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Title: House Staff Rules and Regulations 2017-18
Subject: Individual Schools Policies (RowanSOM)
Policy No: 2018:01
Applies: University-Wide
Issuing Authority: Director of GME
Responsible Officer: Dean
Last Revision: 04/01/2018
Last Reviewed: 04/01/2018


The RowanSOM/Jefferson Health/Our Lady of Lourdes Medical Center Sponsoring Institution members include:  Rowan University – School of Osteopathic Medicine, Jefferson Health NJ, Our Lady of Lourdes Health System

The Graduate Medical Education Internship, Residency and Fellowship programs of RowanSOM, Jefferson Health (JEFF) and Our Lady of Lourdes Health System Camden and Burlington Divisions (OLL) is the responsibility of the Sponsoring Institution. This Manual addresses the rules regulations and procedures for all training programs in the Sponsoring Institution.

The Sponsoring Institution Governing Executive Committee and the Graduate Medical Education Committee are responsible for developing all of the educational programs policies and procedures.  The Chief Medical Officer at JEFF and the Chief-Department of Medicine at OLL, have primary responsibility for all medical and medical center functions related to the Residency/Fellowship and PGY 1-  TR Internship program(s) at their respective medical centers.  These functions include: medical policies and issues, service responsibilities, service delivery orders, medical center policies, and evaluations of clinical rotations. 

RESIDENT/FELLOW AND PGY 1 – TR’s will report directly to, and be responsible to, a Chief of Service (clinical faculty member) at the Division indicated on their schedules.  The Chief of Service (or his/her designee) will be directly responsible for assignments, responsibilities, and evaluation of house staff while on that service. 

RESIDENT/FELLOWS AND PGY 1 - TRs are employees of ROWAN University.  No directives by the hospital or its employees can countermand the RESIDENT/FELLOW AND PGY 1 - TR contract, affiliation agreement, or Committee of Interns and Resident/Fellows (CIR) contract.  If administrative problems occur, they should be brought first to the Office of Graduate Medical Education.  Medical Center based problems should be addressed first with the Chief RESIDENT/FELLOW/ PGY 1 who can mediate with the Chief of Service.  If not resolved, the Divisional Medical Director should be approached.  If not resolved at that level, the Chief Medical Officer, Program Director or Director of Medical Education at the respective hospital will try to resolve the issue. 

The Associate Dean for Graduate Medical Education, staff in the Office of Graduate Medical Education, the Chief Medical Officer, and the Program Directors will meet regularly as part of the Graduate Medical Education Committee (GMEC) to review the program and resolve general issues.  Individual issues will be handled on a case-by-case basis. 


  1. University:  The Rowan University (ROWAN) – The School of Osteopathic Medicine became a member of Rowan University as part of the Higher Education Restructuring act on July 1,  2013.
  2. ROWAN-School of Osteopathic Medicine (ROWAN-SOM):  The School of Osteopathic Medicine (SOM) is based inStratfordNJ and awards the D.O. degree.  SOM also awards combined degrees which include D.O./Ph.D., D.O./J.D. and D.O./M.P.A. These degrees are granted in cooperation with other universities in the state.
  3. Medical Center:  Jefferson Health (Jeff) [Cherry Hill, Stratford and Washington Township Divisions], Our Lady of Lourdes Medical Center - Camden and Burlington (OLL).
  4. OPTI:   Osteopathic Postdoctoral Training Institution.  The method of accreditation by which the American Osteopathic Association (AOA) “approves” PGY 1  – TR internship, residency and fellowship training programs. “ROWANSOM OPTI of New Jersey” is the official name of our OPTI, which includes the University and all member medical centers/hospitals.
    Each OPTI is a community-based training consortium comprised of at least one college of osteopathic medicine and one hospital. Other hospitals and ambulatory care facilities may also partner within an OPTI. 
    OPTIs provide an enhanced quality assurance mechanism for AOA-approved postdoctoral training programs. Partnerships and collaborations between academic medicine, hospitals and other community based healthcare facilities are an integral part of OPTI.  This collaboration helps combine the partners’ resources to minimize duplication of support services for medical education.
    An OPTI provides a seamless continuum of osteopathic medical education; it also requires continuous educational assessment.  AOA approved PGY 1  – TR internships, residencies and fellowship continue to be reviewed regularly.  This review includes a systematic self-study, and annual reporting of data on accreditation procedures established by the Council on Postdoctoral Training and Bureau of Professional Education.
    Part of the accreditation process includes encouraging clinical medical education research.  Research programs are available to osteopathic PGY 1  – TR (interns) and RESIDENT/FELLOW throughout the year of training. These research programs are developed in conjunction with guidelines and requirements of osteopathic specialty colleges for residency training programs and the council on Postdoctoral Training for PGY 1  - TR programs.
    *As we transition programs from AOA to ACGME accreditation the role of the OPTI will only pertain to those programs that only have AOA accreditation status.  As each program moves through the Single Accreditation process they will transition to and follow ACGME Common Program requirements and individual specialty specific Review Committee program requirements.
  5. Board of Directors: The governing bodies of the affiliated medical centers.
  6. Governing Executive Committee – The governing body of the Sponsoring Institution made up of one senior representative from each of the 3 partners (RowanSOM/Jeff/OLOL)  in the Sponsoring Institutions consortium.
  7. Chief Executive Officer (CEO): The President of the medical center; the individual appointed by the respective Hospital Board to act on its behalf in the overall administrative management of the medical center.
  8. Dean:  The individual appointed by the President and Board of Trustees of the Rowan University as Chief Executive Officer of ROWAN-SOM.
  9. Associate Dean for Graduate Medical Education: The individual appointed by the Dean of ROWAN-SOM, responsible for the clinical graduate medical educational programs.
  10. Director of Medical Education:  Appointed by the Medical Center in agreement with the University who is responsible for all medical education programs within the affiliated hospital.
  11. Director of Graduate Medical Education: The individual in the Office of Graduate Medical Education responsible for the daily functions of the Graduate Medical Education office.
  12. Manager of Postdoctoral Training: The individual in the Office of Graduate Medical Education responsible for the planning and daily functions of the PGY 1 internship program.
  13. Program Development Specialist:  The individual in the Office of Graduate Medical Education who assists with the administration of post-graduate education program activities and with the development of plans to improve programs. 
  14. Chief Medical Officer: The individual appointed by the President of the Medical Center to oversee all medical programs at the medical center.  The Chief Medical Officer is also referred to as the Director of Medical Education (DME).
  15. Chief of Service (Department Chief): The individual faculty member appointed by ROWAN-SOM and the medical center who is responsible at the Division for the academic and patient care standards of his/her department.
  16. Attending Physician: The physician assigned by the Chief of Service to implement/conduct the formal teaching program for the section/department for a specific time period.
  17. Chairperson:  The individual appointed by ROWAN-SOM responsible for the academic program of the Department.
  18. Program Director: The individual appointed by ROWAN-SOM to implement and administer resident and fellowship training programs.  This individual may or may not be the same individual as the Track Coordinator.
  19. Track Coordinator: The individual appointed by ROWAN-SOM to implement aspects of the PGY 1  – 1 internship program.  The Track Coordinator performs reviews and evaluations of his or her PGY 1  – TR as well as assures accreditation standards.
  20. Committee of Interns and Resident (CIR): The House staff organization, representing PGY 1  – TR’s and RESIDENT/FELLOWs at ROWAN, responsible for negotiating and implementing house staff contractual services.
  21. PGY 1 : Osteopathic Graduate Medical Education.  PGY 1’s are also referred to as “Interns”.


