Pediatric Critical Care Medicine Fellowship University of San Francisco California UCSF Benioff Children s Hospital San Francisco and Oakland

University of San Francisco California UCSF Benioff Children s Hospital San Francisco and Oakland FELLOWSHIP POLICIES DUTY HOURS... 2 MOONLIGHTING... 4 LEAVE AND SCHEDULE CHANGES... 6 CLINICAL COMPETENCY COMMITTEE... 8 PROGRAM EVALUATION COMMITTEE... 10 EVALUATION AND FEEDBACK... 12 SUPERVISION... 15 TRANSITIONS OF CARE... 19 NOTE WRITING... 21 PROCEDURAL SEDATION... 23 EDUCATIONAL CONFERENCE ATTENDANCE... 25 USE OF EDUCATIONAL FUNDS... 28 PHYSICIAN WELL-BEING AND FATIGUE... 30 APPLICANT SELECTION... 32 ACADEMIC DUE PROCESS AND PROFESSIONAL BEHAVIOR... 34

DUTY HOURS I. PURPOSE To specify the duty hour policy of the Fellowship Program in Pediatric Critical Care Medicine at UCSF Benioff Children s Hospital San Francisco and Oakland. II. DEFINITIONS 1. Duty Hours: All clinical and academic activities related to the fellowship program, i.e. patient care, administrative duties related to patient care, and time spent in the hospital during call activities and scheduled academic activities such as conferences are considered duty hours. Moonlighting activities are also counted towards duty hours. Duty hours do not include reading and preparation time spent away from the duty site. 2. On Call Activities: In house call occurs after normal duty hours when fellows are required to be immediately available in the assigned institution. 12-hr night shifts at the San Francisco site are considered part of a night-float shift system and therefore do not qualify as calls when considering ACGME work hour rules. At home call (pager call) occurs when calls are taken from outside the assigned institution. In the Pediatric Critical Care Fellowship Program this only occurs when on transport call; all other calls are in house. III. POLICY: The Fellowship Program in Pediatric Critical Care Medicine complies with both the UCSF resident duty hour policy http://medschool2.ucsf.edu/gme/coordinators/duty_hours/duty%20hours_80111. pdf and ACGME requirements (see http://www.acgme.org/acgmeweb/graduatemedicaleducation/dutyhours.aspx ). This policy applies to all fellows during their rotations at either teaching site. A. Duty hour restrictions: Duty hours are limited by the following restrictions: 1. Duty hours will be limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities. 2. Fellows will be provided with 1 day in 7 free from all educational and clinical responsibilities, averaged over a 4-week period, inclusive of call. One day is defined as one continuous 24-hour period free from all clinical, educational and administrative activities. 3. A 10-hour period of time must be provided for rest and personal activities between all daily duty periods and after in-house call. 4. Fellows must have at least 14 hours free of duty after 24 hours of in-house duty. 2 Reviewed July, 2016

5. In house call will occur no more frequently than every third night, averaged over a 4 week period 12 hr shifts at the San Francisco site are not considered call for the purpose of this rule. 6. Continuous on site duty, including in-house call, will not exceed 24 consecutive hours. Fellows may not be assigned additional clinical responsibilities after 24 hrs, but may remain on duty for up to 4 additional hours to participate in effective transfer of care of patients.. 7. In unusual circumstances, fellows, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family. Under those circumstances, the fellows must: (i) appropriately hand over the care of all other patients to the team responsible for their continuing care; and, (ii) document the reasons for remaining to care for the patient in question and submit that documentation in every circumstance to the program director. B. Responsibilities: Fellows: are responsible for utilizing the mechanisms put in place at each training site to comply with duty hours. This includes signing out at the San Francisco site at 6:30 PM on Mondays and at 7 PM on Wednesdays to ensure compliance with rule 3, and leaving post call from the Oakland site before 11 AM to ensure compliance with rule 6. Fellows are also responsible for accurately reporting their duty hours in a timely fashion (within 30 days) and are encouraged to notify the program director if duty hour violations occur despite the fellow s best effort. Fellows have to report hours worked in moonlighting activities as part of duty hour reporting. Site directors: are responsible for setting up their institution systems to comply with duty hour requirements, monitor those systems and report to the program director when duty hour violations occur either individually or systematically, and implement changes as needed. Program director: is responsible for scheduling of fellows in a manner that ensures compliance with duty hour regulations. In addition, the program director is responsible for monitoring of overall compliance with the Duty Hours Policy and recommending changes to ensure compliance as needed. The program director responsible for oversight of the collection of data on compliance with duty hour requirements, reporting to all requesting authorities (including UCSF GME and ACGME). 3 Reviewed July, 2016

MOONLIGHTING I. PURPOSE To describe the policy on moonlighting of the Fellowship Program in Pediatric Critical Care Medicine at UCSF Benioff Children s Hospital San Francisco and Oakland. II. POLICY A. General Considerations. Fellows in the Pediatric Critical Care Medicine Fellowship Program are allowed to participate in internal moonlighting only. Internal moonlighting is defined as extra work for extra pay performed at a site that participates in the subspecialty resident s training program. This activity must be supervised by faculty and is not to exceed the level of clinical activity currently approved for the participating trainee. While performing internal moonlighting services, trainees are not to perform as independent practitioners. All internal moonlighting needs to be approved by the general program director and cannot conflict with any clinical or non-clinical pre-assigned duties and must comply with university duty hour policies. To avoid any potential conflicts, moonlighting activities can take place during weekends and vacation time only. In rare occasions, exceptions to this rule can be granted at the discretion of the program director. Fellows are not allowed to participate in moonlighting during PICU rotations. See also the PICU Fellowship Duty Hour Policy and UCSF GME Moonlighting Policy http://medschool2.ucsf.edu/gme/coordinators/duty_hours/moonlighting_080111.p df and the ACGME Duty Hours Policy http://www.acgme.org/acgmeweb/portals/0/dh_dutyhourscommonpr07012007. pdf B. Permission. It is the responsibility of the requesting subspecialty resident to obtain written permission to moonlight from the program director prior to beginning any moonlighting activity. Approval template forms are available from the program administration. Each trainee has to complete a UCSF Resident and Clinical Fellow Moonlighting Approval Form, which needs to be signed by the fellow and the program director. Any trainee moonlighting without permission will be subject to withdrawal of moonlighting privileges. Restitution of moonlighting privileges will be subject to the discretion of the program director. C. Documentation. Moonlighting hours must comply with the written policies regarding duty hours as per the Pediatric Critical Care Medicine Fellowship at UCSF Duty Hours Policy, the UCSF GME Moonlighting Policy and the ACGME Duty Hours Policy. All moonlighting must be documented and submitted in order to comply with Medicare reimbursement requirements for GME. It is the 4 Reviewed July, 2016

responsibility of the moonlighting fellow to document the days, hours, location, and brief description of type of service(s) that s/he has provided and submit these by the beginning of each month to the fellowship coordinator on the Monthly Moonlighting Documentation Form (attached and available from the fellowship coordinator). Failure to submit the Monthly Moonlighting Documentation Form will result in the suspension of that trainee s moonlighting privileges pending completion of documentation. In addition, fellows need to report hours worked during moonlighting as part of duty hour reporting. D. Monitoring and Periodic Review. Fellows must ensure that moonlighting does not interfere with their ability to achieve the goals and objectives of their educational program. Fellows are responsible for ensuring that moonlighting does not result in fatigue that might affect patient care or learning. Performance of every fellow is evaluated on a regular basis, regardless of their participation in moonlighting (see PICU Fellowship Evaluation Policy), which allows the program director to monitor a fellow s performance, patient care, learning and fellow fatigue. If the program director determines that the fellow s performance does not meet expectations, permission to moonlight will be withdrawn. The restitution of moonlighting privileges will be considered at the request of the fellow by the program director after review with the Pediatric Critical Care faculty at both training sites. 5 Reviewed July, 2016

