ROTATING RESIDENT/FELLOW
CHECK LIST
AIMMC Program Name:
______________________________________________________________
Name of Resident/Fellow __________________________________________________________
First Name
Middle Name
Last Name
Dates of Rotation _______________________until_________________________________________
mm/dd/yy
mm/dd/yy
Home Institution _________________________________________________________________
The following information must be attached when submitting your application to Laura Daly, House Staff
Affairs Coordinator, in the Medical Education Office for processing:
Affiliation Agreement and/or Program Letter of Agreement (PLA)
Rotating Resident & Fellow Allegra Request application must include all the following documents:
Copy of Current CV/Resume
Copy of Medical License (Controlled Substance License required with Permanent Medical License)
Copy of DEA License or letter indicating that DEA is privided by home institution (include number)
Copy of ECFMG certificate (Foreign Graduates Only)
Signed CareConnection/Confidentiality Statement
National Provider Identifier Number (NPI)
Current TB/Immunization History (proof of immunization must be attached)
Proof of Malpractice coverage - certificate required with AIMMC listed for rotation dates
Letter of Good Standing
Copy of Current ACLS/BLS Card
AIMMC Program Director’s Signature
”Universal Protocol Video” must be viewed by all residents/fellows. Documentation of review should be
forwarded to the Office of Medical Education at AIMMC within 24 hours or the resident/fellow will not
be able to stay on the rotation. (Click here to view the Universal Protocol Video)
Clearance Form - must be completed on last day of rotation.
To obtain NPI #: https://nppes.cms.hhs.gov/NPPES/Welcome.do
Please type (handwritten applicaton will NOT be accepted).
Updated 04/2016
ROTATING RESIDENT & FELLOW ALLEGRA REQUEST
For Use ONLY at Advocate Illinois Masonic Hospital
Home Institution:
Start Date:
Requested Rotation:
End Date:
RESIDENT & FELLOW BIOGRAPHICAL INFORMATION
Last Name
First Name
Ethnic Origin/Race
Choose one below. . .
Current Street Address
Visa Status
US
PR
Middle
J-1
MD
State
ZIP Code
Gender
M
F
Home Phone No.
( )
E-mail
Name of School
Start Date
RESIDENCY/FELLOWSHIP TRAINING
From-To(mm/dd/yy)
Other_______
Social Security Number
Pager No.
Cellular No.
( )
(
)
MEDICAL SCHOOL INFORMATION
City/State/Country
DO
Birth Date & Place
Other _________
City
DPM
Name of Institution
End Date
Type of Training/Program
Current PG Level
IN CASE OF EMERGENCY
Name of Friend or Relative
Relationship to
Resident/Fellow
Home Phone No.
(
)
Work Phone No.
Cellular No.
(
(
)
PGY Level
PGY-
)
OPERATING ROOM ACCESS REQUEST
Operating Room Access
Yes
No
OR Locker Room Access
Yes
No
OR Orientation Request
Yes
The following information MUST be attached to this form prior to you starting ANY rotation.
No
Copy of Current CV/Resume
Letter of Good Standing
Copy of Licenses: Medical/Controlled Substance /DEA
Signed CareConnection/Confidentiality Statement
Copy of ECFMG certificate (Foreign Graduates Only)
NPI Number
Proof of Malpractice coverage
Copy of Current ACLS/BLS Card
Current TB/Immunization History (attach proof of immunization – Flu Vaccine and TB done within the last 12 months)
X
AIMMC Program Director Approval signature for rotating resident/fellow
Date
X
Director of Medical Education Approval signature
Medical Education Office Use Only
Date
Updated 04/2016
Allegra Number __________ Universal Protocol Video Date _________ P&P Date ________ Clearance Date ________
CC
System Access Request/Change/Termination Form
Care Connection - Resident/Fellow
ms
CC
ms
 Condell (CND)  C hrist (C MC)  Shepherd (GSH)  Good Sam (GSA)  Lutheran (LGH)  Masonic (IMC) South Sub (SSH)
Trinity (TRI)
*Name: ______________________________________ _________________________ _____________________________________
(First)
(Middle)
(Last)
Credentials (circle one): MD DO DDS DPM PsyD PhD
IL license number: ____________________________
Allegra number: ______________________________________
Request type:
 Addition
 Change
 Deletion
Effective date: ___ ___ / ___ ___ / ___ ___ ___ ___ Expiration date: ___ ___ ___ ___ ___ ___ ___
Confidentiality Agreement:
As a non-employee of Advocate Health Care, you or your representatives may have access to patient, medical record, employee or other confidential
information. As a condition to being granted such access, you are required to agree to the following:
I understand that in the course of my working relationship with Advocate Health Care, I share the responsibility of maintaining the confidentiality of any
patient, medical record or employee information that I may have available to me. I understand that it is my responsibility to follow Advocate Health Care
policies and procedures as they relate to the assurance of patient rights and the confidentiality of information both written and verbal.
Computer Systems: I understand that I may receive a unique User-Id and a personal password necessary for me to gain access to an Advocate Health Care
computerized system. I understand and agree that both the User-id and my Password are for my own personal use and are not to be disclosed to or used by
third parties. If at any time I feel that the confidentiality of my User-id or password has been compromised, I will contact appropriate management (Advocate
employee that approved your access) for direction within 24 hours.
Conduct and Confidentiality: I understand that I must maintain the confidentiality of any written or oral patient, medical record or employee information that
I have access to or view as a result of my working relationship with Advocate Health Care. I understand that the release of patient, medical record or
employee information of any kind is only allowed by Advocate Health Care policy guidelines. If I am uncertain or do not understand the Advocate Health
Care policy guidelines, I will contact the appropriate Advocate manager (Advocate employee that approved your access) for assistance and direction within
24 hours. I agree to only release patient, medical record or employee information under the Advocate Health Care policy guidelines or as required by law.
Patient, Medical Records and Employee Information: I acknowledge that all information involving patients, medical records and employee information is
private and confidential. I agree that I shall access only that data necessary for the proper performance of my job responsibilities under my business
relationship with Advocate Health Care. I further agree to keep confidential any and all information that I access, receive or transcribe, and not to disclose
any such information to third parties. I am aware, that, unless specifically identified as part of my job by “Advocate Health Care”, I am not authorized to
discuss any information concerning a patient’s or employee’s personal data or medical condition. I am responsible for ensuring that discussions regarding
patient, medical record and employee information are held in appropriate locations with only authorized individuals.
Any unauthorized disclosure on my part or my representatives will be a very serious offense to Advocate Health Care. Such unauthorized disclosure may
result in Advocate’s repossession of all of my or my representative’s access to patient, medical record and employee information, Advocate may also act up
to and including termination of my business relationship with Advocate and asserting its full rights under the law.
*Resident/Fellow Signature _______________________________________________
Date ______________________________
Access Required:
Emergency Medicine Resident = ED Resident/Inter w/Order Entry
OB, Anesthesia and All Other Specialties Resident or Fellow = Profile: PN Res/Intern w/Order Entry
*Does this Resident/Fellow require access to psychiatric (confidential) units?
X YES
*Reason: Needed for Patient Care
(Please make sure all of the above are correct)
(Upon receipt please allow 3 to 4 business days to complete this request)
Authorized by:
Print Name: ___Laura Daly_____________________________________________________________________________________
Title/Dept: ___Medical Education______________________________
_______________________________________________________
(**Authorizing Signature**)
Phone #: __773-296-5944_______________________
Date: _____________________________________
Scan completed form and send by email ([email protected]) or fax (630-575-5395 c/o IS Security)
(

For Information Systems Security Administration Use Only 
Completed by: ______________________________________________________
November 11, 2013 Version 2
~ Confidential ~
)
Date: __________________________
CareConnection
ms
ms
(Please print and write legibly. The Bold and * items are required)
*Hospital, Choose one only:
CC
CC
ADVOCATE HEALTH CARE
IMPLEMENTING THE
Universal Protocol Policy/Time out Video
Residents rotating at AIMMC
IMMC’s Hospital policy mandates the video MUST be viewed within 24hrs of starting the
rotation. Residents not complying with this request will not be able to rotate.
