Policies & Procedures

University Policy

1.1 Resident and Fellow Appointments

Reason for Policy

To establish compliance that meets Rutgers, state, federal, and accreditation regulations.

Applicable ACGME Institutional Requirements

Section 4: Institutional GME Policies and Procedures

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Committee of Interns and Residents (CIR) Collective Bargaining Agreement
• Rutgers University Policies
• New Jersey Board of Medical Examiners
• American Board of Medical Specialties
• National Resident Matching Program

Scope

The scope of this policy applies to all residents and fellows in training at Rutgers Health.

The Policy

I. Recruitment

1. All candidates must be U.S. citizens, U.S. permanent residents, or be eligible for a J-1 Exchange Visitor visa issued by the Educational Commission for Foreign Medical Graduates (ECFMG) in order to be eligible for admission to a position in any of the Rutgers Health graduate medical education (GME) programs. Requests for exception to this requirement may be made under extraordinary circumstances and must be made in writing by the Program Director to the DIO or designee.
   1. All applicants must meet I-9 criteria to be hired by applicable employer by the anticipated start date.
   2. An eligible IMG must hold a valid ECFMG certificate or hold a full and unrestricted license to practice in New Jersey.
2. Before accepting residents transferring from other programs (including fellows or others who have completed other programs), the Program Director must obtain written or electronic verification of previous educational experiences and a summative competency-based performance evaluation of the transferring resident for all training, including milestones as appropriate.
3. It is the policy of Rutgers Health to obtain a criminal background check on all matched applicants to the University’s postgraduate programs. In order to be admitted to a Rutgers Health postgraduate program, the report results must be deemed favorable.

II. Selection

1. Residency programs should select from among eligible applicants on the basis of residency program-related criteria such as their preparedness, aptitude, academic credentials, personal characteristics, and ability to communicate. Applications must be submitted through a platform such as ERAS or the Central Application Service; otherwise, applications must be submitted through the portal where the position is offered.
   1. The Program Director (PD) or a faculty designee must interview all candidates and is responsible for the resident selection process.
2. All first-year positions in a program must be offered through the NRMP, the San Francisco Match, or the relevant matching program. If a match is not offered in a particular specialty or the position cannot be offered in match, the position must be posted through an appropriate portal, such as jobs.rutgers.edu, and be advertised on appropriate platforms.
   1. A Program Director may request a waiver from this requirement. Requests shall be submitted to the DIO.
   2. Program Directors must ensure applicants do not have a binding match commitment prior to consideration for a position (i.e. prior review of an applicant’s match history in NRMP).
3. There shall be no unlawful discrimination against any applicant because of race, religion, color, national origin, ancestry, age, sex, sexual orientation, pregnancy, gender identity or expression, disability, genetic information, atypical hereditary cellular or blood trait, marital status, civil union status, domestic partnership status, military service, veteran status, and any other category protected by law. Rutgers considers as a basis for selection in employment only those characteristics which are demonstrably related to job performance or requirements.

III. Eligibility

1. In order to be admitted to a graduate medical education program, a candidate must have satisfied the educational requirements under the regulations promulgated by the New Jersey Board of Medical Examiners (NJBME). Candidates must be graduates of a medical school accredited by the Liaison Committee on Medical Education (LCME), the American Osteopathic Association (AOA), or the WHO-sanctioned World Directory of Medical Schools.
   1. For admission to the first postgraduate year (PGY-1), the applicant must qualify for registration with the NJBME as defined in NJBME regulations.
   2. All applicants must have passed Step II of the United States Medical Licensing Examination (USMLE) or Comprehensive Osteopathic Medical Licensing Examination (COMLEX) exam by the anticipated start date.
   3. For admission to PGY-2 and subsequent years, the applicant must qualify for a permit issued by the NJBME as defined in NJBME regulations.
   4. For admission to PGY-3 and subsequent years, the applicant must have passed USMLE Step 3 or COMLEX Level III.
      1. A resident may request a waiver from this requirement. Requests shall be submitted to the Program Director for initial review and then to the Chief Academic Officer or Associate Dean who will present the request to the DIO. If agreeable to the PD, CAO/Associate Dean and DIO, the DIO will bring the request to GMEC for a vote.
   5. For admission to any postgraduate year after the applicant has used up his or her five years of eligibility for registration/permit in the State of New Jersey, the applicant must have a full New Jersey medical license. All residents/fellows at the PGY-6 level or above are required to obtain a NJ State medical license as set forth in the regulations and policies of the NJBME.
   6. All candidates at time of hire must be U.S. citizens, U.S. permanent residents, or holders of J-1 Exchange Visitor visas issued by the Educational Commission on Foreign Medical Graduates (ECFMG) in order to be eligible for admission to a position in any of the Rutgers Health graduate medical education (GME) programs. Requests for exception to this requirement may be made under extraordinary circumstances and must be made in writing by the program director to the DIO.
      1. All applicants must meet I-9 criteria to be hired by the anticipated start date.
      2. An eligible IMG must hold a currently valid ECFMG certificate or hold a full and unrestricted license to practice in New Jersey.

IV. Initial Appointment

1. Applicants who are invited for an interview must be informed, in writing or by electronic means, of the terms, conditions and benefits of their appointment, either in effect at the time of the interview or that will be in effect at the time of the applicant’s eventual appointment, including stipends, benefits, professional liability coverage, disability insurance accessible to residents/fellows, institutional policies for vacation and leaves of absence, including medical, parental, sick, and caregiver leaves of absence, and insurance accessible to residents/fellows and their eligible dependents.
2. Agreement of Appointment/Contract
   1. Residents/fellows shall be provided with a written agreement of appointment/contract outlining the terms and conditions of their appointment to a program. The Sponsoring Institution, through the DIO (or designee), shall monitor each of its programs with regard to implementation of terms and conditions of appointment.
   2. Contracts are prepared by the program and/or institution and forwarded to the local Office of Graduate Medical Education and accompanied by all credentials and documentation as required by the Human Resources and the Graduate Medical Education Office.
   3. The Office of Graduate Medical Education and staff will review the contracts and forward them to the Associate Dean/Chief Academic Officer, who are the DIO’s designees, for approval and signature. Copies of the executed contracts are distributed to the program office. The contract for each resident/fellow in a graduate medical program shall contain or provide reference to:
      1. The specialty and sub-specialty, where applicable, and the level or Postgraduate Year (PGY), e.g., Internal Medicine PGY 1, 2, 3, or Internal Medicine-Cardiology PGY-4, PGY-5, etc., and the term of the contract; and indicate the total salary (wages and stipends) the resident is to receive.
      2. DIO or designee will determine the PGY contract level for all incoming trainees.
      3. Resident/fellow responsibilities; duration of appointment; financial support for residents/fellows; conditions for reappointment and promotion to a subsequent PGY level; grievance and due process.
      4. Registration/permit/licensure requirements of the New Jersey State Board of Medical Examiners must have been met as a pre-condition of the contract.
      5. Reference to scope of practice of registration or permit holders as per regulations of the New Jersey Board of Medical Examiners.
      6. Benefits including professional liability insurance, including a summary of pertinent information regarding coverage; health insurance benefits for residents/fellows and their eligible dependents; disability insurance for residents/fellows; vacation and leave(s) of absence for residents/fellows, including medical, parental, and caregiver leave(s) of absence, and compliant with applicable laws; timely notice of the effect of leave(s) of absence on the ability of residents/fellows to satisfy requirements for program completion; information related to eligibility for specialty board examinations; and institutional policies and procedures regarding resident/fellow clinical and educational work hours and moonlighting, consistent with hospital or University policies or the collective bargaining agreement between the Committee of Interns and Residents (CIR) and the University, where applicable.
      7. Have reference to required copies of applicable employer policies.
      8. Specify that compliance with their applicable employer’s Immunizations and Health policy is required as a condition of the contract.
      9. Contain or provide reference to all the required elements as listed in the ACGME Institutional Requirements.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

1.2 Promotions and Non-Renewals

Reason for Policy

To establish compliance that meets Rutgers, state, federal, and accreditation regulations.

Applicable ACGME Institutional Requirements

Section 4: Institutional GME Policies and Procedures

Resources

1. Accreditation Council for Graduate Medical Education Institutional Requirements
2. Accreditation Council for Graduate Medical Education Common Program Requirements
3. Committee of Interns and Residents (CIR) Collective Bargaining Agreement
4. Rutgers University Policies
5. New Jersey Board of Medical Examiners
6. American Board of Medical Specialties

Scope

The scope of this policy applies to all residents and fellows in training at Rutgers Health.

The Policy

1. Criteria for promotion and/or renewal of a resident’s/fellow’s appointment
   1. Criteria for promotion in each GME program shall be specified and based on the core competencies as defined by the ACGME, maintained current, documented, and communicated to residents/fellows at the beginning of each academic year. Programs are also to provide housestaff with criteria needed to receive credit for the year from the relevant board or certifying
   2. In addition to fulfilling the requirement of satisfactory academic progress, housestaff must satisfy the following requirements regarding registrations, permits, and licenses.
      1. For promotion to PGY-2 or higher, the housestaff member must obtain and maintain a permit issued by the New Jersey State Board of Medical Examiners as defined in its statutes. A housestaff member who does not obtain or make application for such a permit shall automatically be dismissed at the conclusion of PGY-1. A housestaff member who fails to maintain such permit shall be dismissed upon loss of the A New Jersey state medical license shall satisfy this requirement.
      2. A housestaff member who has completed at least one year of accredited training in the United States must apply for a permit even if they are assigned to the PGY-1 level in their current program
   3. For promotion to PGY-3, the housestaff must have passed USMLE Step 3 or COMLEX Level III; a housestaff who has not passed USMLE Step 3 or COMLEX Level III shall automatically be dismissed at the conclusion of PGY-2.
      1. A housestaff may request a waiver from this requirement. Requests shall be submitted to the Program Director for initial review and then to the Chief Academic Officer or Associate Dean, who will present the request to the If agreeable to the PD, CAO/Associate Dean and DIO, the DIO will bring the request to GMEC for a vote.
   4. For promotion to any postgraduate year after a housestaff member has used up the 5 year limit for registration/permit eligibility or before the start of the PGY-6 year as specified in NJ Board of Medical Examiner statutes, the housestaff must have obtained a New Jersey license; a housestaff member whose eligibility for a permit has expired and who has not obtained a New Jersey license shall automatically be dismissed at the conclusion of the last academic year of eligibility for a permit.
   5. The decision to promote a housestaff will be conveyed to the housestaff by the Program Director after the documented semiannual evaluation of performance, in conjunction with the program’s Clinical Competency Committee, in accordance with the program’s promotion policy.
   6. The decision to promote becomes effective upon satisfactory completion of the current year of training and requires the housestaff to continue to maintain appropriate academic progress.
   7. The appeal process for non-promotion decisions is reviewed in the Probation, Suspension, and Dismissal policy. If the housestaff is covered by a collectively negotiated agreement, and that agreement has provisions for the appeal of adverse academic actions, that agreement shall take precedence.

1. Non-Renewal of Appointment
   1. Program directors who wish to give notice of non-renewal to a housestaff member shall review the non-renewal with the DIO. In the event a housestaff’s performance is not satisfactory, the Program Director will inform the housestaff in writing. A non-renewal is not considered an adverse academic action if credit is awarded for the year, and shall not be reported as such to the extent permissible by state law or credentialing requests by state/federal agencies.
   2. Written notification shall be given to the housestaff for non-renewal of agreement. Housestaff who have appointments that begin July 1st will be notified, in writing, by no later than January 15th if their services are not to be renewed for the next year of a given residency/fellowship training program. In the event that a housestaff member commences work on a date other than July 1st, the last date for non- renewal shall be six- and one-half (6.5) months following the date on which such work commences. When possible, earlier notice of non-renewal will be given to such housestaff. If a housestaff is covered by a collectively negotiated agreement and time frames for non-renewal are specified in said agreement, such time frames will control.
   3. Housestaff have the right to appeal adverse academic actions such as non-promotion, probation, suspension, or dismissal from a program.
   4. If they elect to appeal such an action, they must notify the program director and the CAO/Associate Dean in writing no less than five [5] business days after being notified of the action.
      1. If the housestaff requests an appeal, it will be heard by an ad hoc committee within one month. The committee shall be appointed by the DIO and consist of no less than four [4] faculty members, including the Department Chair who will chair the committee. The DIO or designee will also serve as a non-voting member Should the Department Chair be the PD, the DIO or designee will appoint a committee chair.The faculty members should be experienced in graduate medical education. The committee should include at least two faculty members from the program that the housestaff is a member of, when feasible.  The faculty composition is per the discretion of the DIO.  The Program Director shall not be a member of the ad hoc committee.
      2. At the hearing, the program director will review the reasons for the adverse academic action to the committee. The housestaff will then be invited to make a presentation as to why the decision should be reversed. The housestaff may choose to have a faculty member accompany them as an advisor. If represented by a CBU, a CBU representative may attend the meeting but shall not interfere with the hearing or communicate with the committee.
      3. After hearing both presentations, the committee shall then render a decision. The decision of the committee is final.
   5. The Department Chair [or committee, when applicable] shall provide notice of their decision in writing to the housestaff, with copies to the program director, CAO/Associate Dean and DIO.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

2.1 Period of Concern/Remediation

Reason for Policy

To establish compliance that meets Rutgers, state, federal, and accreditation regulations.

Applicable ACGME Institutional Requirements

Section 4: Institutional GME Policies and Procedures

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Committee of Interns and Residents (CIR) Collective Bargaining Agreement
• Rutgers University Policies
• New Jersey Board of Medical Examiners
• American Board of Medical Specialties

Scope

The scope of this policy applies to all residents and fellows in training at Rutgers Health.

Terms

• Period of Concern: a period of focused improvement implemented when the housestaff is not demonstrating anticipated progress in one or more of the core competencies (also known as “remediation”).
• Probation: a time-limited disciplinary period implemented when the housestaff has not demonstrated anticipated progress after a period of concern, or when the housestaff demonstrates severe deficiencies in one or more of the core competencies.

