RCA), led by a faculty member, Quality Improvement analyst or Risk Management consultant and a senior resident.

Since implementing this annual Patient Safety Orientation, we have seen an increase in the events reported by physicians and residents.

4 5 6 10 18

9

43

15 13 18

7 10

010203040506070

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun# Ev

ents

Rep

orte

d

Resident PSN Reporting - Fiscal Year 2015-16 (n=154, 1.7%)

2016 Near Miss PSN Training for residents (35 real events reported during training)

69 86 87

167

113

61 68 76

154 124

0

50

100

150

200

CY12 (n=7609,Resident

Volume=0.8%,Attending

Volume=0.9%)

CY13 (n=7793,Resident

Volume=0.9%,Attending

Volume=1.1%)

CY14 (n=9101,Resident

Volume= 0.8%,Attending

Volume= 1.0%)

CY15 (n=9296,Resident

Volume=1.7%,Attending

Volume=1.8%)

Jan-Jul'16(n=6076, Resident

Volume=2.0%,Attending

Volume=1.9%)

Attending ResidentUW Health Physician/Resident PSN Event Reporting Volume

11

Page 43 of 102

This year, we began tracking PSN events submitted by service, which should help in identifying areas for further investigation. Programs will be provided this information at their annual DIO meeting, providing another tool to assess awareness of the PSN system and barriers to reporting safety events.

GME Quality Improvement and Patient Safety Curriculum

In 2011, a workgroup of the Curriculum Subcommittee created the GME Quality Improvement and Patient Safety Curriculum and administered it to a subset of the first year residents. By 2012, all new PG1s completed the curriculum, supplemented with material from the Institute for Healthcare Improvement (IHI). This past year, all new incoming trainees, including fellows, completed this foundational quality improvement and patient safety learning.

Feedback about the curriculum has called attention to reduce redundancy in the information provided through this curriculum and in‐person presentations at GME Orientation as well as providing more updated information and institution‐specific information. In response to this feedback, an interdisciplinary workgroup of the Curriculum Subcommittee will evaluate and revise the GME Quality Improvement and Patient Safety Curriculum for this coming year.

Curriculum Subcommittee Membership: Dr. Daniel Sklansky (Co‐Chair), Amy Kasper (Co‐Chair), Dr. William Aughenbaugh, Dr. Holly Caretta‐Weyer (Resident), Dr. Anne‐Lise D’Angelo (Resident), Jan Haedt, Barbara Lewis, Robert McDonald, Amy Zelenski, Ian Todaro, Dr. Janis Tupesis, Dr. Bonnie Weigert, and Kara Westmas.

UW Health Central Venous Catheter Curriculum

The UW Health Central Line Training Oversight Committee is responsible for overseeing a standardized training process for central line insertion, replacement, removal and maintenance. Led by Dr. Scott Hagen, the Committee also ensures alignment to institutional goals and UW Health policies and protocols related to central lines.

A major accomplishment for the Committee this year was updating and streamlining the existing on‐line curriculum. The updated on‐line curriculum includes a test of 20 questions. Trainees are required to answer correctly at least 75% of the questions, prior to proceeding to the simulation portion of the training. Amongst the first group of new trainees to complete this updated curriculum, only a handful did not meet this requirement on the first attempt.

The overall feedback of the updated curriculum has been positive. We greatly appreciate the efforts by program directors, program coordinators, faculty members, and the Simulation Center in supporting this opportunity for residents and fellows to practice

this procedure in a zero risk environment. Twenty programs, 100 residents and fellows, and 42 faculty

Dr. Scott Hagen, Chair of the Central Line Training Oversight Committee instructs Pediatric Critical Care fellows on central lines.

12

Page 44 of 102

members participated in this year’s training. A major goal for next year will be the finalization of a GME policy related to competency certification for those residents and fellows seeking the ability to place, replace, or remove a central line under indirect supervision.

Central Line Training Oversight Committee Membership: Dr. Scott Hagen (Chair), Deb Ankowicz, Beth Brace, Ashley Buys, Krystle Campbell, Betsy Clough, Dr. Sara Damewood, Dr. Anne‐Lise D’Angelo, Wendy Garcia, Dr. Walter Kao, Amy Kasper, Leigh Larson, Dr. Laura Maursetter, Mary O’Connell, Dr. Doris Ockert, Dr. Ann O’Rourke, Dr. Carla Pugh, Cindy Schmitz, Dr. David Sonetti, Ian Todaro, Dr. Jeffrey Pothof, Chad Warner, Kara Westmas, and Emily Wilhelmson.

Global Health Subcommittee

GMEC began its Global Health programs during the 2009‐2010 academic year. At that time, it undertook an innovative approach to the development and implementation of a multi‐disciplinary program, allocating 2.0 FTEs/104 weeks of clinical time per academic year to trainees seeking clinical rotations in resource limited settings. Residents and fellows from 19 different residency and fellowship programs have participated in the program since 2010.

Global Health residents have provided clinical care, educational interchange and administrative support to 21 countries, including: Belize, Botswana, Dominican Republic, Ecuador, Ethiopia, Cambodia, Germany, Ghana, Guatemala, Haiti, Honduras, India, Kenya, Liberia, Nepal, Nicaragua, South Africa, South Korea, Uganda, Vietnam and Zambia. Approved clinical rotations in the upcoming 2016‐17 academic year include: South Africa, Uganda, India, Honduras, Thailand and Ethiopia.

Global Health Subcommittee Membership: Dr. Janis Tupesis (Chair), Dr. Cynthe Anderson, Dr. William Aughenbaugh, Dr. Michael Bentz, Dr. Cat Burkat, Dr. Sabrina Butteris, Dr. Suresh Chandra, Dr. Jim Conway, Dr. Doug Dulli, Dr. David Gaus, Dr. Scott Mead, Dr. Deb

48 43 54 63 74 98

0

50

100

150

2010-11 2011-12 2012-13 2013-14 2014-15 2015-16

Global Health Elective Weeks

Elective Weeks

Left to right: Katie Schwartz, Pimkwan Jaru-Ampornpan, MD, Daniel Knoch, MD, Ashley Lundin, MD and Andrew Thliveris, MD, Ophthalmology Program Director

13

Page 45 of 102

McLeish, Dr. Delora Mount, Dr. Kenneth Kushner, Amanda Paus, Dr. Heather Peto, Dr. Erica Riedesel, Dr. Deborah Rusy, Dr. Jessica Schmidt, and Dr. Girma Tefera.

Coordinator Subcommittee

The Coordinator Subcommittee brings together coordinators from all GME programs and meets monthly to discuss administrative issues. Additionally, the Subcommittee has a steering committee that oversees the following workgroups: MedHub, Mentoring, Social and Recognition. This year, the Steering Committee was chaired by Carrie Schaub, program coordinator for Otolaryngology.

A large part of the Committee’s work is focused on coordinator professional development. This year, there were many coordinator‐led presentations and discussions.

2015-16 Coordinator Professional Development

August 2015 Common Program Requirements/Milestones Project

Coordinator Meeting, led by Jami Simpson, Allergy and Immunology Program Coordinator

September 2015 Understanding the ACGME Program requirements

Coordinator Meeting, led by Beth Brace, Program Coordinator for Cardiovascular Medicine Fellowship Programs

January 2016 MedHub Procedure Functionality: How does your program use the system

Brown Bag Presentation, led by Beth Brace, Program Coordinator for Cardiovascular Medicine Fellowship Programs

January 2016 ACGME Faculty/Resident Survey Coordinator Meeting Ian Todaro

February 2016 Common Program Requirement/PEC and APE

Coordinator Meeting, led by Beth Brace, Program Coordinator for Cardiovascular Medicine Fellowship Programs

March 2016 Alumni Tracking & Networking Brown Bag Presentation, led by Carrie Schaub, Otolaryngology Program Coordinator

April 2016 Conference Attendance Tracking with Code Readr

Coordinator Meeting, led by Erica White, Orthopedic Surgery Program Coordinator

April 2016 Smorgasbord of ACGME conference information, including

Coordinator Meeting, led by Ian Todaro, Internal Medicine Fellowship Coordinator

May 2016 MedHub: Rotation Scheduling Brown Bag Presentation, led by Pam Adams, Surgery Program Coordinator, and Amy Romandine, Radiology Program Coordinator

June 2016 Assisting Trainees to Study for the Boards

Brown Bag Presentation, led by Jami Simpson, Allergy and Immunology Program Coordinator

June 2016 Improving Fellow Participation in Feedback: A New CCC Model

Brown Bag Presentation, led by Samantha Strennen, Nephrology Program Coordinator, and Ian Todaro, Internal Medicine Fellowship Coordinator

Resident Wellness Workgroup

UW Health is committed to ensuring residents and fellows remain physically and mentally healthy during their training. As part of our commitment to resident wellness and in light of the recent national dialogue on physician well‐being, a workgroup was formed to increase awareness of the stress of residency among

14

Page 46 of 102

stakeholders, including program directors, faculty, program coordinators, and UW Health leadership. This year all PG1s were asked to complete the Maslach Burnout Inventory (MBI), in order to collect a baseline burnout measurement. In total, 118 new PG1s completed the MBI. Results are currently being analyzed and a second measurement will be taken in January 2017.

Goals for this next year include: formalizing the wellness workgroup into an official Subcommittee of GMEC, assessing MBI results, identifying resources that match resident needs, and continuing to inventory program‐level wellness initiatives. In addition, the workgroup will monitor the ACGME’s physician well‐being initiative to assure institutional alignment with any new ACGME requirements and priorities.

Resident Wellness Workgroup Membership: Dr. Art Walaszek (co‐chair), Amy Kasper (co‐chair), Pam Adams, Dr. Kristin Bradley, Dr. R. Roni Chauhan, Saby Cordoba, Dr. Kimberly Hamilton, Dr. Ellen Hartenbach, Dr. Stuart Jones, Dr. Caroline Kieserman–Shmokler, Leigh Larson, Dr. Janessa Lawhorn, Dr. Kari Obma, Dr. Beth Potter, Dr. Mariah Quinn, Dr. Jessica Robbins, Susan Trier, Dr. Mary Westergaard, Kara Westmas and Amy Zelenski, PhD.

Resident Quality Safety Council (RQSC)

Residents play a key role in patient care. As trainees, they spend countless hours in the hospital and have unique insights into issues they observe. Yet, as the junior‐most members of the medical team, they are not always optimally involved in efforts to improve care. The RQSC is a venue to promote resident engagement with quality and safety efforts and includes representatives from every program. This year the RQSC contributed to projects on reducing Emergency Department procedure timings, central‐line associated bloodstream infections (CLABSI) reduction, improving the consult process, decreasing fatigue and recognizing important drug allergy alerts, avoiding and reporting workplace hazards, increasing resident participation in PSNs, and disseminating and providing feedback on work towards reducing hospital acquired infections (HAIs). RQSC members also participated in a number of UW Health committees, including the Capacity Management Taskforce, Patient Safety and Quality Committee, GMEC, Health Care Evaluation Team (HEET), the RCA Subcommittee, Continuity of Care, Health Link Order Entry Errors, and Intern Safety Orientation Planning Committee.

On April 14, 2016, the RQSC also held its Annual Resident and Student Quality Improvement Symposium. This year’s keynote speaker was Professor Pascale Carayon, a world leader in patient safety and quality improvement innovation. Now in its third year, the symposium included over 20 quality improvement posters. Awards were given for the following three posters:

“Best QI Project Overall” ‐ Screening patients for sleep disordered breathing in an outpatient mental health setting, Shane Creado, MD, Psychiatry PG4;

Left to right: Dr. Peter Kleinschmidt, RQSC Vice-Chair, and Dr. Shashank Ravi, RQSC Chair

15

Page 47 of 102

“Best project that aligns with UW Health Quality Goals” ‐ Decreasing ED Throughput Time for Children with Appendicitis, Christopher Ford, MD, Emergency Medicine PG2; and

“Best QI Project in Progress” ‐ Standardized Airway Management Documentation, Molly Groose, MD, Anesthesiology PG4; Robert Jenkinson, MD, Anesthesiology PG4.

RQSC Membership: Drs. Shashank Ravi (Chair), Peter Kleinschmidt (Vice‐Chair), Hayley Barnes, Poonam Beniwal‐Patel, Larry Bodden, Jocelyn Burke, Katie Cannon, Erin Cheers, Brian Christie, John Coburn, Anne‐Lise D'Angelo, Kristin Eastman, Jamie Elliott, Rachael Ellis, Matthew Fischer, Patrice Grzebielski, Ross Harrison, Sara Heintzman, Jackie Israel, Brett Johnson, Larry Kim, Ian Koszewski, Erin Krizman, Jason Lai, Yiping Li, Amy Lim, Benjamin Lipanot, Michele Luhm Vigor, Christopher McAninch, Kevin McCool, John Meister, Christina Papageorge, Danielle Ries de Chaffin, Alex Ringeisen, Andrew Rogers, Patrick Rush, Andrew Schemmel, Ryan Schmocker, Leah Schuppener, Amanda Smolock, Kaitlin Sundling,

Sarah Tevis, Jessica Tischendorf, Ashley Turner, Matthew Tyl, Andrzej Wojcieszynski, Jill Zabih. Patient & Family Advisors: Mary Baliker and Kristine Wiese.

Residents and Fellows present quality improvement posters at the 2016 Annual Resident and Student Quality Improvement Symposium.

16

Page 48 of 102

Review of Institutional and Program Performance IndicatorsOverall, our residents and fellows are provided an exceptional clinical learning environment in which to train. All programs have either initial or continued accreditation status, and trainees’ and faculty’s perceptions of the educational environment through annual ACGME surveys are generally positive, tracking or exceeding national norms.

The GMEC assesses institutional and program performance through a variety of performance indicators, including:

• Accreditation (accreditation status, citations, results of site visits);• ACGME Resident and Faculty Survey Results;• Program Director tenure;• Recruitment information;• Graduate information;• CLER performance;• Review of Duty Hours/Moonlighting reports; and• Review of Scholarly Activity (see Appendix C)

In addition, the DIO conducts Annual Program Review meetings with core program directors and program coordinators to review the core and subspecialty APEs, assess progress on the previous year’s goals, and establish an action plan for the coming year. The Annual Program Review process, in conjunction with Special and Focused program reviews constitute the primary institutional oversight processes.

2015-16 Annual Program Meeting with Designated Institutional Official Core Program Meeting Date Anesthesiology January 6, 2016 Dermatology December 7, 2015 Emergency Medicine September 9, 2015 Medicine September 30, 2015 Neurology November 23, 2015 Neurosurgery November 4, 2015 Obstetrics and Gynecology September 2, 2015 Ophthalmology December 15, 2015 Otolaryngology December 9, 2015 Pathology November 30, 2015 Pediatrics December 22, 2015 Physical Medicine and Rehabilitation November 16, 2015 Preventive Medicine October 26, 2015 Psychiatry August 5, 2015 Radiation Oncology November 11, 2015 Radiology & Nuclear Medicine October 6, 2015 Surgery November 24, 2015 Urology November 11, 2015 Vascular Surgery January 12, 2016

17

Page 49 of 102

Many more performance indicators could be compiled and additional review mechanisms created. We will continue to study which indicators and processes are most relevant for accurately assessing performance and maintaining robust institutional oversight. Plans are already in the works on the development of additional performance indicators, addressing inaccuracies and improving data collection methods.

Below is a summary of some of the above performance indicators, along with supporting tables. More detailed information can be requested by contacting the UW Health GME Office.

Accreditation Information

As an institution, we continue to operate under Continued Accreditation status. In July of 2013, we received the NAS accreditation letter from the ACGME, notifying us that our next regularly scheduled institutional site visit would be a self‐study site visit, tentatively scheduled for October 1, 2023.

The majority of our programs fall under the Continued Accreditation category. Four newer programs have Initial Accreditation status: Advanced Heart Failure & Transplant Cardiology, Child Neurology, Preventive Medicine, and Surgical Critical Care. Programs continue to receive letters of notification from their Review Committees issuing new citations and outlining citations that have been resolved. It is an institutional goal to have zero citations, and 48 of our 64 programs have met that goal.

The requirements of the new ACGME Next Accreditation System (NAS) place increasing demands on our programs and on the sponsoring institution. Under the NAS, programs in good standing are given a roughly ten‐year accreditation cycle. Among the UWHCA’s 64 ACGME‐accredited programs 62 are now scheduled to have their site visits under the new system. UW Health has developed a reputation of sponsoring high quality residencies and fellowships. To advance this reputation, we must maintain effective mechanisms for oversight in NAS with its prolonged accreditation cycles.

PROGRAM ACCREDITATION DATA Residency Fellowship Total

ACGME Accredited Programs 22 42 64

Trainees in ACGME Accredited Programs 498 112 610

ACTIVITIES Residency Fellowship Total

Program Director Changes 0 6 6 Special or Focused Reviews Conducted 5 4 9

PROGRAM ACCREDITATION DECISIONS Program ACGME Decision Site Visit Date Advanced Heart Failure & Transplant Cardiology Initial to Continued Accreditation 9/24/15 Child Neurology Initial to Continued Accreditation 9/23/15

Complex General Surgical Oncology Accreditation Withheld 9/22/15

Epilepsy Accreditation Withheld n/a

Preventive Medicine Initial to Continued Accreditation 3/30/16

Surgical Critical Care Pending 6/7/17

18

Page 50 of 102

ACGME ACCREDITATION LETTERS Program Citations-New Citations-

Active/Extended Citations-Resolved

Citations-Removed*

Anesthesiology Critical Care Medicine 1 Pediatric Anesthesiology 1 Dermatology 2

Micrographic Surgery & Dermatologic Oncology

Emergency Medicine 1 Internal Medicine 5 Allergy & Immunology 1 Cardiovascular Disease 4 Advanced Heart Failure & Transplant

Cardiology Clinical Cardiac Electrophysiology 2 Interventional Cardiology 2 Endocrinology 1 Gastroenterology 1 Geriatric Medicine 1 Hematology & Oncology 1 Hospice and Palliative Medicine 2 Infectious Disease 1 Nephrology 3 Pulmonary/Critical Care 1 Rheumatology 2 Sleep Medicine 1 Transplant Hepatology 1 Neurology 3 Child Neurology 1 1 Clinical Neurophysiology 3 Vascular Neurology Neurological Surgery 1 1 2 Nuclear Medicine 4 Obstetrics & Gynecology Ophthalmology 5 Orthopedic Surgery Orthopedic Sports Medicine 1 Otolaryngology 2 Pathology Blood Banking/Transfusion Medicine 8 Cytopathology Hematopathology 2 Pediatrics 3 Critical Care Medicine 1 Endocrinology Hematology/Oncology 2 Infectious Disease 1 1 2 Medical Genetics Neonatal‐Perinatal Medicine 3 Pulmonology 6 Sports Medicine 3 Physical Medicine & Rehabilitation 2 Plastic Surgery Preventive Medicine 1 Psychiatry 1 Addiction Psychiatry 2

19

Page 51 of 102

Program Citations-New Citations-Active/Extended

Citations-Resolved

Citations-Removed*

Child & Adolescent Psychiatry 6 Geriatric Psychiatry 1 Radiation Oncology 3 Radiology 5 Neuroradiology 2 Vascular & Interventional Surgery 1 Surgical Critical Care Thoracic Surgery 3 Vascular Surgery‐Integrated Vascular Surgery 1 Urology

GRAND TOTAL 4 37 23 54

*As part of the transition to the NAS, Residency Review Committees removed citations for programs that have undergone two annual reviews in NAS with no new or extended citations as a result of those reviews.

OTHER: Neurological Surgery – 88 duty hour exception approved.

