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   NAME/SIGNATURE PAGES

Revised May, 2001

I acknowledge receipt of a copy of the Louisiana State University Health Sciences Center-Shreveport, House Staff Manual. I understand that it is my responsibility to read and understand its contents. Any questions I may have about its contents should be directed to my program director. I understand that the information in the House Staff Manual is not all-inclusive and that the Medical Center or an individual department may establish additional policies and procedures necessary for the orderly fulfillment of its responsibilities. I understand that it is also my responsibility to learn and follow the policies and procedures established by my department that are not included in the House Staff Manual.

I recognize the Medical Center may, at its discretion, amend, add or eliminate policies when circumstances so require, and that I have a responsibility to do my best to keep apprised of any changes as they occur.

I agree to follow the Medical Center’s policies and I am aware that failure to do so may result in disciplinary action up to and including termination.

House Officer Name (PRINT)

House Officer Signature

House Officer Social Security Number

Date Received

FROM: The Office of Medical EducationWelcome to LSU Health Sciences Center. The Office of Medical Education provides support services to the house officers and training programs at the Health Sciences Center. We look forward to serving your needs.

Please feel free to stop by our office in the hospital (Room A1-19) if we can be of any assistance to you or you can view the Graduate Medical Education Website at www.sh.lsuhsc.edu/gme for information. Sincerely,

(5054)

eguzma@lsuhsc.edu

Jennie Webb

Office Coordinator 2

(5069) jwebb1@lsuhsc.edu

Chasidy Mangham

Residency Coordinator

(5053) cmangh@lsuhsc.edu

On behalf of the faculty and staff, I welcome you to the Louisiana State University Health Sciences Center in Shreveport. By joining the House Staff of the Center, you become a member of a team of highly committed health care professionals devoted to the delivery of quality health care in an academic atmosphere of injury.

The Louisiana State University Health Sciences Center is an outstanding health care facility that provides the latest advances in diagnosis and treatment to the citizens of Louisiana in an atmosphere of caring and concern.

Welcome to the LSUHSC team.

                          Sincerely,

                          John C. McDonald, M.D.
                          Chancellor and Dean

University Hospital excels in its service to patients and its training for residents. We can however always improve, and your thoughts, recommendations and suggestions are always welcome. All of us look forward to the coming years and challenges. We urge you to feel free to communicate your ideas to your staff and to the members of the Graduate Resident Medical Education Committee. Working together we can make a truly great Hospital even better.

Thank you for choosing LSU Health Sciences Center for your postgraduate medical training. We are honored to have a part in the furtherance of your career.

It is a pleasure to welcome you to Louisiana State University Health Sciences Center, University Hospital, in Shreveport. As a member of our house staff, you will have many opportunities to serve patients, to learn about the practice of medicine, to assist in the teaching of other learners, and to grow in your personal life. It is also my hope and expectation that our hospital staff may contribute measurably to you in these important experiences.

The mission of the School of Medicine in Shreveport is to improve the health and human condition of Louisiana residents. The School of Medicine in Shreveport accomplishes its mission through the training of competent, ethical physicians, by serving as a focus for teaching and research in the health sciences, and by delivering quality health care to Louisiana residents.

Fulfillment of the hospital's responsibilities involves many varied problems and requires the help of every person on the staff. Your contribution is most essential. Your suggestions are invited and will be carefully considered.

The standards of care and the patient relationships which you maintain both establish and contribute to the reputation of LSUHSC. Obviously, we must all strive for excellence in all we do. The entire hospital staff stands ready to assist you in any way possible. My thanks to you for the seen and unseen dedication you bring to your work. We all look forward to the good that is yet to be.

Sincerely,

Joe Miciotto

Acting Hospital Administrator

GENERAL INFORMATION

1541 Kings Highway, Shreveport, LA 71130

A HISTORY

The first steps toward establishment of a state-maintained hospital in Shreveport were taken in 1876 when the Louisiana Legislature appropriated $10,000 to maintain a hospital that would care for the indigent in North Louisiana. Shreveport Charity Hospital was established in a group of log and frame buildings located in what is now downtown Shreveport. A five man board was appointed to oversee operations of this new hospital.

A Chief Surgeon, an Intern and a Physician staffed that early hospital. Six years later the Louisiana Legislature appropriated $20,000 to purchase a site for the hospital, and four acres on Texas Avenue was acquired. (This is the present location of Shreveport’s City Hall.)

The first Shreveport Charity Hospital built on the Texas Avenue site was erected in 1889 and was of frame construction. Dimensions of the two-story building were 215 feet by 38 feet. By 1904, there was need for a new hospital building and another was constructed at the same location for about $80,000. At this same time, the Charity Hospital School of Nursing, which is now defunct, was established.

Between 1916 and 1919, an outpatient clinic was begun so that medical needs of the indigent could be treated without having to admit the patients into the hospital. By the mid 1920's the bed capacity at the Shreveport Charity Hospital was 250. The bed capacity was nearly doubled by 1930; however, when extensive renovation was done to repair damage the hospital suffered when a fire destroyed an entire wing in the late 1920's. Two hundred and eighteen patients had to be moved to safety from the fire, none were injured.

The renovation program lasted for two years and when completed, the hospital's bed capacity was 400. Even those number of beds; however, was considered to be insufficient to meet the patient load.

In 1930 the first cancer clinic in the State of Louisiana was organized at Shreveport Charity Hospital. About the same time, the hospital established a public outreach program through daily radio broadcasts of health programs narrated by local physicians. Airtime was provided free to the hospital, which had its own radio studio, by a member of the hospital's board, who also owned a radio station.

The hospital continued to grow, keeping stride with the advances in the health field. By the late 1940's plans were being completed for construction of another hospital building to be constructed on a site further south of downtown that would allow for future expansion.

In 1953 the new building was completed at the corner of Linwood Avenue and Kings Highway. Cost of construction of that building was 10 million dollars. Bed capacity was 800. This building, although modernized and renovated, still houses the hospital today. A three-story Outpatient Clinic building was opened in 1973 adjacent to the hospital as the hospital continued to expand its role as provider of outpatient medical care to the indigent in North Louisiana.

Since 1953, there have been two name changes from Shreveport Charity Hospital to Confederate Memorial Medical Center. Shortly after the hospital marked its 102nd anniversary in 1978, the name again was changed. The name of the hospital today is Louisiana State University Hospital in Shreveport, a part of the Louisiana State University Health Sciences Center.

The change in name reflected the change of status that occurred in the hospital in 1976, when the Louisiana Legislature transferred ownership and control of the hospital from the Louisiana Health and Human Resources Department to the LSU Health Sciences Center.

Since the 1940's, the hospital has been engaged in postgraduate physician training and with the opening of the LSU Health Sciences Center, School of Medicine in Shreveport in 1969, the hospital has become even more closely involved in the medical education not only of physicians but of other health professions as well.

The hospital was the primary teaching hospital for the School of Medicine and with the opening of the School of Medicine buildings adjacent to the hospital in 1976, the affiliation became even closer. The heightened educational emphasis was matched by a rapid growth in institutional commitment to basic and applied research. Programs also grew in various allied health professions.

Since the mid 1970's, the hospital has embarked upon a program of renovation and construction designed to assure that LSU Hospital in Shreveport continues to keep pace with the most current medical advances in patient care and to affirm its obligation to the citizens of Louisiana through excellence of medical care as well as medical education and public service. In addition, LSU Hospital in Shreveport is recognized as a Burn Center, Bone Marrow Transplant Center, Level I Trauma Center, full-service surgery center, and also offers Centers of Excellence for Cancer and Rheumatology.

Today the LSU Hospital in Shreveport is a 432-bed licensed hospital providing tertiary care through its many specialty programs while maintaining it’s special mission for Louisiana’s indigent. The hospital’s outstanding programs increasingly attract a full-spectrum of patients from the region and beyond.

LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER-

The Mission of Louisiana State University Health Sciences Center - Shreveport’s University Hospital is to serve the Ark-La-Tex community by providing:

quality patient care services,

a teaching environment for training future medical and

allied health care professionals,

and support for medical and scientific research.

Quality Patient Care is the first priority of the organization. Empowered employees will maximize Quality Patient Care by balancing Patient Expectations, Patient Needs, and Available Resources.

DEFINITIONS

Patient Expectations are those aspects of care most appropriately identified by the patient. The patient and secondly their families take the leadership role in defining Patient Expectations. These include consideration for a patient’s rights, comfort, culture, dignity, privacy, security, and individuality. Collectively, how these patient’s interests are allowed to affect patient treatment show our respect and care for the individual.

Patient Needs are those clinical aspects of care best identified by healthcare professionals. Attending physicians take a leadership role in defining needs. Others physicians, nurses, technicians, allied health professionals, and others involved in helping those who deliver care all have expertise to contribute towards identifying and meeting the needs of the patient. The patient has the right to expect that these needs will be coordinated in an atmosphere which supports quality, interdisciplinary respect, and professionalism.

Available Resources are the facilities, equipment, supplies and people that are brought to bear to improve the health of the patient. Resources are limited in quantity. The use of resources must respect the long term viability and priority goals of the organization. The end use of all resources should support our mission.