The Policy

Purpose

To establish the process for addressing academic deficiencies within individual housestaff who are in a Rutgers Health GME training program.

Procedure

1. Academic deficiencies should be identified as early as possible and conveyed to the housestaff. This is done through timely evaluations, communications with the program director, CCC meetings, and meetings with the housestaff.
2. When a program director and/or the CCC is concerned that the housestaff is not demonstrating anticipated progress, a period of concern should be initiated.
3. The period of concern is meant to provide the housestaff with structured guidance that will allow them to demonstrate anticipated progress expected for their level of training.
   1. When a period of concern is initiated, it must be done so at a meeting with the resident and documented in a letter to the resident that is entered into their file. The meeting/letter documents:
      • The area(s) of concern, ideally associated with relevant competencies and/or milestones.
      • Examples of the housestaff’s performance that demonstrate the area(s) of concern.
      • An outline of actions to be taken by the housestaff and the program to correct the identified deficiencies.
      • Anticipated length of the period of concern or the anticipated date of the housestaff’s next evaluation by the CCC.
   2. The Chief Academic Officer (CAO)/Associate Dean for GME and the DIO must be notified that a housestaff member has been entered into a period of concern, and a copy of the letter shall be sent to them.
   3. Program directors are strongly encouraged to contact the respective CAO/Associate Dean before placing a housestaff into a period of concern.
   4. The decision to place a housestaff into a period of concern is not appealable. It is not considered an adverse academic action and shall not be reported as such, to the extent permissible by state law or credentialing requests by state/federal agencies.
   5. At the end of the defined period, or after the next evaluation by the CCC, the program director may:
      • Remove the housestaff from the period of concern due to demonstration of anticipated progress;
      • Continue the period of concern and provide the housestaff with an updated letter;
      • Issue a notice of non-renewal or non-promotion (see Promotions policy); or
      • Place the housestaff on probation (see Probation, Suspension, and Dismissal policy).

      This decision must be communicated to the housestaff in person and documented in a letter to the housestaff, with copies to the CAO/Associate Dean and the DIO. The appeal process for a non-renewal is discussed in the Promotions policy. The appeal process for non-promotion and probation is discussed in the Probation, Suspension, and Dismissal policy.

   6. When a housestaff has been in a period of concern without demonstrating anticipated progress, or has severe deficiencies in one or more core competencies, they may be placed on probation (see Probation, Suspension, and Dismissal policy). Examples of severe deficiencies include, but are not limited to, egregious breaches of professionalism, or performance so deficient that the housestaff is not anticipated to reach the point of being able to practice independently and without supervision.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

2.2 Probation, Suspension, & Dismissal

Reason for Policy

To establish compliance that meets Rutgers, state, federal, and accreditation regulations.

Applicable ACGME Institutional Requirements

Section 4: Institutional GME Policies and Procedures

Resources

1. Accreditation Council for Graduate Medical Education Institutional Requirements
2. Accreditation Council for Graduate Medical Education Common Program Requirements
3. Committee of Interns and Residents (CIR) Collective Bargaining Agreement
4. Rutgers University Policies
5. New Jersey Board of Medical Examiners
6. American Board of Medical Specialties

Scope

The scope of this policy applies to all residents and fellows in training at Rutgers Health.

Terms

1. Period of Concern: a period of focused improvement implemented when the housestaff is not demonstrating anticipated progress in one or more of the core competencies (also known as “remediation”)
2. Probation: a time limited disciplinary period implemented when the housestaff has not demonstrated anticipated progress after a period of concern or when the housestaff demonstrates severe deficiencies in one or more of the core competencies.
3. Suspension: a time limited removal or restriction of training activities placed on a housestaff due to violations of policies, safety concerns, or disruptive behavior.
4. Academic termination: dismissal from a training program due to egregious deficiencies or unsatisfactorily completing a probationary period without anticipated progress.

The Policy

1. Purpose: To establish the process for addressing severe academic deficiencies or periods of concern without anticipated progress within individual housestaff that are in a Rutgers Health GME training program.
2. Procedure:
   1. When a housestaff has been in a period of concern and not demonstrated anticipated progress or has severe deficiencies in one or more core competencies, they may be placed on probation.
      1. Examples of severe deficiencies include, but are not limited to, egregious breaches of professionalism or failure to meet basic standards of patient

care or performance that are so deficient that the housestaff is not anticipated to reach the point where they are determined to be able to practice independently and without supervision.

1. When it has been determined by the program director that a housestaff is to be placed on probation, the program director must contact their local CAO/Associate Dean and DIO.

• The housestaff is to be given notice that they are required to attend a meeting where an adverse action may be taken. Such notice shall be given no less than five [5] business days prior to the meeting. If represented by a collective bargaining unit [CBU], the housestaff has the right to have a CBU representative with them at the meeting. The representative shall not interfere with the Once the representative determines in good faith that the matter is academic in nature, they should excuse themselves from the meeting.

1. At the meeting, the housestaff is to be given a letter documenting the reasons for the probation and the subsequent The letter is to be placed in the housestaff’s file. The meeting/ letter documents:
   1. The deficiencies, ideally associated with relevant competencies and/or milestones.
   2. Examples of the housestaff’s performance that demonstrate the

deficiencies.

3. Specific actions that will be taken by the program to guide the
4. Specific actions that the housestaff is expected to engage
5. Length of probation and the anticipated date of the housestaff’s

next evaluation by the CCC.

6. The letter must document that at the end of the period of probation, the program director may decide to remove the housestaff from probation, continue the probation, not promote to the next level of training, or dismiss the housestaff from the program [academic termination].
7. Process for
8. The housestaff is to sign a copy of the letter to document they have received the letter and attended the associated meeting. Signing does not indicate agreement.

1. A housestaff may appeal the decision to be placed on

1. When a housestaff poses a threat to the safety, health, or well-being of others, conducts any criminal activity, or has had repetitive disruptive and egregious behavior that affects the learning environment, the housestaff may be placed on
   1. Examples include but are not limited to:
      1. Safety concerns: any behavior that poses a threat to the safety, health, or well-being of other staff, residents, or patients.
      2. Disruptive conduct: repeated disturbances, harassment, or other behavior that adversely affects the learning environment.
      3. Criminal activity: any criminal conduct occurring within the

housestaff’s training period.

1. When it has been determined by the program director that a housestaff is to be placed on suspension from training, the program director must notify their local CAO/Associate Dean and DIO.

• The housestaff is to be given notice that they are required to attend a

meeting where an adverse action may be taken. Such notice shall be given no less than five [5] business days prior to the meeting. If represented by a collective bargaining unit [CBU], the housestaff has the right to have a CBU representative with them at the meeting. The representative shall not interfere with the meeting. Once the representative determines in good faith that the matter is academic in nature, they should excuse themselves from the meeting. A housestaff member whom the program and/or institution has given notice of disciplinary action may be removed from service without five (5) working days notice where their continued presence is deemed to imperil patient safety, public safety or the safety of any fellow employee (staff, housestaff or medical faculty).

1. At the meeting, the housestaff is to be given a letter documenting the reasons for the suspension and the subsequent The letter is to be placed in the housestaff’s file. The meeting/ letter documents:
   1. The reason for suspension, detailing specific deficiencies and ideally associated with relevant competencies and/or
   2. Examples of the housestaff’s performance that demonstrate the reason for suspension.
   3. Specific actions that will be taken by the program to guide the
   4. Specific actions that the housestaff is expected to engage
   5. Length of suspension and the anticipated date of the housestaff’s

next evaluation by the CCC.

6. The letter must document that at the end of the period of suspension, the program director may decide to remove the housestaff from suspension, continue the suspension, not promote to the next level of training, or dismiss the housestaff from the program [academic termination].
7. Process for
8. The housestaff is to sign a copy of the letter to document they have received the letter and attended the associated meeting. Signing does not indicate agreement.

1. When a housestaff has failed to correct deficiencies after a period of probation, suspension, or demonstrated egregious deficiencies the housestaff may be dismissed from the program.
   1. When it has been determined by the program director that a housestaff is to be dismissed from the program, the program director must notify their local CAO/Associate Dean and DIO.
   2. The housestaff is to be given notice that they are required to attend a meeting where an adverse action may be taken. Such notice shall be given no less than five [5] business days prior to the meeting. If represented by a collective bargaining unit [CBU], the housestaff has the right to have a CBU representative with them at the meeting. The representative shall not interfere with the Once they determine in good faith that the matter is academic in nature, they should excuse themselves from the meeting.

• At the meeting, the housestaff is to be given a letter documenting the reasons for the dismissal from the program. The meeting/letter must document:
  1. The deficiencies, ideally associated with relevant competencies and/or milestones.

2. Examples of the housestaff’s performance that demonstrate the

deficiencies.

3. The effective date of dismissal from the
4. Process for

1. The housestaff is to sign a copy of the letter to document they have received the letter and attended the associated Signing does not indicate agreement.
2. A housestaff may appeal the decision to be dismissed from the

1. Housestaff have the right to appeal adverse academic actions such as non- promotion, probation, suspension, or dismissal from a program.
   1. If they elect to appeal such an action, they must notify the program director and the CAO/Associate Dean in writing no less than five [5] business days after being notified of the action.
      1. If the housestaff requests an appeal, it will be heard by an ad hoc committee within one The committee shall be appointed by the DIO and consist of no less than four [4] faculty members. The faculty members should be experienced in graduate medical education. The committee should include at least two faculty members from the program that the housestaff is a member of, when feasible. The faculty composition is per the discretion of the DIO. The Program Director shall not be a member of the ad hoc committee.
      2. At the hearing, the program director will review the reasons for the adverse academic action to the The housestaff will then be invited to make a presentation as to why the decision should be reversed. The housestaff may choose to have a faculty member accompany them as an advisor. If represented by a CBU, a CBU representative may attend the meeting but shall not interfere with the hearing or communicate with the committee.
      3. After hearing both presentations, the committee shall confer and make a recommendation [uphold the action or reverse it] to the Department Chair.
      4. The Department Chair shall then render a decision, and the decision of the chair is final. If the Department Chair is also the involved Program Director, the decision of the committee is
   2. The Department Chair [or committee, when applicable] shall provide notice of their decision in writing to the housestaff, with copies to the program director, CAO/Associate Dean and DIO.
   3. All academic appeals and other related matters shall be presented to the GMEC at its next scheduled meeting. The DIO and Chair of the GMEC are apprised of any and all academic matters. The GMEC Chair informs the GMEC about any proposed actions and appeals during regular meetings and discusses the issue with committee members.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

2.4 Grievance

Reason for Policy

To provide an institutional process for residents and fellows to raise and resolve GME-related grievances at the program and Sponsoring Institution levels while minimizing conflicts of interest.

Applicable ACGME Institutional Requirements

4.5 Grievances

Resources

1. Accreditation Council for Graduate Medical Education Institutional Requirements
2. Rutgers University Policies
3. Rutgers CIR Agreement
4. Rutgers Health GME Policy 3.6, Mechanisms for Confidential Reporting
5. Rutgers Health GME Policy 2.2, Probation, Suspension, & Dismissal

Scope

This policy applies to all residents and fellows appointed to Rutgers Health-sponsored ACGMEaccredited programs, regardless of employer, primary clinical site, school, funding source, or collective bargaining status. “Resident” includes fellows for purposes of this policy. Rutgers Health, as the Sponsoring Institution, retains responsibility for the institutional grievance process.

The Policy

A grievance is a request by a resident for review and resolution of a GME-related action, omission, practice, or condition that directly affects the resident’s education or learning and working environment and is not governed primarily by another established review or appeal process. Whether a matter is processed as a grievance depends on its nature and the resolution sought, not on the label used by the resident. Illustrative matters that may be appropriate for this policy include:

1. 1. an alleged failure to follow an applicable program or institutional GME policy or procedure;
   2. a recurring or unresolved learning or working environment issue that directly affects the resident’s education;
   3. an alleged materially inconsistent application of a program or institutional requirement, when the matter is not assigned to another process; or
   4. a GME-related issue involving program leadership, multiple programs, or multiple participating sites that cannot reasonably be resolved within the program.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education department for the official, most recent version.

The following matters ordinarily should be raised through the process designed for them:

1. 1. confidential or anonymous concerns about supervision, professionalism, safety, or the learning environment when the resident is reporting a concern rather than requesting an individual determination: GME Policy 3.6 and applicable institutional or clinical reporting systems;
   2. suspension, non-promotion, non-renewal, or dismissal: GME Policy 2.2. The merits of an academic or clinical competency judgment are not subject to review under this policy. An allegation that an applicable GME policy or procedure was not followed may be reviewed under this policy, but such review does not substitute for or extend any appeal available under GME Policy 2.2;
   3. discrimination, harassment, sexual misconduct, disability accommodation, research integrity, patient safety, or compliance matters: the applicable Rutgers, employer, or clinical process; and
   4. contractual claims subject to a collective bargaining agreement: the agreement’s grievance process. Rutgers Health nevertheless retains responsibility for reviewing any distinct GME, learning environment, or accreditation issue raised by the same facts.

A resident is not expected to determine the correct process before raising a concern. The DIO or designee will determine the appropriate route and may coordinate related processes while retaining oversight of any distinct GME or accreditation issue.

General Principles

1. Residents are encouraged to raise concerns with the program director or another appropriate program leader when the matter can reasonably be addressed at the program level.
2. A resident may contact the DIO, the DIO’s designee, or the Rutgers Health Office of GME directly when program-level resolution is unsuccessful, inappropriate, or reasonably perceived to present a conflict of interest or risk of retaliation.
3. Informal discussion, problem-solving, or facilitated resolution is encouraged when appropriate, but is not required before a matter may be considered by the DIO or designee.
4. This policy does not replace or limit rights under law, contract, a collective bargaining agreement, or another applicable policy, and does not extend deadlines established by another process.

Submitting a Grievance

1. Residents are encouraged to raise concerns with the program director or another appropriate program leader when the matter can reasonably be addressed at the program level.
2. A resident may contact the DIO, the DIO’s designee, or the Rutgers Health Office of GME directly when program-level resolution is unsuccessful, inappropriate, or reasonably perceived to present a conflict of interest or risk of retaliation.
3. Informal discussion, problem-solving, or facilitated resolution is encouraged when appropriate, but is not required before a matter may be considered by the DIO or designee.
4. This policy does not replace or limit rights under law, contract, a collective bargaining agreement, or another applicable policy, and does not extend deadlines established by another process.