The purposes of the PGY 1 – TR and Residency/Fellowship Programs are as follows:

  1. To further the graduate medical education of the PGY 1 – TR and RESIDENT/FELLOW in preparation to be eligible for licensure in the State of New Jersey and to enter advanced residency training programs in primary care or specialty training.
    1. To advance competency in the management of medical diseases.
    2. To advance skills in the performance of clinical procedures.
    3. To increase the medical knowledge base.
    4. To learn responsibilities of medical staff citizenship.
    5. To appreciate quality assurance as a means of insuring optimal patient care.
    6. To be exposed to regulatory controls in the health care system.
  2. To provide house staff care to patients in the medical center under the direction of members of the Medical Staff, and in so doing, provide benefits for the patient as well as giving the PGY 1 – TR and RESIDENT/FELLOW medical educational experience.
  3. To teach peers and students assigned to educational programs of the medical center, and in so doing, gain personal education and clinical, professional expertise.
  4. To conduct research under the direction of RESIDENT/FELLOW, medical staff members, and college faculty in order to gain additional medical education experiences.
  5. To experience the responsibility of practice in a medical center and an office and, in so doing, prepare for the medical records, reporting, committee responsibilities, etc., of the health care delivery system.
  6. To assume some administrative responsibilities within the PGY 1 – TR AND RESIDENT/FELLOW training program or the medical staff organizational structure, and in so doing, prepare for responsibilities as a contributing member of a medical staff organization.