LEAVE AND SCHEDULE CHANGES I. PURPOSE To describe the policy for leave including vacation, educational leave and sick leave as well as policies regarding the process for requesting time off and coverage in case of emergencies for the Fellowship Program in Pediatric Critical Care Medicine at UCSF Benioff Children s Hospital San Francisco and Oakland. This policy is in compliance with the UCSF GME Leave Policy as outlined here: http://medschool2.ucsf.edu/gme/residents/pdf/leavepolicy_gmec_june_2008.pd f II. POLICY All requests for leave and switches require prior approval by the program directors/research mentors. A leave/switch request form needs to be completed and signed by the appropriate people and be on file with the fellowship administration. A. Vacation: Fellows have 4 weeks of vacation (20 week days) per year total, which can be taken during research blocks with prior approval of the research mentor and the program director. In addition, fellows can take time to go to one conference a year. Additional educational leave, including time for boards, interviews and courses can be taken with approval by the program director to a maximum of 2 weeks (10 week days) of total educational leave. Educational leave is not considered absence from training for the purpose of the American Board of Pediatrics (ABP) eligibility criteria for subspecialty certification, since it is only granted for activities that the program considers essential to the fellow s education. Vacation and educational leave are accrued annually and do not roll over to subsequent years. B. Schedule changes: Block schedule changes need to be approved by the appropriate program directors, and by the research mentor if they affect research time. The Oakland site director only needs to approve schedule changes that affect time at the Oakland site, whereas the program director has to approve all schedule changes, which will also need to be processed by the fellowship administration. If a schedule change affects any presentations or other non-clinical activities assigned to a fellow, it is the fellow s responsibility to either reschedule these or find a replacement. C. Call switches: All call switches involving clinical time at the Oakland site need to be approved by the Oakland site director. 6 Updated July, 2016

ACGME work hour rules cannot be violated (see duty hour policy) First year fellows cannot take random shifts, i.e. shifts outside a clinical rotation. Weekends at the San Francisco site are covered by senior fellows (year 2 and beyond) with one fellow covering Saturday and Sunday day shifts in the PICU (7 AM 5 PM) and one fellow covering the CICU Saturday day and both units Saturday night. The fellow starting a week of nights in the CICU starts at 11 AM on Sunday, the night time fellow in the PICU starts at 5 PM on Sunday. Fellows make the weekend schedule for the San Francisco site amongst themselves; a copy of this schedule should be forwarded to the program director and the fellowship coordinator and both should be notified of any changes thereafter. D. Illness and emergencies If a fellow cannot work due to illness or emergency, it is the fellow s responsibility to find alternative coverage by one of the other fellows and notify both the sitedirector (if applicable) and the general program director. Depending on the situation, the responsibility of making the necessary calls can be transferred to the program director. Should an illness or other condition prohibit the fellow from fulfilling clinical requirements for more than 2 consecutive shifts, alternative solutions will be sought by the program directors in conjunction with the fellows. This can be switch of (partial) blocks between fellows, or enlisting the help of moonlighters, depending on the situation. Every effort will be made to preserve the fellow s rights to protected research time. For prolonged illness, maternity leave and personal leave, the fellowship follows the UCSF institutional leave policies for house staff (see above). Of note, as per the American Board of Pediatrics (ABP, see https://www.abp.org/abpwebsite/), combined absences in excess of 3 months over the course of 3 years of training must be made up in order to be board-eligible. In exceptional situations, in which the program director believes that combined absences/leave that exceed 3 months is justified, she can send a letter of explanation to the Credentials Committee of the ABP. UCSF does not allow fellows to work without pay; thus, a fellow who has to make up time will need to be paid during this time. Whether the fellow will be paid during the prolonged leave of absence will be determined by the program director and the fellow prior to the leave of absence. Total clinical time will not exceed 60 PICU weeks (excluding electives, anesthesia and adult months) unless this happens by explicit request of the fellow, as part of extra training deemed necessary by all program directors to ensure clinical competency at the end of training, or under a moonlighting agreement. 7 Updated July, 2016

CLINICAL COMPETENCY COMMITTEE I. PURPOSE The goal of this Clinical Competency Committee (CCC) is to provide broad input to the program director about each clinical fellow s performance in the Pediatric Critical Care Medicine Fellowship Program. II. POLICY A. The Committee The CCC functions in an advisory role by meeting regularly to review all completed evaluations and providing a consensus-based recommendation to the program director as to the standing of each trainee in the program. The Committee will provide performance-based assessments that respect the personal privacy of the clinical fellows in the program. The Committee will function objectively and in a manner that promotes the highest levels of professionalism and confidentiality. The program director has final responsibility for each trainee s evaluation and promotion decisions. The CCC will have at least three members of the program faculty and meet every six months. Faculty members may include physicians and non-physicians from the Pediatric Critical Care Medicine Fellowship Program or required rotations in other specialties who teach and evaluate the clinical fellows. Meeting minutes will be taken as a brief summary written in a fair and balanced manner. The Clinical Competency Committee of the Pediatric Critical Care Medicine Fellowship Program is composed of the following members: 1. Chair: Sandrijn van Schaik, MD PhD, Fellowship Program Director 2. Natalie Cvijanovich, MD, Fellowship Program Site Director for UCSF Benioff Children s Hospital Oakland 3. Peter Oishi, MD, Medical Director and Director of Quality and Patient Safety for Pediatric Critical Care 4. Sara Hoover, Fellowship Program Coordinator B. Responsibilities The committee s responsibilities are to: Review all resident or clinical fellow evaluations semi-annually; Prepare and assure the reporting of Milestones evaluations of each resident or clinical fellow semi-annually to the ACGME (RRC); Advise the program director regarding resident or clinical fellow progress, including promotion, remediation, and dismissal; 8

Prepare a report summarizing the Committee s recommendations and rationale for recommending any adverse action from each meeting; and Advise the Program Evaluation Committee about any evaluation issues identified during CCC meetings 9