The challenge to the physicians and the employees of the hospital is to balance Patient Expectations, Patient Needs, and Available Resources to achieve Patient Satisfaction and Quality Care. This can best be accomplished within a culture of mutual trust, mutual respect, and appropriate empowerment of patients, physicians, and hospital employees.

Louisiana State University School of Medicine

P. 0. Box 33932

Shreveport, LA 71130

Established in 1965-66 by Acts of the Louisiana Legislature, the School of Medicine in Shreveport graduated its first class of students in 1973. In 1975 the new School of Medicine complex was completed, and a class enrollment of 100 students per year was approved. The medical school is part of the Louisiana State University Health Sciences Center.

Type: Public

2000-2001 total enrollment: 394

Clinical facilities: (Shreveport):

Louisiana State University Hospital- Shreveport

Overton Brooks Veterans Administration Medical Center

Christus Schumpert Medical Center

Shriners Hospital for Crippled Children

CPC Brentwood

Willis-Knighton Medical Center

E.A. Conway Memorial Hospital (Monroe)

Homer Memorial Hospital

Lake Charles Memorial Hospital

Rapides Regional Medical Center (Alexandria)

North Caddo Memorial Hospital (Vivian)

The letters A-K designate the wings or areas of the hospital.

 ROOM NUMBERING SYSTEM

The last two lines of information in a listing are a location. For example, the first entry in the organizational directory is as follows:

Accounting

5222

(1st Floor-Rm. 115A) 1-115A

Allied Health Bldg.

Building B of the Medical School has two corridors, west and east. The west corridor connects to the hospital via A and G wings. The east corridor overlooks medical center parking lots.

A similar entry pertaining to the hospital would look as follows:

Medical Education

5069

Wing A-1st Fl.-Rm. 19 A-1-19

Building Hospital

SERVICE/BED ASSIGNMENTS
(Due to ongoing construction projects, service assignments are often relocated.)
Nurse Bed

Station Capacity
1-J Burn Unit 12
3-J SICU 20
3-G Day Surgery 21
4-P Perinatal 16

Unit 11

5-G Pediatrics 21
5-J Pediatrics 14
6-G OB/GYN 16

6-J Medical/Surgical 15
7-J MICU/CCU 15

7-G Telemetry 23

3-D PICU 10
10 Psychiatry 33
5-KN NICU II/III 35
6-KE Oncology 17
6-JW Bone Marrow Transplant unit 9

7-K Medicine 44, Ophthalmology-2 46
8-K Surgery 46

9-KE Neuro-9

Step-Down 2

E.M.W 2

*9-KW Orthopaedics 23
10-KE 24 hours observation 16

Med/Surg overflow 6

10-KW FamMed, 10, Urology 8
ENT-5 23
TOTALS LESS NURSERY 420
4JN Nursery 25
TOTALS 445

Paging is by an audible voice system through the hospital switchboard. It is limited to the Hospital.

When needed, you will be paged by name. When you hear your name, go to the nearest hospital telephone and dial "0".

"House phones" are located in the dining room and snack bar and provide automatic connection with the hospital switchboard.

The Medical Center considers it essential to have certain employees readily accessible by phone in order to affirm its mission. To facilitate this accessibility need, the Medical Center maintains and operates a pocket pager system.

The pocket pagers are the property of the Medical Center and, therefore, the person to whom the pager is assigned has the responsibility for its safe keeping.

If the pager is lost, or shows abuse other than normal wear and tear the house officer to whom it has been assigned will be responsible for bearing its replacement cost, $130.00.

Voice-it will state "please dial in your number". Press your number. Press # sign followed by * sign. This procedure will let the next person/call access system immediately.

Inward calls to the Medical Center from off campus will be completed by dialing #675 then the four-digit number of the department desired. Extension telephones will dial a four-digit number to dial any telephone on campus.

Dial "O" for the University operator for long distance calls.

NO 'PERSONAL CALLS MAY BE CHARGED TO THE

MEDICAL CENTER.

Personal calls will not be screened by the operators, but will be placed on call park, if not answered, will be forwarded to Department. Operator will not take or leave word.

Any number followed by 222s

Employment in residency or fellowship training is by contract. The contractual relationship governs issues that are specific to the residency/fellowship program and supplements those rules and regulations of the State of Louisiana and the LSU System. These items are covered more fully in other portions of the House Officer’s Handbook. Residents/fellows are expected to read this handbook as they are held accountable for its content. Although the residency/fellowship training programs may vary in length, contracts are issued for a period of one-year. Renewal of the contract for each subsequent year is completely discretionary at the option of either the resident/fellow or the department.

Written notice of intent not to renew a resident’s contract will be provided no later than four months prior to the end of the resident’s current contract. However, if the primary reason (s) for the non-renewal occur (s) within the four months prior to the end of the contract as much written notice of the intent not to renew will be provided prior to the end of the contract as the circumstances will reasonably allow.

There is no requirement under Louisiana law that the Health Sciences Center allow appeals for a contract non-renewal. However, since the non-renewal of a training contract may have an effect upon a resident’s/fellow’s career the Health Sciences Center does provide a process by which the resident/fellow may appeal the decision of the department not to renew the contract. The appeal for a contract non-renewal will be handled as an adverse action matter. Residents/fellows are advised to read the section under ADVERSE ACTION/DISCIPLINARY POLICY carefully as certain time constraints and other regulations apply. Failure to meet timely the requirements may waive the right of appeal.

Disciplinary action is defined as those actions taken to correct, to encourage the correction of, or punish substandard performance or lack of professional conduct. Disciplinary actions beyond written counseling are considered to be serious offenses.

An adverse action is defined as something that adversely affects a resident’s/fellow’s career and includes not only disciplinary action but also such matters as a non-renewal of a training contract. As stated above a non-renewal of a contract is not appealable under Louisiana law. However, in keeping with the requirements of the GRMEC, appeals for contract non-renewals are allowed since they represent a potential (but not necessarily certain) adverse effect upon the resident’s chosen pathway.

Many disciplinary/adverse action clinical privileges actions require mandatory reporting to national practitioner data bank in accordance with federal regulations (45 CFR, Part 60).

Residents/fellows are professional individuals who are expected to maintain a high standard of ethical conduct and performance. It is assumed that all residents/fellows who enter the various training programs, genuinely want to afford themselves the opportunity to enhance their training, skills, and careers. The training programs at the LSU Health Sciences Center-Shreveport have a responsibility to train individuals to an acceptable level of competence and to protect the general public from unskilled and unqualified practitioners.

The overall role of the Institutional GMEC at LSU Health Sciences Center-Shreveport is one of ensuring that individual departmental programs meet the institutional requirements of the Accreditation Council for Graduate Medical Education (ACGME) and the program requirements of the various Residency Review Committees (RRCs). Residents/fellows with complaints/suggestions about their program are encouraged to bring these matters to the attention of their Program Director and the Departmental Chair. If they feel they have been unable to effect change within their respective program/departments by this method, residents/fellows are encouraged to bring these matters to the attention of their GMEC representative, the Chairman of the GMEC Committee, or the Associate Dean for Clinical Affairs.

The role of the Institutional GMEC in the adverse action/disciplinary policy is one of ensuring that due process mechanisms are in place and functioning. The GMEC Committee does not hear adverse action/disciplinary matters against individual residents/fellows but rather ensures that prompt, appropriate, fair and free access is available through an appeals mechanism.

Faculty in the departments of the sponsored programs are best qualified to judge the performance and capabilities of residents/fellows in their program. The departments under the administrative guidance of the departmental chair and specific supervision of the program director have the responsibility for the educational program for their residency or fellowship program. They are responsible for the evaluation of those individuals enrolled in such programs according to the established guidelines of the respective Residency Review Committees. Each department establishes its mechanisms for the ongoing evaluations of its residents/fellows. Written evaluations should be given and discussed with the residents so that they may be made aware of their strengths, weaknesses, and recommendations for improvement. The departments evaluate their residents/fellows on a regular basis, but in no case less than twice yearly. At this time, the departmental representative conducting the evaluation should attempt to elicit recommendations from the resident/fellow to improve the quality of the resident’s/fellow’s training experience. These evaluations are residency/fellowship program specific but should include (but are not necessarily limited to) an evaluation of:

1. Competency
2. Knowledge
3. Work habits
4. Personal interaction with patients, patient’s families, peers, subordinates, and superiors.

If a resident’s/fellow’s performance is substandard disciplinary action is determined and administered by the individual department. Disciplinary action may take the form of:

1. Oral counseling
2. Written counseling
3. Suspension
4. Probation
5. Extension of residency training
6. Dismissal

The LSU Health Sciences Center-Shreveport is committed to the principal of due process. Due process is defined as allowing an individual to be confronted with the allegations and evidence against him/her, to present his/her side of the story to the decision-makers, and unless the offense is egregious, be given the opportunity for improvement.

The regular periodic evaluations (supplemented by any additional evaluations and counseling, and interactions with faculty) should alert the resident/fellow to his/her status. Since residents/fellows are professionals, they have the responsibility to be aware of their status, and to inquire of the faculty concerning their progress in the residency program. Upon receiving any negative evaluation, the resident/fellow should contact his/her program director immediately for advice and counsel.

Residents/fellows who are dissatisfied with departmental actions must, within five (5) working days, discuss this matter with the departmental chair. The decision of the chair in matters of oral counseling, written counseling, and suspension of less than 30 days will be considered final.