DATE VIDEO VIEWED:_____________________________________________
Name of Rotation:_______________________________________________________
Resident Name (Please Print):_____________________________________________
Resident Signature:______________________________________________________
E-mail:________________________________________________________________
Phone or Cell Phone #:___________________________________________________
Resident must receive from coordinator the following:
• Culture of Safety ID Card
______ (Resident’s initials)
• Dangerous Abbreviations Do Not Use ID Card
______ (Resident’s initials)
Coordinator Initials: ______________
Previously Viewed on_________________
If a resident is returning to AIMMC for a rotation and the Universal Protocol Video was viewed during the
previous rotation please list the viewing date above. Residents are only required to view the video once.
http://immconline.advocatehealth.com/homepage.cfm
Under Culture of Safety - click on <more>:
Universal Protocol Video
Fax copy to Medical Education at 61-5051
Original for Coordinator
ADVOCATE HEALTH CARE MEDICAL EDUCATION
STUDENT/RESIDENT MEDICAL & IMMUNIZATION CLEARANCE FORM
This form must be completed in its ENTIRETY and on file 4 weeks before the rotation start date.
Name:
SSN:(last 5 digits)
Address:
Street
Phone:
City, State
Zip Code
DOB ___/___/___ College/Univ./Sponsor Hosp.:
AHC Hospital/Rotation:
Rotation Dates:
REQUIRMENTS
TB Surveillance:
a.) Skin Testing: Last TB skin test OR Quantiferon (QFT) test must be done WITHIN ONE CALENDAR
YEAR OF THE ROTATION END DATE. Skin test result MUST be read in mm of induration.
b.) If TB skin test OR QFT is/was POSITIVE, the student MUST attach a copy of a negative CXR
report. In addition, if a student/resident has had a positive TB screening in the past
he/she MUST attach a copy of the Advocate annual screening questionnaire completed within
one year of the rotation start date.
DATE of last TB skin test:
RESULT in mm:
DATE of last QFT:
RESULT:
TB Mask Fit Testing: Required prior to rotation start date; must be specific for the mask listed
Required Brand: Kimberly Clark Tecnol Fluid Shield PFR95 N95 Particulate Filter Respirator
TB Mask Fit Test Date: ____/____/____ Size (circle one): Regular/Model #46767 or Small/Model #46867
Immunization Record:
Circle Results
Rubella Immunity Status
Rubella Titer:
Proof of Vaccination:
Date____/____/____
Date # 1 ____/____/____
Result: Immune / Non Immune - or
# 2 ____/____/____
Rubeola Immunity Status
Rubeola Titer :
Proof of Vaccination:
Date ____/____/____
Date
# 1 ____/____/____
Result: Immune / Non Immune - or
# 2 ____/____/____
Mumps Immunity Status
Mumps Titer:
Proof of Vaccination:
Date ____/____/____
Date
# 1 ____/____/____
Result: Immune / Non Immune - or
# 2 ____/____/____
Varicella Immunity Status
Varicella Titer:
Date ____/____/____
Proof of Vaccination:
Date
# 1 ____/____/____
Result: Immune / Non Immune - or
# 2 ____/____/____
Hepatitis B Immunity Status
Hepatitis B AB Titer:
Date ____/____/____
Hepatitis B Vaccination:
Date #1____/____/____
Result: Positive / Negative
# 2 ____/____/____ # 3 ____/____/____
Tetanus/Diphtheria/Pertussis (Tdap): Date vaccinated ____/____/____
Flu Vaccine: Current flu season vaccine required prior to rotations occurring between
10/1 and 4/30. Date vaccinated ____/____/____
The information provided on this questionnaire is accurate to the best of my knowledge.
I understand and agree that any misrepresentation or omissions may be justification for
denial of student/resident privileges. I authorize Advocate Heath Care to verify any
information contained in this health history.
Signature
Date
Please return this form to the appropriate personnel of the Hospital Department/Program
where you will be rotating.
Effective 7/2015
ROTATING RESIDENT/FELLOW CLEARANCE FORM
In order to be released officially from Advocate Illinois Masonic Medical Center the following areas must
be cleared/signed by all the respective departments.
Residents Name:
__________________________________________ Rotation: ____________________
Dates of Rotation:
_______________________________________________________________________
1. Medical Library:
(Room 7501)
(Ext. 61-5084)
___________________________________________Date:_________________________
OFFICE HOURS: (M-TH 8:00am to 6:00pm, F 8:00am to 5:00pm
Closed Weekends and Holidays)
2. Pagers
Communications:
Room (G-240)
(Ext. 61-5211)
3. HIM-Medical Records:
(Room G-130)
(Ext. 61-5191)
(Alternate ext.’s
61-5178 & 61-5438)
___________________________________________Date:_________________________
OFFICE HOURS: (24 Hours)
___________________________________________Date:_________________________
OFFICE HOURS: (M-F 8:00am-4:30pm – Closed Weekends and Holidays)
4. IMMC I.D. Badge:
($10.00 Fee if Lost)
Support Center
(Room G-706)
5. DEPARTMENTResidency Coordinator:
___________________________________________Date:_________________________
OFFICE HOURS: (M-F 7:00am to 4:00pm – Closed Weekends and Holidays)
___________________________________________Date:________________________
Fax copy to Medical Education at 61-5051
Original for Coordinator
Please read the following policies prior to starting your rotation:
1. Graduate Medical Education Policy on Supervision
2. Transitions of Care – Patient Handoff
3. Resident Employment Outside the Residency Program, i.e., Resident
Moonlighting
4. Integrated Quality and Patient Safety Plan
5. Duty Hours and Call Schedules for Residents
6. Implementation of Universal Protocol
7. House Staff Compliance with Timely Completion of Medical Record
8. Advocate Health Care Handwashing Expectations
I ,______________________, reviewed all seven policies on ____________
(full name and signature)
(date)
Title: Graduate Medical Education Policy on Supervision
‫ ܈‬Policy
Advocate Health Care
I.
‫ ܈‬Procedure
Scope: ‫ ܈‬System
‫ ܆‬Site:
‫ ܆‬Guideline
‫ ܆‬Other:
Department: Graduate Medical Education
PURPOSE
To provide guidelines for the supervision of residents and fellows who are
training in Advocate Health Care System.
II.
POLICY
Advocate Health Care (Advocate) will provide a clinical learning environment that
promotes appropriate supervision and progressive responsibility for residents.
This clinical learning environment will include:
x
An identifiable, appropriately credentialed and privileged attending
physician who is ultimately responsible for each patient assigned to a
resident.
x
Patient attending physician information is available to residents, faculty
and patients.
x
Residents and faculty will inform patients of their respective roles in each
patient’s care
x
A mechanism by which residents and/or ancillary staff can report
inadequate supervision in a protected manner.
Each residency program must have a written supervision policy that is available
to residents in the Program Handbook and that is on file in the Graduate Medical
Education Office.
Any Advocate sponsored program that does not have specific accreditation
requirements related to supervision will comply with the ACGME Common
Program Requirements.
Template Date: 05/15/2014
III.
DEFINITIONS/ABBREVIATIONS
Resident: a physician in an accredited graduate medical education program,
including interns, resident sand fellows
IV.
PROCEDURE
Program Supervision Policy
The Program Director shall provide explicit written descriptions of lines of responsibility
for the care of patients, which shall be made clear to all members of the teaching teams.
Residents shall be given a clear means of identifying supervising physicians who share
responsibility for patient care on each rotation. In outlining the lines of responsibility, the
Program Director will use the following classifications of supervision:
Direct Supervision: the supervising physician is physically present with the resident
and patient.
Indirect Supervision, with Direct Supervision immediately available: the supervising
physician is physically within the hospital or other site of patient care and is immediately
available to provide Direct Supervision.