PROGRAM EVALUATION COMMITTEE I. PURPOSE The goal of this Program Evaluation Committee (PEC) is to oversee curriculum development and program evaluations for the Pediatric Critical Care Medicine Fellowship Program. II. POLICY A. The Committee The PEC of the Pediatric Critical Care Medicine Fellowship Program will meet annually. The PEC will have at least three members, two program faculty and one trainee from the program, unless there are not enrolled trainees in the program. Faculty members may include physicians and non-physicians from the Pediatric Critical Care Medicine Fellowship Program. The PEC is composed of the following members: 1. Chair: Sandrijn van Schaik, MD PhD, Fellowship Program Director 2. Natalie Cvijanovich, MD, Fellowship Program Site Director for Children s Hospital Oakland 3. Chief Fellow (4th year fellows) 4. Peer selected fellow representatives of year 1-3 of fellowship training (3 total). Peer selection will take place in July of each year through an online survey process. B. Responsibilities The committee s responsibilities are to: Plan, develop, implement, and evaluate educational activities of the program; Review and make recommendations for revision of competency-based curriculum goals and objectives; Address areas of non-compliance with ACGME standards; Review the program annually using evaluations of faculty, clinical fellows, and others; Document on behalf of the program, formal, systematic evaluation of the curriculum at least annually and render a written Annual Program Evaluation (APE), which must be submitted to the GMEC annually in the Annual Program Director Update; Monitor and track each of the following: o Fellow performance; o Faculty development; o Graduate performance including performance on certifying examination; o Program quality; and 10 Updated July 2016

o Progress in achieving goals set forth in previous year s action plan. Review recommendations from the Clinical Competency Committee. The PEC will be provided with confidential clinical fellow and faculty evaluation data by the program s administrative staff in order to conduct their business. The program director is ultimately responsible for the work of the PEC. The program director must assure that the annual action plan is reviewed and approved by the program s teaching faculty. The approval must be documented in meeting minutes. The program s annual action plan and report on the program s progress on initiatives from the previous year s action plan must be sent to the GME office annually. 11 Updated July 2016

EVALUATION AND FEEDBACK I. PURPOSE To describe the evaluation and feedback process for fellows in the Fellowship Program in Pediatric Critical Care Medicine at UCSF Benioff Children s Hospital San Francisco and Oakland II. POLICY: The ACGME sets minimum standards for evaluation and feedback of trainees, faculty and the program. The Pediatric Critical Care Medicine Fellowship Program has developed and implemented an evaluation and feedback process in accordance with ACGME guidelines, as outlined below. The Program has appointed both a Clinical Competency Committee (CCC) and Program Evaluation Committee (PEC), see relevant policies for details. Per ACGME requirements, the program reports fellows progress towards 21 subcompetencies according to milestones set forth by the American Board of pediatrics (https://www.abp.org/abpwebsite/publicat/milestones.pdf) Determination of a fellow s progress towards the milestones is made by the CCC based on review of evaluation and assessment data. It is extremely important that all fellows and faculty complete evaluations as requested, and that they do so in a thorough, constructive and respectful manner. The evaluation process is confidential. Evaluators should keep in mind that comments are more helpful than numeric evaluations alone. Evaluation and feedback files for fellows, faculty and the program are maintained by the program coordinator and stored in the program administration office/electronic files. Advisors and scholarly mentors: Each fellow has a primary career advisor selected from the PICU faculty at either training site. The primary advisor reviews the fellow s progress at least on a quarterly basis, provides the fellow with feedback and advice and reports any concerns to the program director. The domains in which appropriate progress should be reviewed include 1) clinical performance (using benchmarks as outlined in the PICU fellowship program goals and objectives, available from the program coordinator and on e-portfolio); 2) scholarly work (with the projected outcome of a work product as defined by the ABP, see https://www.abp.org/abpwebsite/becomecert/subspecialties/scholarlyactivity.htm) ; and 3) overall career development in light of the fellow s career goals. The advisor should document review and feedback on a bi-annual basis in the fellow s individual learning plan on e-portfolio. Each fellow will select one primary scholarly (research) mentor who is responsible for oversight of the fellow s scholarly work and meets with the fellows on at least a monthly basis. In addition to the scholarly mentor, each fellow selects 3 additional mentors to make up a Scholarship Oversight Committee 12

(SOC) as mandated by the UCSF Department of Pediatrics (see http://pediatrics.ucsf.edu/fellows-college/soc) following ABP guidelines. A. Fellow evaluation and feedback: a 360 feedback system is in place which is competency based and aligned with milestones. a. The fellow has access to E*Value evaluations at all times and copies of paper evaluations are sent to the fellow by the program coordinator; originals are stored in the fellow s file. 1. Formative a. Faculty evaluate fellows using E*Value on a monthly basis based on clinical schedules. Each faculty member who worked with a fellow for one week or more on clinical service will receive a request to complete an evaluation b. Fellows evaluate each other using E*Value on a monthly basis based on clinical schedules. Each fellow who completed a week or more of clinical service will be requested to evaluate his/her cofellow(s) c. Faculty observe fellows handoffs and complete a paper evaluation using the I-PASS observation tools (see Transitions of Care Policy) d. Other evaluators (nursing staff, social workers, peers, parents etc. see 360 o evaluation process outline) evaluate fellows at the San Francisco site on an ad-hoc basis using paper forms e. Fellows need to document procedures and mock code participation in E*Value using the E-value procedure logging feature. This will generate an evaluation to the supervising attending. f. Fellows receive evaluations after organizing M&M, teaching fellow rotations and journal club evaluations through evaluations generated in qualtrix g. The fellow completes an Individual Learning Plan (ILP) with selfassessment regarding progression towards competencies in the UCSF eportfolio system; this is done twice a year. h. The fellow s advisor meets with the fellow twice a year to review the fellow s ILP, available evaluations and the fellow s Individual Development Plan (IDP), and provides feedback, which is documented in the feedback section of the eportfolio ILP. i. Fellow progress and scholarly work is assessed by the Scholarship Oversight Committee (SOC). The fellow submits an IDP for review by his/her SOC on an annual basis, and receives formal written feedback using the e-portfolio system. j. The program director meets with each fellow twice a year and discusses all of the above evaluations, in-training exam scores, SOC review and career plans with the fellow, provides feedback and creates a plan for further development. Documentation of this meeting is stored in the fellow s e-portfolio file. 2. Summative (at end of fellowship) 13

a. The SOC reviews the fellow s final scholarly work product and verifies and documents board eligibility. b. The program director reviews final evaluations, verifies satisfactory completion of the SOC process and verifies competence of each graduating fellow and documents this in a final letter of completion of fellowship. B. Faculty evaluation and feedback 1. The fellows evaluate individual faculty members using E*Value on a quarterly basis. Evaluations include clinical teaching abilities, commitment to educational program, clinical knowledge, professionalism and scholarly activities 2. The program director reviews evaluations of all faculty members on an annual basis, and shares these with each faculty member accompanied with suggestions for faculty development as needed. C. Program evaluation & improvement 1. The program is evaluated by fellows on an annual basis via E*Value.. 2. An annual meeting to which all faculty and fellows from both training sites are invited but with at minimum the members of the PEC present takes place each year in August/September, during which results of the program evaluation are discussed and any deficiencies will be addressed with a written plan documented in minutes of the meeting. The written plans from the previous year will be reviewed and discussed. 3. The curriculum of fellows conferences is evaluated on an ongoing basis with evaluations completed after each conference, and the curriculum is adjusted accordingly. 4. Informal sessions to discuss program issues between fellows and the program director are held twice a year and on an as-needed basis. 5. The program monitors, tracks and documents fellows performance (evaluations, in-training exam results, SOC review), graduate performance (board results) and faculty development. 14