PROGRAM SPECIFIC CITATION CATEGORY SUMMARY Citation Category Number of Citations Specialties/Subspecialty Receiving Citation

Institutional Support Institutional Support‐Sponsoring Institution 3 Dermatology, Neurology, Ophthalmology Resident Appointment Resident Appointment Issues 2 Nuclear Medicine, Physical Medicine & Rehabilitation Program Personnel & Resources Qualifications of Program Director 1 Pediatric Anesthesiology Responsibilities of Program Director 6 Nuclear Medicine, Physical Medicine & Rehabilitation, Child & Adolescent

Psychiatry, Geriatric Psychiatry, Radiation Oncology‐2 citations Qualifications of Faculty 2 Pediatric Infectious Diseases, Child & Adolescent Psychiatry Responsibilities of Faculty 1 Child & Adolescent Psychiatry Resources 1 Hematopathology The Education Program ACGME Competencies 1 Clinical Neurophysiology Patient Care 2 Neurological Surgery, Ophthalmology Practice‐based Learning & Improvement 1 Clinical Neurophysiology Educational Program‐Patient Care Experience 3 Neurology, Psychiatry, Radiation Oncology Educational Program‐Procedural Experience 3 Hematopathology, Nuclear Medicine‐2 citations Service to Education Imbalance 1 Child & Adolescent Psychiatry Scholarly Activities 1 Child & Adolescent Psychiatry Moonlighting 1 Ophthalmology Evaluation Evaluation of Residents 2 Addiction Psychiatry, Anesthesiology Critical Care Evaluation of Patient Care 1 Neurological Surgery Evaluation of Faculty 1 Ophthalmology Evaluation of Program 4 Child Neurology, Neurology, Ophthalmology, Child & Adolescent Psychiatry Performance on Board Exams 1 Clinical Neurophysiology Citations with Non-Reporting Category Code Educational Program/Goals and Objectives 1 Dermatology Educational Program/Competency‐Based Goals & Objectives for Each Assignment

1 Pediatric Infectious Disease

Educational Program/Curriculum/Resident Experiences/Neuropsychiatry

1 Addiction Psychiatry

20

Page 52 of 102

PROGRAMS WITHOUT CITATIONS Anesthesiology Pathology Micrographic Surgery & Dermatologic Oncology Blood Banking/Transfusion Medicine Emergency Medicine Cytopathology Internal Medicine Hematopathology Allergy & Immunology Pediatrics Cardiovascular Disease Pediatric Critical Care Medicine Advanced Heart Failure & Transplant Cardiology Pediatric Endocrinology Clinical Cardiac Electrophysiology Pediatric Hematology/Oncology Interventional Cardiology Medical Genetics Endocrinology, Diabetes & Metabolism Neonatal‐Perinatal Medicine Gastroenterology Pediatric Pulmonology Geriatric Medicine Pediatric Sports Medicine Hematology & Medical Oncology Plastic Surgery Hospice & Palliative Medicine Preventive Medicine Infectious Disease Radiology Nephrology Neuroradiology Pulmonary Disease & Critical Care Medicine Vascular & Interventional Radiology Rheumatology Surgery Sleep Medicine Surgical Critical Care Transplant Hepatology Thoracic Surgery Vascular Neurology Vascular Surgery‐Integrated Obstetrics and Gynecology Vascular Surgery Orthopedic Surgery Urology Otolaryngology

Data excerpted from ACGME Web Accreditation Data System as of June 30, 2016.

21

Page 53 of 102

2016 ACGME Resident Survey - UW Health Cross Program Dashboard

Prog

ram

2016

Nat

iona

l Mea

n - R

esid

ent S

urve

y

2016

Per

cent

Com

plia

nt N

atio

nally

Perc

ent G

reen

Perc

ent Y

ello

w

Perc

ent R

ed

Alle

rgy

and

Imm

unol

ogy

Anes

thes

iolo

gy

Derm

atol

ogy

Emer

genc

y M

edic

ine

Inte

rnal

Med

icin

e

Card

iova

scul

ar D

isea

se

Endo

crin

olog

y, D

iabe

tes,

Met

abol

ism

Gast

roen

tero

logy

Hem

atol

ogy

and

Onc

olog

y

Hosp

ice

and

Palli

ativ

e M

edic

ine

Infe

ctio

us D

isea

se

Nep

hrol

ogy

Pulm

onar

y Di

seas

e an

d Cr

itica

l Car

e M

edic

ine

Ner

olog

ical

Sur

gery

Neu

rolo

gy

Obs

tetr

ics a

nd G

ynec

olog

y

Oph

thal

mol

ogy

Ort

hope

dic

Surg

ery

Oto

lary

ngol

ogy

Path

olog

y

Pedi

atric

s

Pedi

atric

Crit

ical

Car

e M

edic

ine

Pedi

atric

Hem

atol

ogy/

Onc

olog

y

Phys

ical

Med

icin

e an

d Re

habi

litat

ion

Plas

tic S

urge

ry

Prev

entiv

e M

edic

ine

Psyc

hiat

ry

Radi

olog

y

Neu

rora

diol

ogy

Radi

atio

n O

ncol

ogy

Surg

ery

Uro

logy

Vasc

ular

Sur

gery

4.7 94% 88% 9% 3% 5.0 4.9 5.0 5.0 5.0 5.0 5.0 5.0 4.9 5.0 4.8 5.0 5.0 5.0 4.3 4.2 5.0 4.8 4.7 4.8 4.6 4.7 4.8 5.0 4.5 5.0 4.5 4.8 5.0 4.7 3.6 4.8 4.24.8 97% 91% 9% 0% 5.0 4.9 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.7 5.0 5.0 4.5 4.3 5.0 4.7 4.8 4.9 4.7 5.0 4.8 5.0 4.8 5.0 4.7 4.8 5.0 5.0 4.4 5.0 4.45.0 99% 100% 0% 0% 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.8 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.9 5.0 5.0 4.9 5.0 5.05.0 99% 100% 0% 0% 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.9 5.0 4.8 5.0 4.9 5.0 5.0 4.9 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.6 5.0 5.04.7 97% 92% 8% 0% 5.0 5.0 4.8 5.0 4.8 4.9 4.9 5.0 4.8 4.3 5.0 4.4 4.6 5.0 4.8 4.7 5.0 4.5 5.0 5.0 4.7 4.5 5.0 4.7 4.74.8 97% 92% 8% 0% 5.0 5.0 4.9 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.6 4.4 4.7 5.0 5.0 5.0 4.3 4.8 5.0 5.0 4.9 5.0 5.0 5.0 5.0

Patients' needs NA NA NA NA 0% 0% 0% 3% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 18% 11% 0% 12% 0% 0% 5% 0% 0% 0% 19% 0% 11% 3% 0% 0% 32% 0% 20%Paperwork or admin work NA NA NA NA 0% 6% 0% 3% 0% 0% 0% 0% 0% 0% 0% 17% 0% 0% 18% 26% 0% 12% 0% 0% 7% 0% 0% 0% 13% 0% 15% 6% 0% 0% 36% 0% 20%

Educational experience NA NA NA NA 0% 2% 0% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 11% 0% 8% 0% 0% 0% 0% 0% 0% 6% 0% 0% 0% 0% 0% 18% 0% 20%Cover for someone else NA NA NA NA 0% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 9% 26% 0% 0% 0% 0% 2% 0% 0% 0% 0% 0% 15% 6% 0% 0% 7% 0% 0%

Night-float NA NA NA NA 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 11% 0% 4% 0% 0% 0% 0% 0% 0% 6% 0% 7% 3% 0% 0% 21% 0% 0%Schedule conflict NA NA NA NA 0% 0% 0% 3% 0% 0% 0% 0% 0% 0% 0% 17% 0% 0% 0% 11% 0% 0% 0% 0% 0% 0% 0% 0% 13% 0% 7% 3% 0% 0% 25% 0% 20%

Other NA NA NA NA 0% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 9% 5% 0% 0% 0% 0% 0% 0% 0% 0% 6% 0% 4% 0% 0% 0% 21% 0% 0%4.3 92% 73% 27% 0% 4.6 4.8 4.3 4.8 4.9 4.5 4.5 4.8 4.7 4.8 4.8 4.2 4.6 4.9 4.2 4.6 4.9 4.5 4.5 4.1 4.4 4.3 4.5 4.8 4.9 4.8 4.0 4.5 4.8 4.9 4.3 4.9 4.24.6 96% 94% 6% 0% 5.0 4.9 4.9 4.9 5.0 4.8 5.0 5.0 5.0 5.0 5.0 4.5 4.9 5.0 4.6 4.7 4.9 4.8 4.8 4.7 4.7 4.3 4.8 5.0 4.9 5.0 4.3 4.7 5.0 5.0 4.5 4.9 4.84.2 85% 61% 33% 6% 4.8 4.7 4.3 4.7 4.9 4.5 4.8 4.9 4.6 4.3 4.5 4.0 4.6 4.9 4.3 4.4 4.9 4.3 4.5 3.9 4.3 4.2 4.5 4.5 4.8 4.5 3.7 4.4 5.0 4.9 4.0 4.8 4.04.3 85% 73% 24% 3% 4.8 4.6 4.5 4.9 4.9 4.4 4.8 4.9 4.6 4.5 4.8 4.2 4.7 4.8 4.5 4.6 4.7 4.1 4.5 4.1 4.6 4.2 4.8 4.9 4.9 4.8 3.9 4.2 4.8 4.9 4.1 4.7 4.44.1 79% 61% 30% 9% 4.8 4.7 4.4 4.9 4.9 4.4 4.7 4.8 4.6 4.5 4.5 4.2 4.6 4.9 4.5 4.1 4.4 4.2 4.8 3.9 4.3 3.7 4.8 4.9 4.9 4.8 3.6 4.2 4.8 4.6 4.2 4.7 4.24.9 99% 97% 3% 0% 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.3 5.0 5.0 5.0 5.0 5.0 4.9 5.0 5.0 5.0 5.0 5.04.9 99% 97% 0% 3% 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 2.3 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.04.3 85% 55% 39% 6% 4.0 4.9 4.5 4.4 4.9 4.4 4.5 5.0 4.4 4.8 4.5 4.0 4.6 4.9 4.1 4.1 4.9 4.3 4.6 4.3 4.5 3.3 3.5 4.8 4.8 4.5 4.1 4.3 4.5 4.7 4.3 5.0 4.24.9 98% 100% 0% 0% 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.8 4.9 5.0 5.0 5.0 5.0 5.0 4.6 4.9 5.0 5.0 5.0 5.0 5.04.3 86% 61% 33% 6% 4.2 4.9 4.5 4.5 4.9 4.5 4.5 5.0 4.3 4.8 4.8 4.2 4.6 4.9 4.2 4.3 4.9 4.4 4.8 4.1 4.5 3.8 3.5 4.9 4.9 4.5 4.1 4.4 4.5 4.9 4.4 5.0 4.24.0 74% 45% 33% 21% 4.4 4.8 4.4 4.7 4.9 4.4 4.5 4.9 4.2 4.5 4.5 4.3 4.4 4.8 4.4 4.1 4.7 3.6 4.8 3.8 4.1 3.5 3.5 4.9 4.9 5.0 3.8 4.1 4.5 4.1 3.9 4.5 3.83.9 72% 39% 30% 30% 4.4 4.6 4.2 4.7 4.6 4.4 4.5 4.6 4.3 4.5 4.5 3.7 4.4 4.6 4.3 3.5 4.9 3.8 4.5 3.8 4.0 3.5 3.8 4.8 4.7 3.8 3.9 4.0 4.3 4.4 3.5 4.8 3.64.8 94% 88% 9% 3% 5.0 4.9 5.0 5.0 4.9 5.0 5.0 5.0 5.0 5.0 5.0 4.3 5.0 5.0 3.9 5.0 5.0 5.0 5.0 5.0 5.0 4.3 5.0 5.0 4.5 5.0 4.9 4.9 5.0 4.4 4.7 5.0 5.04.7 92% 76% 24% 0% 5.0 5.0 5.0 4.8 5.0 5.0 5.0 5.0 4.1 5.0 5.0 4.3 5.0 5.0 4.3 4.2 5.0 4.7 5.0 4.4 4.9 4.3 5.0 5.0 4.8 5.0 4.1 4.9 5.0 4.4 4.7 5.0 5.04.0 76% 48% 39% 12% 5.0 4.8 4.4 4.8 4.8 4.2 4.8 4.9 4.6 4.0 4.3 4.2 4.3 4.8 3.3 3.6 4.8 4.2 4.7 4.2 4.3 4.0 4.0 4.8 4.9 4.8 3.7 4.5 4.5 4.4 4.3 4.8 3.84.1 79% 64% 15% 21% 4.8 4.9 4.5 4.6 4.8 4.7 4.8 4.9 4.6 5.0 3.8 4.0 4.7 4.7 3.7 4.0 4.8 4.2 4.5 4.3 4.5 4.0 3.8 4.9 4.5 5.0 3.6 4.5 4.5 3.9 3.8 4.8 3.63.9 69% 33% 33% 33% 4.6 4.6 4.5 4.6 4.7 4.4 4.5 4.6 4.0 4.3 3.3 3.7 4.3 4.6 3.2 3.4 4.6 3.9 4.0 3.9 4.2 3.5 4.0 4.1 4.5 5.0 3.0 4.0 4.3 3.9 3.4 4.1 3.64.6 99% 94% 6% 0% 5.0 5.0 4.8 5.0 4.9 4.7 5.0 5.0 4.9 5.0 5.0 4.5 5.0 4.9 4.5 4.6 4.9 4.5 4.8 4.5 4.4 4.3 4.8 5.0 4.9 4.8 4.6 4.7 4.8 5.0 4.6 5.0 4.83.8 69% 48% 15% 36% 5.0 4.7 4.2 4.8 5.0 5.0 4.3 5.0 4.6 5.0 4.0 5.0 3.3 4.7 4.6 3.5 4.6 4.0 5.0 2.9 3.5 1.7 2.0 3.0 4.3 2.0 3.7 4.5 5.0 3.3 3.4 4.6 2.64.8 96% 85% 9% 6% 5.0 4.9 5.0 5.0 5.0 5.0 5.0 5.0 4.6 5.0 5.0 5.0 5.0 5.0 4.3 4.8 5.0 5.0 5.0 3.9 5.0 3.0 5.0 5.0 5.0 4.0 4.4 4.9 5.0 5.0 5.0 5.0 5.05.0 99% 100% 0% 0% 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.9 5.0 5.0 5.0 5.0 5.04.9 98% 100% 0% 0% 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.04.9 98% 100% 0% 0% 5.0 4.9 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.6 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.9 5.0 5.0 5.0 5.0 5.04.5 84% 94% 6% 0% 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.2 5.0 5.0 5.0 4.6 5.0 5.0 5.0 5.0 5.0 4.0 5.0 5.0 5.0 5.0 5.0 5.0 5.04.1 94% 79% 15% 6% 4.8 5.0 4.4 4.8 4.8 4.6 4.7 4.9 4.9 4.5 4.5 4.5 5.0 4.9 4.6 3.9 5.0 4.6 4.6 3.9 4.6 4.3 4.3 4.9 4.9 4.5 4.1 4.5 4.5 4.4 4.5 4.9 4.64.2 80% 61% 21% 18% 5.0 4.6 5.0 4.5 4.9 5.0 5.0 5.0 3.2 5.0 4.0 4.3 5.0 4.7 3.5 2.7 5.0 4.5 4.7 3.9 4.2 3.7 5.0 5.0 4.8 5.0 3.4 4.1 4.0 4.4 4.0 4.6 5.04.2 80% 45% 36% 18% 4.6 5.0 4.4 4.6 4.9 4.4 4.3 4.9 4.2 4.3 4.8 3.8 4.9 4.7 4.1 3.6 4.6 4.4 4.5 4.2 4.4 3.8 3.3 4.9 4.8 4.5 3.7 4.4 4.5 4.3 4.3 4.7 3.84.5 91% 79% 18% 3% 4.8 5.0 4.6 4.6 4.9 4.9 4.5 4.9 4.3 5.0 5.0 5.0 4.9 4.6 4.5 4.1 4.7 3.7 4.5 4.6 4.3 4.0 4.5 4.6 4.9 5.0 4.6 4.3 4.5 4.7 4.1 5.0 4.64.2 81% 55% 42% 3% 4.8 4.9 4.6 4.7 4.9 4.2 4.8 5.0 4.3 4.5 5.0 4.2 4.7 4.9 4.3 4.0 4.8 4.4 4.7 4.1 4.5 4.2 4.0 4.3 4.9 5.0 3.7 4.4 4.5 4.4 4.3 4.7 4.24.5 99% 79% 18% 3% 4.8 4.9 4.6 4.9 4.9 4.8 4.8 4.6 4.8 5.0 4.8 4.0 5.0 4.6 4.3 4.3 4.9 4.3 4.5 3.2 4.5 4.8 5.0 4.6 4.8 4.8 4.5 4.6 4.8 4.9 4.2 4.9 4.24.5 99% 79% 21% 0% 4.8 4.9 4.6 4.8 4.9 4.8 5.0 4.8 4.7 4.8 5.0 4.3 5.0 4.7 4.5 4.4 5.0 4.5 4.8 4.3 4.5 4.7 5.0 4.6 4.8 4.8 4.3 4.6 4.5 4.3 4.3 5.0 4.44.4 86% 76% 15% 9% 5.0 4.8 5.0 4.9 4.9 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 3.9 3.9 5.0 4.0 5.0 4.6 4.3 4.3 5.0 4.5 4.8 5.0 4.1 3.7 5.0 5.0 4.0 5.0 5.04.0 97% 18% 58% 24% 4.4 4.3 4.5 4.5 4.3 4.3 4.3 4.3 3.8 4.3 4.5 4.0 4.3 4.4 3.5 3.7 4.4 4.0 4.0 4.1 3.9 3.5 4.3 4.0 4.7 4.5 3.6 4.3 4.3 4.3 3.8 4.5 3.64.6 98% 79% 15% 6% 4.6 4.9 4.4 4.9 5.0 4.8 5.0 4.9 4.9 5.0 5.0 4.3 4.9 4.7 4.6 4.7 4.8 4.5 4.8 3.8 4.9 4.8 4.3 5.0 4.9 3.5 4.3 4.1 4.5 4.7 4.9 4.8 5.04.4 99% 73% 21% 6% 4.8 4.9 4.5 4.9 4.8 4.6 4.8 4.6 4.9 4.8 4.8 4.3 5.0 4.9 4.5 4.4 5.0 4.5 4.5 3.8 4.5 4.3 4.3 4.8 4.8 4.5 3.9 4.4 4.5 5.0 4.4 4.7 4.2

Percent Positive overall Evaluation of program 76% 9% 15% 100% 98% 100% 97% 97% 92% 100% 100% 89% 100% 75% 100% 100% 93% 81% 94% 100% 100% 92% 95% 87% 67% 75% 100% 100% 100% 71% 94% 100% 100% 89% 90% 100%Number Surveyed 5.0 49.0 10.0 36.0 80.0 12.0 6.0 9.0 10.0 4.0 4.0 6.0 8.0 14.0 11.0 24.0 9.0 25.0 13.0 20.0 44.0 6.0 4.0 8.0 16.0 4.0 30.0 31.0 4.0 8.0 34.0 11.0 5.0

Number Responding 5.0 47.0 10.0 32.0 74.0 12.0 6.0 8.0 9.0 4.0 4.0 6.0 7.0 14.0 11.0 19.0 9.0 25.0 13.0 19.0 44.0 6.0 4.0 8.0 16.0 4.0 27.0 31.0 4.0 7.0 28.0 10.0 5.0Response rate (percentage) 1.0 1.0 1.0 0.9 0.9 1.0 1.0 0.9 0.9 1.0 1.0 1.0 0.9 1.0 1.0 0.8 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 0.9 1.0 1.0 0.9 0.8 0.9 1.0

Score - score of 4.5 or higher OR higher than 92.6% "yes"Score - score of 4.0 through 4.4 OR 85% through 92.5% "yes"Score - score lower than 4.0 OR lower than 85% "yes"

Continuous hours scheduled

Rule

s Br

oken

Bec

ause

Duty

Hou

rsFa

culty

Eval

uatio

n

Access evaluations

Sufficient SupervisionAppropriate supervision

Sufficient instructionInterest in Residency Education

80 hours/week1/7 days free

In House Call every 3rd nightNight float no more than 6 nights

8 hours off

Program uses evals to improve

Educ

atio

nal C

onte

ntRe

sour

cePa

tient

Sa

fety

Tea

m-

wor

k

Environment of scholarship and inquiry

Evaluate facultyConfidentiality of faculty evaluations

Evaluate programConfidentiality of program evaluations

*EMR abulatory

Satisfaction with feedback after assignmentProvided G/O rotations/assignmentsResidents receive fatigue education

Scholarly activity satisfactionAppropriate balance for education

Education (not) compromised by serviceSupervisors delegate appropriately

Provided data about practice habitsSee patients across a variety of settings

Acess to reference matierals*EMR hospital

Work in interprofessional teams effectively

*EMR integratedEMR effective in daily clinical work

Provided way to transition care when fatiguedSatisfied with process to address resident concerns

Education not compromised by other traineesResidents can raise concerns w/out fear

Tell patients respective role of res/facultyPatient safety responsibility reinforcedResidents particpate in QI/PS activities