Indirect Supervision with Direct Supervision available: the supervising physician is
not physically present within the hospital or other site of patient care but is immediately
available to provide Direct Supervision.
Oversight: the supervising physician is available to provide review of
procedures/encounters with feedback provided after care is delivered.
Supervision shall be structured to provide residents with progressively increasing
responsibility commensurate with their level of education, ability, and attainment of
specialty specific competencies and/or milestones. The Program Director, in conjunction
with the program’s faculty members, shall make determinations on advancement of
house officers to positions of higher responsibility and readiness for a supervisory role in
patient care and conditional independence through assessment of competencies based
on specific criteria (guided by national standards-based criteria when available).
Faculty members functioning as supervising physicians should assign portions of care to
residents based on the needs of the patient and the skills of the resident. Based on
these same criteria and in recognition of their progress toward independence, senior
residents or fellows should serve in a supervisory role of junior residents.
Each program must set guidelines for circumstances and events in which residents must
communicate with appropriate supervising faculty members, such as after-hours clinic
call, the transfer of a patient to an intensive care unit, taking a patient to surgery, or endof-life decisions. Each resident must know the limits of his/her scope of authority and the
circumstances under which he/she is permitted to act with conditional independence.
Each Advocate program will use E*Value as the means for residents, faculty, nurses and
other clinical staff to identify which procedures a resident is privileged to perform and
under what level of supervision. E*value is accessed from the Advocate home page.
Template Date: 05/15/2014
Residents will be assigned a faculty supervisor for each rotation or clinical experience
(inpatient or outpatient). The faculty supervisor shall provide to the Program Director a
written evaluation of each resident’s performance during the period that the resident was
under his or her direct supervision. The Program Director will structure faculty
supervision assignments of sufficient duration to assess the knowledge and skills of
each resident and delegate to him/her the appropriate level of patient care authority and
responsibility.
GMEC Monitoring of Supervision
The Advocate GMEC will monitor supervision by:
x Maintaining an updated supervision policy for each residency program in the
central GME Office,
x Monitoring of the annual ACGME Survey Results (for ACGME programs),
x Monitoring and reviewing any Safety reports that involve resident workload or
supervision issues, Monitoring and reviewing resident reporting of concerns
through the Advocate hotline or Confidential Resident reporting Form.
V.
CROSS REFERENCE
VI.
REFERENCES
ACGME Institutional Requirements www.acgme.org
(Section IV.I)
ACGME Common Program Requirements www.acgme.org
(Section VI. D)
AOA Basic Documents for Postdoctoral Training www.osteopathic.org
(Section VII, I Trainee Supervision Policy)
CODA Commission on Dental Accreditation www.ada.org/coda
(Section 3.)
CPME Council on Podiatric Medical Education www.cpme.org
Section 6.9)
VII.
RELATED DOCUMENTS/RECORDS
Template Date: 05/15/2014
Title: Transitions of Care—Patient Handoff
[x] Policy … Procedure … Guideline … Other ______________
Advocate Health Care
I.
Scope: … System [x] Site IMMC … Department: Medical Education
PURPOSE
To establish a protocol and standards within Advocate Illinois Masonic Medical
Center Training programs (residency and fellowship) to ensure the quality and
safety of patient care when transfer of responsibility occurs during duty hour shift
changes, during transfer of the patient from one level of acuity to another, and
during other scheduled or unexpected circumstances.
II.
POLICY
Individual programs must have a policy addressing transitions of care. Faculty
and trainees must be aware of their Department policy.
Individual programs should provide instruction to and review Departmental
processes with trainees regarding handoff of care.
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 patient safety and
quality of healthcare delivery.
Individual programs should evaluate trainees in their capacity to perform a safe,
effective, and accurate handoff of care.
Recommendations for implementation of this policy can be found in the Protocol
for Implementation of the Transitions of Care Policy.
PROTOCOL FOR IMPLEMENTATION OF TRANSITIONS OF CARE-PATIENT
HANDOFF POLICY
The transition/hand-off process should involve face-to-face interaction with both
verbal and written/computerized communication, with opportunity for the receiver
of the information to ask questions or clarify specific issues. The hand-off
process may be conducted by telephone conversation. Voicemail, text message,
and/or any other unacknowledged message are not an acceptable form of patient
hand-off. A telephonic hand-off must follow the same procedures outlined in this
Section, and both parties to the hand-off must have access to the electronic
medical record and an electronic or hard copy version of the sign-out evaluation.
Patient confidentiality and privacy must be guarded in accordance with HIPAA
guidelines.
1.
The transition process should include, at a minimum, the following
information in a standardized format that is universal across all
services.
SBAR format (Situation, Background, Assessment, Recommendations) is one
such format, or providing the following information:
Essential Elements for Successful Handoffs
x
x
x
x
x
x
x
x
x
x
x
x
x
Each physician team should be assigned a distinctive name and
color (as appropriate).
List all staff names and other team members with pager numbers,
including covering attending physicians if applicable.
Include complete patient identification (full name, age, sex, race,
location, Social Security number or hospital number), date of
admission, and location. At least two forms of identification should
be listed to avoid mistakes of patient identity in case a procedure
needs to be performed while on-call.
Add a one-or-two-sentence assessment of the patient’s
presentation.
Include an active problem list plus a pertinent past medical history.
List all active medications.
List allergies.
Supply information on venous instrumentation and access, status of
access, and any actions to be taken if access changes.
Include the patient’s code status.
Include pertinent laboratory data.
List your concerns for the next 18-24 hours and a recommended
course of action. For the intensive care unit, use a system-based
approach. For the general medical wards, use a problem-based
approach.
Consider listing the long-term plans, as family may visit in the
evening during off-hours to discuss this issue with covering house
staff.
Discuss any psychosocial concerns that may influence therapeutic
choices.
ANTICIpate
x
x
x
Administrative data
New information (clinical update)
Tasks (what needs to be done)
x
x
Illness
Contingency planning/code status
HANDOFF
x
x
x
x
x
x
x
x
Hospital location: wing, room number
Allergies/adverse rx/medications
Name (age, gender)/number (MR)
DNR/diet/DVT prophylaxis
Ongoing medical/surgical problems
Facts about the hospitalization
Follow-up on
Scenarios
SIGNOUT
x
x
x
x
x
x
x
2.
Sick or DNR (code status)
Identifying data (name, age, gender, dx)
General hospital course
New events of the day
Overall health status/clinical condition
Upcoming possibilities with plan, rationale
Tasks to complete overnight with plan
Each residency program must develop components ancillary to the
institutional transition of care policy that integrate specifics from their
specialty field. Programs are required to develop scheduling and
transition/hand-off procedures to ensure that:
x
x
x
x
x
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 be available on
department-specific password-protected websites and also with the
hospital operators.
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.
x
x
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.
3.
Each program must include the transition of care process in its curriculum.
4.
Residents must demonstrate competency in performance of this task.
There are numerous mechanisms through which a program might elect to
determine the competency of trainees in handoff skills and
communication. These include:
x
x
x
x
x
x
x
x
x
Direct observation of a handoff session by a licensed independent
practitioner (LIP)-level clinician familiar with the patient(s).
Direct observation of a handoff session by an LIP-level clinician
unfamiliar with the patient(s).
Either of the previous, by a peer or by a more senior trainee.
Evaluation of written handoff materials by an LIP-level clinician
familiar with the patient(s).
Evaluation of written handoff materials by an LIP-level clinician
unfamiliar with the patient(s).
Either of the previous, 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:
Survey
Reporting hotline
Trigger tool
Chart review
5.
Programs must develop and utilize a method of monitoring the transition of
care process and update as necessary. Monitoring of handoffs by the
program to ensure:
x
x
x
There is a standardized process in place that is routinely followed.
There is consistent opportunity for questions.