SUPERVISION I. PURPOSE To specify the supervision policy for fellows in the Fellowship Program in Pediatric Critical Care Medicine at UCSF Benioff Children s Hospital San Francisco and Oakland. II. DEFINITIONS Direct Supervision: on-site, shoulder-to-shoulder supervision, i.e. staff member is physically present and directly observes and guides fellow during patient care Competencies: procedures or activities that the fellow can usually perform without direct supervision. The underlying patient condition and complexity of the procedure might dictate the need for direct supervision and physical presence of the attending physician. Competencies are institution-specific: for UCSF, competencies are listed per individual trainee on the internal website (accessible via U-care links, UCSF pages, physician privileges and resident competencies) Appropriately credentialed staff member: during all Pediatric Critical Care rotations, this will be a staff member credentialed in Pediatric Critical Care Medicine. During other rotations, this can be a physician credentialed in Anesthesiology, Cardiology, Adult Intensive or Emergency Medicine depending on the nature of the rotation. III. POLICY The Fellowship Program in Pediatric Critical Care Medicine complies with policies on supervision as outlined by the UCSF GME Office http://medschool2.ucsf.edu/gme/pdf/supervision_080111.pdf and the ACGME http://www.acgme.org/acgmeweb/portals/0/pfassets/programresources/comm on_program_requirements_07012011[1].pdf UCSF requires that faculty (members of the Attending Medical Staff) actively supervise all residents and ACGME fellows. Supervision is documented in the medical record. Each institution will have specific rules on precise documentation requirements. A. UCSF Benioff San Francisco An appropriately credentialed Attending Medical Staff member must: 1. Be available to the fellow in person or by telephone 2. Direct the care of the patient and provide supervision. a. The degree to which direct supervision is provided depends on the nature of the patient s condition, the likelihood of major changes in the management plan, the complexity of care and the experience and judgment of the fellow being supervised. 15

b. Fellows can (with Attending Medical Staff member approval) perform certain procedures without direct supervision if they are among the procedures listed under the fellow s competencies (available from the internal UCSF website (U-care links) under physician privileges and housestaff competencies), but only if the Attending Medical Staff member has privileges to perform this procedure. c. All transports must be supervised by an Attending Medical Staff member of the Division of Pediatric Critical Care Medicine: the fellow needs to discuss the initial transport call and all subsequent calls with the Attending Medical Staff member. d. All consults, including Rapid Response Team consultations, must be supervised by an Attending Medical Staff member of the Division of Pediatric Critical Care Medicine (i.e. patient needs to be evaluated by the Attending Medical Staff member) 3. Co-sign all History and Physical notes, Procedure Notes, Consult Notes (including Rapid Response Team Notes), Discharge Summaries and Transport documentation notes as well as Sedation Records for patients until the fellow has completed the required training to obtain sedation competencies (see Procedural Sedation Policy). Fellows must always notify their supervising attending physician in case of: Death (even if expected) Cardiac arrest Respiratory failure requiring either intubation or significantly increased O2 Severe respiratory distress and airway issues Hypotension/hemodynamic instability Bleeding requiring transfusion Symptomatic and severe hypertension Significant or new arrhythmia Significant or abrupt changes in neurological status Medication or treatment error requiring clinical intervention Development of any clinical problem requiring an invasive procedure or operation for treatment Any communication issues with consulting or surgical services Any communication issues with patients/families, including intent to leave against medical advice All Rapid Response Team consults All transport calls All admissions All discharges/transfers out of the ICU not previously discussed B. UCSF Benioff Oakland 16

An appropriately credentialed Attending Medical Staff member must: 1. Be available to the fellow in person or by telephone 2. Direct the care of the patient and provide supervision. a. The degree of supervision is dependent on the nature of the patient s condition, the likelihood of major changes in the management plan, the complexity of care and the experience and judgment of the fellow being supervised. b. Fellows can (with Attending Medical Staff member approval) perform certain procedures without direct supervision c. All transports must be supervised by an Attending Medical Staff member of the Division of Pediatric Critical Care Medicine: the fellow needs to discuss the initial transport call and all subsequent calls with the Attending Medical Staff member. d. All consults must be supervised by an Attending Medical Staff member of the Division of Pediatric Critical Care Medicine (i.e. patient needs to be evaluated by the Attending Medical Staff member) 3. Co-sign History and Physicals, Progress Notes, Procedure Notes, and Transport documentation notes. Fellows must always notify their supervising attending physician in case of: Death (even if expected) Cardiac arrest Respiratory failure requiring either intubation or significantly increased O2 Severe respiratory distress and airway issues Hypotension/hemodynamic instability Bleeding requiring transfusion Symptomatic and severe hypertension Significant or new arrhythmia Significant or abrupt changes in neurological status Medication or treatment error requiring clinical intervention Development of any clinical problem requiring an invasive procedure or operation for treatment Any communication issues with consulting or surgical services Any communication issues with patients/families, including intent to leave against medical advice All transport calls All admissions All discharges/transfers out of the ICU not previously discussed 17

IV. PROCEDURES/RESPONSIBILITIES A. Divisions must publish call schedules, and these must be prominently available, indicating the responsible faculty member. B. Fellows as individuals must be aware of their limitations and are expected to function within graduated levels of responsibility and to communicate significant patient care issues to the responsible attending faculty physician. Failure to do so may result in the removal of the fellow from patient care activities. C. The program director is responsible for adequate supervision as outlined in this policy at both institutions. The site director at Oakland oversees supervision of fellows during rotation on the site, reports problems to the program director and is responsible for implementation of changes if needed. 18

TRANSITIONS OF CARE I. PURPOSE To specify the transitions of care policy of the Fellowship Program in Pediatric Critical Care Medicine at UCSF Benioff Children s Hospital San Francisco and Oakland. II. BACKGROUND & DEFINITIONS 1. With heightened awareness of the effects of handoffs (hand-overs) on patient safety and education, the ACGME common program requirements include specific mandates to design systems, ensure competency for residents and clinical fellows, and monitor efficacy of handoffs. 2. ACGME Standards for Transitions of Care: a) Programs must design clinical assignments to minimize the number of transitions in patient care. b) Programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety. c) Programs must ensure that residents are competent in communicating with team members in the hand-over process. d) 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. III. POLICY: The Fellowship Program in Pediatric Critical Care Medicine complies with both the UCSF GME Transitions of Care Policy http://medschool2.ucsf.edu/gme/pdf/transitions_of_care092611.pdf and ACGME requirements http://www.acgme.org/acgmeweb/portals/0/pfassets/programresources/comm on_program_requirements_07012011%5b1%5d.pdf. This policy applies to all fellows during their rotations at either teaching site. A. Clinical assignments: The clinical schedule at both sites is designed to minimize transitions of care while maintaining compliance with duty hour policies. Ample time is allotted for hand-off at the beginning and end of each shift. B. Hand-off structure: Structured hand-off occurs face-to-face, utilizing a hand-off tool adapted from the pediatric residency I-PASS tool, which has the following elements: I patient Identification and Illness severity P Patient summary with problem list and recent events, important findings on exam, imaging and laboratory studies, review of medications, respiratory support and indwelling catheters. 19