  1. Application
    Application for the PGY 1 – TR Internship and Residency/Fellowship Programs must be submitted by the candidate to the Office of Graduate Medical Education of ROWAN-SOM using the Electronic Residency Application Service (ERAS).  The initiation of the application process shall be instituted by the applicant sending their application materials through ERAS.
    1. Deadline for Application
      Applications must be submitted through ERAS by September 15th of the academic year preceding the start of the next academic year.  (Date Subject to Change)
    2. Application Content
      Every applicant for a PGY 1 internship and residency programs must furnish complete information concerning the following:
      1. Complete the ERAS Common Application Form
      2. Undergraduate and graduate medical training, including the name of each institution, degrees granted and anticipated, program completed, and dates attended
      3. Minimum of three (3) Letters of Recommendation
      4. Official transcript reflecting all courses through Year 3 of Osteopathic Medical School
      5. Copy of Part I, Part II CE and PE of the COMLEX National Board scores and Part 1 and 2 of the USMLE National Boards (if applicable)
      6. Dean’s letter
      7. Other information requested in the application
  2. Effect of Application
    By sending an application through ERAS, the applicant:
    1. Attests to the correctness and completeness of all information furnished.
    2. Signifies his/her willingness to appear for an interview in connection with the application.                           
    3. Agrees to abide by the terms of the PGY 1 – TR and Residency/Fellowship Contract, the PGY 1 – TR and Residency/Fellowship Training Program Rules and Regulations of the ACGME / American OsteopathicAssociation, the Rules and Regulations PGY 1 – TR and Residency/Fellowship Training Program, the medical center Bylaws, Rules and Regulations, Policies and Procedures of the medical staff as they pertain to PGY 1 – TR’s and RESIDENT/FELLOWS and agrees to abide by the terms thereof.
    4. Authorizes and consents to University representatives consulting with those institutions and persons who have information regarding competence and consents to the inspection of all records and documents that may be material to evaluation of said qualifications.   
    5. Releases from any liability all those who, in good faith and without malice, review, act on, or provide information regarding the applicant's competency, ethics, character, health status, and other qualifications for PGY 1 – TR and Resident/Fellow appointment.
  3. Processing the Application
    Applicant's Burden
    1. The applicant is required to produce adequate and correct information for a proper evaluation of his/her training, ability (knowledge and skills), ethical, and attitudinal conduct about the qualification for selection and appointment to the PGY 1 – TR and Residency/Fellowship Training Programs, and of satisfying any reasonable request for information or clarification made by appropriate request.
    2. The applicant further understands that should an appointment be granted, the burden of providing a verifiable diploma from the osteopathic school of graduation prior to beginning the training program is the responsibility of the PGY 1 – TR / RESIDENT/FELLOW.
    3. The responsibility of attending all required orientation programs prior to the PGY 1 – TR / Residency/Fellowship shall be his/hers.
    4. The PGY 1 – TR / RESIDENT/FELLOW must submit to and satisfactorily pass a physical examination conducted by an agent of the medical center and submit to all State Regulations regarding health standards including PPD, MMR, tetanus, polio virus, varicella, hepatitis B and influenza vaccinations.
    5. The PGY 1 – TR / RESIDENT/FELLOW applicant agrees to and must show verifications that he/she has certification in ACLS and PALS prior to starting the PGY 1  program.  Failure to do so will lead to nullification of the contract.
    6. An PGY 1 – TR / RESIDENT/FELLOW employment is contingent upon the satisfactory completion of a background check. The background check will consist of verifying present and past employment, criminal history, social security verification and employment references. Additionally, educational and professional credentials and motor vehicle records will be checked as position requirements demand. All background checks will be conducted in accordance with the Fair Credit Reporting Act (FCRA) and require a signed release by the applicant after an offer of employment has been made. The signed release is a condition of University employment and shall not be waived for any reason. If a background check disqualifies an applicant for any reason, the applicant will be notified and given a reasonable opportunity to correct any inaccuracies contained in the background report.
    Verification of Information
    1. The applicant is responsible for having signed letters of reference, a completed application, Board scores, Dean’s letter, and transcripts sent through ERAS by the application deadline.  The completed application is submitted to the ROWAN-SOM Office of Graduate Medical Education.  The Office of GME collects these references and documents sent in support of the application. 
    2. The PGY 1 – TR / RESIDENT/FELLOW designates to which program(s) the completed application should be sent.
    3. When possible, the Office of GME will notify the applicant of any problems in receiving the information required. Upon notification, it is the applicant's obligation to obtain the required information. 
    4. When collection and verification is completed, the Office of GME forwards a copy of the application to the Chairperson of the program Selection Committee to determine individuals eligible for an interview.
    5. The application file is confidential and may not be reviewed by unauthorized personnel of the University or the applicant.  Information submitted in support of an application for PGY 1 – TR or Residency/Fellowship remains the property of the Office of GME and cannot be forwarded/released to other parties, nor the applican
    PGY 1  – TR / RESIDENT/FELLOW Selection Committee Action
    1. The PGY 1 – TR and Residency/fellowship Selection Committees are responsible for the following actions:
      1. Review the application file and credentials.
      2. Schedule and conduct an interview with appropriate applicants.
      3. Conduct a selection process from among the candidates, indicating selections for admission to the PGY 1 Training Program, and rank alternate candidates.  Make such recommendations to the Associate Dean for Graduate Medical Education.
    Associate Dean for Graduate Medical Education
    1. Review recommendations of the PGY 1 Selection Committee and make final selections.
    2. The Office of Graduate Medical Education shall participate in the AOA Match Registration Program.
    3. The Associate Dean for Graduate Medical Education will monitor the AOA and ACGME Match processes.
    4. ROWAN-SOM contracts will be issued within 10 days after the AOA and ACGME matching processes have concluded. PGY 1 – TR / RESIDENT/FELLOW must sign and return the contract within 30 days after receiving it. 
    5. The Associate Dean for Graduate Medical Education will keep administrators apprised of the final results of the AOA and ACGME Match(s).


  1. General Qualifications

    Every PGY 1  – TR / RESIDENT/FELLOW who seeks or enjoys membership in the  Training Program, at the time of appointment and continuously thereafter, must demonstrate, to the satisfaction of the faculty, administration, and the Governing Executive Body of ROWANSOM/Jeff/OLOL Sponsoring Institution, the Medical Staff of the medical center, its administrative officials and Board of Directors, the following qualifications:

  2. Official Transcripts

    Official, verifiable transcripts showing date of completion of D.O./M.D. degree requirements from an AOA/LCME accredited medical school.

    1. ACLS and PALS verification.

    2. COMLEX or corresponding USMLE results showing date and passing score on Part I and Part II (COMLEX CE and PE) prior to matriculation from medical school.

  3. Performance

    Continuing performance that documents medical competence and clinical skills to provide, under supervision, optimal achievable patient care.

  4. Attitude

    A willingness and capacity, based upon current attitude and evidence of performance:

    1. to work, relate to, and cooperate with other PGY 1 – TR, RESIDENT/FELLOWs, students, medical staff members, members of other health disciplines, medical center management, and employees, visitors and the community, in a professional manner that is essential for maintaining a medical center environment appropriate to quality patient care; and

    2. to adhere to generally recognized standards of professional ethics, including proper dress, demeanor, and conduct at all times.

  5. Restrictions

    To be free of or have under adequate control any significant physical or behavioral impairment that might restrict or present a substantial probability of interfering with the qualifications required herein, such that patient care could directly or likely be adversely affected.

  6. Obligations

    Each PGY 1 TR / RESIDENT/FELLOW shall:

    1. Provide patients with care at the recognized professional level of quality and efficiency recognized as standard at the medical center.

    2. Abide by these Rules and Regulations and by all other lawful standards, policies and rules as they now exist or as they may be amended.

    3. Discharge such functions for which he/she is responsible.

    4. Prepare and complete, in timely fashion, all required medical records for all assigned patients and all service logs and evaluations.

    5. Log duty hours using the system identified by this training program.

    6. Prepare and complete all forms required by this training program.

    7. Abide by the AOA/ACGME Code of Ethics.Satisfy the educational requirements of the program. 

    8. Sit for COMLEX or USMLE Part III during the PGY 1 training year.

    9. Follow the directions of the attending physician, Program Directors, Track  Coordinators, Chairpersons, Directors of Medical Education, Chiefs of  Service Office of Graduate Medical Education and all  administrative persons responsible for the conduct of this program.


  1. Provide responsible patient care under the authority of members of the medical staff to patients assigned to their service. The number of patients assigned to the PGY 1 shall not exceed AOA/ACGME program requirements during a given week.