Information not lost during shift changesResidents work in teams

Page 54 of 102

Prog

ram

2015

Nat

iona

l Mea

n - R

esid

ent S

urve

y

2015

Per

cent

Com

plia

nt N

atio

nally

Alle

rgy

and

Imm

unol

ogy

Anes

thes

iolo

gy

Derm

atol

ogy

Emer

genc

y M

edic

ine

Inte

rnal

Med

icin

e

Card

iova

scul

ar D

isea

se

Endo

crin

olog

y, D

iabe

tes,

Met

abol

ism

Gast

roen

tero

logy

Hem

atol

ogy

and

Onc

olog

y

Hosp

ice

and

Palli

ativ

e M

edic

ine

Infe

ctio

us D

isea

se

Nep

hrol

ogy

Pulm

onar

y a

nd C

ritic

al C

are

Med

icin

e

Ner

olog

ical

Sur

gery

Neu

rolo

gy

Obs

tetr

ics a

nd G

ynec

olog

y

Oph

thal

mol

ogy

Ort

hope

dic

Surg

ery

Oto

lary

ngol

ogy

Path

olog

y

Pedi

atric

s

Pedi

atric

Crit

ical

Car

e M

edic

ine

Pedi

atric

Hem

atol

ogy/

Onc

olog

y

Phys

ical

Med

icin

e an

d Re

habi

litat

ion

Plas

tic S

urge

ry

Prev

entiv

e M

edic

ine

Psyc

hiat

ry

Radi

olog

y

Neu

rora

diol

ogy

Radi

atio

n O

ncol

ogy

Surg

ery

Uro

logy

Vasc

ular

Sur

gery

4.7 94% 5.0 4.9 5.0 5.0 5.0 5.0 5.0 5.0 4.9 5.0 4.8 5.0 5.0 5.0 4.3 4.2 5.0 4.8 4.7 4.8 4.6 4.7 4.8 5.0 4.5 5.0 4.5 4.8 5.0 4.7 3.6 4.8 4.24.8 97% 5.0 4.9 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.7 5.0 5.0 4.5 4.3 5.0 4.7 4.8 4.9 4.7 5.0 4.8 5.0 4.8 5.0 4.7 4.8 5.0 5.0 4.4 5.0 4.4

5 99% 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.8 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.9 5.0 5.0 4.9 5.0 5.05 99% 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.9 5.0 4.8 5.0 4.9 5.0 5.0 4.9 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.6 5.0 5.0

4.7 97% 5.0 5.0 4.8 5.0 4.8 4.9 4.9 5.0 4.8 4.3 5.0 4.4 4.6 5.0 4.8 4.7 5.0 4.5 5.0 5.0 4.7 4.5 5.0 4.7 4.74.8 96% 5.0 5.0 4.9 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.6 4.4 4.7 5.0 5.0 5.0 4.3 4.8 5.0 5.0 4.9 5.0 5.0 5.0 5.0

Patients' needs NA NA 0% 0% 0% 3% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 18% 11% 0% 12% 0% 0% 5% 0% 0% 0% 19% 0% 11% 3% 0% 0% 32% 0% 20%Paperwork or admin work NA NA 0% 6% 0% 3% 0% 0% 0% 0% 0% 0% 0% 17% 0% 0% 18% 26% 0% 12% 0% 0% 7% 0% 0% 0% 13% 0% 15% 6% 0% 0% 36% 0% 20%

Educational experience NA NA 0% 2% 0% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 11% 0% 8% 0% 0% 0% 0% 0% 0% 6% 0% 0% 0% 0% 0% 18% 0% 20%Cover for someone else NA NA 0% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 9% 26% 0% 0% 0% 0% 2% 0% 0% 0% 0% 0% 15% 6% 0% 0% 7% 0% 0%

Night-float NA NA 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 11% 0% 4% 0% 0% 0% 0% 0% 0% 6% 0% 7% 3% 0% 0% 21% 0% 0%Schedule conflict NA NA 0% 0% 0% 3% 0% 0% 0% 0% 0% 0% 0% 17% 0% 0% 0% 11% 0% 0% 0% 0% 0% 0% 0% 0% 13% 0% 7% 3% 0% 0% 25% 0% 20%

Other NA NA 0% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 9% 5% 0% 0% 0% 0% 0% 0% 0% 0% 6% 0% 4% 0% 0% 0% 21% 0% 0%4.3 92% 4.6 4.8 4.3 4.8 4.9 4.5 4.5 4.8 4.7 4.8 4.8 4.2 4.6 4.9 4.2 4.6 4.9 4.5 4.5 4.1 4.4 4.3 4.5 4.8 4.9 4.8 4.0 4.5 4.8 4.9 4.3 4.9 4.24.6 96% 5.0 4.9 4.9 4.9 5.0 4.8 5.0 5.0 5.0 5.0 5.0 4.5 4.9 5.0 4.6 4.7 4.9 4.8 4.8 4.7 4.7 4.3 4.8 5.0 4.9 5.0 4.3 4.7 5.0 5.0 4.5 4.9 4.84.2 85% 4.8 4.7 4.3 4.7 4.9 4.5 4.8 4.9 4.6 4.3 4.5 4.0 4.6 4.9 4.3 4.4 4.9 4.3 4.5 3.9 4.3 4.2 4.5 4.5 4.8 4.5 3.7 4.4 5.0 4.9 4.0 4.8 4.04.2 84% 4.8 4.6 4.5 4.9 4.9 4.4 4.8 4.9 4.6 4.5 4.8 4.2 4.7 4.8 4.5 4.6 4.7 4.1 4.5 4.1 4.6 4.2 4.8 4.9 4.9 4.8 3.9 4.2 4.8 4.9 4.1 4.7 4.44.1 78% 4.8 4.7 4.4 4.9 4.9 4.4 4.7 4.8 4.6 4.5 4.5 4.2 4.6 4.9 4.5 4.1 4.4 4.2 4.8 3.9 4.3 3.7 4.8 4.9 4.9 4.8 3.6 4.2 4.8 4.6 4.2 4.7 4.24.9 99% 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.3 5.0 5.0 5.0 5.0 5.0 4.9 5.0 5.0 5.0 5.0 5.04.9 99% 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 2.3 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.04.2 84% 4.0 4.9 4.5 4.4 4.9 4.4 4.5 5.0 4.4 4.8 4.5 4.0 4.6 4.9 4.1 4.1 4.9 4.3 4.6 4.3 4.5 3.3 3.5 4.8 4.8 4.5 4.1 4.3 4.5 4.7 4.3 5.0 4.24.9 98% 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.8 4.9 5.0 5.0 5.0 5.0 5.0 4.6 4.9 5.0 5.0 5.0 5.0 5.04.3 86% 4.2 4.9 4.5 4.5 4.9 4.5 4.5 5.0 4.3 4.8 4.8 4.2 4.6 4.9 4.2 4.3 4.9 4.4 4.8 4.1 4.5 3.8 3.5 4.9 4.9 4.5 4.1 4.4 4.5 4.9 4.4 5.0 4.2

4 73% 4.4 4.8 4.4 4.7 4.9 4.4 4.5 4.9 4.2 4.5 4.5 4.3 4.4 4.8 4.4 4.1 4.7 3.6 4.8 3.8 4.1 3.5 3.5 4.9 4.9 5.0 3.8 4.1 4.5 4.1 3.9 4.5 3.83.9 70% 4.4 4.6 4.2 4.7 4.6 4.4 4.5 4.6 4.3 4.5 4.5 3.7 4.4 4.6 4.3 3.5 4.9 3.8 4.5 3.8 4.0 3.5 3.8 4.8 4.7 3.8 3.9 4.0 4.3 4.4 3.5 4.8 3.64.8 95% 5.0 4.9 5.0 5.0 4.9 5.0 5.0 5.0 5.0 5.0 5.0 4.3 5.0 5.0 3.9 5.0 5.0 5.0 5.0 5.0 5.0 4.3 5.0 5.0 4.5 5.0 4.9 4.9 5.0 4.4 4.7 5.0 5.04.7 92% 5.0 5.0 5.0 4.8 5.0 5.0 5.0 5.0 4.1 5.0 5.0 4.3 5.0 5.0 4.3 4.2 5.0 4.7 5.0 4.4 4.9 4.3 5.0 5.0 4.8 5.0 4.1 4.9 5.0 4.4 4.7 5.0 5.0

4 76% 5.0 4.8 4.4 4.8 4.8 4.2 4.8 4.9 4.6 4.0 4.3 4.2 4.3 4.8 3.3 3.6 4.8 4.2 4.7 4.2 4.3 4.0 4.0 4.8 4.9 4.8 3.7 4.5 4.5 4.4 4.3 4.8 3.84.1 79% 4.8 4.9 4.5 4.6 4.8 4.7 4.8 4.9 4.6 5.0 3.8 4.0 4.7 4.7 3.7 4.0 4.8 4.2 4.5 4.3 4.5 4.0 3.8 4.9 4.5 5.0 3.6 4.5 4.5 3.9 3.8 4.8 3.63.9 69% 4.6 4.6 4.5 4.6 4.7 4.4 4.5 4.6 4.0 4.3 3.3 3.7 4.3 4.6 3.2 3.4 4.6 3.9 4.0 3.9 4.2 3.5 4.0 4.1 4.5 5.0 3.0 4.0 4.3 3.9 3.4 4.1 3.64.6 99% 5.0 5.0 4.8 5.0 4.9 4.7 5.0 5.0 4.9 5.0 5.0 4.5 5.0 4.9 4.5 4.6 4.9 4.5 4.8 4.5 4.4 4.3 4.8 5.0 4.9 4.8 4.6 4.7 4.8 5.0 4.6 5.0 4.83.7 68% 5.0 4.7 4.2 4.8 5.0 5.0 4.3 5.0 4.6 5.0 4.0 5.0 3.3 4.7 4.6 3.5 4.6 4.0 5.0 2.9 3.5 1.7 2.0 3.0 4.3 2.0 3.7 4.5 5.0 3.3 3.4 4.6 2.64.8 95% 5.0 4.9 5.0 5.0 5.0 5.0 5.0 5.0 4.6 5.0 5.0 5.0 5.0 5.0 4.3 4.8 5.0 5.0 5.0 3.9 5.0 3.0 5.0 5.0 5.0 4.0 4.4 4.9 5.0 5.0 5.0 5.0 5.0

5 99% 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.9 5.0 5.0 5.0 5.0 5.04.9 97% 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.04.9 97% 5.0 4.9 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.6 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.9 5.0 5.0 5.0 5.0 5.04.5 82% 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 4.2 5.0 5.0 5.0 4.6 5.0 5.0 5.0 5.0 5.0 4.0 5.0 5.0 5.0 5.0 5.0 5.0 5.04.1 94% 4.8 5.0 4.4 4.8 4.8 4.6 4.7 4.9 4.9 4.5 4.5 4.5 5.0 4.9 4.6 3.9 5.0 4.6 4.6 3.9 4.6 4.3 4.3 4.9 4.9 4.5 4.1 4.5 4.5 4.4 4.5 4.9 4.64.2 80% 5.0 4.6 5.0 4.5 4.9 5.0 5.0 5.0 3.2 5.0 4.0 4.3 5.0 4.7 3.5 2.7 5.0 4.5 4.7 3.9 4.2 3.7 5.0 5.0 4.8 5.0 3.4 4.1 4.0 4.4 4.0 4.6 5.04.1 80% 4.6 5.0 4.4 4.6 4.9 4.4 4.3 4.9 4.2 4.3 4.8 3.8 4.9 4.7 4.1 3.6 4.6 4.4 4.5 4.2 4.4 3.8 3.3 4.9 4.8 4.5 3.7 4.4 4.5 4.3 4.3 4.7 3.84.5 91% 4.8 5.0 4.6 4.6 4.9 4.9 4.5 4.9 4.3 5.0 5.0 5.0 4.9 4.6 4.5 4.1 4.7 3.7 4.5 4.6 4.3 4.0 4.5 4.6 4.9 5.0 4.6 4.3 4.5 4.7 4.1 5.0 4.64.2 80% 4.8 4.9 4.6 4.7 4.9 4.2 4.8 5.0 4.3 4.5 5.0 4.2 4.7 4.9 4.3 4.0 4.8 4.4 4.7 4.1 4.5 4.2 4.0 4.3 4.9 5.0 3.7 4.4 4.5 4.4 4.3 4.7 4.24.6 99% 4.8 4.9 4.6 4.9 4.9 4.8 4.8 4.6 4.8 5.0 4.8 4.0 5.0 4.6 4.3 4.3 4.9 4.3 4.5 3.2 4.5 4.8 5.0 4.6 4.8 4.8 4.5 4.6 4.8 4.9 4.2 4.9 4.24.5 99% 4.8 4.9 4.6 4.8 4.9 4.8 5.0 4.8 4.7 4.8 5.0 4.3 5.0 4.7 4.5 4.4 5.0 4.5 4.8 4.3 4.5 4.7 5.0 4.6 4.8 4.8 4.3 4.6 4.5 4.3 4.3 5.0 4.44.4 86% 5.0 4.8 5.0 4.9 4.9 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 3.9 3.9 5.0 4.0 5.0 4.6 4.3 4.3 5.0 4.5 4.8 5.0 4.1 3.7 5.0 5.0 4.0 5.0 5.0

4 97% 4.4 4.3 4.5 4.5 4.3 4.3 4.3 4.3 3.8 4.3 4.5 4.0 4.3 4.4 3.5 3.7 4.4 4.0 4.0 4.1 3.9 3.5 4.3 4.0 4.7 4.5 3.6 4.3 4.3 4.3 3.8 4.5 3.64.6 98% 4.6 4.9 4.4 4.9 5.0 4.8 5.0 4.9 4.9 5.0 5.0 4.3 4.9 4.7 4.6 4.7 4.8 4.5 4.8 3.8 4.9 4.8 4.3 5.0 4.9 3.5 4.3 4.1 4.5 4.7 4.9 4.8 5.0

4.3 99% 4.8 4.9 4.5 4.9 4.8 4.6 4.8 4.6 4.9 4.8 4.8 4.3 5.0 4.9 4.5 4.4 5.0 4.5 4.5 3.8 4.5 4.3 4.3 4.8 4.8 4.5 3.9 4.4 4.5 5.0 4.4 4.7 4.2Percent Positive overall Evaluation of program 100% 98% 100% 97% 97% 92% 100% 100% 89% 100% 75% 100% 100% 93% 81% 94% 100% 100% 92% 95% 87% 67% 75% 100% 100% 100% 71% 94% 100% 100% 89% 90% 100%

Number Surveyed 5 49 10 36 80 12 6 9 10 4 4 6 8 14 11 24 9 25 13 20 44 6 4 8 16 4 30 31 4 8 34 11 5Number Responding 5 47 10 32 74 12 6 8 9 4 4 6 7 14 11 19 9 25 13 19 44 6 4 8 16 4 27 31 4 7 28 10 5

Response rate (percentage) 100% 96% 100% 89% 93% 100% 100% 89% 90% 100% 100% 100% 88% 100% 100% 79% 100% 100% 100% 95% 100% 100% 100% 100% 100% 100% 90% 100% 100% 88% 82% 91% 100%

Score above .2 of national specialty meanScore within .2 of national specialty meanScore below .2 of national specialty mean

2016 ACGME Resident Survey - Specialty National Mean Dashboard

Residents particpate in QI/PS activitiesInformation not lost during shift changes

Team

-w

ork Residents work in teams

Work in interprofessional teams effectively

Patie

nt

Safe

ty

Tell patients respective role of res/facultyPatient safety responsibility reinforced

Reso

urce

Acess to reference matierals*EMR hospital

*EMR abulatory*EMR integrated

EMR effective in daily clinical workProvided way to transition care when fatigued

Satisfied with process to address resident concernsEducation not compromised by other trainees

Residents can raise concerns w/out fear

Educ

atio

nal C

onte

nt

Provided G/O rotations/assignmentsResidents receive fatigue education

Scholarly activity satisfactionAppropriate balance for education

Education (not) compromised by serviceSupervisors delegate appropriately

Provided data about practice habitsSee patients across a variety of settings

Eval

uatio

n

Access evaluationsEvaluate faculty

Confidentiality of faculty evaluationsEvaluate program

Confidentiality of program evaluationsProgram uses evals to improve

Satisfaction with feedback after assignment

Facu

lty

Sufficient SupervisionAppropriate supervision

Sufficient instructionInterest in Residency Education

Environment of scholarship and inquiry

Duty

Hou

rs

80 hours/week1/7 days free

In House Call every 3rd nightNight float no more than 6 nights

8 hours offContinuous hours scheduled

Rule

s Br

oken

Bec

ause

Page 55 of 102

Institution Means at-a-glance Residents' overall evaluation of the program

Institution Mean National Mean

Duty Hours% ProgramCompliant

ProgramMean

% NationalCompliant

National Mean

95% 4.7 94% 4.797% 4.8 97% 4.8100% 5.0 99% 5.099% 5.0 99% 5.098% 4.8 97% 4.7

80/88 hours*1 day free in 7In-house call every 3rd nightNight float no more than 6 nights8 hours between duty periods (differs by level of training)‡ Continuous hours scheduled (differs by level of training)‡ 99% 4.9 97% 4.8

Reasons for exceeding duty hours:Patient needs 5%Paperwork 7%Additional Ed. Experience 2%

Cover someone else's work 3%Night float 2%Schedule conflict 3%Other 2%

Faculty% ProgramCompliant

ProgramMean

% NationalCompliant

National Mean

Sufficient supervision 97% 4.6 92% 4.3Appropriate level of supervision 98% 4.8 96% 4.6Sufficient instruction 94% 4.5 85% 4.2Faculty and staff interested in residency education 93% 4.5 85% 4.3Faculty and staff create environment of inquiry 91% 4.5 79% 4.1

Evaluation% ProgramCompliant

ProgramMean

% NationalCompliant

National Mean

Able to access evaluations 99% 5.0 99% 4.9Opportunity to evaluate faculty members 99% 5.0 99% 4.9Satisfied that evaluations of faculty are confidential 91% 4.5 85% 4.3Opportunity to evaluate program 99% 5.0 98% 4.9Satisfied that evaluations of program are confidential 93% 4.6 86% 4.3Satisfied that program uses evaluations to improve 86% 4.4 74% 4.0Satisfied with feedback after assignments 82% 4.3 72% 3.9

Educational Content% ProgramCompliant

ProgramMean

% NationalCompliant

National Mean

Provided goals and objectives for assignments 97% 4.9 94% 4.8Instructed how to manage fatigue 94% 4.8 92% 4.7Satisfied with opportunities for scholarly activities 89% 4.5 76% 4.0Appropriate balance for education 88% 4.4 79% 4.1Education (not) compromised by service obligations 80% 4.2 69% 3.9Supervisors delegate appropriately 100% 4.8 99% 4.6Provided data about practice habits 78% 4.1 69% 3.8See patients across variety of settings 96% 4.9 96% 4.8

Resources % ProgramCompliant / % Yes*

ProgramMean

% NationalCompliant / %

Yes*National

MeanAccess to reference materials 100% 5.0 99% 5.0Use electronic medical records in hospital* 100% 5.0 98% 4.9Use electronic medical records in ambulatory setting* 99% 5.0 98% 4.9Electronic medical records integrated across settings* 98% 5.0 84% 4.5Electronic medical records effective 99% 4.6 94% 4.1Provided a way to transition care when fatigued 85% 4.4 80% 4.2Satisfied with process to deal with problems and concerns 89% 4.5 80% 4.2Education (not) compromised by other trainees 93% 4.6 91% 4.5Residents can raise concerns without fear 91% 4.5 81% 4.2

Patient Safety/Teamwork

% ProgramCompliant

ProgramMean

% NationalCompliant

National Mean

Tell patients of respective roles of faculty and residents 98% 4.6 99% 4.5Culture reinforces patient safety responsibility 99% 4.7 99% 4.5Participated in quality improvement 90% 4.6 86% 4.4Information (not) lost during shift changes or patient transfers

99% 4.2 97% 4.0

Work in interprofessional teams 98% 4.7 98% 4.6Effectively work in interprofessional teams 99% 4.6 99% 4.4

Total Percentage of Compliance by Category

© 2016 Accreditation Council for Graduate Medical Education (ACGME) *Response options are Yes or No. These responses aren't included in the Program Means and aren't considered non-compliant responses.‡ Data are not reported for any program participating in a duty hour study (including rotating programs).

Percentages may not add to 100% due to rounding.

2015-2016 ACGME Resident Survey - page 1

560176 University of Wisconsin Hospitals and Clinics Authority - Aggregated Program Data

Programs Surveyed

Residents Responded

Response Rate

53

562 / 594

95%

Survey taken: January 2016 - April 2016

* Duty hour exception applicable to intermediate and advanced training levels within approved programs.