A Action Items: to do list for the shift, including diagnostic images and laboratory studies to follow-up, procedures to be done and medications to be adjusted S Situation Awareness: if/then statements including overall goals of care, specific goals based on patient problems, which consultants need to be notified of what changes, family members involved in care and interpreter needs S Synthesis by Receiver: read back by receiver to verify understanding. C. Training and Assessment: Training regarding hand-offs is integrated into the new fellow orientation Fellows assess each other s hand-off skills as part of a peer evaluation performed in E*Value. Faculty members assess fellows hand-off skills as part of the E-value evaluations and as separately scheduled hand-off observations using the I-PASS observation tools. D. Availability of schedules All trainee and attending schedules for the San Francisco site are available through amion.com Trainee schedules for the Oakland site are also available through amion.com; the attending schedule is posted in the PICU 20

I. PURPOSE NOTE WRITING To describe the policies regarding the responsibilities of fellows in the Fellowship Program in Pediatric Critical Care Medicine at UCSF Benioff Children s Hospital San Francisco and Oakland in the area of note writing and other documentation of patient care activities. II. POLICY Fellows carry a few responsibilities for documentation of patient care activities, which differ for the 2 training sites as outlined below. Format of documentation should be consistent with institutional policies. A.UCSF Benioff San Francisco At the San Francisco site, fellows are responsible for several pieces of documentation. All require co-signing by the responsible attending; for notes in APeX make sure the box cosign required is checked. 1. Rapid Response Team consultation notes: Fellows have to write a brief consultation note using the template available in APeX for all consultations, including for those patients that are admitted to the ICU (in which case the checkbox see admission note to ICU can be marked). See PICU Fellows Instructions for RRT Consultation Notes, Procedure Notes, and Discharge Summaries at UCSF for further details. Consultation notes should be completed before the end of the shift during which the consultation takes place and need to be electronically co-signed by the responsible attending physician. 2. Discharge Summaries: Fellows need to create a discharge or transfer summary for ALL patients discharged directly from the P(C)ICU to either home or an outside facility, regardless of length of stay, with the exception of patients whose primary team is a surgical service. This includes patients who died in the P(C)ICU and were not on a surgical service. See PICU Fellows Instructions for RRT Consultation Notes, Procedure Notes, and Discharge Summaries at UCSF for further instructions. Discharge summaries need to be created within 48 hours, and are the responsibility of the fellow on service at the time of discharge/death. Transfer notes need be ready to accompany the patient or get faxed at the time of transfer. Failure to complete discharge and transfer notes in a timely fashion will result in suspension of the responsible faculty member. In case a faculty member gets suspended as the result of a fellow not completing a discharge summary, the fellow will be subject to disciplinary action. 3. Procedure notes: Fellows need to complete procedure notes in APeX for all arterial lines, central lines, intubations, chest tubes and other major procedures. Fellows should complete procedure logs in E*Value and assign supervising attendings to complete procedure evaluations. 21

4. Transports: A paper-based transport intake documentation form should be filled out for each request for transfer or consultation by an outside physician directed to the P(C)ICU. All communication with outside physicians should take place via the Access Center and should be recorded. Documentation of follow-up calls can be on the same form; all forms need to be co-signed by the responsible attending. B. UCSF Benioff Oakland At the Oakland site, fellows are responsible for the following documentation: History and Physical: All patients admitted must have an H&P completed by the primary house officer assigned to the patient, co-signed by a senior resident, fellow, or attending. It must be recorded within four hours of admission. If the fellow is on call, he/she is responsible for completing the H & P on patients admitted to his/her primary team. 1. Interim Summary: Fellows need to write a weekly summary on all patients in the PICU for more than 7 days. The weekly summary should include a brief clinical overview, outstanding laboratory, and diagnostic studies, and an anticipated plan. The weekly summary is the responsibility of the fellows on each of the clinical teams. 2. Procedure Notes: All procedures performed require a note. The fellows should dictate or type a note in the Epic system. The note should include the type of procedure, indication, technique used, complications, and the supervising attending. 3. Transports: Fellows are responsible for coordinating transports and answering advice calls. The information is documented on the transport form for each request. All communication with outside physicians must be documented. Documentation of recommendations given to referring physicians, and transport is required. All transport forms need to be co-signed by the responsible attending. 22

PROCEDURAL SEDATION I. PURPOSE To specify the policy regarding the need for training and supervision of fellows in the Fellowship Program in Pediatric Critical Care Medicine at UCSF Benioff Children s Hospital San Francisco and Oakland while providing sedation services. This policy is in compliance with the UCSF Medical Center Policy for Sedation Administration by Non-Anesthesiologists; see also the PICU Fellowship Policy on Supervision. II. DEFINITIONS Direct Supervision: on-site, shoulder-to-shoulder supervision, i.e. staff member is physically present and directly observes and guides fellow during patient care. Competencies: procedures or activities that the fellow can usually perform without direct supervision. The underlying patient condition and complexity of the procedure might dictate the need for direct supervision and physical presence of the attending physician. Competencies are institution-specific: for UCSF, competencies are listed per individual trainee on the internal website (accessible via U-care links, UCSF pages, physician privileges and resident competencies). Appropriately credentialed staff member: during all Pediatric Critical Care rotations, this will be a staff member credentialed in Pediatric Critical Care Medicine. During other rotations, this can be a physician credentialed in Anesthesiology, Cardiology, Adult Intensive or Emergency Medicine depending on the nature of the rotation. Minimal Sedation: a drug-induced state during which patients respond normally to verbal commands; ventilatory and cardiovascular functions are unaffected. Moderate Sedation: a drug-induced depression of consciousness during which patients respond purposefully to verbal commands and/or light tactile stimulation; no interventions are required to maintain a patent airway and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Deep Sedation: a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation; ability to maintain ventilatory function may be impaired, but cardiovascular function is usually maintained. III. POLICY Fellows can provide procedural sedation to patients in the PICU and other patient care areas at both sites, under supervision of an appropriately credentialed staff 23

member. Whether direct supervision is needed depends on the level of training and experience of the fellow. In particular situations the supervising attending may deem direct supervision necessary regardless of fulfillment of specific requirements. Each institution has specific rules on precise training requirements and need for documentation. A. UCSF Benioff San Francisco 1. Minimal Sedation: Minimal sedation is one of the competencies of PICU fellows at UCSF, which means that no direct supervision is required. 2. Moderate Sedation: PICU fellows require direct supervision for the performance of moderate sedation until they have fulfilled the following requirements: a. Completion of the Sedation Training Module (1-hr video available from the program administrator). b. Successful completion of the Sedation post-test. 3. Deep Sedation a. Completion of the Sedation Training Module (1-hr video available from the program administrator). b. Successful completion of the Sedation post-test. c. Maintenance of PALS training. d. Documented completion of 5 supervised deep sedation procedures with an attending physician. After completion of the required training, direct supervision may still be warranted depending on the patient s clinical status, per the attending physician s discretion. Regardless of degree of supervision, fellows need to discuss the sedation plan with the attending ahead of time. All moderate and deep procedural sedation requires informed (parental) consent and a procedural sedation record needs to be completed by the sedating physician, co-signed by the responsible attending. B. UCSF Benioff Oakland Prior to performing any sedation, fellows are required to take a sedation test consisting of a basic and advanced part, which is available from the Oakland fellowship site director. Direct supervision is required for the use of ketamine and propofol. In all other instances, fellows are to discuss the sedation plan with the supervising attending, who will decide on the need for direct supervision depending on the situation. All moderate and deep procedural sedation requires informed (parental) consent and a procedural sedation record needs to be completed by the sedating physician, co-signed by the responsible attending. 24