    1. Be immediately available to provide emergency care during the hours on duty and night/weekend call unless otherwise specified by the Chief of Service.      

    2. Provide care for only those patients within the State of New Jersey for whom the PGY 1 TR/ RESIDENT/FELLOW is directly responsible as directed by the attending physician. The PGY 1 – TR/ RESIDENT/FELLOW  may not provide care out-of-state without proper permission from ROWAN-SOM, licensure in that state, and training requirements of that state where service is being completed.             

    3. Examine all patients admitted to the service as soon after admission as possible, to determine immediate needs of the patient, and to assess the patient's condition.             

    4. Perform a complete history and physical examination, which includes an  osteopathic structural exam, and record such on the chart of all patients assigned to  the service.

      1. Surgical patients prior to surgery.

      2. Critical patients as soon as possible.

      3. All others within 24 hours of admission.

    5. Write a problem oriented progress note on the patient's chart on admission; daily thereafter, and more often as conditions demand.

    6. Complete an osteopathic musculoskeletal examination on admission.

    7. Write and review admission and daily orders on assigned patients only after review of such orders with the patient's staff physician.

    8. Complete all other medical chart responsibilities on patients seen within 24 hours.

    9. Complete all charting responsibilities by 3 p.m. on the date of discharge.

    10. Conduct rounds on all assigned patients at the beginning of and conclusion of duty.

    11. Properly report to peers or supervisors at the time of leaving duty and returning to duty to ensure continuity of care or at any time that a patient's deteriorating condition may  warrant.             

    12. Date and time all materials recorded on the patient's chart.

    13. Beeper/Phone numbers are to be under the RESIDENT/FELLOW/PGY 1  TR's name.

    14. Complete all medical record responsibilities prior to proceeding to the next rotation.

    15. Complete all logs and evaluations prior to proceeding to the next rotation.

  2. Conduct oneself in a professional manner at all times.

    1. Abide by the Bylaws, Rules and Regulations, Policies and Procedures of the PGY 1  – TR and RESIDENT/FELLOW Training Program, Sponsoring Institution, the Department, the medical center, the medical staff, the New Jersey Department of Health, State Board of Medical Examiners, and the Code of Ethics of the American Osteopathic Association as they currently exist and as they from time to time may be amended.

    2. Accept patient care responsibilities and additional call (not to exceed the ACGME regulations/CIR contract limit) as assigned by the Chief of Service, Associate Dean for Graduate Medical Education, Director of Graduate Medical Education, Manager of Postdoctoral Training, other staff in the Office of Graduate Medical Education, or Chief Scheduling RESIDENT/FELLOW.

    3. Dress Code: RESIDENT/FELLOWS/PGY 1  TR’s are expected to maintain high professional standards of dress and behavior. Appropriate male attire includes shirt with tie, trousers (not blue jeans), and a white lab coat with name tag and identification badge. Appropriate female attire includes dresses, skirts or slacks with tops, and a white lab coat with name tag and identification badge. No sandals or open toed shoes are allowed. Scrub suits are the property of the medical center and are to be worn only when required in the medical center. Scrub suits are not to be worn outside the medical center unless RESIDENT/FELLOW/PGY 1  TR's are specifically instructed to do so by the hospital.

  3. Provide clinical teaching and direct supervision to all students assigned to the Service.

    1. Review, correct and approve all materials entered by the student on the appropriate history and physical form and progress record.

    2. Specifically review all student-performed history and physical exams, editing and  commenting on the recorded observations.

    3. Constructively teach from clinical resources available on the service.

  4. Participate in all assigned quality assurance activities of the hospital or medical staff, and as specifically assigned.

  5. Attend assigned formal teaching programs and monthly PGY 1 – TR / RESIDENT/FELLOW meetings with administrators of the Program.

    1. Attend 100% of Core Lecture Series (PGY 1's only). 

    2. Attend 100% of the department formal education programs while assigned to the service.            

    3. Sign the official House staff Attendance Sheet at every educational program/meeting.     

    4. Remediate (by assignment of the Chief) any Core Lecture Series (PGY 1 only) not attended before the conclusion of the Internship Training Program.             

    5. Obtain excused absence from Chief of Service for any Departmental Formal Education Programs.          

  6. Provide written documentation and obtain written approval from the Office of Graduate Medical Education for the following: 

    1. legitimate illnesses

    2. personal days

    3. compensatory days

    4. float days (including your birthday)

    5. requests to attend conferences, CME programs, etc., which will require your absence

    6. changes in your rotation schedule

    7. changes in the on-call schedule

    8. other leaves or absences other than scheduled vacation weeks. Approvals must be made in advance. In the case of illness or personal tragedy, notification as possible is required. 

    9. RESIDENT/FELLOW/PGY 1  TR's must notify the Office of Graduate Medical Education in writing and in advance for the need of verification of malpractice insurance; verification of enrollment for loan deferments or permit/licensing information; or other similar requests.            

  7. The PGY 1 – TR / RESIDENT/FELLOW is responsible for completing the evaluation forms that are outlined in RESIDENT/FELLOW /PGY 1 TR's Manual Appendices within the required time. These forms are needed for conducting periodic appraisals as well as graduation from the training programs. Submit all reports on the quality of the faculty, quality of the training program, and registry of educational experiences (performance evaluations, program service evaluations and PGY 1  – TR/ RESIDENT/FELLOW clinical logs) on a timely basis.

    1. Service/Faculty Evaluation by RESIDENT/FELLOW/PGY 1 - TR: Constructive critique by the PGY 1 – TR/RESIDENT/FELLOW of the service and of the faculty. (TO BE COMPLETED AND RETURNED WITHIN FIFTEEN (15) DAYS OF THE LAST DAY OF THE ROTATION/BLOCK).

    2. PGY 1 - TR (only) Log: A listing of all clinical patients seen during the rotation. (TO BE COMPLETED AND RETURNED WITH A SAMPLE H&P FROM THE ROTATION BY THE LAST DAY OF THE ROTATION).         