Page 56 of 102

Institution Means at-a-glance Faculty's overall evaluation of the program

Institution Mean National Mean

Faculty Supervision and Teaching

% ProgramCompliant

ProgramMean

% NationalCompliant

National Mean

Sufficient time to supervise residents/fellows 96% 4.7 94% 4.6Residents/fellows seek supervisory guidance 93% 4.6 92% 4.5Interest of faculty and Program Director in education 98% 4.7 96% 4.7Rotation and educational assignment evaluation* 99% 99%Faculty performance evaluated* 98% 99%Faculty satisfied with personal performance feedback 90% 4.4 87% 4.3

Educational Content% ProgramCompliant

ProgramMean

% NationalCompliant

National Mean

Worked on scholarly project with residents/fellows* 75% 76%Residents/fellows see patients across a variety of settings* 99% 99%Residents/fellows receive education to manage fatigue* 100% 99%Effectiveness of graduating residents/fellows 98% 4.7 97% 4.6Outcome achievement of graduating residents/fellows 99% 4.9 99% 4.8

Resources% ProgramCompliant

ProgramMean

% NationalCompliant

National Mean

Program provides a way for residents/fellows to transition care when fatigued*

100% 99%

Residents/fellows workload exceeds capacity to do the work

100% 4.4 100% 4.3

Satisfied with faculty development to supervise and educate residents/fellows

97% 4.3 95% 4.2

Satisfied with process to deal with residents'/fellows' problems and concerns

95% 4.6 93% 4.6

Prevent excessive reliance on residents/fellows to provide clinical service

99% 4.5 98% 4.4

Patient Safety% ProgramCompliant

ProgramMean

% NationalCompliant

National Mean

Information not lost during shift changes or patient transfers 90% 4.2 91% 4.2Tell patients of respective roles of faculty and residents/fellows

90% 4.5 91% 4.5

Culture reinforces patient safety responsibility 97% 4.7 96% 4.6Residents/fellows participate in quality improvement or patient safety activities

95% 4.8 92% 4.6

Teamwork% ProgramCompliant

ProgramMean

% NationalCompliant

National Mean

Residents/fellows communicate effectively when transferring clinical care

98% 4.8 98% 4.8

Residents/fellows effectively work in interprofessional teams

100% 4.7 100% 4.6

Program effective in teaching teamwork skills 100% 4.5 99% 4.5

Total Percentage of Compliance by Category

© 2016 Accreditation Council for Graduate Medical Education (ACGME) *Responses options are Yes or No. These responses are not included in the Program Means and are not considered non-compliant responses.

Percentages may not add to 100% due to rounding.

2015-2016 ACGME Faculty Survey - page 1

560176 University of Wisconsin Hospitals and Clinics Authority - Aggregated Program Data

Programs Surveyed

Faculty Responded

Response Rate

53

471 / 530

89%

Survey taken: January 2016 - April 2016

Page 57 of 102

2016 ACGME Faculty Survey Results by Program

Programs listed had at least 3 program faculty members respond to the annual ACGME faculty survey.

Faculty Supervision/Teaching

Educational Content

Resources Patient Safety

Teamwork Program Mean

Overall Evaluation

Anesthesiology 4.7 4.9 4.6 4.7 4.8 5.0 100% Cardiothoracic Surgery 4.3 4.6 4.4 4.3 4.7 4.8 85% Dermatology 4.6 4.8 4.2 4.7 4.7 4.9 89% Micrographic Surgery and Dermatologic Oncology

4.0 4.0 4.3 4.4 4.3 4.2 100%

Emergency Medicine 4.9 4.9 4.8 4.8 4.9 5.0 100% Internal Medicine 4.8 4.8 4.5 4.7 4.6 4.9 100% Allergy and Immunology 4.6 4.8 4.7 4.8 4.9 5.0 100% Cardiovascular Medicine 4.8 4.8 4.4 4.7 4.8 4.9 100% Interventional Cardiology 4.9 5.0 4.8 4.9 5.0 5.0 100% Endocrinology 4.7 5.0 4.7 4.7 4.8 5.0 100% Gastroenterology 4.8 4.9 4.6 4.8 4.9 4.9 100% Geriatrics 5.0 5.0 4.9 4.9 5.0 5.0 100% Hematology Oncology 4.7 4.8 4.7 4.5 4.8 4.9 100% Infectious Disease 5.0 5.0 4.9 5.0 5.0 5.0 100% Nephrology 5.0 5.0 5.0 4.8 5.0 5.0 100% Pulmonary and Critical Care 4.8 4.9 4.7 4.8 4.9 5.0 100% Sleep Medicine 4.4 4.6 4.6 4.9 4.9 4.9 100% Transplant Hepatology 4.9 5.0 4.8 4.8 5.0 5.0 100% Neurology 4.4 4.6 3.9 4.0 4.5 5.0 100% Neurological Surgery 4.8 5.0 4.8 4.7 4.8 4.9 100% Nuclear Medicine 4.5 4.7 4.6 4.6 5.0 5.0 100% Obstetrics and Gynecology 4.5 4.7 4.5 4.4 4.6 4.9 100% Ophthalmology 4.6 4.7 4.5 4.8 4.7 5.0 100% Orthopedic Surgery 4.3 4.6 4.2 4.1 4.4 4.9 100% Orthopedic Sports Medicine 4.6 4.8 4.7 4.3 5.0 4.9 100% Otolaryngology 4.7 4.6 4.5 4.6 4.6 5.0 100% Pathology 4.4 4.5 4.0 4.0 4.1 4.8 90% Cytopathology 4.7 4.7 4.7 4.4 4.6 5.0 100% Pediatrics 4.3 4.4 4.2 4.2 4.4 4.9 100% Pediatrics Critical Care 4.2 4.7 3.9 4.2 4.3 4.9 100% Pediatrics Hematology Oncology

4.7 4.9 4.3 4.7 4.8 4.9 100%

Pediatrics Infectious Disease

4.8 4.6 4.3 4.5 4.6 5.0 100%

Pediatrics Neonatal - Perinatal

4.0 4.4 4.2 4.1 4.6 4.1 100%

Plastic Surgery 4.8 4.9 4.8 4.8 4.8 5.0 100% Preventive Medicine 4.9 4.9 4.4 4.8 4.6 4.8 100% Psychiatry 4.3 4.4 4.1 4.4 4.5 4.3 91% Addiction Psychiatry 4.9 4.4 3.9 4.4 4.0 4.2 75% Child Psychiatry 4.4 4.7 4.0 4.6 4.5 4.2 80% Radiology 4.6 4.8 4.2 4.6 4.6 4.9 100% Vascular Interventional Radiology

4.4 4.7 3.9 4.3 4.4 4.3 100%

Physical Medicine & Rehab 4.4 4.9 4.3 4.5 4.9 4.9 100% Radiation Oncology 4.6 4.8 4.2 4.4 4.7 4.9 100% Surgery 4.5 4.7 4.4 4.5 4.6 5.0 100% Surgical Critical Care 4.5 4.8 4.5 4.6 4.8 4.9 100% Urology 4.6 4.8 4.6 4.6 4.6 4.8 100% Vascular Surgery 4.8 4.8 4.6 4.6 4.6 4.9 100% Vascular Surgery Fellowship 4.8 4.9 4.5 4.5 4.7 4.9 100% All Program Means

26

Page 58 of 102

2016 Recruitment Information

Overall, recruitment continues to be strong, with the vast majority of our programs filling with excellent candidates. A significant percentage of our PG1s continues to come from UWSMPH. Additional refinements in the collection of this data will continue, as this was the GME Office’s first attempt to aggregate this information at the institutional‐level. Program specific information is discussed at annual DIO meetings. Overtime, longitudinal data will allow for identification of trends and anomalies worthy of investigation.

226228230232234236238

2015 2016 LastReportedNational

Mean (2014)

Average PG1 USMLE Step 1 Score

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

2015 2016

Percent of PG1s - AOA

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

2015 2016

Percent of PG1s that graduated from UWSMPH

30%

35%

40%

45%

50%

55%

2015 2016

Percent of PG1s - Female

80.00%

85.00%

90.00%

95.00%

100.00%

2015 2016

Percent of PG1s Filled By Match

0.00%

2.00%

4.00%

6.00%

2015 2016

Percent of PG1s - International Medical

Graduates

27

Page 59 of 102

Graduate information for 2016 was collected through a survey administered by the GME Office. However, 12% of the graduates did not respond to the survey. Additional refinements will need to be made to help ensure accurate and complete collection of this information. In addition, board pass rate information is also incomplete as there is great variability across programs on how this data is reported. By next year, the GME Office hopes to have a more complete and accurate picture of graduate information.

Program Director Years of Service

For the first time this year, we did an analysis of program director tenure. Given the importance of the role and the learning curve associated with being a new program director, tracking program director years of service can be a helpful tool in assessing program performance. Our average length of program director service was just over seven years, which is consistent with the national average. Plans are in the works to begin collecting this information for all program coordinators and managers.

CLER Performance

One key element of the ACGME NAS is the Clinical Learning Environment Review (CLER) program. CLER visits do not result in citations or directly lead to programmatic or institutional accreditation decisions; however, they are intended to achieve higher quality clinical learning environments. CLER assesses institutions in the following six focus areas: Patient Safety, Quality Improvement, Transitions in Care, Supervision, Duty Hours/Fatigue Management and Mitigation, and Professionalism.

Every 18‐24 months, the ACGME sends a CLER team to assess these six areas. In October 2015, UW Health had its second CLER visit, with only two weeks advance notice. The CLER team visited more than 25 clinical

0

2

4

6

8

10

12

14

16

18

0-1.99 2-3.99 4-5.99 6-7.99 8-9.99 10+

Num

ber o

f Pro

gram

Dire

ctor

s

Years of Service

Program Director Tenure (as of June 30, 2016)

Average: 7.09 years Median: 4.29 years

Percent of programs with a Program Directors with 5+ years: 48.4%

Total Years of Experience: 439.67

28

Page 60 of 102

locations and conducted interviews with senior UW Health leadership, the DIO, 52 residents and fellows, 40 faculty members and 34 program directors.

In early 2016, the ACGME issued its first National Report, which summarized the findings from the first set of CLER site visits, including UW Health’s first site visit from December 2013. An overarching theme of the reports was that clinical learning environments vary in their approach and capacity for addressing patient safety and health care quality and graduate medical education. Data from our first site visit was largely in line with national means and norms; however, the report did identify opportunities to make improvements. Our next anticipated CLER site visit is spring 2017.

The below chart summarizes goals for this year in each of the six CLER areas.

2016‐2017 Goals to Support Clinical Learning Environment Review (CLER) Components

1. Patient Safety

◊ Increase physician error reporting and feedbackto physicians on error reports

◊ Task Force on Bedside Timeouts◊ JUST Culture

4. Supervision

◊ Improve compliance with Central LineTraining requirements

◊ Identify any areas of concern withinadequate faculty supervision

2. Health Care Quality

◊ Improve resident access to data on theirpatients

◊ Support RQSC and Resident and Student QualityImprovement Symposium

◊ Add cultural competency training◊ Review and refine QI curriculum

5. Duty Hours/Fatigue Management &Mitigation

◊ Integrate SAFER training into SIC◊ Assess resident wellness through

confidential survey◊ Catalog institutional and program‐level

resident wellness initiatives/resources

3. Care Transitions

◊ Program specific Handoff Policies◊ Implementation of Handoff Policy

6. Professionalism

◊ Create professional reporting processseparate from PSN

29

Page 61 of 102

Report Generated: 08/19/2016 Dates: 07/05/2015 - 06/25/201616hr pd: 24+4hr pd: 8hr bk:

AVG: Viol: AVG: Viol: Viol: Viol: Viol:Anesthesiology 96% 56.3 4 1.7 26 13 24 8 75 49 0Anesthesiology Critical Care n/a - - -- - - -- -- -- -- -- 0 --Pediatric Anesthesiology n/a - - -- - - -- -- -- -- -- 0 --Cardiothoracic Surgery 79% 66.4 0 1.2 2 0 0 0 2 2 0Dermatology 90% 39.8 0 2.4 0 0 0 0 0 10 3Micrographic Surgery & Dermatologic Oncology 88% 43.7 0 2.2 0 0 0 0 0 1 0Emergency Medicine 95% 46.9 0 2.3 15 14 2 82 113 36 8Medicine 84% 52.3 6 1.9 52 59 49 18 184 80 6Advanced Heart Failure & Transplant Cardiology n/a - - -- - - -- -- -- -- -- 0 --Allergy & Immunology 87% 30.3 0 2.9 0 0 0 0 0 5 1Cardiovascular Medicine 93% 49.3 0 1.8 3 0 0 0 3 12 7Clinical Cardiac Electrophys n/a - - -- - - -- -- -- -- -- 0 --Endocrinology 92% 39.6 0 2.5 0 0 0 3 3 6 2Gastroenterology 96% 48.4 0 1.9 1 0 0 2 3 9 1Geriatrics 96% 38.8 0 2.4 0 0 0 0 0 3 3Hematology & Oncology 94% 46.2 0 2.1 0 0 0 0 0 10 1Hospice & Palliative Care 94% 45.8 0 2 0 0 0 0 0 4 1Infectious Disease 95% 47 0 2.2 0 0 6 4 10 4 1Interventional Cardiology 71% 52.1 0 1.5 1 0 0 0 1 2 1Nephrology 90% 51 0 1.6 2 0 0 1 3 6 1Pulmonary Critical Care 92% 56.8 0 1.8 2 0 1 0 3 8 5Rheumatology 100% 49.5 0 1.2 2 0 0 0 2 2 0Sleep Medicine 81% 39 0 2.2 0 0 0 0 0 1 0Transplant Hepatology 100% 48.5 0 1.7 0 0 0 0 0 1 0Medicine/Dermatology 100% 43.5 0 2.1 0 0 1 0 1 2 1Neurology 91% 57.9 0 1.6 9 5 11 6 31 11 2Child Neurology n/a - - -- - - -- -- -- -- -- 0 --Clinical Neurophysiology n/a - - -- - - -- -- -- -- -- 0 --Vascular Neurology n/a - - -- - - -- -- -- -- -- 0 --Neurosurgery** 100% 66.8 0 1.6 13 3 1 2 19 14 0Nuclear Medicine 98% 46.5 0 1.9 0 0 0 0 0 1 0Obstetrics & Gynecology 99% 64.4 3 1.6 26 3 2 11 45 24 0Ophthalmology 100% 51.1 0 1.7 3 0 0 4 7 9 3Orthopedic Surgery 97% 55.4 1 1.7 21 1 3 7 33 25 6Orthopedic Sports Medicine 100% 60.8 0 1.6 0 0 0 0 0 1 0Otolaryngology 89% 62.7 1 1.8 4 0 3 0 8 13 2Pathology 98% 46.3 0 2.1 1 0 0 0 2 20 0Blood Banking/Transfusion n/a - - -- - - -- -- -- -- -- 0 --Cytopathology 81% 39.1 0 2.5 0 0 0 0 0 1 0Hematopathology n/a - - -- - - -- -- -- -- -- 0 --

2015-16 UW Health Duty Hours Institutional Summary

Program: Submitted:80 Hrs/wk: Day off/wk: Total

Viol:Trainee Count:

Moonlighters approved

30

Page 62 of 102

16hr pd: 24+4hr pd: 8hr bk:AVG: Viol: AVG: Viol: Viol: Viol: Viol:

Pediatrics 100% 56.5 4 1.8 20 8 0 5 37 45 0Medical Genetics n/a - - -- - - -- -- -- -- -- 0 --Pediatrics Critical Care 93% 61.5 0 1.7 2 0 0 3 5 6 0Pediatrics Endocrinology 96% 44 0 2.2 0 0 0 1 1 3 0Pediatrics Hem & Onc 90% 46.6 0 1.8 0 0 0 0 0 4 0Pediatrics Infect Disease 92% 48.4 0 1.7 0 0 0 0 0 2 0Perinatal 92% 60 0 1.7 1 0 12 0 13 3 1Pediatrics Pulmonary n/a - - -- - - -- -- -- -- -- 0 --Primary Care Sports 98% 42.8 0 2.3 0 0 0 0 0 1 0Physical Medicine & Rehab 100% 42.7 0 2.1 0 0 0 0 0 8 5Plastic Surgery 83% 61.9 6 1.7 12 9 25 19 71 16 1Preventive Medicine 94% 46.9 0 2.1 0 0 0 0 0 4 2Psychiatry 92% 53.9 0 2 3 9 1 19 32 30 3Addiction Psychiatry 78% 40.1 0 2.6 0 0 0 0 0 2 0Child & Adolesc Psychiatry 93% 44.3 0 1.8 1 0 0 0 1 3 0Geriatric Psychiatry n/a - - -- - - -- -- -- -- -- 0 --Radiation Oncology 100% 51.9 0 1.9 1 0 0 0 1 9 4Radiology 87% 50.1 0 2 4 0 4 17 25 31 4Neuroradiology 98% 51.2 0 2 0 0 0 1 1 4 3Vascular Intervl Radiology 85% 54.6 0 1.6 1 0 0 0 1 2 0

57 43 87

Surgical Critical Care 62% 55 0 1.6 3 0 0 0 3 1 0Urology 100% 61.9 0 1.8 1 0 0 2 3 11 0Vascular Surgery 88% 69.7 5 1.5 7 0 0 0 12 5 0Vascular Surgery Fellowship 75% 63.5 0 1.8 1 0 1 0 2 2 0Summary Total 92% 51.4 94 1.9 334 181 189 220 1019 608 78

Submitted:80 Hrs/wk: Day off/wk: Total

Viol:Trainee Count:

Moonlighters approved

345 44 0

Trainee Count accurate as of April 1, 2016

FIRST Trial Study - Program exempted from these requirements

Surgery 88% 73 64 1.1 94

Program:

31

** Approved for up to 88 hours/week, when averaged over 4 weeks by the ACGME

Page 63 of 102

2015-16 AIR Meeting

On August 17, 2016, the GMEC conducted its Annual Institutional Review (AIR) meeting. The committee reviewed the outcomes from last year’s action plan. All items from last year’s action plan have been completed or are in the process of being completed and are tracked in an institutional improvement spreadsheet. The AIR meeting also included a review of aggregate institutional metrics and potential goals, many of which have been compiled in this report. In addition, the meeting included a discussion on the pros and cons of changing the Sponsoring Institution from UWHCA to UWSMPH. The attendees updated last year’s strengths, weaknesses, opportunities, and threats (SWOT) and developed an action plan for the upcoming year.

Updated Institutional SWOT analysis

Strengths Weaknesses • Excellent reputation and branding of UW Health• Strong financial position of UW Health• We attract strong candidates – (should measure

percentage AOA, fill rate, etc.) – residents oftenbecome faculty

• Overall strong programs; GME has done a great jobbringing up the bottom

• Fantastic environment for interdisciplinary, teamoriented learning

• Close working relationships with QI/PS

• Increasing administrative burdens; resourceconstraints at both the program and GME Officelevels

• Technological difficulties with MedHub• Resident data needs• Lack of cultural diversity in applicants• There’s what we need to do vs. want to do ‐ how

much burden does that take? Striking the rightbalance.

• Clinical program holds leadership – need strongeducation advocates throughout UW Health – GMEshouldn’t be an afterthought

• New CEO and CMO• Lack of an institutional approach to resident

wellness

Opportunities Threats • Strength of the Global Health program and what it

offers to our trainees• Development of trainees into eventual faculty• Strengthen GME within UW Health – need C‐Suite

support• Where should GME sit? UWSMPH vs. UW Health• Highlight noteworthy practices from programs at

GMEC – retreats wear off quickly• With the NAS and Self Study process, there’s an

opportunity to do more than the minimum• Closer ties with UWSMPH with their new

curriculum• Resident health and wellness is also a possibility for

opportunity to support trainees as they progress intheir programs

• Funds flow committee work/ GME costtransparency

• Concerns regarding the funding of future programs• Increased cost of trainees given the current

reimbursement climate• The need for more positions to fulfill future

physician needs for population health• Increasing ACGME requirements/administrative

burdens (e.g., CLER)• Resident burnout/depression• More clinical missions and less educational

missions• MCW statewide growth• Greater financial incentive (sometimes) to work

with medical students versus residents

32

Page 64 of 102

The meeting concluded with the formalization of the below Institutional action plan for the 2016‐17 academic year.