Review and Resolution

1. Program leaders may address a grievance through discussion, review, referral, or other reasonable efforts at resolution. A matter may be referred to the DIO or designee when it is unresolved, requires institutional action, presents a conflict, or otherwise warrants institutional review.
2. The DIO or designee will manage and serve as the institutional decision-maker for grievances under this policy. The DIO or designee will determine the nature and scope of review appropriate to the circumstances and may obtain information from the resident, program, respondent, participating site, or other persons with relevant information.
3. The DIO or designee may consult or refer aspects of a grievance to Human Resources, University Labor Relations, the Office of General Counsel, compliance, a clinical or academic office, or another subject-matter resource, and may appoint a reviewer when useful. This policy does not require a hearing, committee, or review panel.
4. Grievances will be addressed as promptly and reasonably as the nature and complexity of the matter permit. The DIO or designee will communicate the disposition to the resident in a manner appropriate to the circumstances. Personnel, patient, legal, or other confidential information may be withheld.
5. The DIO or designee may facilitate a resolution, clarify or direct application of policy, refer a matter to an authorized office, require programmatic or operational action within institutional authority, monitor follow-up, or take another action appropriate to the GME issue. The DIO’s or designee’s disposition is final under this policy.

Conflict of Interest

1. The DIO or designee will consider actual or reasonably perceived conflicts when determining who will participate in reviewing or resolving a grievance. A person whose conduct is the subject of the grievance will not have sole authority to determine its disposition
2. If the DIO is named in the grievance or has a material conflict, the DIO will take no role in managing or deciding the grievance. The Rutgers Health Chancellor, in consultation with nonconflicted senior Rutgers Health leadership, will designate an appropriate non-conflicted institutional official or reviewer to act in the DIO’s place.

Non-Retaliation and Privacy

1. Rutgers Health prohibits retaliation, intimidation, or coercion against a person who in good faith raises a concern, submits or supports a grievance, provides information, or participates in review.
2. Information will be handled as privately as reasonably possible and shared with persons who need it to review, respond, advise, resolve the matter, or meet legal, accreditation, patient safety, or institutional obligations. Absolute confidentiality cannot be promised.

Records and Institutional Oversight
The Office of GME will retain sufficient documentation of formal grievances and their disposition to demonstrate institutional oversight, support appropriate follow-up, and identify recurring or systemic GME concerns. The DIO or designee may provide de-identified or aggregate information to the GMEC when appropriate for oversight or institutional improvement.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

3.1 Clinical and Educational Work Hours

Reason for Policy

To establish compliance that meets Rutgers, state, federal, and accreditation regulations.

Applicable ACGME Institutional Requirements

3.2.3 Clinical Experience and Education

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Rutgers University Policies
• New Jersey Board of Medical Examiners
• American Board of Medical Specialties

Scope

The scope of this policy applies to all residents and fellows in training at Rutgers Health.

The Policy

1. The Sponsoring Institution ensures effective oversight of institutional and program-level compliance with ACGME clinical and educational work hour requirements.
   1. Responsibility
      1. Responsibility for monitoring compliance with these requirements will rest with the individual Program Director and the GMEC Learning and Working Environment Subcommittee under the direction of the DIO. All programs shall implement policies and procedures consistent with ACGME Institutional Requirements and program requirements for resident/fellow clinical experience and education as well as the working environment.
         1. All programs should adopt procedures so that the clinical and educational work obligations are shared by residents/fellows in all PGY levels in order to mitigate the possibility for excessive after-hours work by junior level residents and fellows.
         2. The DIO may periodically assess compliance by review of on-call schedules and by confidential discussions with individual residents/fellows.
         3. The GMEC Learning and Working Environment Subcommittee will meet regularly to address institutional and individual program compliance with clinical and educational work hour requirements set forth by the ACGME.
2. Clinical and Educational Work Hours
   1. Maximum Hours of Clinical and Educational Work per Week
      1. Clinical and educational work hours must be limited to no more than 80 hours per week, averaged over a four-week period, inclusive of all in-house clinical and educational activities, clinical work done from home, and all moonlighting.
   2. Mandatory Time Free of Clinical Work and Education
      1. The program must design an effective program structure that is configured to provide residents/fellows with educational opportunities, as well as reasonable opportunities for rest and personal well-being.
      2. Ideally, residents/fellows should have eight hours off between scheduled clinical work and education periods.
      3. There may be circumstances when residents/fellows choose to stay to care for their patients or return to the hospital with fewer than eight hours free of clinical experience and education. This must occur within the context of the 80-hour and the one-day-off-in-seven requirements.
      4. Residents/Fellows must have at least 14 hours free of clinical work and required education after 24 hours of in-house call.
      5. Residents/Fellows must be scheduled for a minimum of one-day-in-seven free of clinical work and required education (when averaged over four weeks), unless otherwise specified by an individual RRC. At-home call cannot be assigned on these free days.
   3. Maximum Clinical Work and Education Period Length
      1. Clinical and educational work periods for residents/fellows must not exceed 24 hours of continuous scheduled clinical assignments.
      2. Up to four hours of additional time may be used for activities related to patient safety, such as providing effective transitions of care, and/or resident/fellow education.
         1. Additional patient care responsibilities must not be assigned to a resident/fellow during this time.
   4. Clinical and Educational Work Hour Exceptions
      1. In rare circumstances, after handing off all other responsibilities, a resident/fellow, on their own initiative, may elect to remain or return to the clinical site in the following circumstances: to continue to provide care to a single severely ill or unstable patient; humanistic attention to the needs of a patient or family; or, to attend unique educational events.
      2. These additional hours of care or education must be counted toward the 80-hour weekly limit.
      3. Requests for any other exceptions to the above must be made in writing from the Program Director to the DIO who will then submit to GMEC for review.
   5. In-House Night Float
      1. Night float must occur within the context of the 80-hour and one-day-off-in-seven requirements.
   6. Maximum In-House On-Call Frequency
      1. Residents must be scheduled for in-house call no more frequently than every third night (when averaged over a four-week period).
   7. At-Home Call
      1. Time spent on patient care activities by residents on at-home call must count toward the 80-hour maximum weekly limit. The frequency of at-home call is not subject to the every-third-night limitation but must satisfy the requirement for one day in seven free of clinical work and education, when averaged over four weeks. At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each resident.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

3.2 Supervision

Reason for Policy

To establish compliance that meets Rutgers, state, federal, and accreditation regulations.

Applicable ACGME Institutional Requirements

3.2.d Supervision and Accountability

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Committee of Interns and Residents (CIR) Collective Bargaining Agreement
• Rutgers University Policies
• New Jersey Board of Medical Examiners
• American Board of Medical Specialties

Scope

The scope of this policy applies to all residents and fellows participating in Rutgers Health programs.

The Policy

1. The clinical responsibilities for each resident/fellow must be based on PGY-level, patient safety, resident/fellow education, severity and complexity of patient illness/condition and available support services. In the clinical learning environment, each patient must have an identifiable, appropriately credentialed, and privileged attending physician (or licensed independent practitioner as approved by each Review Committee) who is ultimately responsible for that patient’s care. This information should be available to residents/fellows, faculty members, and patients. Residents/fellows and faculty members should inform patients of their respective roles in each patient’s care.
2. Each program must demonstrate the appropriate level of supervision for all residents/fellows who care for patients and compliance with program specific requirements. Supervision may be exercised through a variety of methods. Some activities require the physical presence of the supervising faculty member. For many aspects of patient care, the supervising physician may be a more advanced resident or fellow. Other portions of care provided by the resident/fellow can be adequately supervised by the immediate availability of the supervising faculty member or resident/fellow physician, either at the site, or by means of telephonic and/or electronic modalities. In some circumstances, supervision may include post-hoc review of resident/fellow delivered care with feedback of the appropriateness of that care.
3. To ensure oversight of resident/fellow supervision and graded authority and responsibility, each program must use the following classification of supervision:
   1. Direct Supervision
      1. The supervising physician is physically present with the resident/fellow and patient.
   2. Indirect Supervision:
      1. With direct supervision immediately available
         1. the supervising physician is physically within the hospital or other site of patient care and is immediately available to provide Direct Supervision.
      2. With direct supervision available
         1. the supervising physician is not physically present within the hospital or other site of patient care but is immediately available by means of telephonic and/or electronic modalities and is available to provide Direct Supervision.
   3. Oversight
      1. the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.
4. The privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each resident/fellow must be assigned by the Program Director and faculty members. The Program Director must evaluate each resident’s/fellow’s abilities based on specific criteria. When available, evaluation should be guided by specific national standards-based criteria (e.g. milestones, evaluation tools, procedural requirements, etc.). Faculty members functioning as supervising physicians should delegate portions of care to residents/fellows, based on the needs of the patient and the skills of the residents/fellows. Senior residents or fellows should serve in a supervisory role of junior residents in recognition of their progress toward independence, based on the needs of each patient and the skills of the individual resident or fellow.
5. Each sponsored program is to establish schedules which assign qualified faculty physicians, residents, or fellows to supervise residents and fellows, at all times and in all settings, in which resident or fellows provide any type of patient care. The type of supervision to be provided is delineated in the residency/fellowship program curriculum’s rotation description.

Each program must set guidelines for circumstances and events in which residents/fellows must communicate with appropriate supervising faculty members. Each resident/fellow must know the limits of their scope of authority, and the circumstances under which they are permitted to act with conditional independence. In particular, PGY-1 residents should be supervised either directly or indirectly with direct supervision immediately available.

6. Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of each resident/fellow and delegate to them the appropriate level of patient care authority and responsibility.
7. Residents and Fellows have the following mechanisms to report inadequate supervision and accountability, involving themselves or their colleagues:
   1. In acute situations, where patient care may be immediately threatened, the resident has the discretion to contact the faculty, chief resident, the program director, or the DIO or designee, as they see appropriate. The person contacted will contact the supervising attending or the Chief Medical Officer for the clinical site as appropriate; alternatively, they may offer guidance to the resident.
   2. For situations where patient care is not immediately threatened, the resident may contact any of the named individuals above directly or other resources including:
      1. The Associate Dean/Chief Academic Officer
      2. The event reporting system for the site involved
      3. GME through their website, anonymous reporting link, e-mail, etc. See also Rutgers Health GME Policy, “Policy on Mechanisms for Confidential Reporting.”
8. Process:
   1. Program Directors are responsible for establishing a detailed written policy describing resident/fellow supervision at each level of training. Program policies must be reviewed and approved by the relevant DIO or designee.
   2. The requirements for on-site supervision are established for and by each program in accordance with ACGME guidelines, monitored through departmental and GMEC special program reviews. Programs’ policies for supervision must ensure that supervision is consistent with:
      1. The provision of safe and effective patient care.
      2. Educational needs of residents.
      3. Progressive responsibility appropriate to residents’/fellows’ level of education, competence, and experience.
      4. All applicable Common and specialty/subspecialty-specific Program Requirements.
   3. It is required that residents/fellows have the ability to report regarding adequacy of supervision and appropriateness of clinical workload. They may also voice their concerns regarding supervision in institutional internal surveys or on the ACGME resident survey. When specific episodes of inadequate supervision or accountability are reported, the Program Director will review the situation and report on the event to the DIO or designee and the involved resident/fellow (if identified). The program director may close the incident without further action or counsel the faculty involved, remove the faculty member from involvement with the residency program or report to the Chair or equivalent for further action.
      1. The analysis of any medical error or near-miss event includes a review to decide whether or not supervision contributed to the situation. When a root cause analysis (RCA) involving a resident/fellow is conducted, the resident/fellow shall participate in the RCA and the possibility of supervision as a contributing factor to the medical error or near miss will be assessed.
      2. The identity of the resident/fellow will not be revealed except to necessary parties. Any action taken by a faculty member, resident/fellow or other person against the resident reporting the event can subject the person to actions as described above.
   4. The sponsoring institution monitors all citations and policies related to supervision including but not limited to ACGME site visits, special program reviews, housestaff reports, program policies, etc.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

3.3 Transitions of Care

Reason for Policy

To establish compliance that meets Rutgers, state, federal, and accreditation regulations.

Applicable ACGME Institutional Requirements

III.B.3

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Committee of Interns and Residents (CIR) Collective Bargaining Agreement
• Rutgers University Policies
• New Jersey Board of Medical Examiners
• American Board of Medical Specialties

Scope

The scope of this policy applies to all Rutgers Health residents and fellows.

The Policy

1. Purpose: To establish protocol and standards within Rutgers Health residency and fellowship programs to ensure the quality and safety of patient care when transfer of responsibility occurs during duty hour shift changes and other scheduled or unexpected circumstances.
2. Definition: A handoff is defined as the communication of information to support the transfer of care and responsibility for a patient/group of patients from one provider to another. Transitions of care are necessary in the hospital setting for various reasons. The transition/hand-off process is an interactive communication process of passing specific, essential patient information from one caregiver to another. Transition of care occurs regularly under the following conditions:
   1. Change in level of patient care, including but not limited to inpatient admission from an outpatient procedure, diagnostic area or Emergency Department, transfers to or from a critical care unit, and transfers to or from outside hospitals.
   2. Temporary transfer of care to other healthcare professionals within procedure or diagnostic areas.
   3. Discharge, including discharge to home or another facility such as skilled nursing care.
   4. Change in provider or service change, including change of shift for nurses, resident sign-out, rotation changes for residents, and subspecialty service changes.
3. Procedure:
   1. The transition/hand-off process should be face-to-face interaction* with the opportunity for the receiver of the information to ask questions or clarify specific issues. The transition process should include information in a standardized format that is universal across all services but may vary depending on trainee level, level of care, or EMR tool used. Some common examples include:
      1. Identification of patient, including name, medical record number, and age
      2. Identification of admitting/primary/supervising physician and contact information
      3. Diagnosis and current status/condition (level of acuity) of patient
      4. Recent events, including changes in condition or treatment, current medication status, recent lab tests, allergies, anticipated procedures and actions to be taken
      5. Outstanding tasks — what needs to be completed in immediate future
      6. Outstanding laboratories/studies — what needs follow up during shift
      7. Changes in patient condition that may occur requiring interventions or contingency plans

      *Hand-offs can be conducted over the phone provided both parties have access to an electronic or hard copy version of the sign-out sheet, and all attempts to preserve patient confidentiality are observed.