An additional appeals process for suspensions of thirty (30) or more days, probation, extension of residency training, or dismissal are allowed under the administrative procedures of the LSU Health Sciences Center-Shreveport. Additionally, although not required by Louisiana law, appeals will also be allowed for contract non-renewal. The decision of the appeals process for all matters will be either to uphold or not uphold the departmental action. The full procedure for appeals (including appeals committee membership) is described in the section entitled Appeals Process.

Residency/fellowship training is a serious responsibility both on the part of the resident/fellow and the faculty responsible for imparting such training. As medicine has progressed, and specialization has become more complex, the departments providing such training are best equipped to judge the clinical capabilities of the resident/fellows in their departments. It is expected that the entire faculty within the department/section sponsoring a residency/fellowship program will be involved in evaluating residents/fellows within their respective programs.

The role of the appeals process is to ensure that the resident/fellow has been fairly evaluated according to departmental standards, has been made aware of all his/her deficiencies, and given the opportunity to correct them. It is also to ensure that appropriate documentation has been made to substantiate the action being taken. The appeals process is an administrative one, and therefore the strict rules of evidence do not apply.

The appeals process follows the following administrative route:

1. Departmental chair
2. Associate Dean for Clinical Affairs
3. Appeals Review Committee
4. Second Review by Associate Dean for Clinical Affairs
5. A final appeal to the Chancellor of LSUHSC-Shreveport (representing the Board of Supervisors).

1. Upon receiving one or more of these disciplinary/adverse actions, the resident fellow desiring to contest this action must within five (5) working days request in writing a review by the Departmental Chair.
2. The Departmental Chair is the final appeal for all disciplinary matters of oral counseling, written counseling and suspensions of less than thirty (30) days. The Departmental Chair has ten (10) working days after receipt of the request to render an opinion. In disciplinary/adverse actions involving thirty (30) or more days suspension or for a non-renewal of a training contract, additional appeals are allowed.
3. In disciplinary/adverse actions involving thirty (30) or more days suspension or for a non-renewal of a contract, the resident/fellow desiring to contest this action must within five (5) working days of the action make a written request for a review by the Departmental Chair.
4. The Departmental Chair will have ten (10) working days from the receipt of the written request to render a decision.
5. Within ten (10) working days after receiving the decision of the departmental chair, the resident/fellow may request a hearing before the Associate Dean for Clinical Affairs. This request must be in writing, must state the factual basis for the appeal in detail, including but not limited to, specific reasons why the Resident/Fellow disagrees with the departmental action, other related issues that the resident/fellow desires to be considered, and the relief sought. FAILURE TO COMPLY TIMELY WITH THESE DEADLINES AND REQUIREMENTS WAIVES THE APPEAL RIGHT UNDER THIS SECTION.
6. The Associate Dean shall schedule a hearing with the resident/fellow as soon as possible but no later than ten (10) working days from the receipt of the written request. The Associate Dean shall have ten (10) working days after the hearing in which to render a decision in the matter. This decision will be in writing and transmitted both to the resident/fellow and the Departmental Chair.

7. If the resident/fellow is dissatisfied with the decision of the Associate Dean, he/she will have five (5) working days to request a formal hearing before an Appeals Review Committee.

8. The Associate Dean will appoint a committee made up of two chief residents from the departments other than that of the resident/fellow and two physician members on the Hospital Clinical Board who are not members of the resident’s/fellow’s department. The fifth member of the committee shall be the hospital administrator, associate hospital administrator, or a senior administrator of the medical school (excluding the Chancellor, Dean, or Associate Dean for Clinical Affairs) who shall preside over the committee but shall not vote except in the case of a tie. The Director of Legal Affairs or a suitable designee shall serve as the legal adviser to the committee, but shall not participate in or be present during the Committee’s closed deliberations.

9. The names of the members appointed to the committee shall be given to the resident/fellow and to the department chair. The resident/fellow and the department chair will each have five days from the receipt of the names of the committee members to notify (in writing) the Associate Dean of Clinical Affairs of any challenges to any member of the committee (including the Chairman). If challenges are not received within the allotted five-day time period, the committee will be considered duly constituted. If challenges are received (and the reasons are deemed valid) the Associate Dean will appoint a replacement(s).

10. All information, including but not limited to, the resident’s/fellow’s house officer files in the medical education office, files in the department/section, any material used by the Associate Dean in rendering the initial determination, and any written determinations shall be made available to the committee, the department, and to the resident/fellow.

11. The chairman of the committee shall notify the resident/fellow of the time and place of the hearing which shall be at least ten (10) days, but not more than thirty (30) days after the resident/fellow has received the written information described above.

12. Not later than five (5) working days prior to the hearing, all parties (resident/fellow and department) shall notify the Chairman of the Appeals Review Committee, in writing, of the witnesses and exhibits that they intend to use at the hearing. It shall be the responsibility of the department chair to prepare and submit the department’s witnesses and exhibits. Failure of either party to timely submit a list of witnesses and exhibits will preclude presentation of those witnesses and exhibits without the consent of the other party.

13. Not later than ten (10) working days prior to the hearing, the department shall submit to that committee, in writing, specific behaviors/conduct or other matters on the part of the resident/fellow.

14 Any person connected with the LSU Health Sciences Center who refuses to testify before the committee shall be subject to disciplinary action. All witnesses shall testify under oath administered by an individual duly authorized to swear witnesses under Louisiana law.

15. The resident/fellow shall have the option of having the hearing opened or closed. Regardless of whether the hearing is open or closed, at the request of either party, witnesses to be called shall be excluded from the hearing until after their testimony.

16. The resident/fellow shall be permitted to have an advisor present at the hearing and such should be indicated in the notice mailed to him/her by the chairman of the committee. The advisor may be a lawyer, friend, or other staff member. Such advisor should have the opportunity to be an active participant in the questioning of any witnesses and presentation of evidence before the committee, however they may not be a witness.

17. The resident/fellow or their representatives shall be permitted to cross-examine accusers and all witnesses, and will be allowed to present exhibits/witnesses on his/her behalf.

18. The resident/fellow shall have the right to remain silent during the proceedings, or to testify in his/her own defense.

19. The committee Chairman shall arrange for a full and complete transcript of the hearing to be made by a certified court reporter. The resident/fellow may order a copy of the transcript from the court reporter at his/her expense.

20. The structure of the hearing shall be as follows:

1. The Chairman of the Committee should read the general charges (unless waived by the resident/fellow and the department) and indicate on the record the parties present during the hearing including any members of the committee who are absent.
2. The department may elect to make any opening statement not to exceed ten minutes or elect to waive the making of such statement.
3. The resident/fellow may make an opening statement not to exceed ten minutes or may waive the right to make such a statement.
4. The department shall present evidence to support the action taken.
5. The resident/fellow shall present evidence or else waive the right to do so.
6. If the resident/fellow presents evidence, the department may present evidence in rebuttal.
7. The department may elect to present a closing statement not to exceed ten minutes in length.
8. The resident/fellow may elect to present a closing statement or else waive the right to do so. The closing statement of the resident/fellow shall not exceed 15 minutes in length.
9. The department may present a closing rebuttal but only in the event the resident/fellow shall have presented a closing statement. The department shall be allowed no more than five minutes for rebuttal. There will be no sur-rebuttal.
10. Upon the conclusion of the presentation of evidence and arguments the case will be submitted to the committee in closed session, with only the committee members. They will make written findings of fact with respect to the charges alleged and render a recommendation to uphold or not to uphold the department’s actions.
11. The decision shall be made by the majority vote of the committee members. Any member not concurring in the opinion may be allowed to file a dissenting opinion indicating the reasons for his/her position. The dissenting opinion will be attached to the committee’s majority opinion.

21. The committee’s signed recommendation shall be submitted to the

Associate Dean for Clinical Affairs and to the resident/fellow. The

Associate Dean may concur or not concur with the recommendation of

the committee. The final decision of the Associate Dean will be

transmitted to the resident/fellow within five (5) working days after the

receipt of the recommendations by the committee.

22. Should the resident/fellow be dissatisfied with this decision he/she may appeal to the Chancellor of LSUHSC-Shreveport (representing the Board of Supervisors) within five working days of the receipt of the Associate Dean’s action on the Committee’s recommendations.

23. The Chancellor will review the matter and will notify all parties of the final decision within 30 calendar days of its submission to the Chancellor. The Chancellor’s review shall be made on the record of the previous hearings.

24. The disciplinary/adverse action will be carried out at the conclusion of the administrative appeals process. This will also include notifying the National Practitioner Data Bank (if required) and the Louisiana State Board of Medical Examiners.

The Graduate Medical Education Committee is responsible for monitoring and advising on all aspects of residency education. The Graduate Medical Education Committee is appointed by the Dean of the Health Sciences Center or his/her designee. Voting members on the committee include representatives of the Program Directors, Resident representatives, House Staff President, Hospital Administrator, Hospital Medical Director/Associate Dean for Clinical Affairs, and the committee chairman. Additional members of the committee include the Associate Dean for Academic Affairs who will serve as an Ad Hoc Member and the Director of Medical Education.

The Chairman of the GMEC attends and reports to the Hospital Clinical Board. The membership and/or attendance of the Clinical Board consists of the Clinical Chairs, Administrative Representatives as well as Medical Staff Committee Chairs.