The necessary materials are available to support the handoff
(including, for instance, written sign-out materials, access to
electronic clinical information).
x
x
6.
III.
A quiet setting free of interruptions is consistently available, for
handoff processes that include face-to-face communication.
Patient confidentiality and privacy are ensured in accordance with
HIPAA guidelines; this includes the appropriate disposal of any
written material in HIPAA-compliant receptacles, and encryption of
any electronic devices used during the handoff process.
Programs should evaluate trainees in their ability to communicate patient
information clearly, accurately, and responsibly to support the safe
transfer of care from one provider to another.
DEFINITIONS/ABBREVIATIONS
A transition of care (“handoff”) is defined as the communication of information to
support the transfer of care and responsibility for a patient/group of patients from
one service and/or team to another. The transition/hand-off process is an
interactive communication process of passing specific, essential patient
information from one caregiver to another. If utilizing email for written
communication, only Advocate email is approved. Transition of care occurs
regularly under the following conditions:
x
x
x
x
x
x
x
Change in level of patient care, including inpatient admission from
the ambulatory setting, outpatient procedure, or diagnostic area.
Inpatient admission from the Emergency Department.
Transfer of a patient to or from a critical care unit.
Transfer of a patient from the Post Anesthesia Care Unit (PACU) to
an inpatient unit when a different physician will be caring for that
patient.
Transfer of care to other healthcare professionals within procedure
or diagnostic areas.
Discharge, including discharge to home or another facility such as
skilled nursing care.
Change in provider or service change, including resident sign-out,
inpatient consultation sign-out, and rotation changes for residents.
IV.
PROCEDURE
N/A
V.
CROSS REFERENCE
N/A
VI.
REFERENCES
N/A
VII.
RELATED DOCUMENTS/RECORDS
Systematic Review of Handoff Mnemonics Literature.
Lost in Translation: Challenges and opportunities in Physician-to-Physician
Communication During Patient Handoffs.
Title: Resident Employment Outside the Residency Program, i.e.,
Resident Moonlighting (Dept)
[x] Policy … Procedure … Guideline … Other ______________
Advocate Health Care
I.
Scope: … System [x] Site IMMC … Department: Medical Education
PURPOSE
This policy establishes a uniform policy and procedure regarding the conditions
under which House Officers may perform moonlighting activities. This Policy is
applicable to all House Officers enrolled in any of the Hospital’s GME Programs.
The term “House Officer” shall include interns, residents or fellows (hereinafter
“Trainees”). It is the aim of this policy to ensure that all GME programs adhere to
the GMEC approved policy and ACGME requirements for Resident Employment
outside the Residency Program.
“Moonlighting,” includes the performance of clinical activity, which is beyond the
duties usually performed by a Trainee in the Hospital GME Program, regardless
to where the practice occurs or the source of compensation.
II.
POLICY
Applies To: This policy applies to the all Graduate Medical Education (GME)
programs.
Moonlighting activities are not included as part of the educational program in the
residency/fellowship programs. Moonlighting activities must not interfere with the
ability of the resident to achieve the goals and objectives of the educational
program. Time spent by residents in Internal and External Moonlighting (as
defined in the ACGME Glossary of Terms) must be counted towards the 80-hour
Maximum Weekly Hour limit. PGY-1 residents are not permitted to moonlight.
III.
DEFINITIONS/ABBREVIATIONS
See ACGME Glossary of Terms on Moonlighting.
IV.
PROCEDURE
A.
B.
All moonlighting, regardless of where it occurs, must be reported and
counted towards the trainees’ weekly 80 hour duty limit in accordance with
the revised ACGME Duty Hour Requirements.
Trainees who wish to moonlight are required to obtain prospective
permission from their program directors. Failure to provide this
information is grounds for discipline under the Residency/Fellowship
Agreement.
V.
C.
The Program Director determines the moonlighting policy for all trainees
within their program. Each Program Director is responsible to review the
Hospital/Program moonlighting policy with the resident.
D.
Program directors will acknowledge in writing their awareness that a
trainee is moonlighting and will include this information in their training file.
E.
Program directors may withdraw permission to moonlight for any given
trainee or group of trainees if those activities have been shown to interfere
with their performance or violate duty hours.
F.
Residents on probation or on an academic remediation plan may have
their moonlighting privileges curtailed or revoked.
G.
Residents may not concurrently moonlight at the same time as they are
conducting scheduled residency activities or they may face disciplinary
action up to and including immediate dismissal from their programs.
H.
Trainees on J-1 visas are not permitted to be employed outside the
residency/fellowship program. Therefore they are not allowed to
moonlight.
I.
Residents are not required to engage in moonlighting.
J.
The resident’s performance will be monitored. If any adverse effects are
discovered as a result of moonlighting activities, permission to moonlight
may be withdrawn.
K.
Internal moonlighting and Home Call will be counted towards the 80 hour
work week
CROSS REFERENCE
Professional Liability:
Moonlighting activities and any activities that are not part of the formal education
Program, are not covered under professional liability policy provided through the
Resident Agreement.
VI.
REFERENCES
N/A
VII.
RELATED DOCUMENTS/RECORDS
N/A
2016 Quality & Patient Safety Plan
Integrated Quality and Patient Safety Plan
2016
I. Philosophy and Framework
In support of Advocate’s vision to be a faith-based system providing the safest environment and best
health outcomes while building lifelong relationships with the people we serve, the core value of
excellence is fundamental. Excellence at Advocate Health Care is defined as empowering people
to continually improve the outcomes of our service, to advance quality, and to increase innovation
and openness to new ideas.
In support of a systematic approach to achieve and sustain excellence, Advocate Health Care
utilizes a balanced scorecard involving six Key Result Areas (KRA’s):
x Safety
x Quality
x Service
x Growth
x Funding Our Future
x Coordinated Care
Advocate lives our MVP through the Advocate Experience, with our commitment to create the
safest and best place for our patients, associates and physicians – always.
The Advocate Experience is:
An experience without harm – Safety
An experience of excellence – Quality
An experience of engagement and trust – Service
Always
II. Quality Management System
Quality Policy: The Advocate Health Care quality policy is: Safety, Quality and Service Always
through Continual Improvement. The leadership and associates of Advocate Health Care execute
our quality policy through our quality management system and a commitment to continual
improvement to enhance patient safety, health outcomes, operational excellence, and patient
satisfaction. Quality and Patient Safety Plans are maintained by the sites to provide operational
framework.
Advocate Health Care is committed to evidence-based performance improvement using a holistic
approach to problem solving. The organization is steeped in a culture of continual improvement
to enhance patient safety, health outcomes, service and operational excellence from the patient’s
perspective. Accountability for performance is addressed through an objective leadership
evaluation system in which management performance objectives directly align to KRA
performance.
Performance improvement initiatives are driven by performance gaps as measured by KRA’s and
opportunities identified by leadership. Advocate’s measurement philosophy is supported by a
robust business intelligence environment:
x
Responsible leadership demands familiarity with and rigorous use of data
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x
x
Processes are in place to accurately and consistently obtain a balanced set of measures that
monitor health outcomes, customer satisfaction, functional status, and resource utilization
that ultimately supports a culture of accountability
Data driven decisions are made that assist in identifying opportunities and corresponding
improvement strategies
ISO 9001 is the foundation for performance improvement for Advocate. The ISO foundation
includes a wholistic approach to performance improvement methods that includes PDSA as the
core performance improvement approach and includes the Change Acceleration Process (CAP),
Lean and Six Sigma tools and methodologies. The Change Acceleration Process is a change model
designed to increase the success and accelerate the implementation of organizational change
efforts. It addresses how to create a shared need for the change; understand and deal with
resistance from key stakeholders; and build an effective strategy and communication plan for the
change. Lean Six Sigma is a business process philosophy that focuses on the customer and
increasing value and improving quality, safety and productivity. Recognizing the complementary
nature of the two methodologies, Advocate uses a blended approach of Lean and Six Sigma
concurrently, utilizing different tools to address specific improvement problems along a value
stream and/or project.