   2. Each residency program must develop components ancillary to the institutional transition of care policy that integrate specifics from their specialty field. Programs are required to develop scheduling and transition/hand-off procedures to ensure that:
      1. A quiet setting free of interruptions is consistently available, for handoff processes.
      2. Patient confidentiality and privacy are ensured in accordance with HIPAA guidelines.
      3. The program uses a standardized process with consistent opportunity for questions and all necessary materials available (for example written sign-out materials and/or electronic clinical information) to support the handoff.
      4. Residents comply with specialty specific/institutional duty hour requirements
      5. Faculty are scheduled and available for appropriate supervision according to the requirements of the scheduled residents.
      6. All parties (including nursing) involved in a particular program and/or transition process should have access to one another’s schedules and contact information. All call schedules should be readily available.
      7. Patients are not inconvenienced or endangered in any way by frequent transitions in their care.
      8. All parties directly involved in the patient’s care before, during, and after the transition have opportunity for communication, consultation, and clarification of information.
      9. Safeguards exist for coverage when unexpected changes in patient care may occur due to circumstances such as resident illness, fatigue, or emergency.
      10. Programs should provide an opportunity for residents to both give and receive feedback from each other or faculty physicians about their handoff skills.
   3. The Sponsoring Institution must facilitate educational programming for core faculty and residents/fellows on structured hand-over processes to facilitate both continuity of care and patient safety. For example, training residents in commonly used transitions of care tools like SBAR or iPASS.
   4. Programs must ensure that residents/fellows are competent in communicating with team members in the hand-over process. There are numerous mechanisms through which a program might elect to determine the competency of trainees in handoff skills and communication. These include:
      1. Direct observation of a handoff session by a licensed independent practitioner (LIP)-level clinician familiar with the patient(s)
      2. Direct observation of a handoff session by an LIP-level clinician unfamiliar with the patient(s)
      3. Either of the previous, by a peer or by a more senior trainee
      4. Evaluation of written handoff materials by an LIP-level clinician familiar with the patient(s)
      5. Evaluation of written handoff materials by an LIP-level clinician unfamiliar with the patient(s)
      6. Either of the previous, by a peer or by a more senior trainee
      7. Didactic sessions on communication skills including in-person lectures, web-based training, review of curricular materials and/or knowledge assessment
      8. Assessment of handoff quality in terms of ability to predict overnight events
      9. Assessment of adverse events and relationship to sign-out quality through:
         1. Survey
         2. Reporting hotline
         3. Trigger tool
         4. Chart review
4. Oversight and Monitoring:
   1. Each program must submit a protocol for their transitions of care process which must be reviewed and approved by the DIO or designee every five years, or sooner if necessitated by accreditation or safety standards. Issues regarding transitions of care may be reported via surveys, evaluations, safety reporting systems (e.g., hotlines, apps, etc.) and other as detailed in RH Mechanisms for Confidential Reporting policy.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

3.4 Moonlighting

Reason for Policy

The purpose of this policy is to establish a unified Rutgers Health standard governing moonlighting and other compensated professional work performed by residents and fellows (“trainees”) outside the scope of their GME training programs. This policy is intended to:

1. Ensure compliance with ACGME Institutional and Common Program Requirements regarding moonlighting, work hours, and supervision.
2. Ensure compliance with Centers for Medicare & Medicaid Services (CMS) regulations governing services furnished by residents, including moonlighting services.
3. Promote patient safety, trainee wellness, and preservation of the educational mission of Rutgers Health and its clinical partners.

Applicable ACGME Institutional Requirements

Section 4: Institutional GME Policies and Procedures

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Committee of Interns and Residents (CIR) Collective Bargaining Agreement
• Rutgers University Policies
• New Jersey Board of Medical Examiners
• CMS Regulations

Scope

This policy applies to all residents and fellows enrolled in Rutgers Health-sponsored graduate medical education programs.

Definitions

• Trainee: any resident or fellow enrolled in a Rutgers Health-sponsored post-graduate training program.
• Extra Duty: additional duty within the training program’s scope of responsibilities, assigned by a program. This is not considered moonlighting and is outside the scope of this policy.
• Moonlighting: voluntary, compensated clinical work performed by a trainee that is outside the scope of the duties and responsibilities of the training program and does not count toward program completion.
• Internal Moonlighting: moonlighting that occurs within the same hospital or health system in which the trainee’s program is based, but outside the rotational structure of the program (e.g., an RWJBarnabas Health hospital).
• Secondary “Class 8” Appointment: a secondary Rutgers employment appointment used when a department assigns clinical work on behalf of Rutgers that is separate from, and in addition to, the trainee’s educational role. A Class 8 appointment applies to internal moonlighting arrangements for Rutgers employed trainees.
• J-1 Supplemental Clinical Activity: internal moonlighting performed by a J-1 physician within their training institution and approved by Intealth as supplemental clinical activity under current guidance.
• External Moonlighting: moonlighting that occurs at a site that is not part of the trainee’s regularly assigned training sites or within the Rutgers Health or RWJBarnabas Health clinical network.
• Outside Professional Activity (Non-Clinical): compensated professional work performed by a trainee that is not clinical care as a physician, but that occurs outside the scope of the trainee’s GME program and may reasonably interfere with the trainee’s educational responsibilities, work-hour compliance, fitness for duty, or patient safety. Examples include, but are not limited to, consulting services, educational advising, content review, professional reviewing activities, or work performed in a prior licensed profession.
• Good Standing: satisfactory academic and professional performance as determined by the Program Director (PD), with no current remediation, probation, or formal disciplinary action.

The Policy

General Principles

1. The primary professional obligation of trainees is the development of the knowledge, skills, and professional competencies required for independent practice in their specialty through participation in their Rutgers Health GME program.
2. Trainees must be in good standing to be eligible to apply for moonlighting privileges.
3. Moonlighting is strictly voluntary. Trainees must not be required or pressured to moonlight as a condition of appointment, promotion, or graduation.
4. PGY-1 residents are prohibited from moonlighting.
5. All moonlighting activities must be approved by the Program Director and the local Associate Dean/Chief Academic Officer.
6. Moonlighting must not interfere with:
   1. Achievement of educational goals and milestones;
   2. Compliance with the ACGME’s 80-hour weekly limit (averaged over four weeks);
   3. Scheduling obligations in the trainee’s GME program;
   4. Fitness for duty;
   5. Patient safety.

• Moonlighting activities are not part of the trainee’s educational program and do not count toward required training time or case volumes.
• Other compensated outside professional activities (non-clinical) may require review and approval if the activity could interfere with the trainee’s educational responsibilities, work-hour compliance, fitness for duty, or patient safety. Such activities are not considered moonlighting for CMS or billing purposes but are subject to program and institutional oversight.
• Residents covered under a Collective Negotiations Agreement (CNA) are not eligible for CNA-negotiated benefits (e.g., meal credits) while performing internal moonlighting activities, as such activities fall outside the scope of the collective bargaining agreement.
• Trainees who are in a period of concern (remediation) or probation are not permitted to moonlight.
• Rutgers Health and individual programs reserve the right to prohibit moonlighting entirely or to withdraw previously granted permission at any time if there are concerns regarding performance, professionalism, work hours, or patient safety.

1. Approval Process

• The approval process outlined below applies to both clinical moonlighting activities and other compensated outside professional activities that may interfere with training, as determined by the Program Director and the Associate Dean for GME/Chief Academic Officer.
• Before engaging in any moonlighting, the trainee must:
  1. Complete Form 1 — Trainee Moonlighting Request & Attestation and submit it to the Program Director.
  2. Obtain Program Director approval (Form 2).
  3. Obtain Associate Dean for GME / Chief Academic Officer approval (Form 3).
  4. If in J-1 status, obtain Intealth approval for supplemental clinical activity after institutional approvals.
• No moonlighting may commence until all required approvals are documented.
• Approvals are time-limited (not beyond the end of the current academic year) and must be renewed annually or sooner if there is a material change in site, responsibilities, schedule, licensure, or visa status.
• Approvals are revocable at any time by the Program Director or Associate Dean for GME/CAO.

Licensure, Immigration Status, and Malpractice Coverage

• Trainees must be appropriately licensed to practice in the state where the moonlighting occurs.
• Trainees holding limited permits or restricted licenses may not engage in moonlighting unless specifically permitted by state law and explicitly approved by the PD and Associate Dean for GME/CAO. Any required supervisory affidavits or verification forms must be completed.
• Trainees in J-1 visa status must comply with all federal immigration regulations and Intealth/USCIS requirements. J-1 physicians:
  1. May engage in internal supplemental clinical activity only with prior Intealth approval;
  2. Must obtain PD and Associate Dean for GME/CAO approval before submitting a supplemental clinical activity request to Intealth;
  3. Must comply with all conditions (same institution, educational appropriateness, no extension of training, and work-hour compliance).
     1. Trainees are responsible for ensuring appropriate professional liability (malpractice) coverage is in place for all moonlighting activities. Such coverage is typically provided by the moonlighting site, obtained directly by the trainee, or, for Rutgers-employed trainees, provided through a separate Rutgers appointment (i.e., a “Class 8” appointment) when applicable. Documentation of malpractice coverage must be submitted as part of the application process.

1. For Rutgers-employed trainees, approved internal moonlighting activities performed at Robert Wood Johnson University Hospital or University Hospital Newark require a separate secondary Rutgers appointment (e.g., a “Class 8” appointment). This requirement does not apply to internal moonlighting activities performed at other RWJBarnabas Health hospitals or external sites.
   1. Moonlighting activities are not considered part of the trainee’s GME responsibilities, and Rutgers Health does not assume responsibility for professional liability or indemnification by virtue of the trainee’s GME status. Trainees are responsible for ensuring that appropriate professional liability coverage is in place for all moonlighting activities, consistent with the requirements of the moonlighting arrangement or site.
   2. Routine privileging and credentialing requirements of the moonlighting site are separate from Rutgers GME approval and must be satisfied in accordance with site policies.

2. CMS Billing Requirements for Internal Moonlighting

• Internal moonlighting services may be billed under the Medicare Physician Fee Schedule only if all CMS criteria for “services of moonlighting residents” in 42 CFR 415.208 are met:
  1. The services are identifiable physician services and meet all conditions for payment under 42 CFR 415.102.
  2. The trainee is fully licensed in the state in which the services are performed.
  3. The services can be separately identified from those required as part of the approved GME program.
  4. These services are not included in the hospital’s full-time equivalent resident count for direct or indirect GME payments.
  5. No additional Medicare payment is made for services of a “teaching physician” associated with these moonlighting services.
• Documentation in the medical record and employment/coverage agreements must clearly reflect that the trainee is functioning as an independently licensed physician, not in the capacity of a resident, during moonlighting shifts.

Application examples:

• A fellow serving as a nocturnist on a general medicine service distinct from their assigned fellowship rotation.
• A resident working in the Emergency Department or on a separate service line in the capacity of an independently licensed physician, not in the role of a resident, and outside the supervision, coverage, and scheduling structure of any residency or fellowship program, with clearly documented separation from GME duties.

3. Work Hours, Wellness, and Monitoring

• All moonlighting hours (internal and external) must be logged in the institution’s residency management software and be clearly designated as moonlighting hours.
• Moonlighting hours are counted toward the 80-hour weekly maximum (averaged over four weeks).
• Program Directors and the GME office will monitor the impact of moonlighting on trainee performance, work-hour compliance, and professionalism. Adverse effects may lead to withdrawal of permission to moonlight.
• Trainees are expected to report any fatigue, burnout, or wellness concerns related to moonlighting and to seek support as needed.

4. Conflict of Interest and Outside Activity Reporting

• Moonlighting must not create a conflict of interest with Rutgers Health responsibilities, consistent with Rutgers Code of Ethics or RWJBH Code of Conduct and policies on outside employment.
• Rutgers employed trainees must complete the required Outside Activity Questionnaire (OAQ) at eCOI+ and any other institutional conflict-of-interest or outside activity disclosures.
• RWJBH employed trainees must disclose any potential conflicts in writing. The facility President and CEO or designee shall approve all employee conflicts of interest.
• Failure to complete required disclosures or to obtain required approvals constitutes a violation of this policy and may result in disciplinary action up to and including termination.

5. Prohibited Moonlighting Arrangements

• Moonlighting will not be approved when:
  1. The trainee is a PGY-1 resident.
  2. The trainee is not in good standing.
  3. The proposed duties represent additional work within the training program’s scope of responsibilities and are more appropriately managed through the program’s extra call or similar internal coverage policies.
  4. The arrangement would result in violation of ACGME work-hour standards.
  5. The work conflicts with Rutgers, RWJBarnabas Health, or other hospital policies on professionalism, conflict of interest, or clinical privileging.

6. Non-Compliance

Failure to comply with this policy, including undertaking moonlighting without approval, failure to report hours, or misrepresentation of duties, may result in:

• Immediate withdrawal of moonlighting permission;
• Notification of the moonlighting site and relevant hospital leadership;
• Disciplinary action under institutional policies, up to and including suspension or termination from the training program.

Accompanying Forms:

• FORM 1 – TRAINEE MOONLIGHTING REQUEST & ATTESTATION
• FORM 2 – PROGRAM DIRECTOR REVIEW AND APPROVAL
• FORM 3 – ASSOCIATE DEAN FOR GME / CHIEF ACADEMIC OFFICER APPROVAL

Note: The Office of Graduate Medical Education may periodically review moonlighting and outside professional activity approvals to ensure institutional compliance with this policy and applicable regulatory requirements.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

3.5 Patient Safety and Quality Improvement

Reason for Policy

To establish and sustain a clinical learning environment in which residents and fellows are educated,
empowered, and accountable to report and learn from patient safety events, participate in quality
improvement (QI) and health equity work, and contribute to system-level improvements that reduce
preventable harm and improve outcomes.