The committee meets at least quarterly. Minutes are maintained in the Office of Medical Education and are available for reference and inspection by appropriate accreditation personnel.

Responsibilities of the committee will include but are not limited to:

1. establishment and implementation of policies that affect all residency programs regarding the quality of education and the work environment for the residents in each program.
2. Establishment and maintenance of appropriate oversight of and liaison with program directors and assurance that program directors establish and maintain proper oversight of and liaison with appropriate personnel of other institutions participating in programs sponsored by the institutions.
3. Regular review of all ACGME letters of accreditation and the monitoring of action plans for the correction of areas of non-compliance.
4. Regular internal reviews of all ACGME accredited programs including subspecialty programs to assess their compliance with the Institutional Requirements and the Program Requirements of the ACGME RRC’s.
5. Assurance that each residency program establishes and implements formal written criteria and processes for the selection, evaluation, promotion, and dismissal of residents in compliance with the Institutional and Program Requirements for the specialties and subspecialties of the ACGME RRCs.
6. Assurance of an educational environment in which residents may raise and resolve issues without the fear of intimidation or retaliation.
7. Collecting of intra-institutional information and making recommendations on the appropriate funding for resident positions, including benefits and support services.
8. Monitoring of the program in establishing an appropriate work environment and the duty hours of residents.
9. Assurance that the resident’s curriculum provides a regular review of ethical, socioeconomic, medical/legal, and cost containment issues that affect GME and medical practice. The curriculum must also provide an appropriate introduction to communication skills and to research design, statistics, and critical review of the literature necessary for acquiring skills for lifelong learning. There must be appropriate resident participation in departmental scholarly activity, as set forth in the applicable Program Requirements.

It is estimated that in a typical employee population, six to ten percent of the work force suffers from alcoholism or an alcohol related problem; two to three percent have difficulty with drugs, and six to seven percent experience emotional problems. Statistics specifically related to hospital employees reflect estimates similar to the general employee population. Studies indicate that approximately 15% of physicians are alcohol or drug dependent. Data regarding nurses indicate problems with chemical dependency as well as with depression, stress, and burn-out. Also, because 75% to 80% of a typical hospital’s employees are women, family problems such as divorce and domestic violence as well as concerns about alcoholism or drug dependence of a family member may be more prominent than in other employee populations. During periods of economic recession and unemployment when many women workers become the family’s sole economic provider, financial and legal difficulties appear more frequently.

Because of the nature of their work, many health care professionals are subject to considerable job stress. The life and death responsibilities of hospital work and the need to be always caring and concerned can create substantial stress and strain on an employee’s emotional life. Also, the disruption in an employee’s routine caused by rotating shifts, weekend work, and on-call duties can magnify personal problems. Stressful work situations can often exacerbate existing problems.

The impact of personal problems on health care workers can have more serious and lasting consequences than in some other occupations. An impaired health care worker can cause direct harm to patients through carelessness, mismanagement of medication, or failure to communicate the patient’s requirements.

Although personal problems occur among hospital employees with at least the same frequency as in other work forces, the belief that health care workers should be immune from personal problems impedes the identification of these problems. An EAP in a hospital can provide "help for the helper."

The Employee Assistance Program (EAP) is a sponsored service which is designed to encourage employees to take the initiative for their own health and wellness. With the assistance of professional consultation, employees can solve a wide range of personal problems that could adversely affect their personal lives or professional careers.

It is in your best interest to seek early counseling through the EAP program. Even if management has talked to you about a possible problem, you may voluntarily seek treatment and counseling by stepping forward and accepting the help that is available. If management is sufficiently concerned about job performance, a formal referral to EAP may be made. If the employee elects not to follow referral for evaluation and possible treatment, the referral person will be notified. Should job performance continue to decline, disciplinary actions may be taken by LSUHSC-S management.

The Employee Assistance Program goes to great lengths to respect your right to privacy. Like all medical files, EAP records and discussions regarding the nature of personal problems will be handled in strict confidence. EAP records will be maintained separately from personnel files by the Director of the EAP program. EAP insures that employees at all levels have the opportunity to obtain the best professional help in an atmosphere of understanding and privacy.

You’re right! Your problems are personal…until they begin to have a detrimental effect on your work performance. Then personal problems affect more than just you; they affect your co-workers and the productivity of your team.

There are two ways to get started in the program. If you feel you have a problem you can simply call the EAP office at 675-7397 and ask to speak to Dr. Betty Joiner, or if your performance has declined, your supervisor may recommend on a formal or informal basis that you call the EAP consultant to discuss your problem.

Absolutely! LSUHSC-S hopes that awareness of the EAP and understanding of its principles will encourage employees to seek help on their own before problems impact job performance.

The EAP guidance and referral services are free. Diagnosis and treatment cost outside Employment Health Services will, to the extent they are covered by regular group health insurance, be paid for by your insurance.

It’s LSUHSC-S’s goal to have all employees receive the help they need as soon as they contact the EAP Director. Once the medical/emotional problem is evaluated, you will be counseled and offered referrals to an appropriate treatment source.

Purpose:

To provide House Officers with a support/assistance program in a confidential manner.

Group Support, Employee Assistance Program and the Physician’s Health Committee are available to provide counseling support and direction for the house officer seeking assistance.

Physician’s Health Committee (PHC) functions under the direction of the Shreveport Medical Society as approved by the Louisiana State Board of Medical Examiners.

The House Officer may contact the PHC directly to seek assistance or a referral/request may be made by a concerned individual regarding the physician. The PHC proceeds very carefully in their review of the individual’s case. All inquiries are handled with extreme confidentiality. In the event the physician in question is in immediate danger or may endanger his patients, a suspension could occur until adequate data has been collected.

If the physician is found to have an impairment and agrees to work with the PHC to address the problem, he or she will not be penalized by the Louisiana State Licensing Board. Confidentiality is always stressed.

Dr. Mary Fitz-Gerald, Department of Psychiatry, is the LSUHSC representative of the PHC. As the needs occur, Dr. Fitz-Gerald will work closely with the PHC and make referrals as appropriate. Dr. Fitz-Gerald will also be available to conduct programs dealing with stress and other related topics for the clinical departments as requested.

Any resident who is in need of psychiatric care may contact Dr. Fitz-Gerald or a psychiatry faculty member. Dr. Fitz-Gerald is available for confidential evaluation and referral if necessary. The resident may also request short term counseling from the Employee Assistance Program.

In the event that a residency training director believes that a psychiatric evaluation is necessary for training to continue, the Residency Training Director will request an evaluation by Dr. Fitz-Gerald or another psychiatry faculty member in writing. This request will also list specific information as to why the evaluation is warranted. Dr. Fitz-Gerald will request the resident sign a release of information in order to notify the Residency director of diagnosis, treatment recommendations, and if the recommendations are followed. If the resident doesn’t agree with the above, he has access to the due process as outlined in this manual.

LSUHSC-Shreveport

Dr. Mary Jo Fitz-Gerald

6040. Department
6041. Operator

Dr. William T. Hall, Chairman

4422. Office

A. PROVISION

B. SCOPE

As a physician, you may already be aware of the need to provide assistance to someone whom may be dealing with a substance abuse problem. Today, there is a mechanism in place to provide counseling of that individual before the full impairment occurs.

At Louisiana State University Health Sciences Center in Shreveport, the Physicians Health Committee is in place and working. The program has been set up through the Shreveport Medical Society. The process is confidential and each case is handled on an individual basis.

If you have questions or comments, please contact Dr. Mary Fitz-Gerald, Room 3-423 in the medical school.

Human Resource Management packets must be completed and ALL forms returned to the Human Resource Management Office (room AHB-116A). Failure to complete the packet will result in you NOT being paid.

The House Officer is required to notify the Medical Education Office and Program Director as soon as placement has been made. The House Officer will be allowed to take the allocated sick leave and annual leave available through their residency program. Any leave required beyond that time frame will be considered Leave Without Pay and result in the extension of the training program.

It is required that proof of Health Care Insurance be presented at the beginning of each contract year. The institution does not offer free health care to house officers.

The institution offers a variety of Healthcare insurance coverage benefit options for its employees. House officers may purchase healthcare insurance as part of the benefits package. Questions should be directed to the Benefits Section of Human Resources.

Your certificate of graduate training will be contingent upon the recommendation and signature of the Residency Program Director, completing all records, settling professional and financial obligations, and returning all medical center property such as books, equipment, beepers, keys, etc. You must complete the check out clearance form in order to receive your certificate or verification of training.

All scheduled leave must be recorded in the Medical Education Office as outlined in the Leave Policy.

Any unscheduled leave, emergency, sick, etc. must be reported immediately to the Assigned Service representative. The House Officer must notify his service contact (Staff or responsible Resident whether Chief Resident or Team Resident). The service resident will be responsible for notifying the Medical Education Office who will notify the Program Director and record the absence.

Upon notification of the need to take leave, the House Officer will be advised to call in daily if sick leave is being requested. A physician’s excuse may be necessary to return to work. Other emergencies will require identifying a specific number of days prior to leave being taken to establish a date of return to service.

Any leave taken without following the proper procedure may result in leave without pay and/or delay in program completion as determined by Program Director/Chief of Service.