  8. Give PGY 1 – TR / RESIDENT/FELLOW Performance Evaluation Form to the attending physician on the service for evaluation of clinical performance. (To be given to the attending physician by the second week on the service and completed by attending physician within fifteen (15) days following completion of the service.) RESIDENT/FELLOW/PGY 1 - TR's are expected to follow-up with the attending to be sure all performance evaluations are received by the Office of Graduate Medical Education or their appropriate program director in a timely manner.            

  9. PGY 1 TR's/RESIDENT/FELLOW’s who are dissatisfied with the performance evaluation of their service rotation may appeal the evaluation. The PGY 1 – TR/RESIDENT/FELLOW should first notify the Office of Graduate Medical Education of his/her request to challenge the evaluation. The GME staff will then inform the service attending of the RESIDENT/FELLOW/PGY 1  - TR's wish to challenge the evaluation and will make an appointment to discuss the evaluation with the attending physician and the PGY 1  TR/RESIDENT/FELLOW. AN PGY 1 – TR / RESIDENT/FELLOW who disagrees with an evaluation shall be allowed to submit written comments which shall become part of the evaluation and placed in the PGY 1  TR's/RESIDENT/FELLOW’s permanent file. 

  10. Requirements of AOA:

    1. PGY 1  - TR's/RESIDENT/FELLOW’s must remain members of the AOA.         

    2. Outside employment or moonlighting is prohibited by the AOA and by the Committee of Interns and Resident (CIR) contract for all Interns.                         

  11. PGY 1 - TR's are released from service to attend the graduation ceremonies as dictated by their individual training programs. RESIDENT/FELLOWs are expected to attend as a requirement of the program only if excused by program director. Coordination of excused absence(s) must be reviewed and approved by the Office of Graduate Medical Education. 

    Failure to complete any of the responsibilities noted above can be considered as a first offense for Corrective Action as outlined in Section 9 of these Rules and Regulations and may lead to Suspension from the program for a second offense.


  1. Appointment
    Appointment of Chief PGY 1 – TR’s/RESIDENT/FELLOWS will be made by the Associate Dean for Graduate Medical Education, Program Director, Director of Graduate Medical Education and Manager of Postdoctoral Training.

    1. The number of Chief PGY 1 – TR’s/RESIDENT/FELLOWS will be determined by the Office of Graduate Medical Education.

    2. Appointments will be made within the first 15 days of the beginning of the training program.

    3. Chief PGY 1 – TR/RESIDENT/FELLOWS will report directly to the Program Director / professional staff in the Office of Graduate Medical Education.

    4. Chief PGY 1 – TR/RESIDENT/FELLOW are members of the management team for the PGY 1  year.

    5. Chief PGY 1 – TR/RESIDENT/FELLOW will be paid for the services provided as outlined in the CIR contract with the University and Article 5.3-2 (c) of the Rules and Regulation.

  2. Duties and Responsibilities of the Chief PGY 1 -TR / RESIDENT/FELLOW
    The Chief PGY 1 – TR/RESIDENT/FELLOW will:

    1. Meet on a regular basis with the Associate Dean for Graduate Medical Education, Director of Graduate Medical Education, Manager of Postdoctoral Training, Program Development Specialist, staff of the Office of Graduate Medical Education, Chief Medical Officer, Track Coordinator, Director of Medical Education, Program Director and/or others as designated by the Associate Dean for Graduate Medical Education, Chief Medical Officer, or Track Coordinator.

    2. Meet with the Office of Graduate Medical Education staff regarding management of the program, information concerning trainees in the residency/Fellowship/PGY-1 TR program, to provide feedback about the trainees in the PGY 1  program, to discuss problems arising in the residency/fellowship and PGY 1-TR programs and to suggest changes that would benefit the training programs

    3. Chiefs will take attendance at Core lectures and meetings using the House staff Attendance Sheet. All Attendance Sheets should be returned to the Office of Graduate Medical Education/residency program administration on a monthly basis.

    4. Assisting in Educational Conferences including but not limited to scheduling conferences and leading educational discussion.

    5. Transmit to the appropriate Department Chief and Chairperson any matters relating to department policy or procedure as it pertains to patient care or education within the department and transmit the issues and decisions of the department to all house staff.

    6. Transmit to the Chief Medical Officer any matters relating to medical staff, corporate, or medical center policies or procedure as it pertains to patient care or education in the conduct of the training program, and transmit decisions, policy and procedures to the house staff.

    7. Oversee compliance on the part of the house staff with the procedural safeguards and Rules and Regulations of their program.

    8. Preside at all meetings of the house staff to discuss problems, inform house staff on various issues and to offer the  trainees the opportunity to express and or discuss concerns.