Applicable ACGME Institutional Requirements

3.2 Learning and Working Environment

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Rutgers University Policies
• New Jersey Board of Medical Examiners
• American Board of Medical Specialties

Scope

This policy applies to applies to all residents and fellows in training at Rutgers Health.

Definitions

1. Patient safety event: an incident, condition, or circumstance that could have resulted, or did result, in unnecessary harm to a patient. This includes adverse events, near misses, and unsafe conditions.  
2. Adverse event: an injury or complication resulting from medical management rather than the underlying disease, which may or may not be preventable.  
3. Near miss: A patient safety event that did not reach the patient and therefore did not cause harm, but had the potential to do so,  
4. Unsafe condition: A circumstance that increases the likelihood of a patient safety event.  
5. Root cause analysis (RCA): A structured method to identify contributing factors and underlying system causes of a patient safety event and to develop actions that reduce the risk of recurrence.  
6. Quality improvement (QI): Systematic, data-guided activities designed to bring about immediate improvements in health care delivery and outcomes (i.e. Plan-Do-Study-Act cycles).  
7. Health equity/health care disparities: Differences in health outcomes and health care access experienced by certain populations; QI work should include efforts to identify and reduce disparities  
8. Patient Safety Event Reporting System: The mechanism(s) used by each clinical site to report errors, adverse events, near misses, and unsafe conditions, including protected reporting outcomes 

The Policy

1. The Sponsoring Institution, through the DIO and GMEC, is responsible for oversight and documentation of resident and fellow engagement in patient safety and quality improvement activities across all participating sites.  The institution will monitor compliance, review participation data, and ensure that each program provides meaningful opportunities consistent with ACGME institutional requirements. 
2. Each program must maintain a clinical learning environment that is committed to patient safety, quality improvement, and accountability.  
3. All physicians share responsibility for promoting patient safety and enhancing quality of patient care. Graduate medical education must prepare residents to provide the highest level of clinical care with continuous focus on the safety, individual needs, and humanity of their patients. It is the right of each patient to be cared for by residents who are appropriately supervised; possess the requisite knowledge, skills, and abilities; understand the limits of their knowledge and experience; and seek assistance as required to provide optimal patient care.  
4. Residents must demonstrate the ability to analyze the care they provide, understand their roles within health care teams, and play an active role in system improvement processes. Graduating residents will apply these skills to critique their future unsupervised practice and effect quality improvement measures.  
5. It is necessary for residents and faculty members to consistently work in a well-coordinated manner with other health care professionals to achieve organizational patient safety goals. 

Roles and Responsibilities

1. GMEC and DIO (Institutional Oversight): Ensure trainees have access to a patient safety event reporting system; provide institution-wide orientation resources on patient safety and QI; make available aggregated/summarized patient safety and quality data to programs; and monitor institutional compliance with ACGME requirements.
2. Program Directors and Faculty: Implement and document program-level patient safety and QI education; encourage and support reporting and participation without fear of reprisal; provide timely feedback to trainees on events and improvement work; and ensure trainees are appropriately supervised during all patient care activities.
3. Residents and Fellows: Complete required patient safety and QI training; report patient safety events (including near misses and unsafe conditions); participate in safety and QI analyses and improvement as assigned; and escalate clinical concerns when patient safety may be compromised.

Confidentiality and Non-Retaliation

The Sponsoring Institution will ensure that all residents and fellows receive formal orientation at onboarding and at each participating site regarding: 

1. How to access and use the patient safety reporting system 
2. How to escalate urgent safety concerns in real time, and 
3. Protections against retaliation for good faith reporting 

Trainees have access to protected mechanisms to report errors, adverse events, near misses, and unsafe conditions, and may do so without fear of intimidation, retaliation, or adverse impact on their evaluation. Trainees may also report concerns to program leadership, the DIO, or the institutional patient safety office if they believe issues are not being addressed or if retaliation is a concern. Examples of reporting mechanisms include but are not limited to: 

1. Confidential electronic event reporting system at all hospitals,  
2. Rutgers Health GME Anonymous Reporting Link 
3. The Rutgers Helpline at 833-RU-ETHICS (833.783.8442) (Rutgers Compliance Helpline) 
4. Rutgers Health GME Sponsoring Institution Ombuds  
5. RWJBH Health System Corporate Compliance Hotline: 1-800-780-1140 
6. RWJBH Health System Corporate Compliance Reporting Link 

Patient Safety

1. A culture of safety requires continuous identification of vulnerabilities and a willingness to transparently deal with them. An effective organization has formal mechanisms to assess the knowledge, skills, and attitudes of its personnel toward safety in order to identify areas for improvement.
2. The program, its faculty, residents, and fellows must actively participate in patient safety systems and contribute to a culture of safety. The program must have a structure that promotes safe, interprofessional, team-based care.
3. Education on Patient Safety Programs must provide formal educational activities that promote patient safety related goals, tools, and techniques.
4. Reporting, investigation, and follow-up of adverse events, near misses, and unsafe conditions are pivotal mechanisms for improving patient safety and are essential for the success of any patient safety program. Ongoing analysis and structured reflection are essential to developing competence in identifying contributing factors and implementing sustainable systems-based improvements.
5. Residents, fellows, faculty members, and other clinical staff members must:
   1. know their responsibilities in reporting patient safety events at the clinical site;
   2. know how to report patient safety events, including near misses, at the clinical site; and
   3. be provided with summary information of their institution’s patient safety reports.
6. Each program must ensure that residents and fellows have structured opportunities to participate in root cause analyses (RCAs), apparent cause analyses, failure mode and effects analyses, or similar risk-reduction processes. Participation may include case review, contributing factor analysis, development of corrective actions, or implementation follow-up. Programs must document such participation.
7. Patient-centered care requires patients, and when appropriate families, to be apprised of clinical situations that affect them, including adverse events. This is an important skill for faculty physicians to model, and for residents to develop and apply.
   1. All residents must receive training in how to disclose adverse events to patients and families.
   2. Residents should have the opportunity to participate in the disclosure of patient safety events, real or simulated.
8. Feedback and Experiential Learning. Programs and the institution will provide trainees with summary information from patient safety reporting (i.e. themes, trends, and improvement actions) and, when feasible, case-based feedback that “closes the loop” on events reported by trainees
9. Interprofessional Participation in Patient Safety Structures. Programs should provide residents and fellows with opportunities to participate in institutional and departmental patient safety activities and committees, including safety committees, peer review processes, safety review meetings, morbidity and mortality conferences, transitions-of-care improvement initiatives, and root cause analyses (RCAs). Participation should promote interprofessional collaboration and systems-based learning.
10. Root cause analyses and related safety investigations are conducted within a protected, non-punitive framework. Residents and fellows who participate in or are interviewed as part of an RCA are afforded confidentiality protections consistent with institutional policy, and participation in such activities will not adversely affect evaluation or advancement.
11. Site-specific reporting and escalation pathways. During onboarding to each participating site, trainees will receive instructions on how to report events and how to escalate urgent safety concerns in real time

Quality Improvement

1. A cohesive model of health care includes quality-related goals, tools, and techniques that are necessary in order for health care professionals to achieve quality improvement goals.
2. Residents must receive training and experience in quality improvement processes, including an understanding of health care disparities.
3. Access to Quality Metrics. Access to data is essential to prioritizing activities for care improvement and evaluating success of improvement efforts. The Sponsoring Institution will collaborate with participating sites to ensure that residents and fellows have access to relevant quality, safety, and equity data applicable to the populations they serve. Such data may include clinical outcomes, patient experience metrics, safety indicators, utilization measures, and disparity metrics.
4. Experiential learning is essential to developing the ability to identify and institute sustainable systems-based changes to improve patient care.
5. Residents must have the opportunity to participate in interprofessional quality improvement activities. This should include activities aimed at reducing health care disparities.
6. Each program must ensure that every resident and fellow participates in at least one meaningful quality improvement activity during training. Meaningful participation could include defining or analyzing a problem, reviewing performance data, participating in a structured improvement methodology (e.g. PDSA cycle), evaluating outcomes, and reflecting on lessons learned.
7. Programs should provide trainees and faculty with relevant, timely, and understandable quality metrics and benchmarks (i.e. patient experience, safety indicators, clinical outcomes, and equity measures) for the patient populations they serve, consistent with institutional policies on confidentiality and data security.
8. Programs should support sharing QI results in scholarly output (i.e. conferences, posters, presentations, publications) and encourage sustainability planning when improvements are successful.

Oversight

1. Programs must document trainee participation in patient safety and QI education and activities (i.e. orientation modules, conferences, RCA participation, QI projects) and review these activities at least annually. Program directors must report patient safety and QI participation and project summaries to the GMEC as part of the Annual Program Evaluation process.
2. The GMEC, or its designated subcommittee, will review and document institutional oversight of resident and fellow engagement in patient safety and quality improvement activities at least annually as part of the Annual Program Evaluation process. The GMEC will identify trends, areas of concern, and opportunities for institutional improvement and will document its oversight in meeting minutes.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

3.6 Mechanisms for Confidential Reporting

Reason for Policy

To establish compliance that meets Rutgers, state, federal, and accreditation regulations.

Applicable ACGME Institutional Requirements

3.2 The Learning and Working Environment

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Committee of Interns and Residents (CIR) Collective Bargaining Agreement
• Rutgers University Policies
• New Jersey Board of Medical Examiners
• American Board of Medical Specialties

Scope

The scope of this policy applies to all residents and fellows in training at Rutgers Health.

The Policy

1. Mechanisms by which residents can report a professionalism or clinical learning environment concern exist across multiple avenues and institutional levels. At any time, any resident has access to several protected options for reporting concerns, ensuring confidentiality and safeguarding against retaliation.
   1. At the Robert Wood Johnson Barnabas Health System Hospitals
      1. Staff, residents, and faculty may report professionalism or learning environment concerns online through the event reporting system or via dedicated Patient Safety Hotline. Complaints can be made anonymously, or user identified. All complaints made by or involving a resident are reported to the Chief Academic Officer and Program Director/Site Director. There is a daily safety briefing, and a member of the GME team reports safety concerns on the hospital-wide call every morning. Data and outcomes from complaints to the event reporting system and the Patient Safety Hotline are also reviewed at the hospital specific GME Councils. Root cause analyses are often scheduled, with a resident representative from each specialty involved in the adverse outcome required to attend.
   2. At other affiliate sites:
      1. At all sites, staff, residents, and faculty may directly report complaints to program leadership, faculty, hospital administration, and the event reporting systems. They may also contact the local Associate Dean for Graduate Medical Education and/or Chief Academic Officer, the Ombudsperson, resident delegates to the local Graduate Medical Education Council, and union delegates when appropriate. Resident representatives may serve on the Quality Councils at each hospital and are encouraged to raise issues based on their experiences in the clinical learning environment.
   3. At the Rutgers Health Sponsoring Institution Level
      1. The following resources are available to any staff or learner to report a professionalism or learning environment concern:
         1. Rutgers Health Anonymous Reporting Link
         2. The Rutgers Helpline at 833-RU-ETHICS (833.783.8442) (Rutgers Compliance Helpline)
         3. Rutgers Health GME Sponsoring Institution Ombuds
         4. RWJBH Health System Corporate Compliance Hotline: 1-800-780-1140
         5. RWJBH Health System Corporate Compliance Reporting Link
         6. Confidential event reporting system at all hospitals with specific tools to report unprofessional workplace behavior
         7. The Committee on Interns and Residents (CIR) Resources (house staff union)
2. Mechanisms by which residents can report inadequate supervision
   1. All Rutgers Health residents are encouraged to report inadequate supervision in the clinical learning environment. There are multiple avenues that residents can use from program specific mechanisms to hospital and institutional-wide mechanisms:
      1. Notify the Chief Resident(s) who can then call supervising faculty member, site director, or program director, depending on the situation
      2. Notify the Site Director
      3. Notify the Program Director
      4. Notify the Department Chair
      5. Notify the local Associate Dean or Chief Academic Officer
      6. Notify the Designated Institutional Official
      7. Notify delegates to Resident Council or collective bargaining unit where applicable
      8. Faculty Evaluations by the Residents — residents can anonymously report supervision issues about specific faculty members as necessary
      9. Rutgers Health Resident Council Townhalls
      10. Incident reporting systems throughout the various hospitals
      11. Anonymous GME Reporting Links in New Innovations
      12. Rutgers Health Anonymous GME Reporting Link
      13. The Rutgers Helpline at 833-RU-ETHICS (833.783.8442) (Rutgers Compliance Helpline)

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

4.1 General Resident Responsibilities

Reason for Policy

To define the core professional, clinical, educational, and administrative responsibilities expected of all Rutgers Health residents and fellows, regardless of specialty, and to ensure compliance with applicable institutional, state, federal, and accreditation requirements.

Applicable ACGME Common Program Requirements

6.1.-6.2., 6.5., 6.12.e.

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• RWJBarnabas Health Compliance Code of Conduct
• Rutgers Office of General Counsel
• New Jersey State Ethics Commission

Scope

The scope of this policy applies to all residents and fellows participating in Rutgers Health post-graduate training programs (i.e., residencies or fellowships), who hold a Resident or Fellow appointment. Residents and Fellows are hereafter referred to as “Residents.” The Rutgers Health policy described here applies to all residents of Rutgers Health.

The Policy

Rutgers Health GME residents are expected to actively participate in the educational opportunities provided by the Sponsoring Institution and its affiliated clinical sites and fulfill the educational objectives established by their training program.