ID badges are required and can be obtained in the Public Safety Office (Room G-213) in the Medical School. Badges will be issued as part of the Orientation Program.

Annual Leave - Vacation

First-year house officers are allowed three weeks (15 weekdays) vacation with pay, and second through sixth year house officers are allowed four weeks (20 weekdays) vacation with pay, except where prohibited by departmental policy or specialty board regulations. You are encouraged to take your vacation in increments of at least one week (5 days). If a house officer applies for one week of vacation (Monday through Friday) it is expected that the house officer will also be free of duty for one of the adjoining weekends (and, the adjoining weekend will not be charged to the house officer’s leave).

Vacation leave is non-cumulative—it must be used during the year earned and cannot be carried forward.

Your request for leave is to be submitted to the Medical Education Office on the appropriate application for leave form. It will be circulated for appropriate departmental approval from the Medical Education Office.

Vacation requests are to be made within the time frame established by the various Departments, but not less than 60 days prior to the leave you are requesting. All leave requests should be submitted in writing. Off service leave requests should be submitted for consideration no later than August 31.

VACATIONS ARE NOT ALLOWED DURING THE FIRST TWO WEEKS OR THE LAST TWO WEEKS OF YOUR RESIDENCY YEAR OF TRAINING.

Exceptions to the above must be approved by the Clinical Department Head to which you are assigned and the Hospital Administrator.

Each house officer is eligible for 10 weekdays of paid sick leave. If an illness exceeds 10 weekdays, vacation leave may be used to cover an extended period of absence due to illness. If sick/annual leave is exhausted, the Office of Medical Education must be notified by the Clinical Department Head so that arrangements can be made to keep your insurance current. Sick leave may not be used for vacation time. Extension of the training contract may be requested by the Program Director if necessary.

In addition to one's vacation, certain holidays and special leave will be considered; i.e., military, civil for court appearances, etc.

The House Officer is required to notify the Medical Education Office and Program Director as soon as pregnancy has been confirmed. Sick leave and Annual leave will be used for the maternity absence. Any leave beyond that will necessitate Leave Without Pay Status and result in the extension of the training period.

Funeral leave may be given to House Officers without loss of pay or required use of annual leave or sick leave to attend the funeral or burial rites of an immediate family member when such rites occur on a scheduled work day. In accordance to University Policy on Funeral leave.

Immediate family is defined as: father, mother, step-father, step-mother, sister, step-sister, brother, step-brother, husband, wife, child, step-child, mother-in-law, father-in-law, grandchild and grandparents.

All employees who have been employed for twelve(12) months and who have worked for at least 1,250 hours during the 12 months preceding the start of a leave, are eligible for up to 12 weeks of unpaid leave for certain qualifying events. Qualifying events include:

1. the birth of a son or daughter and to care for the child,
2. the placement of a son or daughter by adoption or foster care,
3. to care for a spouse, son, daughter or parent if the family member has a serious health condition.

All House Officers are required to use preprinted prescription pads. Initial issue of preprinted prescription pads is four pads of 100.

Requests for additional prescription pads should be made in the Medical Education office.

Initial issue of white coats is three . Requests for new coats should be made in the Medical Education office.

Burgundy Scrub Suits – are to be worn ONLY in the Operating Room Suite

Green Suits – are restricted to Obstetrics, Labor, and Delivery

Blue Suits – initial issue is two. These suits may be worn in the Medical Center other than the restricted areas as outlined.

University Police has been directed to instruct personnel leaving the institution with "Hospital Owned" scrub suits of the current scrub suit policy (hospital owned scrub suits are not to leave the designated area). Continued abuse of the scrub suit policy may result in disciplinary action.

House Staff are encouraged to dress appropriately as a medical professional. Individuals are reminded personal hygiene is also an aspect of a physician’s professionalism.

House Officers receive, without charge, a basic group disability insurance benefit. Any questions concerning the Disability Program and its benefits should be directed to the Medical Education Office.

US Medical School graduates who are first-year house officers may serve the PGY I (internship) year with an INTERN REGISTRATION issued by the Louisiana State Board of Medical Examiners. If you took the NATIONAL BOARDS or USMLE you will be granted Intern Registration on that basis, and a copy of the test results must be furnished to the Medical Education Office. ( National Boards/USMLE)

International graduates who are not eligible for full license will be processed for Licensure of the Graduate Educational Temporary Permit outlined by the LSBME.

Graduates may request the Intern Registration Form from the LSB. One picture is required to complete the form. There is a $25.00 fee, payable by check or money order only, and PERSONAL appearance must be made before the local board member. The Office of Medical Education will schedule your appointment with the local board member. At the time of your personal appearance, you must present your ORIGINAL (absolutely no substitutions) M.D. Degree. A copy of your M.D. Degree must be submitted to the Louisiana State Board with the Intern Registration Form. Fingerprint cards and fees must be submitted with the application.

Once you have received your medical license, registration in the Clerk of Court for the parish(es) in which you will practice needs to be filed. There is a $10 fee. The registration form will be in the LSBME packet. Your ORIGINAL medical license will need to accompany the form. The Medical Education Office will assist you in the filing of your license and will notify you when your license is returned from the Clerk of Court. A copy of your license will remain on file in the Medical Education Office.

Residents (PGY II and beyond) must be FULLY* licensed with the Louisiana State Board of Medical Examiners, and for those graduating after December 31, 1977, ORIGINAL OR RECIPROCAL licensure is granted on the basis of the FLEX or Medical National Boards only. *Any exceptions must be granted by the Louisiana State Board of Medical Examiners.

Applications for Licensure must be obtained from the Louisiana State Board of Medical Examiners in New Orleans and once complete, requires a PERSONAL appearance before the State Board Member with presentation documents as directed by LSBME.

House staff are responsible for making application in accordance with time frames established by the LSBME FOR THE USMLE.* Any questions regarding the USMLE should be referred to the LSBME.

(*Applicable to those who are not fully licensed in Louisiana)

Mailboxes are the combination type and are located on the ground floor of the hospital. Your mailbox should be checked at least twice a week.

Family Practice Residents will continue to receive their mail in assigned boxes as designated by Family Practice Department.

Malpractice insurance is provided through the State of Louisiana self-insurance plan at no cost to the house officer, and covers, in-house duties only. Moonlighting is not covered. In-house duties include those rotations that are approved through a formal LSUHSC-S affiliation agreement. Any questions regarding any malpractice claims or legal inquiry should be reported to the Office of Legal Affairs.

The cafeteria is located on the ground floor of the hospital. Cafeteria hours of operation for hot meals and grill items are:

*Closed Monday-Friday at 9:00 p.m.

Closed Saturday, Sunday and Holidays at 6:00 p.m.

House Staff are not authorized to feed family, friends, students, personnel or others. To do so may result in the loss of your meal privileges. Meals taken by the resident are charged to the house staff account. It is necessary that you stop at the cash register and remain in the cafeteria line until the cashier has added the charges for your meal.

The present payroll deduction of $10.00 biweekly for meals will be continued for the present. Changes in this charge are being considered; however, you will be advised prior to the implementation of such a change.

Obtaining an individual DEA NUMBER for prescribing controlled substances is a three step procedure stated below. (No outpatient prescriptions are filled in the hospital pharmacy).

2. LOUISIANA STATE NARCOTIC NUMBER. This

application is obtainable once you have a current

Louisiana Medical License.

Prescription orders for controlled substances may be issued by physicians, dentists, and veterinarians who are authorized to prescribe controlled substances by the jurisdiction in which they are licensed to practice their profession and either are registered with the DEA under the Controlled Substances Act for the appropriate schedules or are exempt from registration.

House Officer I's are issued a temporary DEA number which can be used during the PGY I year only. You will be responsible for securing the appropriate narcotic licenses and maintaining those permits. Interns, residents and foreign trained physicians may dispense, administer, and prescribe controlled substances under the registration of LSUHSC in Shreveport in lieu of being registered themselves provided that the following conditions exist:

* The dispensing, administering, or prescribing is in the usual course of professional practice;

House Staff should pursue DEA Registration upon receipt of their medical license. Medicaid ID numbers are issued to each House Officer by the Department of Health and Hospitals through the Medical Education Office. The number must be recorded on each Medicaid patient prescription, and will be pre-printed on your prescription pad. Your Medicaid number will remain active until you complete your training.

Applications for parking are obtained from the Office of Auxiliary Enterprises G-112 will issue you a parking tag or card. Priority parking for House Staff (Lots P, and MD-M North) are designated by appropriate signage.

Paydays are every other Friday. Your first payday will be July 13th and will be for the period June 30-July 1. Please note that there are 26 paydays in our fiscal year.

House Officers assigned to E.A. Conway, Alexandria, Homer and Lake Charles still continue to be paid by LSUHSC. Medical Education will mail checks to the appropriate facility on the Thursday preceding the payday for you to receive your check on Friday. House Officers assigned to VAMC, WK, Shriners, etc. will continue to be paid by LSUHSC. Your checks will be delivered to your mailbox.

If you have any questions regarding your check, please contact the Payroll Office.

Your performance is evaluated at the end of each service rotation, or in the case of categorical house officers and residents 2 through 6, at six-month intervals. These reports become part of your permanent record.

Salaries are reviewed on an annual basis. Salaries are listed below.