The 2016 KRAs are listed in the 2016 Balanced Scorecard posted on the intranet.
A. Quality Management System Oversight and Structure
The Advocate Health Care Board of Directors oversees the business management functions of the
Advocate System. There is two way communication and interaction between the Board and
Advocate system senior leadership and the site Governing Councils. The system ISO 9001 Quality
Management Review Committee interacts and is accountable to these two groups. The Medical
Executive Committees at each hospital report to the site Governing Councils. The site Quality
Management Oversight Committees report to the site Governing Councils and to the system
Quality Management Oversight Committee. The system and site Quality Management Oversight
Committees provide leadership and resources to support the quality management system
objectives.
For the purposes of quality review, improved patient outcomes and reduction in morbidity and
mortality, the Health Outcomes Council and Advocate's Quality Management Oversight Committee
will designate specific site committees to provide professional and peer self-evaluation of the
adequacy of patient care. These may include but are not limited to:
x Patient Safety Committees
x Health Outcomes Committees
x Morbidity and Mortality Committees
x Peer Review Committees
x Cause Analysis Committees
The system and each hospital have a Quality Management Representative. The site Quality
Management Representatives report site information to the system Quality Management
Representative.
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The Advocate Health Care Quality Manual provides an overview of the Quality Management
System. Results from the quality management system audits, corrective and preventive actions
will be reviewed and acted upon by the Quality Management Review Committees at the site and
system level.
B. Quality Management System Metrics
The following are required to be reported to the Quality Management Oversight Committee:
x Results of Quality Management System (QMS) audits
x Patient feedback
x Process performance and product conformity
x Status of preventive and corrective actions
x Follow-up actions from previous management reviews
x Changes that could affect the QMS, and
x Recommendations for improvement.
Additional data may also be submitted.
III. Patient Safety Program
The goal of Advocate’s patient safety program is to eliminate all events of serious harm within
the system by December 31, 2020, with a target of achieving an 80% reduction in the rate of
serious events between 2013 and 2017.
In 2012, a strategic plan for patient safety was completed and implementation initiated. This plan
maps out a multi-year plan for achieving high reliability in care delivery across Advocate. The
development of the plan involved the collective efforts of key executive leaders from across the
system, site and system patient safety leaders as content experts together with input from front
line associates and physicians. The strategic plan outlines four key strategies, including:
1. Establish patient safety as the foundation of care
2. Teach leaders how to lead to safety
3. Empower the front line to address safety issues
4. Engage patients and families in patient safety
The strategic plan will serve as the primary roadmap for operational work in patient safety for the
system in the near future. In 2015, the focus of the patient safety program included:
1. Transition from a primary focus on leadership to a focus on safety at the front line through
the creation of High Reliability Units (HRUs). HRUs will be clinical departments in which there
is a focused training effort in high reliability healthcare, training on error prevention
techniques, coaching to integrate the techniques into front line clinical work, and front-line
problem solving with issues that impact the safety of care delivered.
2. Engagement of the front line in safety efforts through implementation of a Safety Coach and
Physician Champion program
3. Launch of the system simulation program focused on in-situ simulated learning, along with
establishing the first hospital-based simulation lab.
1. Completion of the high reliability leader training series.
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2. Greater focus on the integration of the Advocate Experience through the development of a
Leader tool box for safety, quality and service.
3. Initiation of actions to address items on the Safety Top Ten list.
4. Improved reporting of patient safety events.
5. Establishing a baseline for Advocate’s hospital Serious Safety Event Rate.
6. Full standardization of the RCA process throughout the system.
7. Realignment of the patient safety reporting structure across the system to enable safety
standard work.
8. Implementation of the updated version of the Cause Analysis Database (CAD 2.0) for the
collection and utilization of system causal data.
9. Improved focus and utilization of Advocate’s Just Culture Decision Matrix.
In 2016, the focus of the patient safety program as outlined in the strategic plan strategies and
tactics will include:
1. Launch the front line High Reliability Units (HRU) with all clinical departments at Advocate
hospitals across the system. The HRU initiative will appoint and train a team of safety coaches
in each clinical department, training in high reliability principles, coaching techniques and the
PDSA model for front line problem solving.
2. Expand the front line approach to include the medical staff, through launch of the Physician
Safety Champion program. Physician safety champions, as partners to the safety coaches, will
serve to influence the culture of the medical staff in Advocate towards high reliability.
3. Continued development of the system simulation program through in-situ simulations focused
on high risk areas as identified by the Serious Safety Event Rate, opening of the first hospitalbased simulation center at Illinois Masonic Medical Center, and acquisition of funds and
planning for three additional hospital-based simulation labs.
4. Pilot of the Cognitive Bias and Diagnostic Error program throughout all Emergency
Departments across the system
5. Refreshing the Patient Safety Strategic Plan to identify strategies and tactics to guide safety
efforts between 2016 and 2020.
Classifying and Measuring Patient Harm
Advocate utilizes the Serious Safety Event Rate (SSER), through Healthcare Performance
Improvement (HPI) as the foundational measure of patient harm within the system. The SSER
classifies patient harm according to severity (severe, moderate or minimal) and duration
(temporary or permanent), using standardized definitions. The methodology used also
classifies near miss events based on the type of barrier that prevented the event from reaching
the patient. The SSER will serve as a key metric for the advancement of Advocate toward a
culture of high reliability.
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In 2013 Advocate revised the medical staff peer review process in order to align peer review
cases classified as a patient safety event with key reporting metrics. As such, the SSER will
include cases identified as a patient safety event by the peer review process and determined to
be a serious safety event through application of harm classification.
AHRQ Culture of Safety Survey
Advocate Health Care participates annually in the AHRQ Culture of Safety Survey for associates.
This survey serves as a key metric for the movement towards high reliability facilitated by the
strategic plan. It is the expectation that Advocate sites will implement unit/department based
action planning to facilitate advancement of the culture.
A. Patient Safety Program Oversight and Structure
Advocate’s patient safety program is endorsed by the Advocate Board of Directors. The Health
Outcomes Committee of the Board is the safety and clinical oversight committee of the Board.
Advocate’s Health Outcomes Council oversees the system-wide safety and clinical performance
improvement projects and initiatives. The Health Outcomes Council reports to Advocate's Quality
Management Oversight Committee.
For the purposes of quality review, improved patient outcomes and reduction in morbidity and
mortality, the Health Outcomes Council and Advocate's Quality Management Oversight Committee
will designate specific site committees to provide professional and peer self-evaluation of the
adequacy of patient care. These may include but are not limited to:
x Patient Safety Committees
x Health Outcomes Committees
x Morbidity and Mortality Committees
x Peer Review Committees
x Cause Analysis Committees
Patient Safety Team
A corporate patient safety department supports system-wide safety initiatives, reports, data,
education and consultation. Strategic collaboration occurs to enhance this work, including but
not limited to:
x The risk management department collaborates with patient safety to reduce and eliminate
actual and potential risk factors that may impact the safety of care provided to our patients.
x The center for health information services (CHIS) oversees system-wide clinical data
measurement, reporting, analytics and provides public data expertise.
x The department of quality management and regulatory collaborates to integrate safety with
Advocate’s ISO 9001 Quality Management System, and into the Advocate Experience.
x The patient experience department collaborates to integrate safety into the Advocate
Experience.
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All sites of care within Advocate Health Care have identified safety leaders that report directly to
the system safety department. Additionally, each site has a committee that guides clinical safety
and quality initiatives. Together, leaders at the system and site collaborate on key strategies,
programs and tactics that enhance the safety of the system.
B. Patient Safety System Metrics
A variety of metrics are used in the patient safety program. The majority are included in either
the 2016 Balanced Scorecard or the Safety & Quality Close. Both dashboards are distributed to
sites monthly.