Residents are expected to demonstrate progressive competence, as assessed through the program’s educational milestones, in the following domains:

• Patient Care
• Medical Knowledge
• Systems-Based Practice
• Practice-Based Learning and Improvement
• Professionalism
• Interpersonal and Communication Skills

To meet these fundamental responsibilities, all residents must:

• Patient Care: Inform each patient of their respective role in that patient’s care when providing direct patient care. This information must be available to residents, faculty members, other members of the health care team, and patients.
• Culture of Safety: Demonstrate an understanding of their personal role in the safety and welfare of patients entrusted to their care, including the ability to report unsafe conditions and safety events; report concerning behavior such as signs of burnout, depression, substance use disorders, or suicidal ideation in residents or faculty members; actively participate in patient safety systems; and contribute to a culture of safety.
• Confidentiality: Maintain patient privacy at all times in accordance with HIPAA requirements. Compliance includes adherence to the minimum necessary standard, use of encrypted and institutionally approved communication platforms, prevention of incidental disclosures, and safeguarding all protected health information.
• Attendance and Active Participation: Attend and actively participate in required educational activities consistent with program expectations and report on time for all clinical and educational assignments.
• Supervised Care: Render medical care in a kind, compassionate, and competent manner under the appropriate level of supervision of the assigned attending physician or a designated senior resident or fellow.
• Ambulatory Care: Attend all assigned outpatient clinics, ambulatory sessions, and consult services as scheduled by program leadership.
• Performance Evaluations: Complete required evaluations honestly, constructively, and within established timeframes.
• Scholarly and Quality Improvement Engagement: Participate actively in scholarly, patient safety, and quality improvement activities of the program and affiliated clinical sites, including initiatives aimed at reducing health care disparities.
• Punctuality: Be consistently on time for all clinical calls, shift hand-offs, rounds, and consult duties.
• Responsive Communication: Respond and communicate promptly through all approved institutional communication platforms, including pagers, telephones, secure messaging systems, and email, as appropriate to the clinical setting.
• Ethical and Moral Standards: Conduct themselves at all times in a highly professional, moral, and ethical manner consistent with the principles of the medical profession and the Rutgers Code of Conduct.
• Professional Appearance and Conduct: Maintain appropriate personal hygiene, grooming, professional attire, and respectful behavior in all clinical and educational settings.
• Procedure Logging: Document required procedures and clinical experiences accurately and in a timely manner within the appropriate tracking systems, including the ACGME Case Log System and departmental databases when applicable.
• Interprofessional Cooperation: Cooperate and communicate respectfully and professionally with nursing, administrative, and clinical support staff to promote a collaborative learning and patient care environment.
• Teaching Responsibilities: Participate in the education, supervision, and mentoring of medical students, junior residents, and other learners as appropriate to their level of training.
• Policy Compliance: Comply with all applicable institutional, affiliate hospital, and program-specific policies.
• Other Departmental Duties: Perform other reasonable clinical or educational duties consistent with educational objectives, accreditation standards, and institutional policies.

Medical Records and Documentation Standards

The patient medical record reflects the quality of patient care delivered within a hospital or clinical site. It serves as a critical tool for clinical planning, quality assurance, and communication among care providers. Medical records must accurately document each patient’s course of illness and treatment and remain accessible to the clinical team. Documentation must be accurate, timely, complete, legible, and compliant with institutional and regulatory requirements.

Clinical Documentation Requirements:

• Discharge Summaries: Must be completed on the day of or immediately following patient discharge in accordance with clinical site policies.
• Operative and Procedural Reports: Must be completed and submitted within 24 hours of the procedure. A brief procedure note must be entered into the medical record immediately after completion.
• Format and Content: All documentation must comply with the applicable hospital’s policies, formats, and procedures. Unapproved abbreviations may not be used, and handwritten notes or orders must be legible.

Affiliate hospitals may notify Graduate Medical Education regarding delinquent medical records and credentialing deficiencies. Residents are responsible for resolving such deficiencies immediately and completing all documentation and credentialing requirements within the timelines established by the medical staff bylaws of the respective institution.

Resident Involvement in Institutional and Hospital Affairs

To foster professional development and incorporate resident feedback into institutional operations, Rutgers Health provides opportunities for resident participation on committees and councils whose actions affect education and patient care.

Residents are encouraged to participate in committees affecting graduate medical education, including:

• Program Evaluation Committee (PEC)
• Graduate Medical Education Committee (GMEC)
• Quality Assurance and Improvement Committees
• Patient Safety Committees
• Rutgers Health Resident Council

Residents serving as representatives on institutional or hospital committees are expected to attend the majority of scheduled meetings and activities associated with their committee membership.

Through committee engagement, residents are encouraged to raise issues based on their experiences within the clinical learning environment and contribute to ongoing quality and safety improvements.

Monitoring and Compliance

Programs should make reasonable efforts to notify residents of identified deficiencies and provide an opportunity for timely correction when appropriate. Failure to fulfill the responsibilities outlined in this policy may result in corrective or disciplinary action under applicable Rutgers Health GME policies.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education department for the official, most recent version.

University Policy

4.2 Dress Code

Reason for Policy

Healthcare professionals must develop habits of conduct that are perceived by patients as signs of trustworthiness. Professional appearance is a reflection of attitude towards oneself and the people one is likely to encounter. This policy aims to ensure that all staff members present themselves in a manner that fosters trust, professionalism, and respect.

Resources

• ACGME Institutional Requirements
• ACGME Common Program Requirements

Scope

This policy applies to all housestaff, including interns, residents, and fellows, and faculty members in their teaching and supervisory roles.

The Policy

General Appearance

1. All housestaff and faculty must maintain an appropriate standard of personal appearance, hygiene, and grooming at all times while on duty.
2. Clothes must be clean, in good condition, and appropriate for one’s job.
3. Housestaff and faculty should avoid wearing clothing with emblems, slogans, or symbols related to political affiliation, illicit substances, alcohol, tobacco products, obscene language, or sexual connotations.

Guidelines

4. Housestaff and faculty:
   1. Must be clean and minimize body odor.
   2. Examples of unacceptable dress include overly revealing shirts, clothing that exposes the mid-section or back, bare feet, pajamas, and sweatpants.
   3. Scrubs can be worn in lieu of business attire if they have a neat and professional appearance.
   4. Clean white lab coats are preferred; however, any outerwear (e.g. lab coats, fleeces, shells, etc.) must be clean, well-maintained, and be laundered regularly. They should also not have excessively long sleeves or loose fabric that could interfere with patient care or sanitary conditions. Outerwear worn in clinical areas should not be worn outside the facilities to prevent contamination.
5. Hair must be clean and appropriate.
6. No hats, bandannas, sweatbands, or headgear may be worn unless required for medical, safety, religious, or cultural reasons or as part of the uniform.
7. Shoes should be in good repair. Sneakers and athletic shoes are acceptable if clean and in good condition. Open-toed shoes are not permitted for those with direct patient contact.
8. Jewelry should be kept to a minimum and should not interfere with safety or performing assigned functions.
9. Artificial nails, gel overlays, nail art, tips, and/or fillers are not allowed in direct patient care areas.
10. Consider covering body tattoos, particularly if illicit substances, alcohol, tobacco products, obscene language, or sexual connotations are visible.
11. Housestaff and faculty with direct patient contact should avoid heavily scented products.
12. Dress must also adhere to facility guidelines and expectations.

Compliance and Enforcement

13. Program Directors are responsible for ensuring compliance with this policy.
14. Housestaff who are not compliant may be sent home to change if they wear inappropriate attire to work.
15. Housestaff will be notified by the program director when concerns for noncompliance with this policy have been raised. The housestaff officer shall have the opportunity to respond. In extreme cases, disciplinary action (i.e. termination, probation, etc.) may be considered and must follow due process as per Rutgers Health policies.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

4.3 Social Media

Reason for Policy

The purpose of this policy is to provide guidelines for the appropriate use of social media by residents, fellows, faculty, and staff within the Rutgers Health Graduate Medical Education (GME) programs. This policy aims to balance the benefits of social media in education, research while ensuring that social media use aligns with the professional standards of the medical community, maintains ethical behavior, protects patient confidentiality, and upholds the reputation of the institution.

Resources

• ACGME Institutional Requirements
• ACGME Common Program Requirements

Scope

This policy applies to all residents, fellows, core faculty, and staff involved in GME programs. It covers all forms of social media, including but not limited to blogs, social networking sites, professional networking sites, video and photo sharing sites, and other platforms that facilitate online communication, both personal and professional. In the context of this policy, professional accounts refer to social media posts developed for the purpose of promoting Rutgers-related activities. All other accounts would be considered personal.

The Policy

Professionalism and Conduct

1. Personal and professional social media accounts should be clearly distinguished. Professional accounts should be used for educational and professional purposes only.
2. Personal use of social media should not interfere with work responsibilities or institutional missions.
3. Housestaff must also comply with the social media use policies of their respective employers.

Patient Confidentiality

4. Under no circumstances should patient information be shared on social media. This includes any information that could potentially identify a patient, directly or indirectly.
5. Residents, fellows, faculty, and staff must comply with HIPAA regulations and institutional policies regarding patient privacy and confidentiality.
6. Do not disclose any confidential or proprietary information related to the institution, patients, or colleagues, including references to public events that may provide patient identifiers.

Institutional & Facility Representation

7. When representing the institution on social media, residents and fellows must adhere to the institution’s branding and communication guidelines.
8. Include disclaimers to indicate that personal opinions are not representative of the institution’s official position.
9. Residents, fellows, faculty, and staff should not post social media in real time during the workday, particularly in relationship to active or sensitive work issues.

Personal Use

10. Residents and fellows should be mindful of the potential impact of their online presence on their professional reputation and the reputation of the institution.
11. Personal opinions should be clearly stated as such and should not be presented in a way that implies institutional endorsement.
12. Residents and fellows should not post images of themselves in Rutgers-branded attire involving illicit substances, alcohol, or tobacco products, or engaging in disorderly, disrespectful, or offensive actions inconsistent with the institution’s values.

Conduct and Behavior

13. Demonstrate sound judgment and accountability for your online actions.
14. Maintain respect and courtesy in all online interactions, particularly on institutional social media platforms.

Monitoring and Enforcement

15. The sponsoring institution reserves the right to monitor social media activity related to its programs and to take appropriate action as necessary. Disciplinary actions (i.e. termination, probation, etc.) must follow due process as per Rutgers Health policies.

Conclusion: This policy is designed to support the responsible use of social media by GME participants, ensuring that their online activities reflect the high standards of the medical profession and the institution. Adherence to this policy will help protect patient confidentiality, maintain professional integrity, and promote a positive institutional image.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

5.1 Vacation and Leaves of Absence

Reason for Policy

To establish compliance that meets Rutgers, state, federal, and accreditation regulations.

Applicable ACGME Institutional Requirements

IV.H.

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Committee of Interns and Residents (CIR) Collective Bargaining Agreement
• Rutgers University Policies
• New Jersey Board of Medical Examiners
• American Board of Medical Specialties

Scope

The scope of this policy applies to all residents and fellows participating in accredited Rutgers Health post-graduate training programs (i.e., residencies or fellowships), accredited by the Accreditation Council for Graduate Medical Education (ACGME), who hold a Resident or Fellow appointment. Residents and Fellows are hereafter referred to as “Residents”. The Rutgers Health policy described here applies to all residents of Rutgers Health. Further details related to this policy, as applicable to the existing legacy residents bound by and limited by the policies and procedures originating from the programs in which they were originally contracted, may be found, and defined by the following Rutgers Health training program policies associated with:

• New Jersey Medical School Graduate Medical Education & CIR MOU
• Robert Wood Johnson Medical School Graduate Medical Education & CIR MOU
• Community Medical Center Graduate Medical Education
• Cooperman Barnabas Medical Center Graduate Medical Education
• Jersey City Medical Center Graduate Medical Education & CIR MOU
• Newark Beth Israel Graduate Medical Education
• Monmouth Medical Center Graduate Medical Education
• Robert Wood Johnson University Hospital – Somerset
• Trinitas Regional Medical Center Graduate Medical Education

The Policy

1. With regard to each of its ACGME-accredited programs, the Sponsoring Institution, monitored by the DIO (or designee), will require that the applicable employer provide its residents/fellows with accurate information regarding vacation as well as the impact of an extended leave of absence upon the criteria for satisfactory completion of the program and upon a resident’s/fellow’s eligibility to participate in examinations by the relevant certifying board(s). The policy is as follows:
   1. provide residents/fellows with a minimum of six weeks of approved medical, parental and caregiver leave(s) of absence for qualifying reasons that are consistent with applicable laws at least once and at any time during an ACGME-accredited program, starting the day the resident/fellow is required to report
   2. provide residents/fellows with at least the equivalent of 100 percent of their salary for the first six weeks of the first approved medical, parental, or caregiver leave(s) of absence taken
   3. provide residents/fellows with a minimum of one week paid time off reserved for use outside of the first six weeks of the first approved medical, parental or caregiver leave(s) of absence taken
   4. ensure the continuation of health and disability insurance benefits for medical, parental, or caregiver leave(s) of absence;
   5. describe the process for submitting and approving the requests for leave(s) of absence;
   6. be available for review by residents/fellows at all times

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

5.2 Professional Liability Insurance

Reason for Policy

To establish compliance that meets Rutgers, state, federal, and accreditation regulations.

Applicable ACGME Institutional Requirements

IV.F.

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Committee of Interns and Residents (CIR) Collective Bargaining Agreement
• Rutgers University Policies
• New Jersey Board of Medical Examiners
• American Board of Medical Specialties

Scope

The scope of this policy applies to all residents and fellows participating in accredited Rutgers Health post-graduate training programs (i.e., residencies or fellowships), accredited by the Accreditation Council for Graduate Medical Education (ACGME), who hold a Resident or Fellow appointment. Residents and Fellows are hereafter referred to as “Residents”. The Rutgers Health policy described here applies to all residents of Rutgers Health. Further details related to this policy, as applicable to the existing legacy residents bound by and limited by the policies and procedures originating from the programs in which they were originally contracted, may be found and defined by the following Rutgers Health training program policies associated with:

• New Jersey Medical School Graduate Medical Education & CIR MOU
• Robert Wood Johnson Medical School Graduate Medical Education & CIR MOU
• Community Medical Center Graduate Medical Education
• Cooperman Barnabas Medical Center Graduate Medical Education
• Jersey City Medical Center Graduate Medical Education & CIR MOU
• Newark Beth Israel Graduate Medical Education
• Monmouth Medical Center Graduate Medical Education
• Robert Wood Johnson University Hospital – Somerset
• Trinitas Regional Medical Center Graduate Medical Education

The Policy

1. The Sponsoring Institution will require that the applicable employer provide professional liability coverage to residents/fellows, including legal defense and protection against awards from claims reported or filed during participation in each of its ACGME-accredited programs, or after completion of the program if the alleged acts or omissions of a resident/fellow are within the scope of the program.
2. The Sponsoring Institution will require that the applicable employer provide to the resident/fellow and the local site GME Office:
   1. official documentation of the details of their professional liability coverage before the start date of the resident/fellow appointments; and,
   2. written advance notice of any substantial change to the details of their professional liability coverage

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

This page reflects the most current version of this policy. A downloadable copy is available in our Box folder.