EDUCATIONAL CONFERENCE ATTENDANCE I. PURPOSE To specify the policy of the Fellowship Program in Pediatric Critical Care Medicine at UCSF Benioff Children s Hospital San Francisco and Oakland on attendance of educational conferences. II. POLICY: Fellows in the Pediatric Critical Care Medicine Fellowship Program at UCSF Benioff Children s Hospital San Francisco and Oakland are expected to attend and/or participate in a number of educational conferences. The RRC mandates that the program track attendance of trainees at educational conferences. A. Fellows conference is a 2-hour educational session organized on a weekly basis and is considered a core component of the fellowship curriculum. It takes place every Wednesday morning from 7 9 AM in San Francisco, with the exception of the 3 rd Wednesday of the month, when it is held in Oakland. Attendance at fellows conference is mandatory, and the Pediatric Critical Care Program strives for 100% attendance. Fellows are excused from clinical duties during fellows conference, and are expected to notify the attending prior to leaving the unit, if on service, to sign-out any active issues. Only in rare circumstances will clinical care prevail over attendance at conference; this is at the discretion of the attending on service. Fellows are excused from fellows conference only in cases of vacation, educational leave or other leaves of absence approved by the program director as indicated in the leave policy, and in the case of a fellow who worked an overnight shift and feels that driving to fellows conference may be hazardous as a result of fatigue. Attendance is tracked with a sign-in sheet and inadequate attendance, including repeated tardiness, will be noted in the fellows evaluation file. PICU M&M Conference (monthly) and Journal Club (approx. monthly in second half of academic year) are part of fellows conference and fellows are expected to actively participate in these sessions. Senior fellows are scheduled to be the M&M fellow (responsible for coordination of the case presentations for monthly M&M conference. Rescheduling of these responsibilities can only be done with prior approval of the fellowship program director. The remainder of fellows conference is made up of educational sessions taught by expert faculty in a variety of topics consistent with the educational curriculum as outlined by the RRC. The program director is responsible for the quality of the curriculum, and to this end each session is formally evaluated. B. Other regularly scheduled conferences Schedules and locations for the various conferences can be obtained from the (site) fellowship director; see also the Fellowship Expectations and Guidelines page available on the PICU Fellowship Group page in UCSF eportfolio 25 Version July 15, 2014

Fellows Conference PICU Board Review: PICU bedside teaching: Cardiac M&M: CT Presurgical Conference: Pediatric Grand Rounds: GME Grand Rounds: PICU Mock Codes: PCICU Mock Codes: ICN/PICU Research: Open Pediatrics Webinar: Fellows Forum: Every Wednesday from 7-9 AM Every 4th= M&M, Every 3 rd = in Oakland, see schedule on e-portfolio for topics Every Wednesday, 9:00-10:00 AM; mandatory for all fellows except those on clinical service Every Wednesday, 10:00 AM 11:00 AM; mandatory for all fellows except those on clinical service Every 3 rd Monday of the month, 7:00 AM 8:30 AM; mandatory for all fellows except those on clinical service SF: Every Tuesday, 7:30 9:00 AM; fellows on clinical service in the CICU in San Francisco should attend Oak: Every Tuesday 7:00-8:00 AM; fellows on clinical service in Oakland should attend Every Thursday, 8:00 9:00 AM, recommended depending on topic See schedule on http://medschool.ucsf.edu/gme/grounds/index.html mandatory for all fellows as clinical duties allow 4 th Tuesday of every even month, 2:30-4:00 PM; mandatory for all fellows except for fellows on clinical service Announced via email approx 2 weeks ahead of time, at least annual participation is mandatory for all fellows Every 2 nd Tuesday of the month 2:30-4:00 PM; mandatory for all fellows not on clinical duty. All fellows present their research at least annually Every 4 th Wednesday 11-12, recommended Quarterly sessions announced via separate email, mandatory for all fellows not on clinical service Children s Hospital Oakland Research Institute (CHORI) hosts several conferences a month, given by the CHORI staff or visiting scientists. Attendance 26 Revised July 2016

by the fellows is suggested for all fellows as clinical duties allow. See http://www.chori.org/education/seminars/seminars.html for schedule Quarterly Fellowship Didactics are given at CHORI as an evening session and will focus on issues common to all pediatric subspecialty training programs in clinical care and research, recommended. Fellows College and Research Day: See http://pediatrics.medschool.ucsf.edu/fellowscollege/ for the schedule. Attendance is mandatory for all fellows. Fellows should make call switches ahead of time to ensure that they remain in compliance with duty hours while attending Fellows College/Research Day. UCSF ECMO course: organized annually in the fall, dates are announced over the summer. All fellows should attend this course at least once during fellowship. Fellows can attend other conferences and courses as desired, provided there is no conflict with clinical and research duties. Courses/conferences lasting more than one day require prior approval by the program director and/or research mentor as outlined in the educational leave policy. C. Teaching responsibilities: All fellows in year 2, 3 and beyond participate in teaching fellow rotations at least once a year. The teaching fellow has the following responsibilities: 1) Following a two-year syllabus based on Roger s Textbook of Critical Care, lead the group in an informal teaching session, followed by 2-5 relevant questions. Syllabus is posted on eportfolio. 2) Give a case-based conference for all pediatric residents in San Francisco on the first Wednesday of the month, chalk-talk interactive format preferred. Touch base with the UCSF Parnassus Chief Resident to discuss the topic and list it on the appropriate forum on the eportfolio site. 3) Organize the PICU resident talks for the month; give at least 2-3 talks and ensure the other fellows who give talks get feedback. 27 Revised July 2016

USE OF EDUCATIONAL FUNDS I. PURPOSE To specify acceptable use of educational funds available to fellows in the Fellowship Program in Pediatric Critical Care Medicine at UCSF Benioff Children s Hospital San Francisco and Oakland. II. POLICY: There is approximately $1500 per fellow per academic year (July 1 June 30) for use towards educational expenses. This does not apply to fellows on a T32 or PSDP grant, for whom separate funds for educational expenses are available (with different rules and restrictions see policy associated with the grants for details). The main goal of educational funds is to promote fellows professional development through attendance and presentation at conferences and engagement in activities beyond clinical critical care training.. Educational expenses include: Cost associated with attendance at national and international conferences relevant to critical care or the scholarly activity the fellow is engaged in Courses relevant to critical care or the scholarly activity the fellow is engaged in Textbooks relevant to courses or the scholarly activity the fellow is engaged in Professional memberships (SCCM membership is sponsored by industry and enrollment is arranged by the program coordinator) On occasion, board review courses and critical care books may be reimbursed from educational funds (see below) Fellows are strongly encouraged to go to one conference a year, and the budget is allocated preferentially to fellows who present their own work at conferences. Prior permission to leave for a conference needs to be obtained from program directors and research mentors as outlined in the PICU Fellowship Leave Policy. Fellows who plan to submit abstracts to multiple conferences should plan ahead with their research mentor to verify existence of additional funds since there is no guarantee that the program can pay for more than one conference per year. Also, fellows are strongly encouraged to limit expenses by choosing less expensive hotels and sharing rooms when possible, and getting posters printed for free or at low cost (at the CTSI or CHORI). Extra expenses due to late registration and other avoidable fees will not be reimbursed. The program director needs to be notified of all (projected) educational expenses by May 1 of each year. Remaining funds will be distributed as follows, in order of prioritization: 1) fellows who travelled to conferences to present their own work or took relevant course work and incurred expenses exceeding the annual allowance of $1,500 2) educational goals that benefit all fellows (for example, a 28