    9. Be responsible for and appoint members of the house staff to participate as assigned in quality assurance activities of the medical center and  medical staff, or the PGY 1-TR/residency/fellowship programs.
    10. Review and enforce compliance with standards of conduct and professional demeanor among members of the house staff. Including: acting as a role model and assist in maintaining professional atmosphere, conduct, and attitude of house staff and clinical clerks, be able to problem solve and provide conflict resolution as appropriate, maintain strict confidentiality at all times.
    11. Represent the house staff at all organizational levels of interface with students, medical staff and administration/medical center departments.
    12. Report problems at the medical center to the staff in the Office of Graduate Medical Education.
    13. Assign on-call coverage from those house staff at the division if assigned PGY 1-TR staff is ill, absent, etc.  The Chief house staff officer is not responsible for covering all such activities him/herself; the Chief should distribute assignments equitably and in regard to appropriate patient care.
    14. Assist house staff in obtaining service/phone coverage when other house staff are on vacation, on ambulatory service, etc.
    15. Provide technical assistance as needed for morning report and other educational functions that utilize the teleconferencing system.
    16. Perform other related duties as assigned by the staff in the Office of Graduate Medical Education.
    17. The Chief Scheduling house staff officer will develop the house staff on-call schedule (weekends and nights) at least six (6) weeks in advance of the beginning of each new rotation.
  3. Coverage
    1. There will be one Chief PGY 1 -TR or RESIDENT/FELLOW assigned for each rotation at each division.
    2. Chief PGY 1 -TR or RESIDENT/FELLOW may be selected after individual schedules have been completed or by AOA Specialty College standards/ACGME Program Requirements.  Therefore, if for any reason due to scheduling conflicts, personal leaves, or if there is disproportionate coverage, the following will occur:
      1. An alternate Chief PGY 1 - TR / RESIDENT/FELLOW within the Division will be designated by the Program Director/ staff of the Office of Graduate Medical Education during the first month.
      2. The relieved Chief PGY 1 -TR / RESIDENT/FELLOW will be absolved of the Chief PGY 1 – TR / RESIDENT/FELLOW duties during that month.
    3. Chief PGY 1 – TR / RESIDENT/FELLOW (or their replacements) will be paid for service, pro-rated over the number of rotations.  The rate for a full service is determined by the CIR contract.
  4. Resignation/Removal from Office
    1. A Chief PGY 1 – TR / RESIDENT/FELLOW may resign at any time by giving written notice to the Associate Dean for Graduate Medical Education.  Such resignation shall take effect on the date of receipt or at any later time by mutual agreement.
    2. Removal from office may be initiated and implemented by the Program Director, Associate Dean for Graduate Medical Education or the Director of Graduate Medical Education for the following reasons:
      1. Failure to perform duties of the position timely and appropriately
      2. Failure to continuously satisfy the qualifications for the position; or
      3. Failure to establish and lead by example of competency or citizenship


  1. Academic Year
    The PGY 1 – 1 2017-18 academic year shall commence on Monday, June 19, 2017, at 7:00 a.m. and conclude on Monday, June 18, 2018 at 7:00 a.m.  The new residency year will commence on July 1 , 2017
  2. Orientation Programs
    1. An PGY 1 Orientation Program will be conducted prior to the first day of PGY 1  year.
      1. The PGY 1 will be notified in writing at least 28 days in advance of the dates and times of the orientation program.
      2. PGY 1 attendance is mandatory.                           
      3. The PGY 1 shall be responsible for transportation, lodging and other expenses incurred for the orientation program.                           
      4. All incoming house staff will be paid a onetime fee, as described in the CIR contract, for attending the orientation program payable in July after all necessary University entrance requirements are fulfilled.
    2. Divisional Orientation - Each medical center will conduct an PGY 1  Orientation at a time near the beginning of the first rotation on days preceding the starting date of the program.
    3. Service Orientation- Upon entering a new service for assignment, the PGY 1  shall be oriented to the service.  The PGY 1 should review the Objectives, Responsibilities and Evaluation sheet provided for each service.  The Chief of the Department (or his/her designee) is responsible for such orientations.
      1. The PGY 1 shall be responsible to contact and make appointment for such orientation at least 24 hours before the start of the service.
      2. The Chief may delegate orientation responsibilities (Section Head, Chief RESIDENT/FELLOW, another attending, another RESIDENT/FELLOW, etc.), but shall be responsible for such arrangements.
      3. The Chief will review the PGY 1 Rotation Goals and Objectives with the PGY 1.
    4. RESIDENT/FELLOW Orientation will be held on July 1, of each academic year.  RESIDENT/FELLOWs will receive notification of orientation schedule from their respective Program Director. 
  3. Formal Lectures
    1. Core Lecture Series.  ALL PGY 1 trainees shall attend Core Lectures at the onset of the training program, as well as additional training as designated by the Chief Medical Officer, Program Director, Director of Medical Education or Divisional Medical Director.  Such lectures shall be deemed by the Department Chief to be of special importance regarding emergency care and other issues related to the care of patients of the medical center.  PGY 1 must sign the House staff Attendance Sheet, or if an excused absence is granted, must remediate the lecture material in a manner recommended by the Chief of the Department in a timely fashion.
    2. Departmental Lectures/Educational Programs.Each department shall conduct a variety of educational and patient care programs that shall include, but not be limited to, attending rounds, conferences, lectures, etc.  The PGY 1  – TR / RESIDENT/FELLOW is required to attend all such programs and sign the House staff Attendance Sheet, unless an approved excused absence is granted by the Chief of the Department, and approved by the Chief Medical Officer, Program Director, or Director of Medical Education
  4. Meetings
    1. The PGY 1 – TR/ RESIDENT/FELLOW is responsible to attend all other meetings recommended by the University, Chief of Service, or medical center administration.  This includes the monthly PGY 1 meetings at the division where the rotation is being completed.  The PGY 1 must sign the House staff Attendance sheet as indication of participation at these meetings.
  5. External Education Programs
    1. Official External Programs
      1. Formal conferences and other teaching programs, which are provided at another division of the medical center, and which are approved as part of the official PGY 1  – TR / RESIDENT/FELLOW training program, shall be attended by the PGY 1  – TR/RESIDENT/FELLOWSHIP with the same attendance requirements as internal programs.
      2. An approved portion of the training program that is conducted at another institution shall be attended by the PGY 1 / RESIDENT/FELLOW with the same attendance requirements as internal programs.
      3. All PGY 1 rotations across all residencies and the one year Traditional Rotating program shall occur within the Sponsoring Institutions facilities.
    2. Non-Official Programs
      1. Lectures, conferences, and other educational programs which are not an official part of the PGY 1  – TR / RESIDENT/FELLOW Training Programs may be attended provided that
        1. Attendance is approved by the sponsoring organization.
        2. Attendance is approved by the Program Director, Service in agreement/coordination with the service Attending Physician, Office of Graduate Medical Education, Chief Medical Officer.
        3. All expenses are incurred by the PGY 1  – TR / RESIDENT/FELLOW
        4. Acceptable peer-patient responsibilities are arranged and guaranteed by the PGY 1 – TR / RESIDENT/FELLOW to the satisfaction of the Department Chief, and Chief Medical Officer, and Office of Graduate Medical Education.