The following are key patient safety metrics for 2016 reported on the Safety & Quality Close and
reported to the Quality Management Oversight Committee:
x Safety Event Reporting Rate
x AHRQ Culture of Safety Survey Results
x Serious Safety Event Rate Change
x RCA Aging
x OSHA Employee Injury Rate
x Unassisted Falls Percentile
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Title: Duty Hours and Call Schedules for Residents (Dept)
[x] Policy … Procedure … Guideline … Other ______________
Advocate Health Care
I.
Scope: … System [x] Site IMMC … Department: Medical Education
PURPOSE
The purpose of this policy is to ensure training programs at Advocate Illinois
Masonic Medical Center meet the Accreditation Council for Graduate Medical
Education (ACGME), and the American Osteopathic Association (AOA)
requirements for resident duty hours. Each residency program is required to
develop and communicate to residents and faculty, a program specific policy on
Resident/Fellow Duty Hours and call Schedules to ensure training programs
meet the requirements of the ACGME Resident Review Committee (RRC).
In addition, the purpose of this policy is to support the physical and emotional
well-being of the resident while promoting an educational environment. Duty
hour assignments recognize that faculty and residents collectively have
responsibility for the safety and welfare of patients. These procedures have been
developed to regularly monitor resident/fellow duty hours for compliance with this
Policy and the ACGME Institutional and Program Requirements.
Applies To:
This policy applies to all ACGME, and AOA, approved residency and fellowship
programs at Advocate Illinois Masonic Medical Center. It sets forth minimum
criteria for resident duty hours. More detailed written duty hour policies shall be
established by each residency program director. Residency program policies
must be approved by the Graduate Medical Education & Research Committee
(GMERC).
II.
POLICY
All Graduate Medical Education (GME) programs will use standard criteria to
coordinate resident duty hours and on-call schedules as mandated by the
program and institutional requirements of the ACGME and AOA.
III.
DEFINITIONS/ABBREVIATIONS
A.
Duty Hours are defined as all clinical and academic activities related to
the residency program, i.e., patient care (inpatient and outpatient),
administrative duties related to patient care, the provision for transfer of
patient care, time spent in-house during call activities, and scheduled
academic activities such as conferences. Duty hours do not include
reading and preparation time spent away from the duty site.
IV.
A.
In-house Call is defined as those duty hours beyond the normal workday
when residents are required to be immediately available in the assigned
institution.
B.
At-home (pager) Call is defined as call taken from outside the assigned
institution.
PROCEDURE
A.
Oversight
1.
The Graduate Medical Education and Research Committee
(GMERC) is responsible for establishing and implementing formal
written policies and procedures governing resident duty hours in
compliance with the ACGME and AOA Institutional and Program
Requirements. Requirements for resident’s on-call or duty hours
should reflect an educational rational and patient need (including
continuity of care).
a. Each program must establish written policies and
procedures with regard to resident duty hours and working
environment consistent with the Institutional, Common and
Specialty Program Requirements. The GMERC will work
with the individual programs to ensure compliance with the
duty hour regulations specific to those programs’
accreditation bodies. As necessary, program directors are
encouraged to agree on duty hour specifics for a given
rotation between departments through a written agreement.
Program policies must be approved by the GMERC and
distributed to all residents and the faculty.
b. Resident duty hours and on-call periods must be in
compliance with the Institutional and Program
Requirements. The structuring of duty hours and on-call
schedules must focus on the needs of the patient, continuity
of care, and the educational needs of the resident.
c. Programs must assure that residents are provided with
appropriate backup support when patient care
responsibilities are especially difficult or prolonged.
d. Programs are to monitor the duty hours and call schedules
and adjustments made as necessary to address excessive
service demands and/or resident fatigue.
e. Program Directors are responsible for educating residents
and faculty on duty hour requirements.
B.
Monitoring
1.
The Program Directors are responsible for monitoring Trainee
working hours with oversight from the GMERC. Each Program
must employ an acceptable electronic methodology for logging of
duty hours on a continuous basis. Monitoring must be done for all
work hours Trainees spend at all training sites, including all
moonlighting activities, if permitted by the Program. Monitoring of
duty hours is required with frequency sufficient to ensure an
appropriate balance between education and service. Each Program
Director shall report duty hour compliance to the GMERC. The
GMERC shall review and monitor duty hours and ensure
compliance with the Common Program Requirements. Program
Directors are responsible for obtaining data on compliance with
Resident Duty Hours Policy for their programs. Each resident will
be responsible for providing accurate and timely data on
compliance with the Resident Duty Hours to the Program Director,
the ACGME and AOA, when this information is requested.
Programs which demonstrate regular non-compliance will be
required to develop an action plan and report more frequently at the
discretion of the GMERC.
In order to provide appropriate responses to non-compliance with
duty hours requirements, complaints from Trainees shall be brought
to the Program Director, Chairpersons, Designated Institutional
Official, Director of Medical Education or Vice President Medical
Management. Upon receipt of a complaint, a thorough investigation
shall be conducted and corrective measures implemented, as
appropriate.
C.
Duty Hour Requirements
1.
Must be limited to 80 hours per week, averaged over a four-week
period inclusive of all in-house call activities and all moonlighting.
Time spent in the hospital by residents on at home call must count
towards the 80 hour maximum weekly hour limit.
2.
Residents must be scheduled for a minimum of one day free of duty
every week (when averaged over four weeks). At- home call
cannot be assigned on these free days.
3.
Duty periods of PGY-1 residents must not exceed 16 hours in
duration. PGY-1 residents should have 10 hours off duty and must
have eight hours, free of duty between scheduled duty periods.
Duty periods of PGY-2 residents and above may be scheduled to a
maximum of 24 hours of continuous duty in the hospital. Programs
must encourage residents to use alertness management strategies
in the context of patient care responsibilities. Strategic napping,
especially after 16 hours of continuous duty and between the hours
of 10:00 pm and 8:00 a.m. is strongly suggested.
Intermediate-level residents (as defined by the Residency Review
Committee (RRC) should have 10 hours free of duty and must have
eight hours between scheduled duty periods. They must have at
least 14 hours free of duty after 24 hours of in-house duty.
Residents in the final years of education (as defined by the RRC
must be prepared to enter the unsupervised practice of medicine
and care for patients over irregular or extended periods. This
preparation must occur within the context of the 80 hour, maximum
duty period length, and one-day-off in seven standards.
While it is desirable that residents in their final years of education
have eight hours free of duty between scheduled duty periods,
there may be circumstances (as defined by the RRC) when these
residents must stay on duty to care for their patients or return to the
hospital with fewer than eight hours free of duty. Circumstances of
return-to hospital activities with fewer than eight hours away from
the hospital by residents in their final years of education must be
monitored by the program director.
Programs must encourage residents to use alertness management
strategies in the context of patient care responsibilities. Strategic
napping, especially after 16 hours of continuous duty and between
the hours of 10:00 pm and 8:00 am, is strongly suggested.
The program must:
Educate all faculty members and residents to recognize the signs of
fatigue and sleep deprivation; educate all faculty members and
residents in alertness management and fatigue mitigation
processes, and adopt fatigue mitigation processes to manage the
potential negative effects of fatigue on patient care and learning
such as naps or back-up call schedules.
4.
D.
E.
Residents may remain on duty for up to 6 additional hours to
participate in didactic activities, transfer care of patients, conduct
out-patient clinics, and maintain continuity of medical and surgical
care as defined in Specialty and Subspecialty Program
Requirements.
Call Activity
1.
In-house call must occur no more than every 3rd night, averaged
over a four-week period.
2.
The frequency of at-home call is not subject to every 3rd night
limitations. However, at-home call must not be so frequent as to
preclude rest and reasonable personal time.
3.
Residents taking at-home call must be provided with 1 day in 7
completely free from all educational and clinical responsibilities,
averaged over a 4-week period.
4.
When residents are called into the hospital form home, the hours
spent in-house are counted toward the 80-hour limit.
5.