University Policy

5.3 Health and Disability Insurance

Reason for Policy

To establish compliance that meets Rutgers, state, federal, and accreditation regulations.

Applicable ACGME Institutional Requirements

IV.G.

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Committee of Interns and Residents (CIR) Collective Bargaining Agreement
• Rutgers University Policies
• New Jersey Board of Medical Examiners
• American Board of Medical Specialties

Scope

The scope of this policy applies to all residents and fellows participating in accredited Rutgers Health post-graduate training programs (i.e., residencies or fellowships), accredited by the Accreditation Council for Graduate Medical Education (ACGME), who hold a Resident or Fellow appointment. Residents and Fellows are hereafter referred to as “Residents”. The Rutgers Health policy described here applies to all residents of Rutgers Health. Further details related to this policy, as applicable to the existing legacy residents bound by and limited by the policies and procedures originating from the programs in which they were originally contracted, may be found and defined by the following Rutgers Health training program policies associated with:

• New Jersey Medical School Graduate Medical Education & CIR MOU
• Robert Wood Johnson Medical School Graduate Medical Education & CIR MOU
• Community Medical Center Graduate Medical Education
• Cooperman Barnabas Medical Center Graduate Medical Education
• Jersey City Medical Center Graduate Medical Education & CIR MOU
• Newark Beth Israel Graduate Medical Education
• Monmouth Medical Center Graduate Medical Education
• Robert Wood Johnson University Hospital – Somerset
• Trinitas Regional Medical Center Graduate Medical Education

The Policy

1. Health Insurance
   1. The Sponsoring Institution, monitored through the DIO (or designee) will require that the applicable employer ensure the provision of health insurance benefits for residents/fellows and their eligible dependents beginning on the first day of insurance eligibility. If the first day of health insurance eligibility is not the first day that residents/fellows are required to report, then the residents/fellows will be given advanced access to information regarding interim coverage so that they can purchase coverage if desired.
2. Disability Insurance
   1. The Sponsoring Institution, monitored through the DIO (or designee) will require that the applicable employer ensure the provision of disability insurance benefits for residents/fellows beginning on the first day of disability insurance eligibility. If the first day of disability insurance eligibility is not the first day that residents/fellows are required to report, then the residents/fellows will be given advanced access to information regarding interim coverage so that they can purchase coverage if desired.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

6.0 Resident Services

Reason for Policy

To establish compliance that meets Rutgers, state, federal, and accreditation regulations.

Applicable ACGME Institutional Requirements

IV.I.1., IV.I.2., IV.I.3., IV.I.4., IV.I.5.

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Committee of Interns and Residents (CIR) Collective Bargaining Agreement
• Rutgers University Policies
• New Jersey Board of Medical Examiners
• American Board of Medical Specialties

Scope

The scope of this policy applies to all residents and fellows participating in accredited Rutgers Health post-graduate training programs (i.e., residencies or fellowships), accredited by the Accreditation Council for Graduate Medical Education (ACGME), who hold a Resident or Fellow appointment. Residents and Fellows are hereafter referred to as “Residents”. The Rutgers Health policy described here applies to all residents of Rutgers Health. Further details related to this policy, as applicable to the existing legacy residents bound by and limited by the policies and procedures originating from the programs in which they were originally contracted, may be found, and defined by the following Rutgers Health training program policies associated with:

• New Jersey Medical School Graduate Medical Education & CIR MOU
• Robert Wood Johnson Medical School Graduate Medical Education & CIR MOU
• Community Medical Center Graduate Medical Education
• Cooperman Barnabas Medical Center Graduate Medical Education
• Jersey City Medical Center Graduate Medical Education & CIR MOU
• Newark Beth Israel Graduate Medical Education
• Monmouth Medical Center Graduate Medical Education
• Robert Wood Johnson University Hospital – Somerset
• Trinitas Regional Medical Center Graduate Medical Education

The Policy

1. Behavioral Health: The Sponsoring Institution will ensure that the applicable employer provides residents/fellows with access to confidential counseling and behavioral health services, including access to confidential, affordable mental health assessment counseling, and treatment, including access to urgent and emergent care 24 hours a day, seven days a week and access to appropriate tools for self-screening.
2. Physician Impairment: The Sponsoring Institution will ensure that the applicable employer will have a policy, not necessarily GME-specific, which addresses physician impairment.
3. Harassment: The Sponsoring Institution will ensure that the applicable employer will have a policy, not necessarily GME-specific, covering unlawful discrimination, prohibited retaliation, sexual and other forms of unlawful harassment, which allows residents/fellows access to processes to raise and resolve complaints in a safe and non-punitive environment and in a timely manner, consistent with applicable laws and regulations.
4. Prohibited Discrimination: The Sponsoring Institution will ensure that the applicable employer will have a policy and procedure, not necessarily GME specific, prohibiting discrimination in employment and in the learning and working environment, consistent with all applicable laws and regulations.
5. Accommodation for Disabilities: The Sponsoring Institution will ensure that the applicable employer have a policy, not necessarily GME-specific, regarding accommodations for disabilities, consistent with all applicable laws and regulations.
6. Oversight
   • GMEC or the applicable subcommittee will periodically review all available services.
   • The applicable employer will submit the policy to GMEC for review and thereafter whenever substantial modifications are made to said policy.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

6.2 Wellbeing

Reason for Policy

Rutgers Health recognizes that physician wellbeing is fundamental to professionalism, patient safety, high quality clinical care, and excellence in graduate medical education. This policy establishes institutional expectations for fostering healthy learning environments, supporting resident and fellow wellbeing, and ensuring access to appropriate resources while promoting a culture of professionalism and shared responsibility.

Applicable ACGME Institutional Requirements

3.2 The Learning and Working Environment

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Rutgers University Policies
• Physician Wellbeing Academic Consortium (PWAC) resources and validated wellbeing assessment tools
• Rutgers Health and RWJBarnabas Health Employee Assistance Programs (EAP) and institutional wellbeing resources

Scope

This policy applies to all Rutgers Health-sponsored residency and fellowship programs, residents, fellows, faculty members, program leadership, and participating clinical learning environments.

Definitions

Wellbeing is the ability of physicians to thrive personally and professionally while providing safe, compassionate, high quality patient care. Fatigue is a state of physical or mental exhaustion that may impair judgment, performance, learning, or patient safety.

The Policy

Rutgers Health is committed to creating clinical learning environments that promote physician wellbeing as a shared responsibility of the Sponsoring Institution, participating sites, program leadership, faculty members, residents, and fellows. Wellbeing extends beyond individual resilience and includes organizational practices, workplace culture, and systems that enable physicians to provide exceptional patient care while maintaining their own health and professional fulfillment.

Learning Environment and Culture

Rutgers Health expects each clinical learning environment to foster professionalism, civility, mutual respect, inclusion, teamwork, and psychological safety. Residents and fellows should feel comfortable raising concerns regarding wellbeing, patient safety, fatigue, mistreatment, or the learning environment without fear of retaliation. Faculty members and program leaders are expected to model behaviors that promote wellbeing, collegiality, professionalism, and respectful communication.

Sponsoring Institution Expectations

Rutgers Health, in partnership with its ACGME-accredited programs, shall:

1. Provide education for residents, fellows, and faculty members regarding physician wellbeing, including the recognition of fatigue, burnout, depression, substance use disorders, suicidal ideation, and other conditions that may affect wellbeing. Education shall include recognition of these conditions in oneself and colleagues, available institutional resources, and appropriate pathways for seeking confidential assistance.
2. Encourage residents, fellows, and faculty members to report concerns regarding colleagues who may be demonstrating signs of burnout, depression, substance use disorder, suicidal ideation, or other conditions that may place themselves, patients, or others at risk, consistent with applicable institutional policies.
3. Maintain confidential access to mental health assessment, counseling, treatment, self-screening resources, and urgent behavioral health services.
4. Support residents, fellows, faculty, and care teams following adverse patient events and other potentially traumatic workplace experiences.
5. Ensure that participating clinical learning environments provide access to food, rest facilities, and other basic resources consistent with applicable ACGME Institutional Requirements.
6. Periodically evaluate institutional wellbeing initiatives through the GMEC Wellbeing Subcommittee and other institutional oversight processes.

Program Expectations

1. Promote and maintain a respectful and psychologically safe learning environment.
2. Program leadership shall model behaviors that promote wellbeing and foster a culture that is respectful, supportive, and free from stigma.
3. Engage residents, fellows, and faculty in developing local wellbeing initiatives.
4. Identify and address systems, workflows, and administrative processes that unnecessarily contribute to burnout.
5. Promote meaningful patient care experiences by minimizing unnecessary non-physician administrative responsibilities whenever feasible and supporting appropriate progressive autonomy.
6. Monitor workload, work intensity, scheduling practices, and workplace safety as components of resident wellbeing.
7. Provide residents and fellows the opportunity to attend medical, mental health, and dental appointments, including those occurring during working hours when appropriate.
8. Maintain policies ensuring appropriate patient care coverage when a resident or fellow cannot safely work because of illness, fatigue, or family emergency without punitive consequences.
9. Programs shall periodically evaluate the effectiveness of local wellbeing initiatives and identify opportunities for improvement in collaboration with residents, fellows, faculty, and the Sponsoring Institution.

Resident and Fellow Responsibilities

1. Practice self-care and recognize the effects of fatigue, burnout, illness, or impairment.
2. Promptly seek assistance when personal wellbeing or patient safety may be compromised.
3. Participate in required wellbeing education.
4. Support colleagues by encouraging timely use of available institutional resources.

Fatigue Mitigation

1. Rutgers Health recognizes that fatigue is both a patient safety and physician wellbeing issue. Residents and fellows are expected to recognize the signs and symptoms of fatigue in themselves and others and utilize appropriate fatigue mitigation strategies when necessary.
2. Residents and fellows who believe fatigue or illness may impair their ability to safely provide patient care shall promptly notify the supervising physician, chief resident, or other designated supervisor so that appropriate patient care coverage can be arranged without fear of punitive consequences. Residents and fellows are encouraged to recognize fatigue early and utilize fatigue mitigation strategies before fatigue compromises patient care or personal safety.
3. Recognized fatigue mitigation strategies may include:
   1. strategic napping when clinically appropriate;
   2. transfer of patient care responsibilities using safe transitions of care;
   3. use of designated sleep or rest facilities;
   4. adjustment of clinical responsibilities when necessary to protect patient and resident safety.
4. Residents and fellows utilizing recognized fatigue mitigation strategies in accordance with this policy shall not be penalized, provided appropriate patient care coverage and safe transitions of care are maintained.

Safe Transportation

1. Rutgers Health is committed to facilitating safe transportation options for residents and fellows who may be too fatigued to safely return home following clinical duties.
2. Residents and fellows who believe they are too fatigued to safely operate a motor vehicle should not drive. They should notify the supervising physician, chief resident, or other designated supervisor and utilize available fatigue mitigation resources.
3. Each participating site shall provide safe, clean, quiet, and readily accessible sleep/rest facilities in proximity appropriate for safe patient care that are available for use by residents and fellows who require additional rest before returning home. Programs shall ensure that trainees are aware of these resources and how to access them.
4. Additional transportation resources may be made available by participating sites consistent with local policies and available resources.

Oversight

1. The Rutgers Health GMEC exercises oversight of institutional wellbeing initiatives via the GMEC Wellbeing Subcommittee. The Subcommittee advises GMEC by evaluating the effectiveness of the Sponsoring Institution’s efforts to promote resident, fellow, and faculty wellbeing; identifying opportunities for improvement; and making recommendations to the GMEC regarding institutional priorities, resources, and initiatives.
2. The GMEC Wellbeing Subcommittee shall monitor institutional and program compliance with this policy and applicable ACGME wellbeing requirements through periodic review of institutional metrics, program evaluations, accreditation findings, resident survey data, and other available information, and shall recommend corrective actions when opportunities for improvement are identified.
3. To inform continuous improvement, the Sponsoring Institution will periodically review multiple sources of information, which may include ACGME Resident/Fellow Survey Results, Physician Well-Being Academic Consortium (PWAC) wellbeing survey results, institutional quality and safety data, resident and faculty feedback, program evaluations, and other validated assessment tools. Rutgers Health participates in the Physician Well-Being Academic Consortium (PWAC) and may utilize PWAC wellbeing surveys and benchmarking data to assess organizational wellbeing and guide institutional improvement efforts.
4. The GMEC shall receive regular reports from the Wellbeing Subcommittee and oversee implementation of institutional initiatives designed to promote physician wellbeing and continuously improve the clinical learning environment.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

6.3 Harassment and Discrimination

Reason for Policy

Rutgers Health Graduate Medical Education (GME) is committed to maintaining a clinical and educational environment that is respectful, inclusive, and free from discrimination, harassment, and retaliation. This policy establishes expectations, definitions, and reporting mechanisms consistent with applicable laws, institutional expectations, and ACGME Institutional Requirements.

Applicable ACGME Institutional Requirements

3.2.f.4, 4.9.c Harassment, 4.9.e Discrimination

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Committee of Interns and Residents (CIR) Collective Bargaining Agreement
• Rutgers University Policy 60.1.12
• RWJBarnabas Health Compliance Code of Conduct
• New Jersey Board of Medical Examiners

Scope

This policy applies to all residents and fellows participating in Rutgers Health-sponsored programs, regardless of employer or training site.