  1. Standard Services
    *The traditional rotating PGY 1 internship training program will comply with the standards established by the American Osteopathic Association (AOA) and shall include a minimum of the following:At least six months of training rotations in any or all basic core disciplines.  These include general internal medicine, general surgery, family practice, pediatrics, obstetrics/gynecology (ambulatory gynecology) and emergency medicine.

    1. No less than two months of exposure in general internal medicine, and must be under the supervision of an internist.
    2. One month exposure in emergency medicine at the base institution or an affiliate training site is required.
    3. At least one month in family practice in a hospital or ambulatory site or one-half day per week for a minimum of 46 weeks of ambulatory exposure in a family practice continuity of care type practice site.
    4. No more than three months of elective exposure adequate to meet the individual needs of the PGY 1 – TR and approved by the internship program director.
    5. All remaining time may be scheduled at the discretion of the base institution.
    6. No more than one month may be spent in non-clinical experience (research, scholarly pursuits, administration, etc.).
    7. Exposure must occur to the support disciplines of pathology, radiology, and didactic anesthesiology.  This may occur directly by rotation or indirectly by formal conferences and/or exposure while on medical and surgical services.  This exposure must be verified on PGY 1 - 1 logs.
      *The family medicine, internal medicine, emergency medicine, general surgery, ob/gyn, general urology, otolaryngology and psychiatry PGY 1 - TRs will also comply with the standards established by the AOA.
      *Upon pre accreditation and Initial accreditation the above programs will abide by the ACGME Common Program requirements and their respective training program RC requirements.
  2. Elective Services (When applicable and if available)
    1. The Track Coordinators, Office of Graduate Medical Education, and Chief Medical Officers will designate specific electives designed to provide appropriate educational experiences.
    2. The PGY 1 – TR/RESIDENT/FELLOW may request one or more services he/she desires in the designated time period.
    3. Electives are permitted only within the designated medical center.
    4. The Office of Graduate Medical Education must approve the elective service, which must be an AOA-recognized service.
    5. If an PGY 1 – TR/RESIDENT/FELLOW has not made a choice of an elective two months in advance, the Track Coordinator/Program Director or Office of Graduate Medical Education will designate a service and division to be covered.  This may be altered only by written permission of the Track Coordinator/Program Director or Office of Graduate Medical Education and approval by the service that will no longer be covered.
    The Office of Graduate Medical Education reserves the right to change or alter service rotations for educational or other purposes.
  3. Patient Care Obligations
    1. It is a clear premise of the RowanSOM/Jeff/OLOL Sponsoring Institution that both education and patient care obligations are of prime importance.
  4. On Call
    1. In-House Call: Nights, Weekends and Holidays
      1. PGY 1 – TR/RESIDENT/FELLOW will not leave the hospital while on call.
      2. Call will be assigned from the full PGY 1 – TR/RESIDENT/FELLOW group not to exceed the number of calls allowed by the AOA Basic Standards and CIR contract with the University.
      3. The staff in the Office of Graduate Medical Education, Hospital Director of Medical Education, Program Coordinator/Program Director, and the Chief PGY 1  – TR/RESIDENT/FELLOW are empowered with the authority to assign PGY 1  – TR/RESIDENT/FELLOW to in-house or from home call to meet patient care standards (in accordance with the Agreement between ROWAN and the CIR).
        1. Coverage assignments may not exceed those established by the ACGME/AOA and outlined in the CIR contract.
        2. Regular assignments to in-house call shall not exceed in excess of an average of every third night in each and every 30-day period.
        3. In cases of emergency, where it is deemed necessary for patient care standards to be met, the Chief PGY 1 – TR/RESIDENT/FELLOW, the Chief Medical Officer, Track Coordinator/Program Director, and staff in the Office of GME have the authority to request a house staff officer not in-house to be on-call and to respond if needed.
        4. All University and hospital duties and regulations regarding call must be adhered to strictly.
    2. If patient care demands so dictate, the staff in the Office of Graduate Medical Education, are authorized to give weekdays off in lieu of scheduling weekend duty so long as such scheduling does not significantly affect the educational aspects of the PGY 1  - TR's/RESIDENT/FELLOW’s experience.
    3. Emergency/Unusual Situation
      1. The Chief Medical Officer, Track Coordinator/Program Director, and Director of Medical Education have the responsibility of ensuring the educational experiences of the PGY 1  – TR/RESIDENT/FELLOW and the patient care obligation of the medical center.  As such, he/she is authorized to temporarily alter any schedule to ensure a better educational experience or to provide emergency patient care.
  5. General Medical Rules and Regulations
    1. Verbal Orders:  Protocol for voice orders is in accordance with individual hospital policy.
    2. Time/Date: Orders and other chart documentation will be invalid unless also dated and timed.
    3. Legibility:  Illegibly written orders are invalid.
    4. Signature: All materials written in a patient chart by an PGY 1  – TR/ RESIDENT/FELLOW shall be signed by the PGY 1  – TR/RESIDENT/FELLOW including the phone number and written on behalf of a licensed physician responsible for the case (Example: Dr. Attending / Dr. PGY 1  - 1, Beeper #1234).
    5. Sequence of Record:  All materials written on a chart will be written in appropriate sequence after the last entry.
    6. Stop Order:  The PGY 1 - TR/RESIDENT/FELLOW shall be responsible to notify the attending of any pending stop-order of drugs and seek advice on further continuation of the drug.
    7. Informed Consent:  The PGY 1 – TR/RESIDENT/FELLOW will abide by the intent of the Informed Consent Policy and Procedure of the medical center.
    8. “No Code" or "DNR":  The PGY 1 – TR/RESIDENT/FELLOW will abide by the intent of the Policy and Procedure of the "No Code Policy" of the medical center.
    9. Consultations:  A PGY 1 shall not perform a consultation.  The PGY 1 's activities may include obtaining a history and physical examination and reports of necessary evaluations, but shall not include rendering medical opinion or recommendations.  All activities of the PGY 1’s in this request shall be directly supervised by the consultant.
    10. First Associate for Major Surgery:  In elective major surgery, a PGY 1 – TR/ RESIDENT/FELLOW shall serve as a first Associate only when under the direction of a licensed physician and in full compliance with State regulations.
    11. Invasive Procedures:  A PGY 1 – TR / RESIDENT/FELLOW shall perform invasive procedures only under the direct supervision of a licensed physician on the Medical Staff of the medical center who is granted such privilege by the Governing Board.
    12. Osteopathic Musculoskeletal Examination: Required as an integral part of the physical examination performed by osteopathic physicians on their admitted patients unless contraindicated.
    13. At Our Lady of Lourdes, all PGY 1 – TR / RESIDENT/FELLOW (registered practitioners) must clearly write their “PGY 1 ” status in addition to their officially recognized signature and title after every entry on every medical chart.  (e.g. “John Doe”, PGY 1  - 1 Phone #-----) PGY 1 – TR’s / RESIDENT/FELLOW’s are encouraged to use the signature stamp that will be provided by Our Lady of Lourdes after every entry on medical charts.