2016-17 Action Plan

• Formalize Wellness Work Group as a GMEC Subcommittee (follow MBI survey results, identifyresources, and inventory Program Wellness initiatives)

• Prepare for 2017 CLER Visit• Support ACGME NAS Program Self Study Process• Continue to brief/educate new UW Health leadership on GME• Update Institutional Quality Improvement Curriculum• Continue work with Information Management to identify opportunities to increase resident access

to practice habit data• Participate in defining the role of trainees in relation to UW Health’s increased geographic footprint• Understand impact of the UWSMPH Curriculum Transformation on GME• Increase transparency of all GME related costs• Assess existing differences in incentives for education of UME and GME• Improve resident access to necessary Information Technology resources

33

Page 65 of 102

Appendix A: 2015-16 GME Program Overview Table

Program Name Date of Next Self Study/Site Visit

Length of Training (years) UWHCA FTE VAH FTE Meriter FTE SSM FTE Other FTE Total FTE

Anesthesiology 4/1/2021 4 44.33 2.00 3.00 0.00 0.00 49.33 Critical Care Medicine 4/1/2021 1 0.00 0.00 0.00 0.00 0.00 0.00 Pediatric Anesthesiology* 7/1/2017 1 0.00 0.00 0.00 0.00 0.00 0.00 Dermatology 5/1/2019 3 7.23 2.77 0.00 0.00 0.00 10.00 Micrographic Surgery & Dermatologic Oncology 5/1/2019 1 0.00 0.00 0.00 0.00 1.00 1.00 Medicine/Dermatology (combined) NA 5 1.60 0.40 0.00 0.00 0.00 2.00 Emergency Medicine 2/1/2021 3 31.40 1.84 0.92 0.00 1.84 36.00 Internal Medicine 10/1/2017 3 45.66 30.34 5.00 0.00 0.00 81.00 Allergy/Immunology 6/1/2023 2 2.00 1.00 0.00 0.00 2.00 5.00 Cardiovascular Disease 10/1/2017 3 8.00 4.00 0.00 0.00 0.00 12.00

Advanced Heart Failure & Transplant Cardiology 10/1/2017 1 0.00 0.00 0.00 0.00 0.00 0.00 Clinical Cardiac Electrophysiology 10/1/2017 1 0.04 0.00 0.00 0.00 0.00 0.04 Interventional Cardiology 10/1/2017 1 1.00 0.00 0.00 0.00 1.00 2.00

Endocrinology, Diabetes & Metabolism 10/1/2017 2 1.17 2.00 0.00 0.00 3.00 6.17 Gastroenterology 10/1/2017 3 2.00 3.00 1.00 1.00 2.00 9.00

Transplant Hepatology 10/1/2017 1 0.00 0.00 0.00 0.00 1.00 1.00 Geriatric Medicine 10/1/2017 1 0.00 4.00 0.00 0.00 0.00 4.00 Hematology & Oncology 10/1/2017 3 5.00 4.00 0.00 0.00 1.00 10.00 Hospice and Palliative Care 10/1/2017 1 2.00 1.00 0.00 0.00 1.00 4.00 Infectious Disease 10/1/2017 2 2.00 2.00 0.00 0.00 0.00 4.00 Nephrology 10/1/2017 2 3.50 2.00 0.50 0.00 0.00 6.00 Pulmonary Disease & Critical Care Medicine 10/1/2017 3 5.00 3.00 0.00 0.00 0.00 8.00 Rheumatology 10/1/2017 2 1.00 1.00 0.00 0.00 0.00 2.00 Sleep Medicine 10/1/2017 1 0.00 1.00 0.00 0.00 0.00 1.00 Neurological Surgery 6/1/2023 7 9.86 1.39 1.00 0.00 1.75 14.00 Neurology 11/1/2018 4 7.92 3.08 0.00 0.00 0.00 11.00 Child Neurology 11/1/2018 3 0.00 0.00 0.00 0.00 0.00 0.00 Clinical Neurophysiology 11/1/2018 1 0.00 0.00 0.00 0.00 0.00 0.00 Vascular Neurology 11/1/2018 1 0.00 0.00 0.00 0.00 0.00 0.00 Nuclear Medicine 11/1/2018 3 1.00 0.00 0.00 0.00 0.00 1.00 Obstetrics & Gynecology 12/1/2020 4 7.78 0.00 12.90 3.32 0.00 24.00 Ophthalmology 5/1/2017 3 6.00 3.00 0.00 0.00 0.00 9.00 Orthopedic Surgery 1/1/2024 5 19.35 2.00 3.45 0.20 0.00 25.00 Orthopedic Sports Medicine 1/1/2024 1 1.00 0.00 0.00 0.00 0.00 1.00 Otolaryngology 2/1/2024 5 10.00 2.00 1.00 0.00 0.00 13.00 Pathology - Anatomic & Clinical 4/1/2023 4 14.24 4.00 0.80 1.00 0.00 20.04 Blood Banking/Transfusion Medicine* 5/1/2017 1 0.00 0.00 0.00 0.00 0.00 0.00 Cytopathology 4/1/2023 1 0.50 0.00 0.00 0.00 0.50 1.00 Hematopathology 4/1/2023 1 0.00 0.00 0.00 0.00 0.00 0.00 Pediatrics 3/1/2016 3 40.06 0.00 5.20 0.00 0.00 45.26 Medical Genetics 9/1/2019 2 0.00 0.00 0.00 0.00 0.00 0.00 Neonatal – Perinatal Medicine 3/1/2016 3 0.00 0.00 2.75 0.00 0.25 3.00 Pediatric Critical Care Medicine 3/1/2016 3 6.00 0.00 0.00 0.00 0.00 6.00 Pediatric Endocrinology 3/1/2016 3 1.00 0.00 0.00 0.00 2.00 3.00 Pediatric Hematology/Oncology 3/1/2016 3 2.00 0.00 0.00 0.00 2.00 4.00 Pediatric Infectious Disease 3/1/2016 3 1.41 0.00 0.00 0.00 0.59 2.00 Pediatric Pulmonology 3/1/2016 3 0.00 0.00 0.00 0.00 0.00 0.00 Pediatric Sports Medicine 3/1/2016 1 1.00 0.00 0.00 0.00 0.00 1.00 Physical Medicine & Rehabilitation 8/1/2018 3 8.25 0.00 0.00 0.00 0.75 9.00 Plastic Surgery 5/1/2024 6 10.52 1.43 3.05 1.00 0.00 16.00 Preventive Medicine 4/1/2026 2 0.00 1.00 0.00 0.00 3.00 4.00 Psychiatry 4/1/2020 4 23.11 5.00 0.00 0.00 2.06 30.17 Addiction Psychiatry 4/1/2020 1 0.00 1.91 0.00 0.00 0.00 1.91 Child & Adolescent Psychiatry 4/1/2020 2 2.68 0.00 1.50 0.00 0.03 4.21 Geriatric Psychiatry 4/1/2020 1 0.00 0.00 0.00 0.00 0.00 0.00 Radiation Oncology 9/1/2021 4 8.84 0.16 0.00 0.00 0.00 9.00 Radiology - Diagnostic 4/1/2016 4 28.20 2.00 0.80 0.00 0.00 31.00 Neuroradiology 4/1/2016 1 2.00 1.00 0.00 0.00 1.00 4.00 Vascular & Interventional Radiology 4/1/2016 1 1.00 0.00 0.00 0.00 1.00 2.00 Surgery 11/1/2021 5 25.28 4.72 3.00 0.00 11.00 44.00 Surgical Critical Care Pending 1 1.00 0.00 0.00 0.00 0.00 1.00 Thoracic Surgery 1/1/2017 2 1.50 0.50 0.00 0.00 0.00 2.00 Vascular Surgery Integrated 11/1/2021 5 2.97 1.50 0.53 0.00 0.00 5.00 Vascular Surgery 11/1/2021 2 1.50 0.50 0.00 0.00 0.00 2.00 Urology 3/1/2023 4 6.00 2.00 1.00 1.00 1.00 11.00

414.90 102.54 47.40 7.52 40.77 613.13 64 ACGME-accredited programs and 1 combined program. All programs have Continued Accreditation status unless * (Initial Accreditation)

Page 66 of 102

Appendix B: 2015-16 Program Directors

Program Program Director Program Appointment Date Anesthesiology Paul Kranner, MD 4/22/99

Anesthesiology Critical Care Medicine Jonathan Ketzler, MD 12/11/01

Pediatric Anesthesiology Bridget Muldowney, MD 6/15/16

Dermatology William Aughenbaugh, MD 10/1/06

Procedural Dermatology Juliet Aylward, MD 7/1/12

Emergency Medicine Mary Westergaard, MD 7/1/14

Internal Medicine Bennett Vogelman, MD 1/1/89

Cardiovascular Disease Peter Rahko, MD 1/1/14

Advanced Heart Failure/Transplant Cardiology David Murray, MD 1/1/14

Clinical Cardiac Electrophysiology Michael Field, MD 7/18/12

Interventional Cardiology Giorgio Gimelli, MD 7/1/09

Endocrinology, Diabetes & Metabolism Jennifer Poehls, MD 4/1/16

Gastroenterology Eric Gaumnitz, MD 7/1/01

Geriatric Medicine Steven Barczi, MD 7/1/97

Hematology/Oncology Thomas McFarland, MD 12/15/10

Hospice and Palliative Care Toby Campbell, MD 10/20/10

Infectious Disease Jeannina Smith, MD 7/1/14

Nephrology Arjang (Aji) Djamali, MD 7/1/11

Pulmonary Disease & Critical Care Medicine Mark Regan, MD 7/1/04

Rheumatology Kevin McKown, MD 9/1/00

Sleep Medicine David Plante, MD 8/1/13

Transplant Hepatology Adnan Said, MD 9/15/10

Neurological Surgery Daniel Resnick, MD 7/1/12

Neurology Justin Sattin, MD 7/1/12

Child Neurology Chris Ikonomidou, MD 7/1/13

Clinical Neurophysiology Rama Maganti, MD 10/17/12

Vascular Neurology Edward "Luke" Bradbury, MD 5/20/15

Nuclear Medicine Lance Hall, MD 3/20/13

Obstetrics & Gynecology Ellen Hartenbach, MD 7/1/13

Ophthalmology Andrew Thliveris, MD 7/1/14

Orthopedic Surgery Gerald Lang, MD 4/1/15

Orthopedic Sports Medicine John Orwin, MD 8/1/90

Otolaryngology Tony Kille, MD 6/24/15

Pathology ‐ Anatomic & Clinical Robert Corliss, MD 5/1/15

Blood Banking/Transfusion Medicine Thomas Raife, MD 7/1/15

Hematopathology Catherine Leith 11/1/2000

Pediatrics John Frohna, MD 8/13/07

Pediatric Critical Care Medicine Michael Wilhelm, MD 1/1/09

Pediatric Endocrinology David Allen, MD 1/1/03

Pediatric Infectious Disease James Conway, MD 7/1/12

Medical Genetics Gregory Rice, MD 10/1/15

Neonatal ‐ Perinatal Medicine John Frohna, MD 11/1/12

35

Page 67 of 102

Program Program Director Program Appointment Date Pediatric Sports Medicine David Bernhardt, MD 7/1/94

Physical Medicine & Rehabilitation Bonnie Weigert, MD 7/1/05

Plastic Surgery Neil Salyapongse, MD 4/1/12

Psychiatry Art Walaszek, MD 11/15/04

Addiction Psychiatry Timothy Cordes, MD 2/1/15

Geriatric Psychiatry Lisa Boyle, MD 9/1/14

Radiology ‐ Diagnostic David Kim, MD 7/1/05

Neuroradiology Tabby Kennedy, MD 2/20/13

Radiology Vascular & Interventional Orhan Ozkan, MD 8/1/09

Radiation Oncology Kristen Bradley, MD 4/20/11

Surgery Eugene "Chip" Foley, MD 6/1/08

Surgical Critical Care Suresh Agarwal, MD 7/1/14

Thoracic Surgery Nilto De Oliveira, MD 5/18/16

Urology Daniel Williams, MD 6/24/11

Vascular Surgery John Hoch, MD 07/01/99

Vascular Surgery – Integrated John Hoch, MD 07/01/99

36

Page 68 of 102

Appendix C: 2015-16 Scholarly Activity*

Awards

Resident Awards

Lauren Craddock, Medicine ‐Dermatology PG4, received the Society for Investigative Dermatology Future Academician award.

Mircea Cristescu, Radiology PG4, received two Excellent Poster Abstract awards and a Resident-in-Training Travel Scholarship from World Congress on Interventional Oncology (WCIO).

Juan Danobeitia, General Surgery PG3, received the American Society of Transplant Surgeons 2016 Resident Scientist Scholarship and the 2016 Association for Academic Surgery Research Fellowship Award for Basic Science/Translational Research.

Jason Eccleston, Internal Medicine PG1, received the Emerging Resident Liver Scholar Award from the American Association for the Study of Liver Disease.

Jamie Elliot, Neurology PG4, received the Francis M. Forster Award at the Wisconsin Neurological Society Annual Conference.

Alexander Fisher, General Surgery PG2, received the American College of Surgeons Resident Research Scholarship.

Sara Heintzman, Orthopedic Surgery PG3, received the Wisconsin Orthopedic Society Resident Research Presentation award (Wisconsin Cup Winner) and was named Resident Scholar by the American Orthopaedic Foot and Ankle Society.

Benjamin Jensen, Anesthesiology PG2, received First Place for Airway Presentation at Multicenter Airway Research Collaboration (MARC).

Katherine O’Rourke, Obstetrics and Gynecology PG4, recognized by Brava Magazine as one of the 2016 Women to Watch and by the Wisconsin Alliance of Women’s Health as the 2016 Woman of Character. Both awards recognized Dr. O’Rourke for her work co‐creating “Share the Health” nonprofit clinic, which provides gynecologic specialty care to underserved women at no cost.

Christina Papageorge, General Surgery PG3, received the Clinical Research Fellowship from the Association of Academic Surgeons.

Jennifer Philip, General Surgery PG2, received the Nina Starr Brunwald Fellowship from the Thoracic Surgery Foundation for Research and Education and the American College of Surgeons Resident Research Scholarship.

Carolina Sandoval-Garcia, Neurosurgery PG6, received the American Association of Neurological Surgeons/Congress of Neurological Surgeons (CNS) Resident Research Award in Cerebrovascular Disease.

Robert Strait, Pediatric Endocrinology PG5, was awarded the PES Travel Award to attend the PES Spring Fellows Retreat and the Endocrine Fellows Foundation Research Grant.

Molla Teshome, Pulmonary and Critical Care Medicine PG5, received the Minority Trainee Development Scholarship Award by the American Thoracic Society (ATS).

Ying Wang, Psychiatry PG2, awarded the AAAP Travel Award to attend the AAAP Annual Meeting.

* The included scholarly activity was self‐reported through a survey developed by the GME Office. For Program Director (PD), Associate Program Director (APD) and Faculty work, the selected activity is limited to work directly related to ACGME accreditation or the clinical learning environment. Bolded names indicate UW Health residents, PDs, APDs, or program faculty.

37

Page 69 of 102

Andrzej Wojcieszynski, Radiation Oncology PG4, was accepted as the American Society of Clinical Oncology/American Association for Cancer Research Methods in Clinical Research Fellow.

Kerry Zajicek, Anesthesiology PG3 and the UW Anesthesiology residents, received Second Place for the Resident Quality Improvement Project Award from the Anesthesiology Patient Safety Foundation at the American Society of Anesthesiologists’ Annual Meeting.

Carly Zeal, Obstetrics and Gynecology PG3, received the Ryan Resident Scholarship.

Program Director and Associate Program Director Awards

Steven Barczi (Geriatrics), Designated representative for field of Geriatric Medicine on the Association of Specialty Professors Council of the Alliance of Academic Internal Med; Outgoing Chair for the Geriatric Medicine Fellowship Directors Council through the Association for Directors of Geriatric Academic Programs

John Frohna (Pediatrics) received MPPDA Leadership in Med-Peds Award, honoring a physician who has made “significant contributions to Medicine‐Pediatrics (Med‐Peds) as a profession."

Daniel Sklansky (Pediatrics, Associate), Selected for APPD LEAD 1-year pediatric leadership and scholarship development program.

Tabassum Kennedy (Neuroradiology) received the Best Exhibit Award at the American Society of Spine Radiology annual meeting.

Poster Presentations Selected presentations highlighting Educational and Quality Improvement work

Resident Poster Presentations

Caretta-Weyer HA, Wilbanks MD, Snow BS, Kraut AS, Barclay‐Buchanan CJ, Westergaard MC. 360 degree feedback: a novel format for a program evaluation committee in an academic emergency medicine residency program. Poster presented at: CORD Academic Assembly Advances in Education Research and Innovation Forum; May 2017; Nashville, TN.

Holden T, Stammer K, King J, Campbell, T. Improved clinical trial accrual using a novel decision support intervention: a communication tool called best case/worst case: clinical trials. Poster presented at: Palliative Care in Oncology Symposium; October 2015; Boston, MA.

McBride J. Influence of a “No MRSA, No Pseudomonas” comment to a respiratory culture in antibiotic utilization during treatment of lower respiratory tract infection. Poster presented at: Infectious Disease Week Research Forum; October 2015; San Diego, CA.

Shirley DK, Scholtz H, Osterby K, Fox BC, Safdar NA. Optimizing urine culture ordering practices using the electronic medical record: a pilot study. Poster presented at: SHEA Spring 2016 Conference; May 2016; Atlanta, GA.

Taylor L, Aditbhatla S, Nace D, Crnich C. Antibiotic stewardship structure and process in Wisconsin nursing homes: a follow‐up telephone survey. Poster presented at: Infectious Disease Week Research Forum; October 2016; New Orleans, LA.

Tevis S, Ravi S, Buel L, Clough B, Goelzer S. Blueprint for a successful resident quality and safety council. Poster presented at: Institute for Healthcare Improvement 27th Annual National Forum; December 2015; Orlando, FL.

Tevis S, Schmocker R, Wetterneck T. Improvement of resident reported patient safety events. Poster presented at: Institute for Healthcare Improvement 27th Annual National Forum; December 2015; Orlando, FL.

38

Page 70 of 102

Program Director and Associate Program Director Poster Presentations

Quinn M, Zelenski A. How do burnout, emotional style, and empathy relate? A preliminary correlation study. Poster presented at: SGIM 2016 National Meeting; May 2016; Hollywood, FL.

Sklansky DJ, Syverson GD, Cercone M, DeSantes K, Eikhoff J, Frohna J. Correlation of pediatric residency applicant scoring with mean pediatric milestone assessment scores for 2013‐14 and 2014‐15 pediatric interns at a medium sized pediatric residency program. Poster presented at: Association of Pediatric Program Directors National Meeting; April 2016; New Orleans, LA. Poster presented at: Pediatric Academic Society National Meeting; May 2016; Baltimore, MD.

Welch L, Barczi S, Eastman A, Boyle L, Hermann C, Schroeder R. Interprofessional learner’s performance in a geriatric simulation experience. Poster presented at: American Geriatric Society Annual Meeting; May 2016.

Presentations

Resident Presentations

Allen H, Sadowski EA. Comparison of surgical outcomes in endometrial cancer patients undergoing pre‐operative MRI. Presented at: Association of University Radiologists; 2016; San Diego, CA.

Boly M. Integrated information theory of consciousness. Lecture, tutorial presented at: Association for the Scientific Study of Consciousness Meeting; June 2016; Buenos Aires, Argentina.

Boly M. Integrated information theory: from consciousness to its physical substrate. Lecture, plenary symposium presented at: Association for the Scientific Study of Consciousness Meeting; June 2016; Buenos Aires, Argentina.

Boly M. Quantifying Consciousness. Lecture, plenary symposium presented at: Organization for Human Brain Mapping Meeting; June 2016; Geneva, Switzerland.

Bonnichsen, KD. HPV‐associated squamous neoplasia and a partial review of the lower anogenital squamous terminology criteria. Talk presented at: Wisconsin Dermatological Society Spring Meeting; April 2016; Madison, WI.

Brin L. Pseudolymphoma. Talk presented at: Wisconsin Dermatological Society; April 2016; Madison, WI.

Cristescu M, Smolock A, Carberry G, Nocerino E, Brace C, Lee F. Actual Versus Expected Ablation Zone Margins: Evaluation in In‐Vivo Porcine Liver Demonstrates Margin Overestimation. WCIO, Boston, MA. June 2016.

Elliott JL. From migraine to coma: a complex neurological presentation of systemic disease. Talk presented at: WNS; October 2015; Wisconsin Dells, WI.

Feld S, Tevis S, Cobian A, Craven M, Kennedy G. Big data in surgery: modeling how post‐surgical complications increase risk for further complications. Presented at: Annual Academic Surgical Congress; February 2016; Jacksonville, FL.

Gunter RL, Fernandes‐Taylor S, Wiseman JT, Barnes ML, Ma Y, Rathouz PJ, Kent KC, Yamanouchi D. Validating the use of smartphone digital images for postoperative wound monitoring. Talk presented at: 2015 Agency for Healthcare Research and Quality Research Conference; Washington, DC. Talk presented at: 2016 American Surgical Congress; Jacksonville, FL.

Heintzman SE, Hughes MJ, Scerpella TA. Retrospective analysis of osteoporosis evaluation and treatment following fragility fracture of the hip. Oral presentation: Wisconsin Orthopedic Society; October, 2015; Milwaukee, WI.

Hullett CR, Rosenberg SR, Wojcieszynski AP, Geurts MW, Labby ZE, Hill PM, Bayliss RA, Paliwal BR, Bayouth J, Harari PM, Bassetti M. Quantitative differences in planned and delivered dose for liver SBRT using MRI guided delivery. Oral Presentation: ASTRO Annual Meeting 2015; San Antonio, TX.

39

Page 71 of 102

Israel J, Greenhalgh D, Gibson A. Variations in burn excision and grafting: a survey of the American burn association. Oral presentation: Midwestern Association of Plastic Surgeons; Chicago, IL.

Martin, MD. A wolf in sheep’s clothing: lung cancers with benign features on CT. Lecture presented at: Wisconsin Radiological Society 67th Annual Meeting: The Crossroads of Radiology: The Future is you; April 2016; Kohler, Wisconsin.

Martin, MD. LungRadsTM: algorithm and ambiguity. Lecture presented at: Wisconsin Radiological Society 67th Annual Meeting: The Crossroads of Radiology: The Future is you; April 2016; Kohler, Wisconsin.

Papageorge CM, Kennedy GD, Carchman EH. National trends in short‐term outcomes following non‐emergent surgery for diverticular disease. Talk presented at: Wisconsin Surgical Society Annual Conference; November 2015; Kohler, WI.

Papageorge CM, Kennedy GD. Transfusion is a predictor of worse short‐term postoperative outcomes following colectomy. Talk presented at: Academic Surgical Congress; February 2016; Jacksonville, FL.

Philip J, Macke R. Robotic Morgani hernia repair. Talk presented at: AATS Annual Meeting; May 2016; Baltimore, MD.

Sandoval-Garcia C, Yang P, Schubert T, Schafer S, Ahmed A, Strother C. Comparison of the Diagnostic Utility of 4D DSA with Conventional 2D and 3D DSA in the Diagnosis of Cerebrovascular Pathologies. Talk presented: 54th Annual Meeting of the American Society of Neuroradiology. Washington, DC. May 21‐26, 2016.

Sandoval-Garcia C, Aagaard‐Kienitz B, Uluc K, Iskandar BJ. Outcome and surgical technique of a wide arterial sparing encephalo‐duro‐synangiosis (waseds) for moyamoya disease. Talk presented at: 44th Annual Meeting; December 2015; Seattle, WA.

Schmocker RK, Vanness DJ, Greenberg CC, Havlena JA, LoConte NK, Weiss JM, Neuman HB, Winslow ER. Utilization of endoscopic ultrasound prior to surgery in patients with pancreatic adenocarcinoma. Talk presented at: Academic Surgical Congress; February 2016; Jacksonville, FL.

Schmocker RK, Reeder SB, Winslow ER, Weber SM. A novel magnetic resonance imaging protocol for pancreatic cystic lesions. Talk presented at: Academic Surgical Congress; February 2016;Jacksonville, FL.

Schwalbe ML, Mrak LN, Gill KG, Pinchot JW, Aagaard‐Kienitz BL, Moe D, King D, Buehler D and North PE. Non‐syndromic low‐flow mixed venous/lymphatic malformation of skeletal muscle of the extremity (fibro‐adipose vascular anomaly): a clinicopathologic study of 23 cases. Talk presented at: International Conference for the International Society for the Study of Vascular Anomalies; April, 2016; Buenos Aires, Argentina.

Trask DJ, Squire MW, Keene JS. Analysis of the current indications for microfracture of chondral lesions in the hip. Talk presented at: AAOS 2016 Annual Meeting; March 2016; Orlando. FL.

Wojcieszynski AP, Hill PM, Rosenberg SR, Brower JV, Hullett CR, Mittauer K, Geurts MW, Labby ZE, Bayouth J, Anderson B. Prospective results of real‐time MRI‐guided lumpectomy cavity boost treatment. Oral Presentation at: ASTRO Annual Meeting 2016; Boston, MA.

Wojcieszynski AP, Abel EJ, Lee F, Best S, Lubner M, Chappell R, Ritter MA, Bassetti M. Real‐time MRI‐guided stereotactic body radiation therapy and microwave ablation for non‐operable renal cell carcinoma. Oral Presentation at: 14th International Kidney Cancer Symposium; 2015; Miami, FL.

Program Director Presentations

Barczi S. Geri‐PACT and learners: the academic PACT model. Talk presented at: Geri‐PACT National Summit, Veterans Health Administration and Geriatrics Extended Care; March 2016.

Barczi S. Beyond the match—next steps for evaluating program outcomes. Talk presented at: Geriatric Medicine Fellowship Pre‐Conference, American Geriatric Society Annual Meeting; May 2016.

40

Page 72 of 102

Frohna J, Sklansky DJ. Learner‐Centered Feedback: Content Based on Milestone Achievement, Delivery Using Self‐Determination Theory Workshop. American Society of Cytopathology Annual Conference. Chicago, IL.

Frohna, J. (2016) Pearls of Wisdom: Information from Early Self‐Studies Broadly Relevant to All Programs. ACGME Annual Education Conference. Washington, DC.

Frohna, J. (2016) The ACGME Self‐Study and Program Improvement: New Tools, New Ways of Thinking. Association of Pediatric Program Directors Annual Meeting. New Orleans, LA.

Robbins JB, Sarkany D. Program oversight and evaluation: the self‐study‐ large and small program perspectives. Talk presented at: Association of University Radiologists Annual Meeting; March 2016; San Diego, CA.

Sklansky DJ. A medium‐sized program’s approach to recruitment and selection of excellent residents who aren’t deterred by snow. Talk presented at: Association of Pediatric Program Directors National Meeting; New Orleans, LA.

Sklansky DJ, Syverson G, Frohna J. Workshop: Empowering faculty to foster resident initiative and ownership across clinical and educational settings using practical examples and self‐determination theory. Talk presented at: Association of Pediatric Program Directors National Meeting; 2016; New Orleans, LA.

Book Chapters Authored by Residents

Baggott C. Anatomization: the history of a uniquely human art. In: Amgad H, Anatomy and Exposures of Spinal Nerves. Springer.

Baggott C, Haldeman C, Resnick D. Treatment of injuries at the cervicothoracic unction. In: Youmans and Winn Neurological Surgery.

Berhanu, D, et al. Hernias in the emergency department. In: Hamilton (ON). Scientific American Emergency Medicine. Decker Intellectual Properties; 2016.

Hess JR, Pagano M, Hess AS. Bleeding and clotting: blood and drugs. In: Recent Advances in Anesthesiology: Essential Clinical Updates for Practitioners. Sharjah, UAE: Bentham; 2016.

Israel JI, King TW. Pediatric and fetal wound healing. In: Bentz ML, Bauer BS, Zuker RM, eds. Principles and Practice of Pediatric Plastic Surgery. 2nd ed. CRC Press; 2016.

Papageorge CM, Foley EF. Colonic volvulus. In: Zinner MJ, Ashley SW, eds. Maingot's Abdominal Operations. 13th ed.

Papageorge CM, Kennedy GD. Cryptoglandular disease. In: Chen H, ed. Illustrative Handbook of Surgery. 2nd ed.

Resnick D, Baggott C, Chiles BW, Cooper PR. Trauma of the mid‐ and lower cervical spine. In: Atlas of Neurosurgical Techniques: Spine.

Said A, Ghufran A. Viral hepatitis: other viral hepatides. In: Saeian K, Shaker R. eds. Liver Disorders: A Point-of-Care Clinical Guide. Springer International Publishing; 2016.

Tevis S, Kennedy G. Lateral internal sphincterotomy. In: Chen H. Illustrative Handbook of General Surgery. 2nd ed. London, UK: Springer; 2016.

Tevis S, Kennedy G. Post‐operative complications. In: Clinics in Colon and Rectal Surgery. 2016.

Tevis S, Stomas HC. In: Chen H. Illustrative Handbook of General Surgery. 2nd ed. London, UK: Springer; 2016.

41

Page 73 of 102

Journal Articles

Resident Articles

Allen C, Evans G, Sutton EL. Pharmacologic Therapies in Women's Health: Contraception and Menopause Treatment. Med Clin North Am. 2016 Jul;100(4):763‐89. PubMed PMID: 27235614.

Block L, Gosain A, King TW. Emerging Therapies for Scar Prevention. Adv Wound Care (New Rochelle). 2015 Oct 1;4(10):607‐614. PubMed PMID: 26487979.

Block L, King TW, Gosain A. Debridement Techniques in Pediatric Trauma and Burn‐Related Wounds. Adv Wound Care (New Rochelle). 2015 Oct 1;4(10):596‐606. PubMed PMID: 26487978.

Block LM, Jee YM, Baskaya MK, Bentz ML, Poore SO. Denying the Obvious: Four Extreme Cases of Neglected Tumors. Plast Reconstr Surg Glob Open. 2015 Nov;3(11):e571. PubMed PMID: 26893996.

Brower JV, Saha S, Rosenberg SA, Hullett CR, Ian Robins H. Management of leptomeningeal metastases: Prognostic factors and associated outcomes. J Clin Neurosci. 2016 May;27:130‐7. PubMed PMID: 26778048.

Burr AR, Molkentin JD. Genetic evidence in the mouse solidifies the calcium hypothesis of myofiber death in muscular dystrophy. Cell Death Differ. 2015 Sep;22(9):1402‐12. PubMed PMID: 26088163.

Chiang J, Cristescu M, Lee MH, Moreland A, Hinshaw JL, et al. Effects of Microwave Ablation on Arterial and Venous Vasculature after Treatment of Hepatocellular Carcinoma. Radiology. 2016 Jun 3;PubMed PMID: 27257951.

Christensen J, Trask D, Dunn WR. What's New in Sports Medicine. J Bone Joint Surg Am. 2016 Apr 20;98(8):693‐9. PubMed PMID: 27098329.

Chu YH, Lloyd RV. Medullary Thyroid Carcinoma: Recent Advances Including MicroRNA Expression. Endocr Pathol. 2016 Aug 18;PubMed PMID: 27539727.

Cleveland EC, Albano NJ, Hazen A. Roll, Spin, Wash, or Filter? Processing of Lipoaspirate for Autologous Fat Grafting: An Updated, Evidence‐Based Review of the Literature. Plast Reconstr Surg. 2015 Oct;136(4):706‐13. PubMed PMID: 26397249.

Correll RN, Goonasekera SA, van Berlo JH, Burr AR, Accornero F, et al. STIM1 elevation in the heart results in aberrant Ca²⁺ handling and cardiomyopathy. J Mol Cell Cardiol. 2015 Oct;87:38‐47. PubMed PMID: 26241845.

Cristescu M, Abel EJ, Wells S, Ziemlewicz TJ, Hedican SP, et al. Percutaneous Microwave Ablation of Renal Angiomyolipomas. Cardiovasc Intervent Radiol. 2016 Mar;39(3):433‐40. PubMed PMID: 26390876.

Danobeitia JS, Hanson MS, Chlebeck P, Park E, Sperger JM, et al. Donor Pretreatment With IL‐1 Receptor Antagonist Attenuates Inflammation and Improves Functional Potency in Islets From Brain‐Dead Nonhuman Primates. Cell Transplant. 2015;24(9):1863‐77. PubMed PMID: 24759633.

Eccleston JL, Su H, Ling A, Heller T, Koh C. Gastrointestinal: Adult presentation of intestinal malrotation. J Gastroenterol Hepatol. 2016 Aug;31(8):1382. PubMed PMID: 27060900.

Egan KG, Israel JS, Ghasemzadeh R, Afifi AM. Evaluation of Migraine Surgery Outcomes Through Social Networking Sites. Plast Reconstr Surg. 2015 Oct;136(4 Suppl):66‐7. PubMed PMID: 26397573.

Elmore SN, Kopecky KE, Jennings K, de Moya M, Beresin G, et al. Supporting Medical Students' Pursuit of Longitudinal Patient Experiences: Piloting an Innovative Visit Notification Tool at the Massachusetts General Hospital. Acad Med. 2016 Jan;91(1):70‐4. PubMed PMID: 26222324.

42

Page 74 of 102

Francis DM, Huang S, Armstrong EA, Werner LR, Hullett C, et al. Pan‐HER Inhibitor Augments Radiation Response in Human Lung and Head and Neck Cancer Models. Clin Cancer Res. 2016 Feb 1;22(3):633‐43. PubMed PMID: 26420857.

García Nores GD, Cuzzone DA, Albano NJ, Hespe GE, Kataru RP, et al. Obesity but not high‐fat diet impairs lymphatic function. Int J Obes (Lond). 2016 Jun 21;PubMed PMID: 27200507.

Garg RK, Poore SO, Wieland AM, Mcculloch TM, Hartig GK. Elective free flap revision in the head and neck cancer patient: Indications and outcomes. Microsurgery. 2015 Nov;35(8):591‐5. PubMed PMID: 26419863.

Garg RK, Poore SO, Wieland AM, Sanchez R, Baskaya MK, et al. Recipient vessel selection in the difficult neck: Outcomes of external carotid artery transposition and end‐to‐end microvascular anastomosis. Microsurgery. 2015 Jul 17;PubMed PMID: 26186688.

Garg RK, Alsheik NH, Afifi AM, Gentry LR. Pterygoid Plate Fractures: Not Limited to Le Fort Fractures. J Craniofac Surg. 2015 Sep;26(6):1823‐5. PubMed PMID: 26147022.

Garg RK, Wieland AM, Poore SO, Sanchez R, Hartig GK. The radial forearm snake flap: A novel approach to oral cavity and oropharyngeal reconstruction that reduces forearm donor site morbidity. Microsurgery. 2015 Jun 9;PubMed PMID: 26069099.

Garg RK, Hartman MJ, Lucarelli MJ, Leverson G, Afifi AM, et al. Nasolacrimal System Fractures: A Description of Radiologic Findings and Associated Outcomes. Ann Plast Surg. 2015 Oct;75(4):407‐13. PubMed PMID: 25815677.

Guldenmund P, Gantner IS, Baquero K, Das T, Demertzi A, (Boly M), et al. Propofol‐Induced Frontal Cortex Disconnection: A Study of Resting‐State Networks, Total Brain Connectivity, and Mean BOLD Signal Oscillation Frequencies. Brain Connect. 2016 Apr;6(3):225‐37. PubMed PMID: 26650183.

Gunter RL, Chouinard S, Fernandes‐Taylor S, Wiseman JT, Clarkson S, et al. Current Use of Telemedicine for Post‐Discharge Surgical Care: A Systematic Review. J Am Coll Surg. 2016 May;222(5):915‐27. PubMed PMID: 27016900.

Haldeman CL, Baggott CD, Hanna AS. Intraoperative ultrasound‐assisted peripheral nerve surgery. Neurosurg Focus. 2015 Sep;39(3):E4. PubMed PMID: 26323822.

Hess AS, Hess JR. Understanding standard deviations and standard errors. Transfusion. 2016 Jun;56(6):1259‐61. PubMed PMID: 27145184.

Hudetz AG, Liu X, Pillay S, Boly M, Tononi G. Propofol anesthesia reduces Lempel‐Ziv complexity of spontaneous brain activity in rats. Neurosci Lett. 2016 Aug 15;628:132‐5. PubMed PMID: 27291459.

Israel JS, Carlson AR, Bonneau LA, Kempton SJ, King TW, et al. Reconstructive surgery and patients with spinal cord injury: Perioperative considerations for the plastic surgeon. J Plast Surg Hand Surg. 2016;50(1):44‐9. PubMed PMID: 26450444.

Jackson DC, Sandoval-Garcia C, Rocque BG, Wilbrand SM, Mitchell CC, et al. Cognitive Deficits in Symptomatic and Asymptomatic Carotid Endarterectomy Surgical Candidates. Arch Clin Neuropsychol. 2016 Feb;31(1):1‐7. PubMed PMID: 26663810.

Kalra AS, Walker AJ, Benson ME, Soni A, Guda NM, et al. Comparison of Capsule Endoscopy Findings to Subsequent Double Balloon Enteroscopy: A Dual Center Experience. Diagn Ther Endosc. 2015;2015:438757. PubMed PMID: 26420979.

Kempton SJ, Bentz ML. Making Master Surgeons Out of Trainees: Part I Teaching Surgical Judgment. Plast Reconstr Surg. 2016 May;137(5):1646‐53. PubMed PMID: 27119935.

Koch C, Massimini M, Boly M, Tononi G. Neural correlates of consciousness: progress and problems. Nat Rev Neurosci. 2016 May;17(5):307‐21. PubMed PMID: 27094080.

43

Page 75 of 102

Kratz JD, Chaddha A, Bhattacharjee S, Goonewardena SN. Atherosclerosis and Nanotechnology: Diagnostic and Therapeutic Applications. Cardiovasc Drugs Ther. 2016 Feb;30(1):33‐9. PubMed PMID: 26809711.

Kruser JM, Nabozny MJ, Steffens NM, Brasel KJ, Campbell TC, et al. "Best Case/Worst Case": Qualitative Evaluation of a Novel Communication Tool for Difficult in‐the‐Moment Surgical Decisions. J Am Geriatr Soc. 2015 Sep;63(9):1805‐11. PubMed PMID: 26280462.

Kusmirek J, Robbins J, Allen H, Barroilhet L, Anderson B, et al. PET/CT and MRI in the imaging assessment of cervical cancer. Abdom Imaging. 2015 Oct;40(7):2486‐511. PubMed PMID: 25666968.

Li Y, Cikla U, Baggott C, Yilmaz T, Chao C, et al. Surgical treatment of adult moyamoya disease with combined STA‐MCA bypass and EDAS: demonstration of technique in video presentation. Turk Neurosurg. 2015;25(1):126‐31. PubMed PMID: 25640557.

Livermore A, Tueting JL. Biomechanics of Tendon Transfers. Hand Clin. 2016 Aug;32(3):291‐302. PubMed PMID: 27387073.

Minami CA, Sheils CR, Bilimoria KY, Johnson JK, Berger ER, et al. Process improvement in surgery. Curr Probl Surg. 2016 Feb;53(2):62‐96. PubMed PMID: 26806271.

Moliver CL, Sanchez ER, Kaltwasser K, Sanchez RJ. A Muscular Etiology for Medial Implant Malposition Following Subpectoral Augmentation. Aesthet Surg J. 2015 Sep;35(7):NP203‐10. PubMed PMID: 26104475.

Montemayor Garcia C, Sandoval Garcia C, Bragg T, Patel NJ, Salamat S. An 11‐Year‐Old Boy with A Sacral Spinal Mass. Brain Pathol. 2015 Sep;25(5):653‐4. PubMed PMID: 26276029.

Nabozny MJ, Barnato AE, Rathouz PJ, Havlena JA, Kind AJ, et al. Trajectories and Prognosis of Older Patients Who Have Prolonged Mechanical Ventilation After High‐Risk Surgery. Crit Care Med. 2016 Jun;44(6):1091‐7. PubMed PMID: 26841105; NIHMSID: NIHMS745570.

Nabozny MJ, Kruser JM, Steffens NM, Pecanac KE, Brasel KJ, et al. Patient‐reported Limitations to Surgical Buy‐in: A Qualitative Study of Patients Facing High‐risk Surgery. Ann Surg. 2016 Jan 18;PubMed PMID: 26797323; NIHMSID: NIHMS760273.

Nabozny MJ, Steffens NM, Schwarze ML. When Do Not Resuscitate Is a Nonchoice Choice: A Teachable Moment. JAMA Intern Med. 2015 Sep;175(9):1444‐5. PubMed PMID: 26075795; NIHMSID: NIHMS684283.

Nelsen EM, Matkowskyj K, Rice JP. A Rare Cause of Ischemic Colitis. Clin Gastroenterol Hepatol. 2016 Aug;14(8):e96‐7. PubMed PMID: 26972985.