PGY - I $36,413 PGY - IV $40,422
PGY - II $37,484 PGY - V $41,815

PGY - III $38,852 PGY - VI $43,643

SECURITY ACCESS CARDS

Each House Officer will be issued an access card to allow access to the Medical Center. There is no fee for the initial issuance of the card, however, replacement cost is $25. To ensure security efforts are not hindered the Office of Public Safety should be notified of any lost/misplaced card immediately.

The Graduate Medical Education Committee (GMEC) supports the LSU Health Sciences Center pre-employment requirements, which include a drug screen and full background review, including a review of any questions, which may be raised concerning the application. The signature of the applicant on the application gives the Institution approval to verify any information pertaining to the application involving inquiries.

The Department of Human Resources coordinates the pre-employment process and reports any significant "findings" to the appropriate individual for action and/or follow-up.

Individuals who fail to comply with the pre-employment requirements may not be eligible for employment at LSU Health Sciences Center-Shreveport. The Department of Human Resources shall notify the appropriate individual (s) as soon as feasible.

In the event that a Resident’s status changes and he/she does not meet the requirements established by the Institution, the Resident will be advised of his/her non-compliance and appropriate action will be taken. The action taken may include "leave without pay status" until compliance with the institutional requirements are met, or the action may extend to Resident resignation, and/or termination.

If a House Officer in a graduate training program in the University Hospital intends to leave that program prior to its completion to accept an appointment in another graduate training program within the institution, the House Officers’ intentions should be made known to the Clinical Department Head in which he is presently serving at least 90 days before the end of his contract period.

Chairmen who are discussing appointments to their Department should require the House Officer to obtain a release from the Chairman of his present Department before making an offer to accept that House Officer in his program.

All residents receive instruction in quality assurance/performance improvement at the Annual House Staff Orientation. The House Staff are required to participate in the University’s Quality Improvement Program as approved by the Clinical Board. Each clinical department is charged with including resident(s) in the discussion of the QI events in their department. As part of the educational program, it is important that autopsies are performed whenever possible and appropriate. The institution encourages the House Officer to request an autopsy when appropriate in order to provide not only an adequate educational experience but to enhance the quality of patient care. The Medical Records System is available at all times and documents the course of each patient’s illness and care.

All House Staff in training programs function under the supervision of a member of the Medical Staff.

Each Clinical Service may have the following levels of supervision.

Clinical Chair

Section Chief

Program Director

Attending Physician

Clinical Fellow

Chief Resident

Resident

Medical Students

Other Allied Health Students and Medical Center Staff

Medicaid ID numbers are issued to each House Officer by the Department of Health and Hospitals through the Medical Education office. The number must be recorded on each Medicaid patient prescription, and will be pre-printed on your prescription pad. Your Medicaid number will remain active until you complete your training.

The direct provision of patient service for pay (moonlighting) is considered an augmentation and a privilege which should not detract from the goals and objectives of the educational program. As recommended by the Clinical Board, the House Staff are encouraged to limit the number of moonlighting hours per month as outlined by their Program Directors. If the performance of the House Staff Officer begins to decline, the number of moonlighting hours should be reduced, if performance continues to decline, moonlighting privileges would be denied. House Staff are encouraged to notify their Program Directors of the average number of moonlighting hours per month. House Staff are reminded that malpractice for moonlighting hours outside the LSU System are not covered by the Louisiana State Malpractice Plan. Under no circumstances should the House Officer moonlight during their regular scheduled program hours of service. Due to Federal Guidelines, individuals with the J-1 VISA are not allowed to moonlight. Clinical services may establish moonlighting guidelines more limiting than these. Moonlighting hours worked within the medical center are processed by the Medical Education Office on a monthly basis.

Resident Program Directors are encouraged to utilize the National Resident Matching Program (NRMP) in the selection process of their incoming residents. Contracts for participation in the NRMP are prepared by the Medical Education Office and approved by the Program Director and Hospital Administrator. Changes in quotas and other program data must

be submitted on the appropriate NRMP forms. The Medical Education Office provides support to the Residency Programs in the data entry of the ranking listings. The Program Directors confirm the official NRMP results and the individual is then processed as a new resident.

Requests for House Staff to rotate to an away elective must be reviewed and approved by the Office of the Associate Dean for Academic Affairs prior to processing by the Legal Affairs Office. The review will allow Administration to determine if services are not offered at this facility and to review the benefits of the rotation provided by another facility or affiliation. It is the responsibility of the House Officer and Program Director to provide the required documentation for rotations that are not within the current affiliation rotations of the program. The Office of Legal Affairs requires at least two to three months to process the request. Appropriate supervision, license, evaluation, malpractice coverage, salary and other benefits will be addressed in the affiliation agreement by the Legal Affairs Office.

The Graduate Medical Education Committee (GMEC) has delegated the responsibility of communicating results of all Residency Review Committee (RRC) surveys. If the Residency Program should receive notification of a change in the Residency Program the Department Chairman and/or Resident Program Director will notify the Residents of the changes, which includes a reduction in the size of the residency program, or to close a Residency Program. Interviewing and potential Resident applicants shall also be notified by the Department Chairman and/or Resident Program Director of a reduction in the status of a Residency Program. The notification shall be in writing to each resident enrolled in the current program and LSUHSC-Shreveport shall allow the Residents already in the program to complete their education or assist the Residents in enrolling in another ACGME accredited program to complete their education.

Further, it is the institution’s policy to both inform Residents of the results of a Resident Review Committee survey and continue their financial support as outlined in the ACGME guidelines for Residency closure.

The Office of Legal Affairs serves as the liaison for all immigration issues involving the House Staff. The Chancellor of the Health Sciences Center has noted in a memorandum of February 17, 1997: "Taking into consideration intended use, as well as the additional eligibility standards, requirements and liabilities for the University, the H-1B is determined to be an inappropriate mechanism for graduate medical training. Authority and responsibility to administer the proper forms in all cases involving the admission and certification for foreign physicians who wish to receive graduate medical education or training has been delegated to ECFMG by the United States Information Agency (USIA). As such, ECFMG sponsorship as a J-1 exchange visitor is the appropriate and only mechanism whereby foreign physicians may enter graduate medical education/training programs at the LSU Medical Center."

The U.S. code of Federal Regulations governing the alien physician category of the J-1 Exchange Visitor Program strictly forbids the performance of activities outside the primary objective of clinical training covered by the resident/fellow contract and is considered unauthorized employment. An exchange visitor who is found by ECFMG to engage in unauthorized employment is considered to be in violation of program status and may be terminated. In addition, the consequences of allowing unauthorized employment could result in a loss of federal grants and contracts for LSUHSC. The House Officer is responsible for the continuity of his/her sponsorship or employment authorization to continue as a House Officer at this institution.

2000-2001 Officers:

c/o Charla McClusky

327 Ellerbe Ridge Road

Shreveport, LA 71106

Phone: 524-1161

The RPA is an organization whose membership is open to Interns, Residents, Fellows, and their spouses or significant others of LSUHSC-Shreveport.

Supporters of the RPA include the Medical Education Office of LSUHSC-Shreveport, the Shreveport Medical Society Auxiliary, and the Louisiana State Medical Auxiliary.

The RPA provides a peer support group, offers social activities, helps newcomers get established. As a member of the RPA, you are invited to the Shreveport and Louisiana State Medical Auxiliary functions throughout the year. Membership dues are $15 per year which entitles you to receive monthly newsletters which keeps you informed of the group's activities.

The Graduate Medical Education Committee welcomes you as a new employee. LSUHSC-Shreveport employees more than 3,200 employees who have chosen to work in this large teaching hospital and who contribute by their services to the important task of patient care, teaching, research either directly or indirectly. The future development of this campus depends on each employee, their pride, and a continued development of productive effort. The Graduate Medical Education Committee (GMEC) recognizes that communication plays a vital role toward your development. Toward that goal, the following responsibilities have been outlined to communicate your responsibility in maintaining LSUHSC-Shreveport a center of excellence in providing patient care, teaching and learning. The following guidelines will be reviewed with you during orientation and may be re-emphasized by your assigned Medical Staff Department.

As a House Officer of LSU Health Sciences Center-Shreveport you will have the responsibility to:

POLICIES OF THE UNIVERSITY HOSPITAL

LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - SHREVEPORT

ADMISSION TO LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER

LOUISIANA STATE UNIVERSITY MEDICAL CENTER - SHREVEPORT

UNIVERSITY HOSPITAL

AUTOPSIES

Purpose:

Policy:

1. The department of Pathology shall perform autopsies that have been properly authorized by the legal custodian of the body.