The program director and faculty must monitor the demands of athome call in their programs and make scheduling adjustments as
necessary to mitigate excessive service demands and/or fatigue.
Moonlighting
1.
Moonlighting must not interfere with the ability of the resident to
achieve the goals and objectives of the educational program.
2.
Time spent by residents in Internal and External Moonlighting (as
defined in the ACGME and AOA Glossary of Terms) must be
counted towards the 80 hour Maximum Weekly Hour Limit.
3.
Resident moonlighting must be approved in advance and monitored
by the Program Director.
4.
PGY-1 and OGME-1 Residents are not permitted to moonlight.
F.
Duty Hour Exception
1.
G.
H.
Transitions of Care
1.
t is essential for patient safety and resident education that effective
transitions in care occur. Residents may be allowed to remain onsite in order to accomplish these tasks; however, this period of time
must be no longer than an additional four hours.
2.
Residents must not be assigned additional clinical responsibilities
after 24 hours of continuous in-house duty.
3.
Programs must design clinical assignments to minimize the number
of transitions in patient care.
4.
Sponsoring institutions and programs must ensure and monitor
effective, structured hand-over processes to facilitate both
continuity of care and patient safety.
5.
Programs must ensure that residents are compliant in
communicating with team members in the hand-over process.
6.
The sponsoring institution must ensure the availability of schedules
that inform all members of the health care team of attending
physicians and residents currently responsible for each patient’s
care.
Institutional Communication
1.
V.
If a program requests an exception in the weekly limit on duty hours
up to 10 percent or up to a maximum of 88 hours, the Program
Director must submit such request to the GMERC which must
review and endorse such request prior to submission of such
request to RRC. Request for duty hour exception shall be made in
writing by the Department Chairperson and residency training
Program Director and submitted to the GMERC. The GMERC shall
review each request and provide a documented written statement
of approval or denial of the request.
The GMERC is to report on compliance with the duty hour
requirements to the organized Medical Staff and the governing
body annually.
CROSS REFERENCE
N/A
VI.
REFERENCES
N/A
VII.
RELATED DOCUMENTS/RECORDS
N/A
Title: Implementation of Universal Protocol
‫ ܈‬Policy
Advocate Health Care
‫ ܈‬Procedure
Scope: ‫ ܈‬System
‫ ܆‬Site:
‫ ܆‬Guideline
‫ ܆‬Other:
Department:
I. PURPOSE
A. The purpose of this policy and procedure is to define the expectations for
compliance with the Universal Protocol (UP) within all Advocate facilities, and
corrective actions that will occur should a failure of the Time Out process
occur.
B. The UP requirements are applicable to all high-risk medical and surgical
procedures for which a written informed consent is obtained. For a list of
those procedures, please refer to Attachment A.
C. The UP applies to these procedures regardless of the Advocate site in which
they are performed. The UP applies to procedures performed in operating
rooms, emergency departments, at the patient’s bedside, in hospital
ambulatory settings or in special procedures units including but not limited to
the cardiac catheterization lab, GI lab, and interventional radiology.
II. POLICY
A. Compliance with the Universal Protocol is mandatory for all associates and
physicians at Advocate sites of care who perform or participate in high-risk
medical procedures for which a written informed consent is obtained. It is the
responsibility of every Advocate associate and medical staff member to
actively participate in the safety procedures of the Universal Protocol.
III. DEFINITIONS/ABBREVIATIONS
A. Team: All individuals assigned to a particular medical or surgical procedure.
B. Informed Consent: Agreement or permission accompanied by full notice of
what is being consented to. A patient must be apprised of the purpose,
nature, risks and benefits of the procedure, alternatives to the procedure, the
risks and benefits of the alternatives, the risk of no intervention and the
probability of success of the procedure, before the physician or other health
care professional begins any such course. After receiving this information,
the patient then either consents to or refuses such a procedure or treatment.
C. Emergency Procedure: A case in which there is an immediate threat to life or
limb, and the patient is unable to give informed consent.
Template Date: 05/15/2014
D. Governing Council: The term Governing Council, as used in this policy and
procedure shall refer to the leadership body that has the authority to approve
privileges recommended by the hospital or surgicenter medical staff, or the
authority to hire and terminate physicians in the medical groups. That body
may be called Governing Council or Board of Directors or other similar names
conveying this concept regarding its role in governance.
IV. PROCEDURE
A. COMPONENTS OF THE UNIVERSAL PROTOCOL
1. The components of the Universal Protocol include:
a) Pre-procedure brief including site marking
b) Time out
c) Closing debrief
2. Performance of ALL elements of the UP are required for all nonemergency procedures. For EMERGENCY PROCEDURES:
a) The Time Out will be performed with the exception of the
informed consent (refer to definition of emergent procedures in
section III)
b) The closing debrief
3. All procedures requiring written informed consent will not be started
unless there is a trained clinical associate, resident or physician
present to assist the individual performing the procedure (see
exception below). The responsibilities of the second individual include:
a) Assist in the procedure set-up
b) Participate in the completion of the Universal Protocol
c) Monitor the status of the patient during the procedure
4. The Surgical Safeguards Checklist (Attachment B) will be used to
guide the completion of the Universal Protocol in the Operating
Rooms.
B. PRE-PROCEDURE BRIEF, INCLUDING SITE MARKING
1. Verification of the correct person, correct site and correct procedure
should occur at the following times:
a) When the procedure is scheduled
b) At the time of pre-admission testing and assessment
c) Upon admission or entry into the facility for a procedure. At this
time, include the patient in the verification when able.
d) When the responsibility for the patient is transferred from one
team member to another.
2. Prior to the procedure, a checklist is used to verify the following:
a) An ID band is in place and patient’s identity has been verified
b) An accurate and complete informed consent
c) The site is confirmed with the patient or duly appointed
guardian.
d) Relevant documentation is available
e) Relevant diagnostic reports are available
Template Date: 05/15/2014
3.
4.
5.
6.
7.
8.
9.
f) Any required blood or blood products are available
g) Any required implants, devices or equipment are available
h) All documents match the patient
i) All documents list the correct site or side
Site marking is required regardless of the location in which the
procedure is performed. Marking is required for procedures that
include:
a) Laterality (regardless of approach)
b) Level (spine)
c) Digit (fingers and toes)
d) Sites involving multiple lesions (i.e. skin)
For spinal procedures, in addition to pre-operative skin marking of the
general spinal region, intra-operative radiographic techniques will be
used to mark the exact vertebral level.
For procedures in which a regional block will be used, the intended site
of injection must be marked in addition to the intended site of incision.
The site is to be marked before the procedure is performed.
The site will be marked with the initials of the individual performing the
procedure, by the individual performing the procedure.
The site marking should occur prior to sedation with the patient, or their
duly appointed guardian, awake and involved, if possible.
The mark is positioned so that it will remain visible after skin prep and
drape, and with the patient in their final position.
C. TIME OUT
1. The Time Out involves all immediate members of the surgical or
procedural team who will be participating in the procedure from the
beginning.
2. During the Time Out, all other activities are suspended, to the extent
possible without compromising patient safety.
3. Interactive, challenge-response communication will be used.
4. The Time Out is initiated by the physician or licensed clinical associate
performing the procedure.
5. If the physician or licensed clinical associate fails to initiate the Time
Out, every member of the team is individually responsible for calling
attention to this omission. Team members will then work together to
ensure that the Time Out occurs prior to the start of the procedure.
6. Any and all team members are authorized and required to express any
concerns or discrepancies that exist.
7. No procedure will be initiated until all identified differences and/or
concerns are reconciled to the satisfaction of all team members.
8. The Time Out will verify:
a) Correct patient identity
b) Agreement on the procedure to be done
c) Confirmation of an accurate and complete informed consent
d) Confirmation that the correct site, including side, is marked
Template Date: 05/15/2014
e) Immediate availability of relevant diagnostic reports and images
that match the patient
f) Images are appropriately displayed
g) Antibiotics have been administered
h) Immediate availability of the correct equipment, devices or
implants.