Nelsen EM, Johnson EA, Walker AJ, Pfau P, Gopal DV. Endoscopic ultrasound‐guided pancreatic pseudocyst cystogastrostomy using a novel self‐expandable metal stent with antimigration system: A case series. Endosc Ultrasound. 2015 Jul‐Sep;4(3):229‐34. PubMed PMID: 26374582.

Papageorge CM, Kennedy GD. Strategies to Reduce Postoperative Urinary Tract Infections. Adv Surg. 2016 Sep;50(1):79‐91. PubMed PMID: 27520864.

Papageorge CM, Zhao Q, Foley EF, Harms BA, Heise CP, et al. Short‐term outcomes of minimally invasive versus open colectomy for colon cancer. J Surg Res. 2016 Jul;204(1):83‐93. PubMed PMID: 27451872.

Papageorge CM, Kennedy GD, Carchman EH. National Trends in Short‐term Outcomes Following Non‐emergent Surgery for Diverticular Disease. J Gastrointest Surg. 2016 Jul;20(7):1376‐87. PubMed PMID: 27120447.

Philip JL, Razzaque MA, Han M, Li J, Theccanat T, et al. Regulation of mitochondrial oxidative stress by β‐arrestins in cultured human cardiac fibroblasts. Dis Model Mech. 2015 Dec;8(12):1579‐89. PubMed PMID: 26449263.

44

Page 76 of 102

Poore SO, Israel JS, Rao VK. Thirty‐Year Follow‐up of Total Hand Replantation: A Case Report. Ann Plast Surg. 2016 May;76(5):521‐3. PubMed PMID: 25046672.

Sanchez ER, Sanchez R, Moliver C. Anatomic relationship of the pectoralis major and minor muscles: a cadaveric study. Aesthet Surg J. 2014 Feb;34(2):258‐63. PubMed PMID: 24402060.

Sanchez R, Ward K, St Hilaire H, Mussell J. Basicranial venous anomalies associated with complex nonsyndromic craniosynostosis in a child. J Craniofac Surg. 2013 Nov;24(6):1970‐3. PubMed PMID: 24220384.

Sandoval-Garcia C, Royalty K, Aagaard‐Kienitz B, Schafer S, Yang P, et al. A Comparison of 4D DSA with 2D and 3D DSA in the Analysis of Normal Vascular Structures in a Canine Model. AJNR Am J Neuroradiol. 2015 Oct;36(10):1959‐63. PubMed PMID: 26089314.

Sandoval-Garcia C, Royalty K, Yang P, Niemann D, Ahmed A, et al. 4D DSA a new technique for arteriovenous malformation evaluation: a feasibility study. J Neurointerv Surg. 2016 Mar;8(3):300‐4. PubMed PMID: 25583531; NIHMSID: NIHMS710652.

Sarasso S, Boly M, Napolitani M, Gosseries O, Charland‐Verville V, et al. Consciousness and Complexity during Unresponsiveness Induced by Propofol, Xenon, and Ketamine. Curr Biol. 2015 Dec 7;25(23):3099‐105. PubMed PMID: 26752078.

Savetsky IL, Albano NJ, Cuzzone DA, Gardenier JC, Torrisi JS, et al. Lymphatic Function Regulates Contact Hypersensitivity Dermatitis in Obesity. J Invest Dermatol. 2015 Nov;135(11):2742‐52. PubMed PMID: 26176761; NIHMSID: NIHMS707125.

Saxena N, Parajuli S (2016) Spontaneous Perinephric Hematoma with Newer Oral Anticoagulation in Kidney Transplant Recipient. J Renal Ther. 2:002.

Schemmel A, Lee M, Hanley T, Pooler BD, Kennedy T, et al. Radiology Workflow Disruptors: A Detailed Analysis. J Am Coll Radiol. 2016 Jun 13;PubMed PMID: 27313127.

Schmocker RK, Vanness DJ, Macke RA, Akhter SA, Maloney JD, et al. Outpatient air leak management after lobectomy: a CMS cost analysis. J Surg Res. 2016 Jun 15;203(2):390‐7. PubMed PMID: 27363648; NIHMSID: NIHMS796446.

Schmocker RK, Holden SE, Vang X, Lumpkin ST, Cherney Stafford LM, et al. The number of inpatient consultations is negatively correlated with patient satisfaction in patients with prolonged hospital stays. Am J Surg. 2016 Aug;212(2):282‐8. PubMed PMID: 26792276; NIHMSID: NIHMS745084.

Schmocker RK, Holden SE, Vang X, Leverson GE, Cherney Stafford LM, et al. Association of Patient‐Reported Readiness for Discharge and Hospital Consumer Assessment of Health Care Providers and Systems Patient Satisfaction Scores: A Retrospective Analysis. J Am Coll Surg. 2015 Dec;221(6):1073‐82.e1‐3. PubMed PMID: 26474513; NIHMSID: NIHMS725525.

Sethakorn N, O'Donnell PH. Spectrum of genomic alterations in FGFR3: current appraisal of the potential role of FGFR3 in advanced urothelial carcinoma. BJU Int. 2016 Jun 7;PubMed PMID: 27271022.

Shapiro DD, Harel M, Ferrer F, McKenna PH. Focusing on organ preservation and function: paradigm shifts in the treatment of pediatric genitourinary rhabdomyosarcoma. Int Urol Nephrol. 2016 Jul;48(7):1009‐13. PubMed PMID: 27068815.

Sharma R, Hassan C, Chaiban JT. Severe Insulin Resistance Improves Immediately After Sleeve Gastrectomy. J Investig Med High Impact Case Rep. 2016 Jan‐Mar;4(1):2324709615625309. PubMed PMID: 26788532.

Sheka AC, Tevis S, Kennedy GD. Urinary tract infection after surgery for colorectal malignancy: risk factors and complications. Am J Surg. 2016 Jan;211(1):31‐9. PubMed PMID: 26298687.

Smolock AR, Cristescu MM, Potretzke TA, Ziemlewicz TJ, Lubner MG, et al. Microwave Ablation for the Treatment of Hepatic Adenomas. J Vasc Interv Radiol. 2016 Feb;27(2):244‐9. PubMed PMID: 26830938.

45

Page 77 of 102

Smolock AR, Lubner MG, Ziemlewicz TJ, Hinshaw JL, Kitchin DR, Brace CL, Lee FT. Microwave ablation of hepatic tumors abutting the diaphragm is safe and effective. AJR Am J Roentgenol. 2015 Jan;204(1):197‐203.

Steffens NM, Tucholka JL, Nabozny MJ, Schmick AE, Brasel KJ, et al. Engaging Patients, Health Care Professionals, and Community Members to Improve Preoperative Decision Making for Older Adults Facing High‐Risk Surgery. JAMA Surg. 2016 Jun 29;PubMed PMID: 27368074.

Tevis SE, Cobian AG, Truong HP, Craven MW, Kennedy GD. Implications of Multiple Complications on the Postoperative Recovery of General Surgery Patients. Ann Surg. 2016 Jun;263(6):1213‐8. PubMed PMID: 27167563.

Tevis SE, Carchman EH, Foley EF, Harms BA, Heise CP, et al. Postoperative Ileus‐‐More than Just Prolonged Length of Stay? J Gastrointest Surg. 2015 Sep; 19(9):1684‐90. PubMed PMID: 26105552.

Tevis SE, Kennedy GD. Patient satisfaction: does surgical volume matter? J Surg Res. 2015 Jun 1; 196(1):124‐9. PubMed PMID: 25796107.

Theccanat T, Philip JL, Razzaque AM, Ludmer N, Li J, et al. Regulation of cellular oxidative stress and apoptosis by G protein‐coupled receptor kinase‐2; The role of NADPH oxidase 4. Cell Signal. 2016 Mar;28(3):190‐203. PubMed PMID: 26631573; NIHMSID: NIHMS749660.

Titchen KE, Loo D, Berdan E, Rysavy MB, Ng JJ, et al. Domestic Sex Trafficking of Minors: Medical Student and Physician Awareness. J Pediatr Adolesc Gynecol. 2015 May 20;PubMed PMID: 26341745.

Tononi G, Boly M, Massimini M, Koch C. Integrated information theory: from consciousness to its physical substrate. Nat Rev Neurosci. 2016 Jul;17(7):450‐61. PubMed PMID: 27225071.

Vásquez‐Montoya GA, Danobeitia JS, Fernández LA, Hernández‐Ortiz JP. Computational immuno‐biology for organ transplantation and regenerative medicine. Transplant Rev (Orlando). 2016 May 26;PubMed PMID: 27296889.

Vidaver RM, Shershneva MB, Hetzel SJ, Holden TR, Campbell TC. Typical Time to Treatment of Patients With Lung Cancer in a Multisite, US‐Based Study. J Oncol Pract. 2016 Jun;12(6):e643‐53. PubMed PMID: 27143146.

Walczak BE, Johnson CN, Howe BM. Myositis Ossificans. J Am Acad Orthop Surg. 2015 Oct;23(10):612‐22. PubMed PMID: 26320160.

Wang LJ, Kin T, O'Gorman D, Shapiro AM, Naziruddin B, (Danobeitia J), et al. A Multicenter Study: North American Islet Donor Score in Donor Pancreas Selection for Human Islet Isolation for Transplantation. Cell Transplant. 2016;25(8):1515‐23. PubMed PMID: 26922947.

Wiseman JT, Fernandes‐Taylor S, Gunter R, Barnes ML, Saunders RS, et al. Inter‐rater agreement and checklist validation for postoperative wound assessment using smartphone images in vascular surgery. J Vasc Surg Venous Lymphat Disord. 2016 Jul;4(3):320‐328.e2. PubMed PMID: 27318052; NIHMSID: HHSPA773133.

Wojcieszynski AP, Rosenberg SA, Brower JV, Hullett CR, Geurts MW, et al. Gadoxetate for direct tumor therapy and tracking with real‐time MRI‐guided stereotactic body radiation therapy of the liver. Radiother Oncol. 2016 Feb;118(2):416‐8. PubMed PMID: 26627702.

Wojcieszynski AP, Olson AK, Rong Y, Kimple RJ, Yadav P. Acute Toxicity From Breast Cancer Radiation Using Helical Tomotherapy With a Simultaneous Integrated Boost. Technol Cancer Res Treat. 2016 Apr;15(2):257‐65. PubMed PMID: 25780060.

Zyskind JW, Wang Y, Cho G, Ting JH, Kolson DL, et al. E2F1 in neurons is cleaved by calpain in an NMDA receptor‐dependent manner in a model of HIV‐induced neurotoxicity. J Neurochem. 2015 Mar;132(6):742‐55. PubMed PMID: 25279448; NIHMSID: NIHMS639277.

46

Page 78 of 102

Program Directors and Associate Program Directors

Kolehmainen C, Stahr A, Kaatz A, Brennan M, Vogelman B, et al. Post‐Code PTSD Symptoms in Internal Medicine Residents Who Participate in Cardiopulmonary Resuscitation Events: A Mixed Methods Study. J Grad Med Educ. 2015 Sep;7(3):475‐9. PubMed PMID: 26457160.

Nayar HS, Salyapongse AN, Bentz ML. Discussion: A Closer Look at the 2013 to 2014 Integrated Plastic Surgery Match. Plast Reconstr Surg. 2016 Mar;137(3):630e‐631e. PubMed PMID: 26910707.

Umscheid CA, Maenner MJ, Mull N, Veesenmeyer AF, Farrar JT, (Frohna J), et al. Using educational prescriptions to teach medical students evidence‐based medicine. Med Teach. 2016 Apr 13;PubMed PMID: 27075864.

Choo EK, Kass D, Westergaard M, Watts SH, Berwald N, Regan L, Promes SB, Clem KJ, Schneider SM, Kuhn GJ, Nobay F. The Development of Best Practice Recommendations to Support the Hiring, Recruitment and Advancement of Women Physicians in Emergency Medicine. Acad Emerg Med. 2016 Jun 11. PMID 27286760.

Patterson BW, Batt RJ, Wilbanks MD, Otles E, Westergaard MC, Shah MN. Cherry Picking Patients: Examining the Interval Between Patient Rooming and Resident Self‐assignment. Acad Emerg Med. 2016 Feb 13. PMID 26874338.

Faculty Members

Benson M, Lucey M, Pfau P. Outcomes of Procedures Performed by Attending Surgeons after Night Work. N Engl J Med. 2015 Dec 10;373(24):2383. PubMed PMID: 26650166.

Reardon CL, Behrens J. State Licensing Issues: Controversy and Compromise. Acad Med. 2016 Aug;91(8):1037‐8. PubMed PMID: 27465084.

Reardon CL, Walaszek A. Residency Patient Safety Curricula and American Board of Psychiatry and Neurology Patient Safety Courses. Acad Psychiatry. 2016 Jul 11;PubMed PMID: 27400693.

Reardon CL, Bentman A, Cowley DS, Dunaway K, Forstein M, et al. General and Child and Adolescent Psychiatry Resident Training in Integrated Care: a Survey of Program Directors. Acad Psychiatry. 2015 Aug;39(4):442‐7. PubMed PMID: 25778670

47

Page 79 of 102

Appendix D: GME Supervision Policy

Graduate Medical Education Departmental Policy

Policy Title: Supervision of Residents Effective Date: November 18, 2015 Version: Revision

I. PURPOSE

To establish an institutional supervision policy to ensure all residency and fellowship training programs provide increasing amounts of responsibility with appropriate supervision of residents.

II. PERSONS AFFECTED

This policy applies to all Graduate Medical Education (GME) programs and residents sponsored by the University of Wisconsin Hospitals and Clinics (UWHC).

III. DEFINITIONS

A. Resident is intended to include all residents and fellows in ACGME accredited training programssponsored by the University of Wisconsin Hospitals and Clinics.

B. Program(s) will refer to ACGME‐accredited program(s).

IV. POLICY

A. Program Policies: All UWHC GME training programs must create a program‐specific supervisionpolicy that aligns with ACGME program requirements, this policy, the Bylaws, Rules and Regulationsof the Medical Staff of the University of Wisconsin Hospital and Clinics, the Joint Commission, lawand other hospital policies. In the case of inconsistent requirements, the most restrictive must befollowed.

B. Supervision of Residents: In the clinical learning environment, each patient must have anidentifiable, appropriately‐credentialed and privileged attending physician (or licensedindependent practitioner as approved by each Review Committee) who is ultimately responsiblefor that patient’s care.1. This information should be available to residents, faculty members, patients and other hospital

staff.2. Residents and faculty members should inform patients of their respective roles in each

patient’s care.3. In all resident care cases, the ultimate responsibility rests with the attending physician, who

determines the level of supervision required for appropriate training and to assure quality ofpatient care.

C. Levels of Supervision1. Direct Supervision – the supervising physician is physically present with the resident and

patient.

48

Page 80 of 102

2. Indirect Supervision:a. With direct supervision immediately available – the supervising physician is physically

within the hospital or other site of patient care, and is immediately available to providedirect supervision.

b. With direct supervision available – the supervising physician is not physically present withinthe hospital or other site of patient care, but is immediately available by means oftelephonic and/or electronic modalities, and is available to provide direct supervision.

3. Oversight – The supervising physician is available to provide review of procedures/encounterswith feedback provided after care is delivered.

D. Progressive Authority and Responsibility1. The privilege of progressive authority and responsibility, conditional independence, and a

supervisory role in patient care delegated to each resident must be assigned by the programdirector and faculty members.

2. Each resident’s abilities should be evaluated based on specific criteria. When available,evaluation should be guided by specific national standards‐based criteria.

3. Faculty members functioning as supervising physicians should delegate portions of care toresidents, based on the needs of the patient and the skills of the residents.

4. Senior residents or fellows should serve in a supervisory role of junior residents in recognitionof their progress toward independence, based on the needs of each patient and the skills of theindividual resident or fellow.

5. Programs must set guidelines for circumstances and events in which residents mustcommunicate with appropriate supervising faculty members, such as the transfer of a patientto an intensive care unit, or end‐of‐life decisions.

6. Each resident must know the limits of his/her scope of authority, and the circumstances underwhich he/she is permitted to act with conditional independence.

7. Faculty supervision assignments should be of sufficient duration to assess the knowledge andskills of each resident and delegate to him/her the appropriate level of patient care authorityand responsibility.

E. On‐call schedules and rotation schedules are developed to provide residents with a variety ofpatient experiences. Supervision is available at all times through more senior residents and facultyattending physicians.

V. PROCEDURE

A. Each GME program must establish and review annually a program level policy and proceduresassociated with supervision of residents that incorporates the standards set forth in this policy.

B. GME programs are responsible for educating their residents and faculty regarding appropriatesupervision for patient care activities.

C. Policy must include circumstances in which clinical trainees must communicate with thesupervising physician including but not limited to end of life decisions, discharge againstmedical advice and transfer to an intensive care unit.

D. Policy must assure supervising physicians and clinical trainees receive and understand the linesand levels of supervision for each graduate level and rotation (when appropriate).

E. Each program will post their supervision policy on MedHub in the trainee job description area, tobe available to hospital staff. UWHC leadership as needed may set additional proceduredocumentation requirements.

F. Occasionally the need arises for nursing unit staff or other UWHC clinical staff to reach asupervisory physician. Reasons for this include inability to reach the physician (usually a resident)on call, or the need to resolve a concern that has not been resolved after discussion with the

49

Page 81 of 102

physician on call. We have encouraged moving up the chain of command when clinical issues require resolution. UWHC Paging has used the chain of command concept for years. The proposed change will make our front line clinical staff aware of the chain of command. Some have indicated to us they are unsure of who to call if the intern on call does not answer a page—the chain of command may vary by department. In general, the Message Center (UWHC Paging) will follow this algorithm:

Intern or junior resident ↓

Senior resident ↓

Fellow (if applicable) ↓

Staff physician on call ↓

Division Head (if relevant) ↓

Vice Chair for Clinical Affairs ↓

Department Chair ↓

Chief Medical Officer

If an individual does not respond, UWHC Paging will move to the next line of the algorithm. The change will be making front line staff aware of the chain of command option. The goal is to provide timely high quality care to all of our patients.

VI. MODIFICATIONS

This Policy creates no rights, contractual or otherwise. Statements of policy obtained herein are not made for the purpose of inducing any person to become or remain an employee of UWHC, and should not be considered "promises" or as granting "property" rights. UWHC may add to, subtract from and/or modify this Policy at any time. Nothing contained in this Policy impairs the right of a non‐represented employee or UWHC to terminate the employment relationship at‐will.

VII. REFERENCES

ACGME Institutional Requirements (www.acgme.org) ACGME Policies and Procedures Manual (www.acgme.org) ACGME Common Program Requirements (www.acgme.org) Bylaws, Rules and Regulations of the Medical Staff of the University of Wisconsin Hospital and Clinics

50

Page 82 of 102

VIII. COORDINATION

Sr. Management Sponsor: Susan L. Goelzer, M.D., Designated Institutional Official Author: Director, Graduate Medical Education and Medical Staff Administration Review/Approval Committee: Graduate Medical Education Committee 11‐18‐15

SIGNED BY

Susan L. Goelzer, M.D., M.S. Professor of Anesthesiology, Internal Medicine and Population Health Sciences Senior Medical Director for GME/Designated Institutional Official Associate Dean for Graduate Medical Education

Revision Details:

Previous Revision Date: 8/31/2013 Next Revision Due: 10/21/2018 (3 years after effective date)

51

Page 83 of 102

Appendix E: GME Transitions of Care/Hand offs Policy

Graduate Medical Education Department Policy

Policy Title: Transitions of Care / Handoff Policy Effective Date: November 18, 2015 Version: New

I. PURPOSE

To establish protocol and standards within UW Hospitals and Clinics Authority sponsored residency and fellowship programs to ensure consistent, accurate, timely and unambiguous communication between health care personnel that leads to high quality and safety of patient care when transfer of responsibility occurs during duty hour shift changes and other scheduled or unexpected circumstances.

II. PERSONS AFFECTED

This policy applies to all Graduate Medical Education (GME) programs sponsored by the University of Wisconsin Hospitals and Clinics Authority (UWHCA).

III. DEFINITIONS

A. The term “resident” refers to residents and fellows of accredited training programs.B. Program(s) will refer to ACGME‐accredited program(s).C. UW Health: For the purpose of this policy, the term “UW Health” shall mean University of

Wisconsin Hospitals and Clinics Authority, which is the sponsoring institution of the ACGME‐accredited training programs. “UW Health” is the trade name of University of Wisconsin Hospitalsand Clinics Authority and its affiliates.