new textbook for the fellows library), 3) requests for books, courses etc. pertinent to critical care. Fellows can submit requests at any time prior to May 1; the decision regarding allocation of funds is made by the program directors. Funds do not carry over to the following academic year, and all paperwork for reimbursement must be submitted to the program administration by June 15. Proof of payment, attendance, boarding passes etc need to be in the name of the person who attended the conference/course and certain restrictions apply towards international travel. Contact the program coordinator ahead of time to ensure all paperwork is complete. The annual in-training examination is mandatory; costs are reimbursed by the program. Allocation of educational funds is contingent on the fellow s compliance with the program standards for professionalism, as outlined in the PICU Fellowship Policy on Academic Due Process and Professional Behavior 29

PHYSICIAN WELL-BEING AND FATIGUE I. PURPOSE To describe the mechanisms through which the Fellowship Program in Pediatric Critical Care Medicine at UCSF Benioff Children s Hospital San Francisco and Oakland provides support for the fellows well-being and monitors both fatigue and well-being. II. POLICY A. Well-being Joint faculty meetings with faculty from both sites are held on a semi-annual basis, during which fellows progress and performance is discussed and any concerns are raised. When there are any concerns, the program director will discuss this with the fellow s primary advisor, and will take action as needed, which may include: 1. Referring the fellow to the Faculty and Staff Assistance Program (FSAP), or other pertinent health resources. 2. Requiring the fellow to seek a confidential assessment by a mental health professional. 3. Notifying the Physician Well-Being Committee of the UCSF Medical Staff. 4. Notifying the Physicians Confidential Assistance Line of the California Medical Association. 5. Providing ongoing support and monitoring of the fellow. The program director, together with the fellow s primary advisor and site-advisor (as appropriate), monitors the fellow s progress, ensuring that the fellow receives appropriate support and is able to safely perform his/her patient care duties. In addition, any fellow who is concerned about his/her own psychological wellbeing, or any resident, faculty member or student who has concerns about a colleague, may contact the program director, or use any of the resources outlined below. B. Fatigue Fellows will be educated on the effects of fatigue on well-being, performance and patient care during divisional fellows conferences, departmental lectures/workshops organized by Fellows College, and through UCSF GME Grand Rounds. Fellows spend several hours per day working under direct supervision of attending physicians who will assess for fatigue and stress and report concerns to the program director. Any fellow who is noted to suffer from fatigue and/or stress compromising safety of patient care will be sent home after discussion with the program director. In case of recurrent or structural problems, further support will be provided as outlined under III. A. and if needed adjustments will be made in the schedule. In addition, the UCSF GME Office has 30

available for viewing a Fatigue Module for UCSF Residents and Fellows (http://medschool.ucsf.edu/gme/prog_resources/safer.html) and an Impairment Module for UCSF Residents and Clinical Fellows (http://medschool.ucsf.edu/gme/prog_resources/impairment.html). III. SOURCES OF SUPPORT A. Faculty and Staff Assistance Program (FSAP) This group is available to any member of the campus community for confidential consultation. An appointment can be made directly via (415) 476-8279, or by referral through one's primary physician or a member of the Physician Well-Being Committee. See http://ucsfhr.ucsf.edu/assist/index.html for more information. Outside the University Psychologists, psychiatrists, and chemical dependency recovery specialists are available for consultation outside the University, again in strict confidence. Referral can be made through the Faculty and Staff Assistance Program, through a member of the Physician Well-Being Committee, through one's primary physician, or by oneself. Alternately, the Physicians Confidential Assistance Line of the California Medical Association can be reached at (650) 756-7787. See also http://www.cmanet.org/resources/confidential-assistance/ Hospital Committees The Medical Staff of each hospital has a Physician Well-Being Committee dedicated to recognizing and offering assistance to staff and physicians who have problems with substance abuse or physical and mental illness which impair their ability to practice safely and effectively. Each committee handles cases involving physicians of all departments in that hospital. The names of these committees and the corresponding contact persons are: 1. Moffitt-Long Physician Well-Being Committee; call the Medical Staff Office at (415) 885-7268 2. UCSF Benioff Children s Hospital Oakland Well-Being Committee; call the Medical Staff Office at (510) 428-8356 31

APPLICANT SELECTION I. PURPOSE To describe the applicant selection policy for the Fellowship Program in Pediatric Critical Care Medicine at UCSF Benioff Children s Hospital San Francisco and Oakland. II. POLICY: The Pediatric Critical Care Medicine Fellowship Program participates in the National Residency Matching Program (http://www.nrmp.org/) and complies with the rules as set forth by the NRMP. Some fellows may be appointed outside of the match: 1) Fellows who are also appointed in the Molecular Medicine Training Program at UCSF (http://medicine.ucsf.edu/molmed/index.html). Application and selection of candidates takes place at time of application for pediatric residency training at UCSF. Trainees in the Molecular Medicine Program are guaranteed a fellowship training position in the subspecialty fellowship of their choice. 2) Fellows who are participating in the Physician Scientists Development Program (http://psdp.yale.edu/). Applications to the PSDP are due in February of the year prior to start of clinical fellowship; the application process is separate from application to fellowship. Because announcement of PSDP awards is not made until June (1 month prior to start of clinical fellowship, 13 months prior to PSDP training), the Pediatric Critical Care Fellowship Program may choose to offer serious PSDP candidates a position for clinical training outside the match. 3) Fellows who are appointed for additional research training under the divisional T32 training grant. Applicants with a serious interest in pursuing an academic career may apply for a 4-year training program prior to start of fellowship, extending the standard 3 years with one year of research funded by the divisional T32 grant. The program may choose to offer such candidates a position outside of the match. A. Fellowship applicant eligibility: Fellows must have completed a residency in pediatrics at one of the ACGME-approved residency programs and be eligible for board certification in pediatrics, or, in case of foreign medical graduates, have equivalent training and experience in another country. B. Fellow selection: Faculty from both training sites participate in fellow selection, which is done on the basis of the applicant s preparedness, ability, aptitude, academic credentials, communication skills and personal qualities such as motivation and integrity. The selection process does not discriminate with regard to gender, race, religion, color, national origin, disability or veteran status. 32

Selected applicants are invited for a 1 1/2-day interview (divided over the two sites) during which they attend educational conferences and rounds and view the clinical and research facilities at both sites. Applicants have unrestricted ability to interact with current fellows in the absence of attending physicians during dinner after the first interview day. Prior to the interview, applicants will be sent information regarding salary and benefits via email as dictated by ACGME guidelines. 33