9. Multiple Time Outs are required when:
a) Multiple procedures are performed on a single patient that
requires completion of multiple informed consents.
b) Multiple procedures are being performed on the same patient by
different surgical or procedural teams.
This includes
administration of a regional anesthetic block prior to or following
the procedure.
c) Multiple procedures are being performed on the same patient by
the same team, and the procedures involve laterality, spinal
level, digit or lesion OR the procedures are not usually
performed together.
10. Documentation of the Time Out
a) The Time Out is documented in the patient’s medical record.
b) If multiple Time Outs were performed, each will be documented.
c) If the procedure was halted during the Time Out due to any
concerns or discrepancies, the details will be noted in the
medical record.
D. CLOSING DEBRIEF
1. Performing a Sign Out at the conclusion of surgeries or procedures
performed in the OR or procedural areas, is recommended to enhance
patient safety.
2. The Sign Out should include the following, as applicable
a) The procedure(s) performed
b) Verification of correct counts, when applicable
c) Verification of specimen labeling, when applicable
d) Identification of the estimated blood loss
e) Key concerns for recovery or management of the patient
3. During the Closing Debrief, all other activities are suspended, to the
extent possible without compromising patient safety, so that all
members of the team are focused on the process.
E. RED RULE: COMPLETION OF THE TIME OUT
1. Educational requirements for physicians, residents and associates
related to completion of the Time Out are detailed in Attachment C
(The Universal Protocol: Education and Red Rule Implementation).
2. Information on dealing with failures of the Time Out are also detailed in
Attachment C (The Universal Protocol: Education and Red Rule
Implementation)
Template Date: 05/15/2014
V. CROSS REFERENCE
A. N/A
VI. REFERENCES
A. Joint Commission Comprehensive Accreditation Manual, 2013
VII.
RELATED DOCUMENTS AND RECORDS
A. Hospital Procedures Requiring Completion of the Informed Consent Form
B. Surgical and Procedural Site Marking Alternative Body Diagram
C. The Universal Protocol Education and Red Rule Implementation
Template Date: 05/15/2014
Title: House Staff Compliance with Timely Completion of Medical
Records
‫ ܈‬Policy
Advocate Health Care
‫ ܆‬Procedure
Scope: ‫ ܆‬System
‫ ܈‬Site: AIMMC
‫ ܆‬Guideline
‫ ܆‬Other:
Department: Medical Education
I.
PURPOSE
To outline a process for timely completion of medical records (MR) by the House
Staff at Advocate Illinois Masonic Medical Center (AIMMC); define terms and
outline responsibilities and procedures involved to ensure compliance with this policy;
and provide a process that holds residents accountable for their role in the timely
completion of patient records to facilitate appropriate continuity of patient care and
ensure AIMMC’s ability to meet regulatory expectations on MR completion.
II.
POLICY
House Staff will be required to complete all elements of the Medical Record for
which they are responsible within fifteen (15) business days of patient discharge.
III.
DEFINITIONS/ABBREVIATIONS
Resident: A physician in in an accredited graduate medical education program, including
interns, residents and fellows. Residents have a contractual relationship with Advocate
for graduate medical education training.
IV.
PROCEDURE
Residents must complete all elements of the Medical Record as directed by AIMMC’s
Medical Staff Rules and Regulations. Such items of completion include signing of the
history, physical, operative notes, and verbal orders. These items also include dictating
the discharge summary and operative report. Failure to do so may result in negative
evaluations citing failure to meet proficiency in the core competency of professionalism.
In addition, requests for verification of affiliation or education during search for
employment will include a reference regarding timely MR completion.
Department-specific methods may be used to ensure compliance with this policy.
Programs choosing to develop a different process from that prescribed within this policy,
should obtain approval from the Graduate Medical Education and Research Committee
before implementation.
RESIDENT:
All residents should adhere to the following guidelines:
1. All residents will have immediate notification of, and access to, all MR items requiring
dictation via their electronic MR Inbox.
2. Residents/fellows will be encouraged to dictate discharge summaries from the
patient care area.
3. Discharge summaries can also be dictated from any phone (in or out of hospital)
using the dictation system and accessing the patient record via portal access to
CareConnection.
4. It is expected that operative reports will be dictated the day of the procedure.
5. A list of “To Be Dictated” reports is easily available to the resident/fellow on line via
CareConnection/Profile/Provision.
HEALTH INFORMATION MANAGEMENT (HIM):
1. The HIM will assure multiple notifications of items requiring completion of patient
documentation by using the following steps:
x All incomplete patient documentation will remain visible in a user’s MR Inbox until
dictated.
x Every Wednesday, HIM staff distributes a list of all deficiencies including
delinquent records to the Residency Program Directors (PDs) for final notification
to the responsible residents. At this point, following notification by the PDs, the
resident must complete the records within five (5) business days.
x Program Directors will receive a weekly list from the HIM Department detailing
their resident delinquent charts – greater than 15 days up to and including
greater than 120 days.
PROGRAM DIRECTOR (PD):
1. Each PD is expected to have their own program medical records completion policy,
consistent with institutional policy, which will include measures to monitor and ensure
resident/fellow compliance.
2. The PDs are encouraged to use the following steps with residents who have
delinquent items reported:
a. Verbal Counseling – For the first occurrence, the PD will meet with the resident
to detail the concern, including the date of the event, and review the Medical
Records policy and expectations for record completion. The resident’s
explanation will be heard and documented.
b. Letter of Formal Counseling – For the second occurrence, the PD will inform
the resident of the delinquency incident, document the details of the concern in a
formal letter of counseling and then meet with the resident to discuss the event
and expectations for resolution.
c. If the resident shows persistent deficiency in ability to meet this professional
proficiency or other core competencies, the PD may determine the need to
engage disciplinary steps as determined by the program and this may result in
actions such as program-level remediation and subsequent formal probation.
V.
CROSS REFERENCE
N/A
VI.
REFERENCES
N/A
VII.
RELATED DOCUMENTS/RECORDS
N/A
Created 2/16
The following are the Advocate expectations of either hand washing with soap and water or with hand sanitizer.
QMS audits will be following these expectations to ensure appropriate hand hygiene to reduce hospital acquired
infections. Hand hygiene is expected both when entering and exiting any area occupied by a patient.
Clean hands prevent the spread of infection!
SITUATION
Entering
and
Exiting
Consecutive
Rooms
Use Soap and Water
Use of Gloves
Carrying
Clean
Items
Dirty Store/Utility
Room/Carrying
Contaminated
Items
EXPECTATION
COMMENTS
If an associate or physician
leaves one room or patient bed
area and cleans their hands and
goes directly into the next room
without touching anything, this
is considered compliant with
hand hygiene. If the person
touches a phone, computer,
paper or supplies, he/she must
clean his/her hands before
entering the next patient area.
This applies between beds in
the NICU, ED and other
areas where patients do not
have their own room and in
diagnostic testing areas.
Hands shall be washed with
soap and water when hands or
gloves are visibly soiled and
during outbreaks of C.difficile
and norovirus infections.
Water in the absence of soap
is not considered effective
hand hygiene.
When using alcohol sanitizer,
hands must air dry. Do not
use paper towels to dry.
Hand hygiene is expected
prior to putting on gloves and
after removing gloves.
When entering the patient’s
area and carrying clean items,
the person may place the
clean item down and is then
expected to proceed to the
hand sanitizer dispenser and
clean hands.
Food trays or clean supplies
are applicable.
When exiting a patient area
with soiled items, the person
may carry the items directly
into the soiled utility room.
Upon exiting the room, the
person is expected to perform
hand hygiene.
Hand hygiene is expected
upon exiting a soiled
storage/utility room.
Created: April 19, 2016
Created by: Donna Willeumier, Quality/Regulatory
Revised: April 25, 2016
Reviewed by: Donna Currie, Laurel Mode & Linda Stein
Post until: