ROWAN UNIVERSITY POLICY

Title:   Graduate Medical Education Housestaff Evaluation
Subject:  RowanSOM Housestaff
Policy No:   2018:01 (00-01-20-87.00)
Applies:  School of Osteopathic Medicine
Issuing Authorities:  Dean, School of Osteopathic Medicine
Responsible Officers: Associate Dean, Graduate Medical Education and Assistant Dean, Graduate Medical Education
Adopted:  7/27/95
Last Revision:  2/1/18
Last Reviewed:  2/1/18 

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I.     PURPOSE

To specify minimum standards of the University for the eligibility, selection, evaluation, promotion and dismissal of Housestaff in postgraduate programs sponsored by Rowan University.  Rowan University postgraduate program shall establish its own requirements, which may be more stringent, but shall not be less stringent, than the requirements specified herein. 

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II.   ACCOUNTABILITY

Under the direction of the Associate Dean, Rowan University School of Osteopathic Medicine and the Assistant Dean, Graduate Medical Education shall ensure compliance with this policy.  The appropriate Deans or their designee shall implement this policy through the Graduate Medical Education Program Director.

III.  DEFINITIONS

1. Housestaff:  Interns, residents and clinical fellows
2. House officer:  Individual intern, resident or clinical fellow
3. Postgraduate program:  Internship, residency or clinical fellowship program

REFERENCESIV.   REFERENCES

1. Background Checks for Housestaff Positions 
   https://confluence.rowan.edu/display/POLICY/Background+Check+Policy

2. Outside Employment     
   https://www.rowan.edu/compliance/conflict/documents/NJOutsideActivityQuestionnaire2012.pdf

3. Housestaff Immunizations and Health Requirements 
   https://confluence.rowan.edu/display/POLICY/Housestaff+Immunizations+and+Health+Requirements

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V.   POLICY

1. Requirements for Admission to Rowan University postgraduate programs:
   1. It is the policy of Rowan University to obtain a consumer report or investigative consumer report, as those terms are defined in the federal Fair Credit Reporting Act, on all applicants to the University's postgraduate programs.  In order to be admitted to a Rowan University postgraduate program, the applicant must receive a consumer report and/or investigative report deemed favorable by Rowan University.
2. Other requirements for admission are as follows:
   1. Graduate Medical Education Programs
      1. For admission to the first postgraduate year (PGY1 or OGME-I), the applicant must qualify for registration with the New Jersey State Board of Medical Examiners as defined in State Board of Medical Examiners Regulation 13:35-3.15(c) (EXHIBIT A)
      2. For admission to PGY2 or OGME-II and subsequent years, the applicant must qualify for a permit issued by the New Jersey State Board of Medical Examiners as defined in State Board of Medical Examiners Regulation 13:35-3.15 (EXHIBIT A).
      3. For admission to PGY3 and subsequent years, the applicant must have passed United States Medical Licensing Exam (USMLE) Step 3.  For admission to the OGME-III and subsequent years, current OGME II trainees must have passed the Comprehensive Osteopathic Medical Licensing Examination (COMLEX) Level III before the completion of four months of OGME II training.  For OGME II's and higher, outside the Rowan University system applying for OGME III or higher positions in the Rowan University system, the applicants must have passed the COMLEX Level III exam.
      4. For admission to any postgraduate year after the applicant has used up his or her five (5) years of eligibility for registration/permit in the State of New Jersey, the applicant must have a New Jersey license.
      5. International Medical Graduates (IMGs) must, in addition to the above:
         1. be U.S. citizens, U.S. permanent residents, asylees, refugees, or J-1 exchange visitors sponsored by the Educational Commission on Foreign Medical Graduates (ECFMG); an hold a currently valid ECFMG certificate.
         2. In rare instances under special circumstances, the University may sponsor an IMG for H-1B temporary worker status.   Such sponsorship must be approved by the School's Associate Dean for GME, the Dean and the Director of Human Resources following justification from the Dean.
   2. Housestaff Selection
      1. Postgraduate programs should develop selection criteria appropriate to the discipline and to the goal of producing caring and competent practitioners.
   3. Housestaff Contracts
      1. The contract for house officer in a graduate medical program shall:
         1. specify the specialty and sub-specialty, where applicable, and the level or Postgraduate Year (PGY), e.g., Internal Medicine PGY 1, 2, 3, or OGME-I, II, III, or InternalMedicine-Cardiology PGY 4, 5, or OGME-IV, V, etc., and the term of the contract;
         2. have an attachment describing assigned duties including patient care and teaching, and the program's overall work schedules;
         3. specify that the pertinent registration/permit/licensure requirements of the New Jersey State Board of Medical Examiners must have been met as a precondition of the contract;
         4. contain an attachment for medical housestaff defining scope of practice of registration or permit holders as per regulations of the New Jersey State Board of Medical Examiners;
         5. describe benefits including vacations, professional and/or sick leave, family leave, liability insurance, health insurance and other insurance for housestaff and their families, and meals and laundry or their equivalent, consistent with hospital or University policies or the collective bargaining agreement between the Committee of Interns and Residents (CIR) and the University, where applicable
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   1. 1. 2. in accordance with any applicable accreditation or regulations or requirements, specify whether or not extramural employment (moonlighting) is permissible; and, where moonlighting is permissible, specify that malpractice coverage is not provided by the University for moonlighting and additionally specify that the house officer must (a) have approval of the Program Director and (b) must give assurance that this activity will not interfere with responsibilities to the postgraduate program (see University policy, Outside Employment https://www.rowan.edu/compliance/conflict/documents/NJOutsideActivityQuestionnaire2012.pdf
         3. have as attachments copies of Sections V.E (Academic Evaluation of Housestaff) and V.F (Promotion) of this policy;
         4. specify that compliance with the University's Housestaff Immunizations and Health
   1. 1. 1. Requirements policy is required as a condition of the contract; and
         2. state that "the house officer agrees that this agreement is contingent upon receipt by Rowan University of a consumer report or investigative report, as those terms are defined in the federal Fair Credit Reporting Act, deemed favorable by Rowan University."  
         3. state that the house officer agrees to immediately notify the School in the event of any future convictions, guilty pleas or no contest pleas to any crime, misdemeanor or otheroffense; and in the event of any future arrests, charges or investigations by any law enforcement authorities or professional licensing authority".
   2. Academic Evaluation of Housestaff
      1. Evaluation System
         The postgraduate program must have in place a system of evaluation used to assess the academic performance of housestaff on a continuing basis; this system must be followed uniformly for all housestaff in the program.  There shall be timely feedback to housestaff, particularly with regard to any deficiencies noted.  Evaluations shall be documented in each house officer's academic record.
      2. Requirement of Satisfactory Progress
         In order to continue in a postgraduate program a house officer must make satisfactory academic progress as determined in accordance with the postgraduate program's evaluation system.
      3. Scope of Academic Evaluations
         All academic matters, including the ACGME and AOA competencies and scholarly activities, as appropriate, shall be considered in determining whether a house officer is making satisfactory academic progress.  ACGME and AOA competencies include patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, systems-based practice, osteopathic philosophy and osteopathic manipulative medicine.
      4. The University's Model Statement on Academic Evaluation of Housestaff and Procedures for Academic Dismissals of Housestaff (EXHIBIT C) should be used as a guide in the academic evaluation of housestaff
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   3. Promotion

1. 1. Criteria for promotion in the postgraduate program shall be specified, updated, documented and communicated to housestaff at the beginning of each academic year.
   2. In general, a housestaff's postgraduate level is determined by the Program Director, the Department Chair and the Dean on the basis of previous training and experience.
   3. In addition to fulfilling the requirement of satisfactory academic progress as specified in Section D above, housestaff must satisfy the following requirements:
      1. Graduate Medical Education Program:
         1. For promotion to PGY2 through PGY5, or OGME-II through OGMEV, the house officer must either have a New Jersey medical license or obtain and maintain a permit issued by the New Jersey State Board of Medical Examiners as defined in State Board of Medical Examiners Regulation 13:35-3.15 (EXHIBIT A); an unlicensed house officer who does not obtain or make application for such a permit shall automatically be terminated at the conclusion of PGY1 or OGME-I; an unlicensed house officer who fails to maintain such a permit shall be terminated upon the loss of the permit.
         2. For promotion to PGY3 or OGME-III, the house officer must also have passed USMLE Step 3, NBOME Part III or COMLEX Level III (which replaced NBOME Part III in February 1995); a house officer who has not passed USMLE Step 3, NBOME Part III or COMLEX Level III shall automatically be terminated at the conclusion of PGY2 or OGME-II.
         3. For promotion to any postgraduate year after a house officer has used up the five (5) year limit for registration/permit eligibility (as specified in NJSA 45:9-21d), the house officer must have a New Jersey license; a house officer whose eligibility for a permit has expired and who has not obtained a New Jersey license shall automatically be terminated at the conclusion of the last academic year of eligibility for a permit; and
         4. Postgraduate programs have the option of requiring housestaff to obtain New Jersey licensure as a condition of promotion to PGY3 or OGMEIII if eligible at that time, or to any succeeding postgraduate
year.
2. 1. 1. 1. yeaDismissal for Academic Cause
3. The school shall develop, maintain and follow a defined, written process for dismissal for academic cause.  The process must satisfy the requirements of fundamental fairness and must apply equally to all housestaff.  The process description should include details of determination of cause for dismissal, notification, and the right to be heard.  The University's Model Statement on Academic Evaluation of Housestaff and Procedures for Academic Dismissals of Housestaff should be followed as a guide in all dismissals for academic cause (EXHIBIT C).
4. Inclusion of Policy in Housestaff Manuals

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