2. GENERAL AUTOPSY GUIDELINES

A. Medical staff shall attempt to obtain autopsies in all deaths meeting at least the following indications:

1. Cause of death is not documented in the chart (Cause of death is not known with certainty on clinical grounds).

2. Patient expired within 48 hours of surgical procedure (or other invasive procedure).

3. Patient that was not a "no code" or did not have a terminal condition that expired on a general care floor.

4. All obstetric and perinatal deaths (up to 6 weeks after delivery).

5. All neonatal and pediatric deaths (up to 18 years of age).

6. Cases meeting the definition of a coroner’s case but for which the coroner has elected not to perform an autopsy.

B. Permission: In general, the right to grant permission for the autopsy rests with the following persons IN THE ORDER NAMED:

1. Judicially appointed curator, if one has been appointed.

2. Spouse (legal divorce voids any rights over deceased; common law spouses are not recognized in Louisiana).

3. Any child of legal age (18 years old).

4. Any parent irrespective of age.

5. Any brother or sister of legal age (18 years old).

6. Any relative by blood or marriage who assumes the right to control the disposition of the remains.

7. Any friend who assumes control of the remains.

1. The Pathology resident or faculty member handling the case will contact the requesting physician or the contact person for that area listed on the Patient Care Services directory; this individual will be informed that the autopsy can not be completed until the paperwork is corrected. An Incomplete Return Form will be attached to the request, indicating the problem(s).
2. The paperwork shall be forwarded to the Morgue Desk in Admitting, where it will be picked up by the responsible party, completed/corrected and returned.
3. The Morgue Desk will notify Pathology when the autopsy paperwork has been returned.
4. Pathology will pick up the Autopsy request and verify accuracy and completeness.

1. Identify himself/herself orally.
2. Affirm his or her relationship to the deceased.
3. His/her approval of the procedure.
4. Any restrictions which are to be made.

POLICY ON CONSULTATIONS

LOUISIANA STATE UNIVERSITY HOSPITAL

The Consultation Policy is designed for Physician to Physician/ Clinical Service to Clinical Service consultations. The policy is not to be used for ordering ancillary or diagnostic services. Dietary, Radiology, Respiratory Therapy, Specialty Nurses, PT, etc., requests are to be ordered through the terminal unless instructed otherwise.

Policy number 6.5

Effective Date: 5/1/98

A request for a routine consultation shall be noted in the physician’s orders. The consultation request form shall be completed and placed on the patient’s medical record. The form should indicate the current date, time, reason for consultation, requesting physician’s signature, printed name, hospital service and beeper number. The physician or his/her designee requesting the consultation is responsible for contacting the service to be consulted. A monthly listing of designated consultants for each Clinical Service is published and distributed each month to all patient care areas for utilization by the requesting physicians. Problems obtaining consultations should be directed to the attention of Hospital Administration.

For outpatient consults, the physician shall submit consultations to the appropriate service.

Emergency or ‘STAT’ consultations should be requested only when there is an emergency or urgent need for the consultation. The consultation form will remain on the chart. The physician will notify the Switchboard or the clinical Service directly of the need for the consultation, giving the patient’s name and location. Emergency or "stat" consultations should be answered within thirty (30) minutes of notification.

FIRE SAFETY

If a fire should occur in the hospital we cannot sound the alarm and evacuate like most other types of businesses. Many of our patients are non-ambulatory to varying degrees and many are on life support systems; therefore, we must be prepared to fight, control and contain the fire while the building is occupied. The responsibility of initial containment and control of fire rests with hospital personnel. Your actions in a fire emergency could be the difference between a minor incident and a tragic event.

Procedures If You Discover A Fire:

1. Rescue

Telephone lines will be kept clear for emergency use. Switchboard will immediately call the Hospital Administrator on call, Safety Officer, and Director of Physical Plant at office or home.

Switchboard will page the "All Clear" when the emergency situation is over.

1. If in a room with a patient, remain in the room pending the conclusion of the drill or fire emergency and continue to treat the patient. Close room doors, if practical, if not, other staff will close them.
2. If in a patient care area, go to the nursing station where they will be available for response to a medical emergency.
3. If in another area, (non-patient care area) remain in that location, until the "all clear", then return to your activity.

Physicians in clinic buildings will assist other staff in moving patients and visitors to safety, and will evacuate with other staff.

Volunteers and students will be treated as visitors, and asked to go into room and stay until the "all clear" is announced.

The Immigration Reform and Control Act of 1986 and the subsequent amendment by the Immigration Act of 1990 requires employers to verify that employees hired after November 6, 1986 are either United States citizens and nationals or aliens authorized to work in the United States. This law seeks to preserve jobs for those who are legally entitled to them. In order to comply with this law, LSU Health Sciences Center must complete and certify the Employment Eligibility Verification Form (I-9) For each new person hired.

The form requires each new employee to produce for employer examination and verification the appropriate original document or documents as listed on the reverse side of the form. If employees are unable to present the required document(s) within three (3) business days of the date employment begins, they may be subject to dismissal from the University. When an employee’s work authorization expires, the employment eligibility must be reverified. The employee must present a document that shows either an extension of the employee’s initial employment authorization or new work authorization. If the employee cannot provide this proof of current work authorization, LSU Health Sciences Center cannot continue to employ that person.

INFORMED CONSENT

"LIVING WILL"

By revised Statute 40:1299.58.lA, Louisiana's legislature addressed the fundamental right of persons to control decisions related to withholding life sustaining procedures in instances where such persons are diagnosed as having a terminal and irreversible condition. Nothing in that act of the Legislature requires application of medically *inappropriate treatment of life sustaining procedures or, in any way, interferes with medical judgment with respect to the application of medical treatment of life sustaining procedures.

DEFINITIONS

1. The document must be produced and must conform to the

requirements of state law.

2. To activate the document, the patient must be diagnosed as

suffering from a terminal and irreversible condition as determined by two physicians who have personally examined the patient.

3. The patient must also be mentally incapacitated and have little or

1. ensure a copy of the advance directive is placed in the medical

record;

2. notify the attending physician if patient has executed an advance

directive;

3. consult Social Services if the patient wished to execute an advance

directive or wishes to obtain additional information;

4. enter appropriate activities or discussion of advance directives in

1. upon notification from nursing, meet with the patient to provide

information regarding advanced directives, answer questions.

2. if the patient wishes to execute an advanced directive, the Social

Worker shall assist the patient in completing the directive, and

3. notify the patient’s nurse that the patient has executed a directive.

1. assists patients in making decisions about advance directives by

providing information necessary to make an informed decision;

2. review advance directive with patient upon admission or at

significant change in patient’s condition, or at patient’s request.

3. records reviews of advance directives in the medical record.

TREATMENT FOR NON RESIDENT PATIENTS

LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - SHREVEPORT

PHOTOGRAPHING, VIDEO RECORDING, AUDIO RECORDING OR

CINEMATOGRAPHY OF PATIENT IN THE UNIVERSITY HOSPITAL

Louisiana State University (LSU) Health Sciences Center is an equal opportunity employer and makes employment decisions on the basis of merit. We want to have the best available persons in every job. LSU Health Sciences Center policy prohibits unlawful discrimination based on race, color, creed, sex, age, national origin, physical handicap, disability, medical condition, sexual orientation, or any other consideration made unlawful by federal, state or local laws. All such discrimination is unlawful.

LSU Health Sciences Center is committed to complying with all applicable laws providing equal employment opportunities to all individuals. That commitment applies to all persons employed by LSU Health Sciences Center and prohibits unlawful discrimination by all employees, including supervisors and co-workers.

To comply with applicable laws insuring equal employment opportunities to qualified individuals with a disability, LSU Health Sciences Center will make reasonable accommodations for the known physical or mental limitations of an otherwise qualified individual with disability who is an applicant or an employee unless undue hardship would result.

Any applicant or employee who requires an accommodation in order to perform the essential functions of the job should contact the Department of Human Resource Management and request such an accommodation. If the accommodation is reasonable and will not impose an undue hardship, LSU Health Sciences Center will make the accommodation.

If you believe you have been subjected to any form of unlawful discrimination, provide a written complaint to the Director, Department of Human Resource Management, within 180 days of the alleged discriminatory act. Your complaint must be specific and include the names of the individuals involved and the names of any witnesses. LSU Health Sciences Center will investigate and attempt to resolve the situation. If the complaint relates to personnel of the Department of Human Resource Management, provide your complaint to the Vice Chancellor of Business and Reimbursements.

If LSU Health Sciences Center determines that unlawful discrimination has occurred, effective remedial action will be taken commensurate with the severity of the offense. Appropriate action will also be taken to deter any future discrimination. Whatever action is taken will be made known to you and LSU Health Sciences Center will take appropriate action to remedy any loss to you as a result of the discrimination. LSU Health Sciences Center will not retaliate against you for filing a complaint and will not willingly permit retaliation by management, employees, or your co-worker.

Louisiana State University Health Sciences Center in Shreveport is an Affirmative Action Equal Opportunity Employer and fully supports both in practice and in spirit, the full intent of Titles VI and VII of the Civil Rights Act of 1964, Executive Order No. 11246, and subsequent amendments. Qualified persons are employed and advanced without regard to race, color, religion, sex, national origin, age, handicap, marital status, or veteran status.

The Affirmative Action/Equal Opportunity Employment policy has been carried out through the development and maintenance of an Affirmative Action plan. The execution of this policy requires vigorous efforts to identify and attract qualified applicants from groups underutilized at all levels in the University. The policy further insures that all applicants receive fair consideration for employment and that all employees are treated fairly. Such action shall include, but not be limited to, the following: employment; promotion upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; selection for training; and tenure.

The Affirmative Action Equal Opportunity policy relates not only to employment but assures that no qualified person shall, on the basis of race, color, religion, sex, national origin, age, handicap marital status, or veteran’s status, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any University program or activity. The provisions of this policy must be communicated to present and prospective employees and others by publication of the policy through campus policy

statements, bulletins, catalogs; newspapers, magazines, annual reports, and other media; explanation in meetings of executive management, and supervisory personnel; communication to employees and any labor union with a collective bargaining agreement; inclusion where appropriate in every contract, lease subcontract, or purchase order; by posting on bulletin boards, and by listing in all recruiting material, including advertisements and application forms.