ACADEMIC DUE PROCESS AND PROFESSIONAL BEHAVIOR I. PURPOSE The joint Fellowship Program in Pediatric Critical Care Medicine complies with the UCSF GME policy regarding Academic Due Process and Leave (available in the UCSF Housestaff Information Booklet http://medschool.ucsf.edu/gme/pdf/housestaff_info_booklet_2010_2011_020111.pdf and attached to this policy). This policy describes additional policies and procedures regarding standards for professionalism and procedures for promotion, academic probation, dismissal and appeal for the Fellowship Program in Pediatric Critical Care Medicine at UCSF Benioff Children s Hospital San Francisco and Oakland. II. DEFINITIONS: Professionalism is one of 6 ACGME identified competencies and is defined as the ability to demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population Disciplinary Measure: A disciplinary measure is a measure imposed on the fellow by the program director for serious or continued non-compliance with program standards, and may involve temporary loss of a variety of privileges as deemed appropriate by the program director and outlined below. Academic Probation: Academic Probation is a temporary measure which, at a minimum, involves participation in an academic remediation program as determined by the fellowship director and loss of moonlighting privileges. Suspension: Suspension involves removal of the fellow from part or all of the fellow s regular and usual assignments in the fellowship program, including but not limited to clinical, didactic and research activities. Dismissal: This term means expulsion from the GME fellowship program including responsibilities in the hospital, other clinical settings and research areas. Dismissal from the GME training program will result in the fellow s automatic dismissal from any and all related appointments such as medical staff membership. Appeal: Appeal refers to the process through which a fellow can request a formal review of the disciplinary measure, academic probation or dismissal. III. POLICY: A. General Policies: Fellows are appointed for a one-year period, which is normally renewed annually, at which time the fellow is promoted to the next PGY level. The fellow may be suspended for a finite period, for an indefinite period, or permanently dismissed, 34

or be subject to non-renewal of contract. A warning, counseling letter or notice of concern or disciplinary measure usually precedes academic probation, suspension or dismissal. Fellows are expected to comply with PICU Fellowship policies, to complete clinical assignments, to comply with standards of professionalism, to comply with codes of conduct at both institutions, and to comply with HIPAA regulations. Expectations and standards are outlined in the Fellowship Expectations and Guidelines page and the Program Goals and Objectives. The program evaluates the fellows on a regular basis as outlined in the PICU Fellowship Evaluation Policy and provides formative feedback. The PICU fellowship administration maintains a record of fellow performance, as well as written documentation of feedback, any difficulties identified and remedial interventions. Failure to correct marginal or unsatisfactory performance may result in either a marginal rating being issued to the American Board of Pediatrics (ABP) with or without additional time being required at the current or previous level of training, or an unsatisfactory rating to the ABP. If the fellowship director cannot sign off on clinical and research competence to the ABP, the fellow will not be eligible to take the subspecialty board examination. If during the evaluation process significant deficiencies are identified, a remediation plan will be developed in conjunction with the individual fellow and the fellowship director or faculty advisor assigned, and a counseling letter or notice of concern may be placed in the fellow s file. A timetable of re-evaluation and performance expectations will be formulated. Failure to achieve required performance expectations upon re-evaluation, continued marginal or unsatisfactory evaluations, or failure to comply with the assigned remediation plan will generally result in the imposition of academic probation and/or nonrenewal of contract. B. Disciplinary measure: A fellow who demonstrates serious or repeated failure to meet expectations as outlined in the Fellowship Manuals, or serious or repeated failure to comply with program policies and/or program standards, may be subject to a disciplinary measure. A disciplinary measure may involve temporary suspension of privileges such as educational leave and educational expense reimbursement, and loss of moonlighting privileges. In addition, if deemed appropriate by the fellowship director, the fellow may be required to participate in a program consisting of psychiatric evaluation and/or counseling, or behavior modification. The program director will issue the fellow a written notice outlining the reasons for the disciplinary measure, the exact nature of the measure and the period of time the measure will be in place as well as the conditions under which the measure will be discontinued. A fellow can appeal a disciplinary measure as outlined under II.C in the GME Academic Due Process and Leave Policy. If a fellow, despite a disciplinary measure, continues to violate policies and/or program standards, the 35

fellowship director may institute further disciplinary action, including academic probation, non-renewal of contract, or dismissal from the program. C. Non-renewal of contract: If the fellow does not demonstrate sufficient progress and/or fails to meet program standards, the fellow s appointment may not be renewed at the end of the term. If following at least six months of clinical or research activities the fellow has displayed a level of academic performance that appears to the fellowship director to likely result in either a marginal or unsatisfactory rating to the ABP, the program director may elect to not offer reappointment to the next year of training. Notification of this decision shall be made as soon as possible prior to the end of the fellow s year of training. In exceptional circumstances, termination from the program prior to the end of the academic year may result. The fellow can appeal a non-renewal decision as outlined in section III.E of the UCSF GME Academic Due Process and Leave Policy. D. Academic Probation Academic probation may be imposed for academic or clinical performance deficiencies that are sufficiently serious and/or continue to occur despite attempts at remediation. Academic probation involves the following: 1) The fellow must participate in, and complete in a satisfactory manner, an academic remediation program which may consist of assigned readings, periodic sessions with an assigned attending or preceptor, mandatory conference attendance above that required for other fellows, and other educational interventions. Other interventions such as psychiatric evaluation and/or counseling may also be required as deemed appropriate by the fellowship director. 2) Loss of moonlighting privileges. As described in section II.C.1 of the UCSF GME Academic Due Process and Leave Policy, the fellowship program director will communicate the conditions of academic probation to the fellow in writing, including the reasons for probation, the required remedial activity and the specific time frame. Probationary status can be extended depending upon the fellow s progress and success in correcting identified deficiencies as determined by the fellowship director. The fellow can appeal an academic suspension as outlined under section II.D of the UCSF GME Academic Due Process and Leave Policy. E. Suspension In exceptional cases in which the program director has evidence that there is immediate danger to hospital personnel, patients or the public by the continued functioning of the fellow, the fellow may be immediately suspended from patient care duties until a definitive course of action is determined. In addition, automatic suspension occurs for a variety of reasons outlined in section II.A.1 of the UCSF GME Academic Due Process and Leave Policy. F. Dismissal 36

Grounds for dismissal and appeal procedures are described in sections III.A.2 and III.E, respectively, of the UCSF GME Academic Due Process and Leave Policy. G. Appeal Procedures Fellows have the right to appeal academic actions with the Department as outlined in the UCSF GME Academic Due Process and Leave Policy. Disciplinary measures can only be appealed within the fellowship program by submitting a written request for review of the disciplinary action within 2 weeks of receipt of the written notification from the program director. The program director will appoint an ad hoc committee consisting of the fellowship director, the Oakland site-director, the fellow s faculty advisor and one senior fellow. This committee will review the situation and reach a majority decision as to whether the disciplinary measure should be sustained or amended. ALL POLICIES REVIEWED BY: Sandrijn van Schaik, MD PhD Fellowship Director 7/6/16 37