D. A handoff is defined as a transfer and acceptance of patient care responsibility from one caregiver(sender) to another caregiver (receiver). The sender is responsible for sending or transmitting thepatient data and releasing the care of the patient to the receiver, who receives the patient dataand accepts care of the patient. The transition/hand‐off process is an interactive communicationprocess of passing specific, essential patient information from one caregiver to another. Transitionof care occurs regularly under the following conditions:• Change in level of patient care, e.g., inpatient admission from an outpatient procedure or

diagnostic area or ER and transfer to or from a critical care unit,• Temporary transfer of care to other healthcare professionals, e.g., to and from procedure or

diagnostic areas,• Discharge, including discharge to home or another facility such as skilled nursing care• Change in caregiver or service change, e.g., change of shift, on call, and rotation changes for

residents.

52

Page 84 of 102

IV. POLICY

Individual programs must design schedules and clinical assignments to maximize the learning experience for residents as well as to ensure quality care and patient safety and adhere to general institutional policies concerning transitions of patient care. Each GME program must establish and maintain an intradepartmental policy and procedures associated with transitions of patient care. GME programs are responsible for educating their trainees on UW HEALTH and program policies and procedures related to transitions of patient care.

V. PROCEDURE

A. The transition/hand‐off process must involve communication between the person handing overpatient care (sender) and the person assuming patient care responsibilities (receiver). Whenfeasible, synchronous communication, e.g., face‐to‐face interaction with both verbal andwritten/computerized communication should be done, especially for patients that are critically illor have rapidly changing status. Asynchronous communication is permissible. Hand‐offs can beconducted over the phone as long as both parties have access to an electronic or hard copy versionof the sign‐out sheet. All attempts to preserve patient confidentiality will be observed. The receivermust have the opportunity to ask questions or clarify specific issues. The transition process shouldinclude, at a minimum, the following IDEAL information in a standardized format:• I = Identify patient and physician name or service,• D = Diagnosis and current condition,• E = (Recent) Events / changes in condition or treatment,• A = Anticipated changes in condition or treatment, what to watch for in next interval of care,

contingency plans,• L = Leave time for the opportunity to ask questions and clarify information

B. Each residency program must develop components ancillary to the institutional transition of carepolicy that integrate specifics from their specialty field. Programs are required to developscheduling and transition/hand‐off procedures to ensure that:• Hand‐off communications are be part of the resident work expectations and designed to fit into

the workflow of sending and receiving caregivers.• Residents comply with specialty specific/institutional duty hour requirements• Faculty are scheduled and available for appropriate supervision levels according to the

requirements for the scheduled residents.• All parties (including nursing) involved in a particular program and/or transition process have

access to one another’s schedules and contact information. All call schedules should beavailable on department‐specific password‐protected websites and also with the hospitaloperators.

• Patients are not inconvenienced or endangered in any way by frequent transitions in their care.• All parties directly involved in the patient’s care before, during, and after the transition have

opportunity for communication, consultation, and clarification of information.• Safeguards exist for coverage when unexpected changes in patient care may occur due to

circumstances such as resident illness, fatigue, or emergency.• Programs should provide an opportunity for residents to both give and receive feedback from

each other or faculty physicians about their handoff skills.

C. Each program must include the transition of care process in its curriculum.

53

Page 85 of 102

D. Residents must demonstrate competency in performance of this task. There are numerousmechanisms through which a program might elect to determine the competency of trainees inhandoff skills and communication. These include:• Direct observation of a handoff session by a licensed independent practitioner (LIP)‐level

clinician• Direct observation of a handoff session by a peer or by a more senior trainee• Evaluation of written handoff materials by an LIP‐level clinician• Evaluation of written handoff by a peer or by a more senior trainee• Didactic sessions on communication skills including in‐person lectures, web‐based training,

review of curricular materials and/or knowledge assessment• Assessment of handoff quality in terms of ability to predict overnight events• Assessment of adverse events and relationship to sign‐out quality through:

o Surveyo Reporting hotlineo Trigger toolo Chart review

E. Programs must develop and utilize a method of monitoring the transition of care process andupdate as necessary. Monitoring of handoffs by the program to ensure:• There is a standardized process in place that is routinely followed

o The standardized process should include: The routine situations that handoff communications should occur in and when and

where the handoff is expected to occur. For example, “handoff at the end of a dailywork shift should occur between 4‐5pm to the overnight call person in theresidents office,” or “handoff of patient after an OR case should occur between theanesthesia resident and the PACU nurse immediately upon arrival to the PACU”.

The minimum content of the communication should include all details of IDEALabove. Any additional requirements should be specified.

Expectations for how the handoffs should occur, i.e., face‐to‐face with writteninformation also provided.

Expectations for documentation of the handoff in the medical record, if any• There is consistent opportunity for questions between the sender and receiver• The necessary materials are available to support the handoff (including, for instance, written

sign‐out materials, access to electronic clinical information)• A quiet setting free of interruptions is consistently available, for handoff processes that include

face‐to‐face communication• Sufficient time is scheduled into the resident work schedule to allow for complete hand‐off

preparations and communications.• Barriers to high‐quality handoffs are addressed.• Patient confidentiality and privacy are ensured in accordance with HIPAA guidelines

54

Page 86 of 102

COORDINATION

Sr. Management Sponsor: Susan L. Goelzer, M.D., M.S., Designated Institutional Official Author: Director, Graduate Medical Education and Medical Staff Administration Approval Committee: Graduate Medical Education Committee 11‐18‐15

SIGNED BY

Susan L. Goelzer, M.D., M.S. Professor of Anesthesiology, Internal Medicine and Population Health Sciences Senior Medical Director for GME/Designated Institutional Official Associate Dean for Graduate Medical Education

Revision Details:

Previous Revision Date: 8/31/2013 Next Revision Due: (3 years after effective date)

55

Page 87 of 102

UW Health GME Policies and Statements

IR: Institutional Requirements, effective July 1, 2015CPR: Common Program Requirements, effective July 1, 2016

ACGME Reference Key Words UW Health Policy/Statement Dept of GME Policies/Statements

GME Policy Date Revision Due

Program Policy

Required?IR IV.G.1. Absences UWHCA 9.40 Leaves of Absence,

Excluding Sick, Family and Medical Leaves and UWHCA 9.72 Sick, Family and Medical Leaves of Absence

Resident Absences and Leaves

7/1/2013 7/1/2016 NIR IV.H.4 Accomodation UWHCA 9.68 Accomodation for

Disability NI.B.5. AIR Annual Institutional Review 9/16/2015 9/16/2018 NIR IV.C.1.b) Appeals Appeals of Resident Corrective Action 12/16/2015 12/16/2018 YIR IV.B. Appointment Letter,

Contract, AIDAppointment Letter and Appointment Information Document annually N

Code of Ethics UW Professional Conduct in the Learning Environment 9/21/2005 N

CVAD Policy Training and Certification for Central Vascular Access Devices "CVADs" 7/20/2016 7/20/2019

IR IV.M. Disaster Disaster Management for GME 8/21/2013 8/21/2016 NIR IV.J Duty Hours, Fatigue Resident Duty Hours 8/21/2013 8/21/2016 YCPR V. Evaluation Evaluation of Residents and Faculty 11/18/2015 11/18/2018 YIR I.B. GMEC GMEC Charge 3/15/2015 3/15/2018 NIR IV.D. Grievances Resident Grievances Related to Employment Concerns

8/21/2013 8/21/2016 YIR III.B.3. Handoffs Transitions of Care, Handoff Policy 11/18/2015 11/18/2018 YIR IV.H.3 Harassment,

Discrimination, or Retaliation

UWHCA 9.27 Equal Employment Opportunity and No Harassment/Discrimination/Retaliation N

IR IV.H.2 Impaired Residents UWHCA 9.15 Employee Assistance Program

Impaired Residents Policy Summary8/21/2013 8/21/2016 N

IR IV.K. Industry, Vendors UWHCA 11.19: Regulation of Vendor Representatives and the Vendor Liaison Office (this policy is used by UWHC, UWMF and UWSMPH)

To be developed

NIR I.A.6. Institutional

Commitment GME Institutional Commitment Statement 5/4/2015 5/4/2020 NIR IV.J.1 Moonlighting Moonlighting and Other Outside Activities 5/20/2015 5/20/2018 Y

Name Use Resident Use of Legal Name and Name Changes 4/15/2015 4/15/2018 NOffsite Electives Resident OffSite Electives 10/23/2013 10/23/2016 N

Page 88 of 102

UW Health GME Policies and Statements

IR: Institutional Requirements, effective July 1, 2015CPR: Common Program Requirements, effective July 1, 2016

IR IV.N Program Closure/Reduction

Program Closure or Reduction 5/20/2015 5/20/2018 N

IR IV.C.1. Promotion Promotion of Residents 4/20/2016 4/20/2019 YIR IV.A.1. Recruitment Resident Selection and Appointment 2/16/2011 2/16/2014 YIV.C.C.1.a) Remediation and

Corrective Action Academic Improvement and Corrective Action 12/16/2015 12/16/2018 NResident Files Resident Files and Retention 8/20/2014 8/20/2017 NResident Positions Resident Position Request for New and Existing

Programs 5/20/2015 5/20/2018 NIR IV.L. Restrictive Covenant,

Non-CompetitionRestrictive Covenant Prohibition

8/21/2013 8/21/2016 NSocial Media UW Health 1.47 Social Media N

IR I.B.6. Special Review NIR II.D. Stipends Stipend Administration of GME Trainees 7/15/2015 7/15/2018 NIR IV.I. Supervision Supervision of Residents 11/18/2015 11/18/2018 Y

Transfers Transfers of Residents Approved 4/20/2011 4/20/2014 NCPR V.C. APE, Program

Evaluation not required as a policy

Page 89 of 102

Graduate Medical Education 2639 University Avenue, Suite 201

Madison, WI 53705 Phone: 608-263-0572

E-mail: uwgme@uwhealth.orgUWHealth.org

Page 90 of 102

UW Health Financial Reports

FY17

Consolidated Financial ReviewYear to Date December 31, 2016

Page 91 of 102

UW Health YTD Operating Margin

December 31, 2016

* Combined total includes eliminations and the Academic support included as an operating expense. $90M Integration commitment is reflected in

other non-operating revenue.

** Combined HC/MF without eliminations, which ties to the Incentive Plan metric

4.9%

2.4%

4.2%

1.5%

3.7%

5.8%

-1.7%

3.6%

0.6%

3.1%

5.4%

0.5%

3.9%

1.5%

3.5%

UWHCA UWMF Combined HC/MF ** SAHS /RDI Total *

Actual Budget Prior Year

Page 92 of 102

Selected Hospital Volume Statistics – YTD December 31, 2016

Swedish

American

Madison

Hospitals

(UWHC, TAC, and

AFCH)

3

3.0%

-1.8% -1.6%

2.5%3.1%

-1.5%

-4.0%

-2.0%

0.0%

2.0%

4.0%

Adult and peds admissions Clinic visits Surgeries

Versus budget Versus prior year

-2.9%

0.5%

3.3%2.4%

3.2%

5.7%

-4.0%

-2.0%

0.0%

2.0%

4.0%

6.0%

8.0%

Adult and peds admissions Clinic visits Surgeries

Versus budget Versus prior year

Page 93 of 102

Hospital Volume – YTD December 31, 2016

4

YTD - December 31, 2016 Actual Budget

Variance

from

Budget Prior Year

Variance

from Prior

Year

UWHC (Includes UH, TAC, and AFCH)

Admissions 16,487 16,987 (500) 16,093 394

Clinic visits 335,461 333,876 1,585 325,121 10,340

Surgeries 18,713 18,119 594 17,701 1,012

SAHS

Admissions 8,800 8,543 257 8,582 218

Clinic visits 198,597 202,228 (3,631) 192,685 5,912

Surgeries 4,716 4,794 (78) 4,787 (71)

Page 94 of 102

UWMF wRVU’s through December 31, 2016

Work Relative Value Units (wRVUs) are a measure developed by CMS as part of the Medicare reimbursement formula for physician

services. wRVUs reflect the time, skill, training and intensity to provide a given service. For example, a surgical code will typically have

a higher value (and corresponding payment) than a routine appointment code. wRVUs are also used by UW Health and other practice

plans to measure provider productivity (volume). When payors determine payments based on RVU’s, they typically include two

additional RVU components to reflect the practice expense costs (technical) and malpractice insurance costs.

*Two fewer business days in July FY17 compared to July FY16

Specialty care wRVUs increased 4.8%

and Primary care wRVUs increased 0.1%YTD Variance

5

362 365

1,785 1,871

0

500

1,000

1,500

2,000

wRVUs FY16 wRVUs FY17

Tho

usa

nd

s

Primary Care Specialty Care

-2.0%

4.1%

-3.0%

-2.0%

-1.0%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

Versus budget Versus prior year

Page 95 of 102

UW Health Primary Care Volumes

Clinic visits year over year are up by 5.8% while non face-to-face encounters are up by 3.5%. Clinical Physician

FTE are down by 2.2% and head count is down by 0.5% while number of active panels are up by 3.2%.

Note: Includes Fam Med (including Wingra ACHC), GIM & GPAM excluding Augusta, Eau Claire & Fox Valley. Clinic visits are arrived or

completed appointments that include nurse only visits. Non face-to-face encounters include MyChart, Telephone and Refill encounters

logged in HealthLink. Other includes all provider types not listed as MD, DO, NP or PA. Clinical Physician FTE, Head Count and Active

Panel are for MD/DO faculty only.

Data source: Ambulatory Encounters dashboard and Panel Activity Report.Page 96 of 102

Summary of Enterprise-Wide December 31, YTD Operating Results

Volume Margin

7

-1.0% -0.4%

2.3%

2.5%3.1%

4.2%

-2.0%

0.0%

2.0%

4.0%

6.0%

8.0%

Adult and PedsAdmissions Clinic Visits Surgeries

Versus budget Versus prior year

3.7%

3.1%

3.5%

Actual Budget Prior Year

Actual YTD Budget YTD Actual YTD Variance Vs.

Dec 2016 Dec 2016 Dec 2015 Budget

Operating Revenue 1,490.3$ 1,486.3$ 1,394.9$ 0.3%

Operating Expenses:

Salaries and fringe benefits 820.1 834.1 783.0 1.7% Medical materials and supplies 301.6 295.4 279.9 -2.1% Other expenses 277.7 274.5 245.4 -1.1%

Total Operating Expenses 1,399.3 1,404.0 1,308.2 0.3%

Operating Income 91.0 82.3 86.7 10.5%

Academic Advancement Support (non-operating) (35.2) (35.9) (37.5) 1.8%

Operating Income, before other non-operating 55.8 46.5 49.2 20.0%

Nonoperating Income * 22.4 19.3 (106.4) 15.7%

Net Income 78.2$ 65.8$ (57.2)$ 18.8%

*Includes Income Tax (Expense)

Page 97 of 102

Enterprise-Wide December 31, 2016 YTD Performance Ratios

8

Favorable

Direction FY 17

S&P "A+"

Rated (1)

Moodys "Aa3"

Rated (2)

Operating Margin (excluding Academic Support) 6.1%

Operating Margin (including Academic Support) 3.7% 4.1% 3.7%

Total Margin 5.3% 5.6% 7.4%

Days Cash on Hand * (excluding Academic Support) 196.2

Days Cash on Hand * (including Academic Support) 191.2 200.3 267

Days in Accounts Receivable ** 49 46 48

Long Term Debt to Capitalization 21.8% 35.9% 29.6%

Operating Cash Flow 10.7% 10.3% 10.0%

Cash-to-Debt 233.5% 154.8% 199.1%

* excludes provision for bad debt and retiree health insurance

** average for 6 months

(1) S&P's 2016 financial ratios based on 30 obligators rated "A+" by S&P. Based on 2015 audited financials.

(2) Moody's 2015 financial ratios based on 43 "Aa3" rated hospitals. Based on 2014 audited financials.

Industry Comparisons

Healthcare System

Page 98 of 102

UW Health Non-Operating Revenue

Year-to-Date December 31, 2016(Amount in $$ Thousands)

9

Actual

Earned Investment Income 12,631,572

Equity in earnings of joint ventures 1,012,939

Unrealized gain (loss) on investments 3,952,636

Other, net * 4,760,247

Total revenues (expenses) 22,357,394

* includes Income Tax (Expense)

Page 99 of 102

UW Health Consolidating Balance Sheet

YTD December 31, 2016

10

UWHCA UWMF

UW Health

Madison

Eliminations

Total UWHCA

and UWMF RDI

UW Health

Consolidated

Cash & Investments

Unrestricted 880,001,436 272,895,373 - 1,152,896,809 278,613,461 1,431,510,270

Restricted by Trustee & Donors 9,785,887 - - 9,785,887 - 9,785,887

Accounts Receivable 246,813,019 68,125,024 - 314,938,043 80,308,863 395,246,906

Property, Plant & Equipment, Net 762,057,029 72,107,494 - 834,164,523 321,531,657 1,155,696,180

Other Assets & Deferred Outflows of Resources 435,096,149 87,692,592 (21,306,313) 501,482,428 44,334,486 545,816,914

Total Assets & Deferred Outflows of Resources 2,333,753,520$ 500,820,483$ (21,306,313)$ 2,813,267,690$ 724,788,467$ 3,538,056,157$

Current Liabilities 285,727,784 138,862,791 (25,393,313) 399,197,262 109,391,743 508,589,005

Long-term Debt & Deferred Inflows of Resources 684,761,051 70,175,000 - 754,936,051 145,541,933 900,477,984

Net Position

Unrestricted 1,354,035,401 291,782,692 4,087,000 1,649,905,093 459,831,825 2,109,736,918

Restricted 9,229,284 - - 9,229,284 10,022,966 19,252,250

Total Liabilities, Deferred Inflows of Resources

& Net Position 2,333,753,520$ 500,820,483$ (21,306,313)$ 2,813,267,690$ 724,788,467$ 3,538,056,157$

Page 100 of 102

UW Health Consolidating Income Statement

YTD December 31, 2016

11

UWHCA UWMF

UW Health

Madison

Eliminations RDI Eliminations

UW Health

Consolidated

Net Patient Service Revenue (net of provision for

bad debts) 874,755,250 345,596,948 - 220,008,398 - 1,440,360,596

Other Revenues 13,600,329 3,252,574 - 33,086,811 - 49,939,714

Total Revenue 888,355,579 348,849,522 - 253,095,209 - 1,490,300,310

Operating Expenses:

Salaries & Benefits 383,377,573 249,747,539 61,011,505 125,941,744 - 820,078,361

Supplies, Drugs and Other Expenses 400,272,221 64,150,597 (61,011,505) 107,691,586 - 511,102,900

Interest 9,413,329 204,705 - 1,673,846 - 11,291,880

Depreciation 39,175,470 3,673,687 - 13,977,667 - 56,826,824

Total Operating Expenses 832,238,593 317,776,528 - 249,284,843 - 1,399,299,964

Operating Income 56,116,986 31,072,994 - 3,810,366 - 91,000,346

Academic Advancement Support (non-operating) (12,522,340) (22,681,363) - - - (35,203,703)

Income Before Other Other Non-Operating Activity 43,594,646 8,391,631 - 3,810,366 - 55,796,643

Total Non-operating Revenue and Income Tax

Expense 10,016,174 9,065,416 - 3,275,804 - 22,357,394

Net Income 53,610,820 17,457,047 - 7,086,170 - 78,154,037

Page 101 of 102

UW Health Financial Structure

Affiliation Agreement

University of Wisconsin Hospitals and Clinics Authority

University of Wisconsin Medical Foundation

Regional Division, Inc.1

Swedish American Health System

Equity-BasedJoint Ventures

Majority-Owned Non-Consolidated

Ventures

Non-Consolidated Joint Ventures

University HospitalAmerican Family Childrens Hospital

The American CenterAmbulatory Clinics

InnTowner, LLC

Faculty Practice Plan17 Clinical Departments

Ambulatory Clinics

SA Hospital RockfordSA Hospital Belvidere

SA Medical GroupRegional Cancer Center

SA Home HealthOther Entities

University Health Care, Inc.2

Unity/GHP Insurance Companies

Madison Surgery CenterWisconsin Dialysis

Chartwell EnterprisesGenerations

UW Health ACO

UWH Rehabilitation HospitalMadison United Linen

Madison EnvironmentalTransformations Surgery Center

Wisconsin SleepMadison Medical Center

1 Includes minority investments in UW Cancer Center Johnson Creek and AboutHealth

2 Includes Health Professionals of Wisconsin and eCare of Wisconsin

These entities were integrated on July 1, 2015.

Page 102 of 102