Employees are the state’s most valuable resource. Their safety and security at their job are necessary. Every employee should expect to perform his/her job in a place free of threats and assaults. The Governor of the State of Louisiana issued an executive order that workplaces for state employees should be free of violence. Louisiana State University Health Sciences Center – Shreveport is committed to a violence free workplace.

Workplace violence is, but is not limited to:

1. unwelcome name-calling, obscene language;
2. direct or indirect verbal threats that intimidate;
3. physically touching another employee in a way that intimidates, is hostile or is sexually harassing. This could be hitting, slapping, poking, kicking, pinching, grabbing, and pushing;
4. physically threatening others, such as obscene gestures, "getting in your face," fist-shaking, or throwing any object.

Employees at LSUHSC Shreveport must report to their immediate supervisor and/or department head all threats or incidents of workplace violence which they observe or of which they are informed.

An employee who has been threatened or assaulted by another by LSUHSC Shreveport should report the situation to his/her supervisor immediately. Depending on the severity of the incident, supervisors should do the following:

1. If the situation is dangerous, call University Police at #6165. Do not try to physically remove an individual.
2. Separate employees involved. Isolate them until they are interviewed and their statements are taken.
3. Document all actions and statement.
4. Contact the proper Administrative Staff and Human Resource Management to discuss further action.

Any employee found in violation of this policy may be subject to disciplinary action up to an including termination.

1. Policy

LSU Health Sciences Center – Shreveport is committed to providing a professional work environment that maintains equality, dignity and respect for all members of it community. In keeping with this commitment, the Medical Center prohibits discriminatory practices, including sexual harassment. Any sexual harassment, whether verbal, physical or environmental, is unacceptable and will not be tolerated. The purpose of this policy is to define sexual harassment and to establish a procedure whereby alleged sexually harassed employees, staff and students may lodge a complaint immediately.

2. Definition

1. Submission to the conduct is made either explicitly or implicitly a term or condition of individual’s employment;
2. Submission to or rejection of such conduct by an individual is used as basis for an employment decision affecting the individual; or

The conduct has the purpose or effect of unreasonable interfering with the individual’s performance or of creating an intimidating, hostile or offensive working environment.

Types of behavior that constitute sexual harassment may include, but are not limited to:

• unwelcome sexual flirtations, advances or propositions;
• derogatory, vulgar or graphic written or oral statements regarding one’s sexuality, gender or sexual experience;
• unnecessary touching, patting, pinching or attention to an individual’s body;
• physical assault;
• unwanted sexual compliments, innuendo, suggestions, or jokes; or the display of sexually suggestive pictures or objects

A staff member who believes he or she has been sexually harassed, should immediately report the incident to the Assistant Director or Employee Relations, Human Resource Management (318-675-5611) or to the Director of Human Resource Management (318-675-5620) or to an appropriate administrator or the Dean of the respective school. In addition, staff members may report the incident to any supervisor. Any recipient of such a complaint shall notify Human Resource Management.

The Department of Human Resource Management will be responsible for investigating complaints of sexual harassment occurring between staff members; complaints made by staff students; and complaint made by staff against other third parties. Human Resource Management will either investigate or assist those responsible for investigating complaints made by or against faculty members, students or House Staff Officers.

Action taken to investigate and resolve sexual harassment complaint shall be conducted confidentially to the extent practicable and appropriate in order to protect the privacy of persons involved. An investigation may include interviews with the parties involved, and if necessary, with individuals who may have observed the incident or conduct or who have other relevant knowledge. The individuals involved in the complaint will be notified of the results of the investigation.

The Medical Center will not tolerate discrimination or retaliation against any individual who makes a good-faith sexual harassment complaint, even if the investigation produces insufficient evidence to support the complaint , or any other individual who participates in the investigation of a sexual harassment complaint. If the investigation substantiates the complaint, appropriate corrective measures and/or disciplinary action, up to and including termination, will be taken swiftly.

LSU Health Sciences Center – Shreveport will make every reasonable effort to insure that all members of the Medical Center Community are familiar with this policy. You are encouraged to address questions or concerns regarding this policy with the Assistant Director for Employee Relations, Human Resource Management.

LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - SHREVEPORT

SMOKING POLICY

Purpose:

Policy:

1. Physician must document reasonable cause for exception which may include the following:

a. terminally ill patient.

b. patient is undergoing detoxification for substance abuse.

2. The physician shall discourage smoking by the patient and explain the potential health hazards. No adolescent patient shall be approved for smoking as an inpatient.
3. No oxygen or flammables shall be allowed in the room.
4. The patient must be in an isolation room with no other patients.
5. The patient must be capable of sitting in a chair without assistance.
6. There must be documentation of the patient’s acknowledgment of the hazards of smoking in the progress notes, which should be signed by the patient, physician, and a witness.
7. The order to smoke by the physician must be time limited.

TRANSFER OF UNSTABLE EMERGENCY PATIENTS

FROM OTHER HOSPITALS

Policy:

Definitions:

(1) The term "emergency medical condition" means -

(A) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in -

(I) placing the health of the individual (or, with respect to a pregnant women, the health of the woman or her unborn child) in serious jeopardy,

(II) serious impairment of bodily functions, or

(III) serious dysfunction of any bodily organ or part; or

(B) with respect to a pregnant women who is having contractions -

(I) that there is inadequate time to effect a safe transfer to another hospital before delivery, or

(II) that transfer may pose a threat to the health or safety of the woman or the unborn child.

Procedure:

1. Requests from other health care providers to transfer patients who have an emergency medical condition as defined by EMTALA and require emergency and tertiary level medical care not available at that facility should be immediately approved when services, space, facilities, and personnel are available to provide appropriate care.

1. When the transferring facility is requesting the transfer of an

TRANSFER OF STABLE PATIENTS

1. Use standard precautions for all patients — treat all patients the same.
2. Wash your hands before and after each patient contact with soap and water. Use an antiseptic soap before performing an invasive procedure, when hands have been heavily contaminated, and/or when working with a patient with a resistant microbe. Since the patient’s diagnosis may be unknown, good handwashing techniques between all patients is a protective practice.
3. Wear clean gloves when handling all patients’ body fluids. You never know what infections the patient may have before the work-up. Remove gloves after each patient contact, after contact with a contaminated area of the patient’s body, and before contacting another part of the patient’s body. Wash your hands thoroughly. Do not wash gloved hands.
4. The Bloodborne Pathogens Exposure Control Plan and the TB Control Plan found in the Infection Control Bit are available from your department chairman, the Infection Control Department, or the nursing unit. It is your responsibility to practice these protective measures.
5. If a patient has a history of coughing, "think TB". Hospital-related TB epidemics occur when patients are not diagnosed quickly. Assure patient has tissue to use for coughing and teach patients how to cover their mouth. Place a submicron mask on the patient if the patient has no breathing difficulty, but, do not leave the mask on the patient for more than 15 minutes. Place patient in a single room, preferably with negative pressure, as quickly as possible. If you are exposed to TB, consult Occupational Health for appropriate follow-up.
6. Place the patient in appropriate isolation when you suspect any infectious disease; do not wait until the diagnosis is confirmed.
7. When ordering isolation precautions, follow the hospital’s isolation guidelines. These guidelines are located on each nursing unit in the Infection Control Bit. An isolation manual is available upon request form the Infection Control Department.
8. Perform a surgical scrub and wear sterile gloves when performing invasive procedures, especially when placing central lines. Chlorhexidine is the most effective antiseptic. When in doubt, consult the nursing manager or the Infection Control Practitioners for the appropriate standard.
9. Remove invasive devices as quickly as possible. Patients are at increased risk of infection when they have invasive devices. The answer is to remove them as quickly as possible.
10. Stay healthy. If you are sick, take care of yourself and do not work until you are well. When you are ill, you are at risk of causing nosocomial infection. Also, while you are susceptible, you can contract a disease. Do not work if you have cuts, abrasions, or lesions that are leaking body fluid, especially on your hands and arms. You must not perform invasive procedures and/or surgery if you have cuts, abrasions, or infected wounds.
11. Do not eat or drink in a patient care area. Eating and drinking is allowed only in break rooms.
12. Do not treat employees; send them to the Occupational Health Clinic for job-related injuries or possible infectious diseases. Other health problems should be addressed by their private physician or the Ambulatory Care Clinic. Many difficulties have occurred from casual treatment of employees.
13. If there is a possibility of splashing of body fluids, wear appropriate PPE, (gloves, goggles, mask, and splash-proof gown). If you are exposed to any body fluids, contact the Occupational Health Clinic (6281) for appropriate follow-up.
14. Obtain the hepatitis vaccine. The influenza vaccine is also recommended for all physicians. This should be taken in late fall. These vaccines are available in the Occupational Health Clinic.
15. Acquaint yourself with the Infection Control policies for each patient care practice. These guidelines are current and approved by the Infection Control Committee. These procedures are located on each nursing unit.
16. When you have any questions, consult the Infection Control Practitioners at 5110.

MEDICAL RECORDS CONTENT/DOCUMENTATION