Definitions

• Discrimination: Conduct, whether intentional or unintentional, that adversely affects an individual’s employment, training, or educational opportunities based on legally protected characteristics.
• Harassment: Conduct based on protected characteristics that is sufficiently severe, pervasive, or persistent to create an intimidating, offensive, or hostile work or learning environment, or that unreasonably interferes with an individual’s training or professional activities.
  • Harassment may occur even when an individual is not the direct target. A single incident may constitute harassment depending on the circumstances.
• Sexual Harassment: Unwelcome verbal, written, visual, or physical conduct of a sexual nature when such conduct:
  1. Affects employment or training decisions;
  2. Interferes with work or educational performance; or
  3. Creates a hostile environment.

  Sexual harassment may occur regardless of gender identity or sexual orientation.

Policy Statement

1. Rutgers Health is committed to maintaining a safe, respectful, and professional learning environment. Residents and fellows may raise concerns without fear of intimidation, retaliation, or adverse impact on their training.
2. Consistent with this commitment, Rutgers Health prohibits discrimination, harassment, and retaliation within all clinical, educational, and professional settings involving residents and fellows.
   1. Discrimination and harassment compromise professionalism, disrupt the learning environment, and may adversely affect patient care, resident/fellow well-being, and institutional integrity.
   2. This policy supplements, but does not replace, applicable Rutgers University, hospital, or employer policies. Allegations may be reviewed under multiple policies where appropriate.
3. Allegations involving conduct governed by Title IX will be referred through established processes to the appropriate institutional office.

Professional Boundaries and Conflicts of Interest

• Romantic, intimate, or sexual relationships within supervisory, evaluative, or authority-based roles may create conflicts of interest and risks of perceived coercion, favoritism, or exploitation.
• Individuals must disclose relationships that present actual or perceived conflicts and must recuse themselves from evaluative, supervisory, or decision-making roles involving the other party.
• Romantic or sexual relationships between residents/fellows and patients under their care are strictly prohibited.

Reporting Concerns

1. Residents/fellows and faculty are expected to report conduct that may violate this Policy so that concerns can be reviewed and addressed appropriately. Reports may be made through any available pathway and are not required to be directed solely through program leadership. Concerns may be reported regardless of whether the individual raising the concern is directly affected by the conduct. Residents/fellows and faculty may report concerns through multiple pathways, including:
   1. Program leadership
   2. Supervisors or faculty
   3. Human Resources
   4. Corporate Compliance
   5. Ombuds services
   6. Institutional reporting systems
2. Available reporting mechanisms include:
   1. Rutgers Health GME Anonymous Reporting Link
   2. Rutgers Health GME Site Specific Ombuds
   3. The Rutgers Helpline at 833-RU-ETHICS (833.783.8442) (Rutgers Compliance Helpline)
   4. Hospital event reporting systems
   5. Human Resources or Office of Employment Equity; RWJBH Health System Corporate Compliance Hotline: 1-800-780-1140
   6. RWJBH Health System Corporate Compliance Reporting Link
3. Any individual who believes that he or she has been the victim of a crime (including but not limited to forced physical contact and/or sexual violence) also has a right, and is encouraged, to report the incident to the appropriate law enforcement agency.

Institutional Response

1. Rutgers Health will review and address reports in a timely, fair, and appropriate manner consistent with applicable University, employer, and hospital policies, and with principles of due process. Rutgers Health may implement interim and supportive measures independent of a formal investigation when appropriate.
2. Institutional responses may include:
   1. Supportive measures
   2. Education or training
   3. Remediation or corrective action
   4. Disciplinary action where warranted
3. Reports will be evaluated promptly and addressed through appropriate institutional processes based on the nature, severity, and circumstances of the concern.
4. Rutgers Health reserves the right to initiate review or investigation when necessary to protect the learning environment, patient care, or institutional interests.

Retaliation and False Statements

1. Retaliation against any individual who raises a concern in good faith or participates in a review process is strictly prohibited and constitutes a separate violation of institutional policy.
2. Knowingly making false statements or providing false information in connection with a report or investigation may result in corrective or disciplinary action.
3. The filing of a complaint that does not result in a finding of a policy violation does not, by itself, constitute a false statement.

Confidentiality

Rutgers Health will maintain confidentiality to the extent reasonably possible, consistent with institutional obligations, fair process, and applicable law.

Oversight

The Sponsoring Institution, through the GMEC and the DIO, maintains oversight of matters affecting the clinical learning environment, including concerns related to discrimination, harassment, and professionalism.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

This page reflects the most current version of this policy. A downloadable copy is available in our
Box folder.

University Policy

8.1 Substantial Disruptions in Patient Care or Education

Reason for Policy

To establish compliance that meets Rutgers, state, federal, and accreditation regulations.

Applicable ACGME Institutional Requirements

IV.N.

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Committee of Interns and Residents (CIR) Collective Bargaining Agreement
• Rutgers University Policies
• New Jersey Board of Medical Examiners
• American Board of Medical Specialties

Scope

The scope of this policy applies to all residents and fellows participating in accredited Rutgers Health post-graduate training programs (i.e., residencies or fellowships), accredited by the Accreditation Council for Graduate Medical Education (ACGME), who hold a Resident or Fellow appointment. Residents and Fellows are hereafter referred to as “Residents”. The Rutgers Health policy described here applies to all residents of Rutgers Health. Further details related to this policy, as applicable to the existing legacy residents bound by and limited by the policies and procedures originating from the programs in which they were originally contracted, may be found, and defined by the following Rutgers Health training program policies associated with:

• New Jersey Medical School Graduate Medical Education & CIR MOU
• Robert Wood Johnson Medical School Graduate Medical Education & CIR MOU
• Community Medical Center Graduate Medical Education
• Cooperman Barnabas Medical Center Graduate Medical Education
• Jersey City Medical Center Graduate Medical Education & CIR MOU
• Newark Beth Israel Graduate Medical Education
• Monmouth Medical Center Graduate Medical Education
• Robert Wood Johnson University Hospital – Somerset
• Trinitas Regional Medical Center Graduate Medical Education

The Policy

1. If a local Rutgers Health site and a program is unable to offer appropriate educational experiences due to a declared emergency or disaster, a severe adverse action from the ACGME, or other substantial disruption in patient care or education, residents/fellows shall be transferred to a program with similar training within another Rutgers Health site. If no similar training site exists within the system, Rutgers Health will make every effort to help provide, identify, or secure an opportunity for the resident/fellow to continue their education and training at site outside of the system.
2. If more than one institution or program is available for temporary or permanent transfer of a particular resident/fellow, the preferences of the resident/fellow must be considered by Rutgers Health. Rutgers Health must expeditiously make the decision to reconstitute the program and/or arrange for temporary or permanent transfers of the residents/fellows so as to maximize the likelihood that each resident/fellow will complete the academic year with the least disruption to their education.
3. Residents/fellows will continue to receive stipends, fringe benefits and professional liability coverage during any disaster response and recovery periods.
   1. If the duration of the disaster exceeds 30 days, every attempt will be made to relocate the residents/fellows to an alternate training facility.
4. At the outset of a temporary resident/fellow transfer, programs must inform each transferred resident/fellow of the estimated duration of their temporary transfer. When a program determines that a temporary transfer will continue through the end of the academic year, it must promptly notify each transferred resident/fellow.
5. During Emergency Declarations or extraordinary circumstances, Rutgers Health will act in order to protect the safety and training of the residents/fellows, which may include variants of standard procedures.
6. Rutgers Health will disseminate official information via ENS, the Emergency Notification System through Rutgers University to keep the Rutgers Health community informed regarding emergencies and situations that may disrupt normal operations. ENS is available to all faculty, residents/fellows, students, and staff.
7. Any substantial disruptions in patient care or education (as defined in I. above) and responses thereto will be reported to and monitored by the GMEC.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.

University Policy

09-001 Closures and Reductions

Reason for Policy

To establish compliance that meets Rutgers, state, federal, and accreditation regulations.

Applicable ACGME Institutional Requirements

IV.O.

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Committee of Interns and Residents (CIR) Collective Bargaining Agreement
• Rutgers University Policies
• New Jersey Board of Medical Examiners
• American Board of Medical Specialties

Scope

The scope of this policy applies to all residents and fellows participating in accredited Rutgers Health post-graduate training programs (i.e., residencies or fellowships), accredited by the Accreditation Council for Graduate Medical Education (ACGME), who hold a Resident or Fellow appointment. Residents and Fellows are hereafter referred to as “Residents”.

The Rutgers Health policy described here applies to all residents of Rutgers Health. Further details related to this policy, as applicable to the existing legacy residents bound by and limited by the policies and procedures originating from the programs in which they were originally contracted, may be found and defined by the following Rutgers Health training program policies associated with:

• New Jersey Medical School Graduate Medical Education & CIR MOU
• Robert Wood Johnson Medical School Graduate Medical Education & CIR MOU
• Community Medical Center Graduate Medical Education
• Cooperman Barnabas Medical Center Graduate Medical Education
• Jersey City Medical Center Graduate Medical Education & CIR MOU
• Newark Beth Israel Graduate Medical Education
• Monmouth Medical Center Graduate Medical Education
• Robert Wood Johnson University Hospital – Somerset
• Trinitas Regional Medical Center Graduate Medical Education

The Policy

1. In the event that Rutgers Health decides to reduce the number of resident/fellow positions in any GME program, the GMEC, the DIO, and the residents/fellows will be notified as soon as possible of any reduction decision. Programs that wish to voluntarily reduce the size of the program or to withdraw accreditation must obtain prior approval for the reduction or closure from the DIO and GMEC before notifying the ACGME and the program’s residents/fellows.
2. Should Rutgers Health as the sponsoring institution intend to close, the DIO or designee must inform the Chief Academic Officers/Associate Deans for GME, the GMEC, programs, and residents/fellows within 30 days of the decision to close the institution.
3. In the event of a Rutgers Health GME program reduction or closure, or closure of the institution, Rutgers Health and the program will work collaboratively to ensure that residents/fellows currently enrolled in the program are able to complete their education within the program or will assist residents/fellows in enrolling into another ACGME-accredited program in which they may continue their education.
4. Rutgers Health will consider such issues as transfer of funding and board-specific requirements of residents/fellows and will make every attempt to phase out the program over a period of time to allow all trainees currently in the program to complete their training. In all cases, Rutgers Health and the program will fulfill the terms of appointment (e.g., stipend, benefits) for the duration of the current academic year, if applicable.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education department for the official, most recent version.

University Policy

Vendor Interactions Between Representatives/Corporations and Residents/Fellows

Reason for Policy

To establish compliance that meets Rutgers, state, federal, and accreditation regulations.

Applicable ACGME Institutional Requirements

IV.L.

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements
• Accreditation Council for Graduate Medical Education Common Program Requirements
• Rutgers University Policy; 60.1.31 Gratuities, Guests, Gifts, and Use of University Resources
• RWJBH Compliance Code of Conduct; Vendor Relations, p23
• Rutgers Office of General Counsel
• New Jersey State Ethics Commission

Scope

The scope of this policy applies to all residents and fellows participating in accredited Rutgers Health post-graduate training programs (i.e., residencies or fellowships), accredited by the Accreditation Council for Graduate Medical Education (ACGME), who hold a Resident or Fellow appointment. Residents and Fellows are hereafter referred to as “Residents”.

The Rutgers Health policy described here applies to all residents of Rutgers Health.

The Policy

1. It is the priority of the institution to ensure that all dealings with vendors are fair and open. Thus, all employees including housestaff must avoid any interaction with a vendor that could create a conflict of interest or even an appearance of impropriety.
2. Residents/Fellows are not directly responsible for the selection of vendors or decisions regarding the acquisitions of goods and services and should not present themselves as such.
3. Residents/Fellows are not permitted to interact with vendors in facilities associated with Rutgers Health, except for approved educational activities.
4. Vendors, whether invited by residents/fellows or faculty, must receive prior approval by the residency Program Director to conduct an educational activity with their housestaff. A faculty member must be present during educational activities presented by vendors.
5. Vendors who wish to contact residents/fellows of Rutgers Health must conform to all policies and procedures set forth by Rutgers Health and the local facility.
6. Vendors may not use any Rutgers Health or facility communication system to contact residents/fellows.
7. Promotional materials, without substantial educational content, are barred from Rutgers Health sites except in the following circumstances:
   • Items of nominal value can be accepted. However, the use of vendor-branded items at work is discouraged as it can convey a commercial bias.
   • Educational materials, product samples, and educational grants are allowed.
   • Exhibits and discussion of pharmaceuticals, devices, and services as part of a medical education program are permitted in appropriate educational locations.
8. The receipt of gifts and favors, other than educational materials and grants from vendors to Rutgers Health residents/fellows is prohibited under Rutgers Health policy.

Monitoring and Enforcement

• The sponsoring institution reserves the right to monitor vendor activities related to its programs and to take appropriate action as necessary.
• Questions regarding vendor-related gifts or activities should be brought to the sponsoring institution’s GME office or site-specific compliance office.
• Issues regarding vendor-related activities may be reported via surveys, evaluations, safety reporting systems (e.g., hotlines, apps, etc.) and other as detailed in RH Mechanisms for Confidential Reporting policy.

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education department for the official, most recent version.

University Policy

8.4 Non-Competition

Reason for Policy

To establish compliance that meets Rutgers, state, federal, and accreditation regulations.

Applicable ACGME Institutional Requirements

IV.M.

Resources

• Accreditation Council for Graduate Medical Education Institutional Requirements

Scope

The scope of this policy applies to all residents and fellows participating in accredited Rutgers Health post-graduate training programs (i.e., residencies or fellowships), accredited by the Accreditation Council for Graduate Medical Education (ACGME), who hold a Resident or Fellow appointment. The Rutgers Health policy described here applies to all residents and fellows of Rutgers Health.

The Policy

Rutgers Health specifically prohibits the creation and enforcement of any restrictive covenants as a condition of resident or fellow participation in graduate medical education programs. Neither the applicable employer nor any GME training program will require residents or fellows to sign a non-competition guarantee or restrictive covenant, as monitored by the DIO (or designee).

All policies are subject to amendment. Please refer to the Rutgers Health Graduate Medical Education
department for the official, most recent version.