  1. Definitions
    The following definitions shall apply:
    1. Information: record of proceedings, minutes, interviews, records, reports, forms, memoranda, statements, recommendations, findings, evaluations, opinions, conclusions, actions, dates and other disclosures or communications whether in written or oral form relating to any of the subject matter specified in the Rules and Regulations.
    2. Representative: an official of a medical school, Board of any medical center and any director, Sponsoring Institution Governing executive Committee member, administrator, or committee thereof; a medical center Chief Executive Officer or his designee, a College/University or medical school faculty member, an officer of any clinical or academic training program, or any individual authorized by any of the forgoing to perform any specific information gathering, analysis, use or disseminating function.
    3. Activities: all acts, communications, proceedings, memoranda, statements, recommendations, findings, evaluations, opinions, conclusions, or disclosures performed or made in connection with this or any health care facilities or organization's activities.
  2. Authorizations
    By submitting an application for admission to the PGY 1 – TR/RESIDENT/FELLOW Training Program, the PGY 1 – TR/RESIDENT/FELLOW:
    1. Authorizes representatives of the Sponsoring Institution to solicit, provide and act upon information bearing on his/her training and qualifications.
    2. Agrees to be bound by the provisions of these Rules and Regulations.
    3. Agrees to be bound by the provisions of this article in the release of information by the Sponsoring Institution, as recorded during the  training program, and described in this Article as Activities and Information covered, to any agency requesting such information in accordance with his/her written consent.
    4. Acknowledges that the provisions of this Article are conditions to any application for graduate medical education training programs.
  3. Confidentiality of Information
    1. Information with respect to any applicant for training submitted, collected or prepared by any representative of this or any other health care facility or organization, or medical staff, or medical school for the purpose of evaluating the candidate for acceptance to the Training Programs or for concurrent evaluation of the candidate with regard to progress to fulfill requirements of graduation from the Training Program, and as such information regards evaluation toward advancement toward further training or the documentation of competency to treat conditions or perform medical procedures, shall be confidential and shall not be disseminated to anyone other than a representative.  This information shall not be used in any way except as provided herein or except as otherwise required by law.  Such confidentiality shall also extend to information of like kind that may be provided by third parties.  This information shall not become part of any patient's records.
  4. Immunity from Liability
    1. No representative of the University, medical centers, or medical staff and no third party shall be liable to a trainee for damages or other relief by reason of providing information, including otherwise privileged or confidential information, to a representative of the medical centers or medical staff or to any other health care facility or organization of health professionals concerning a trainee who is or has been a member of the house staff, provided that such representative or third party acts in good faith and without malice and provided further that such information is related to the performance of the individual as it relates to attitude, knowledge and skills of the house staff, and is reported in a factual manner.
  5. Activities and Information Covered
    1. Activities
      1. The confidentiality and immunity provided by this Article applies to but is not limited to:
        1. Periodic reappraisals for progress in the AOA/ACGME approved Training Program(s).
        2. Verifications of completion of the training program.                           
        3. Application for further training in residency or fellowship fields.                           
        4. State licensure boards.
        5. Applications for appointments, clinical privileges, or specified service to this or other health care facilities.                           
        6. Profiles and profile analysis.
        7. Quality assurance activities.
        8. Other medical center and staff activities related to monitoring and maintaining quality and efficient patient care and professional conduct.
    2. Information
      1. The information referred to in this Article may relate to the house staff's professional qualifications, clinical ability, judgment, character, physical or mental health, emotional stability, professional ethics, or any other matters that might directly or indirectly affect patient care.
  6. Releases
    1. Each applicant for training shall execute general and specific releases in accordance with the tenor and import of this Article, subject to such requirements, including those of good faith, absence of malice and the exercise of a reasonable effort to ascertain truthfulness, as may be applicable under the laws of this State.
  7. Program Director Letters/Verifications
    1. The Associate Dean for Graduate Medical Education/Program Director is responsible for signing Program Director Letters and verifications for all Sponsoring Institution programs.  All PGY 1’s must complete the request for Program Director’s letter and release for immunity form and submit it with the appropriate fee.  Requests must be made at least four (4) weeks in advance of the date the letter(s) are needed. See instructions for “PGY 1 Program Director’s Letters” and “Authorization for Release of Information for PGY 1 Program Director’s Letters” in the Appendices section of the Internship Manual.


  1. Purpose
    The corrective actions in this Article apply to academic and medical judgment issues.  In compliance with the Agreement between ROWAN and the House staff Organization of ROWAN/Committee of Interns and Residents (CIR), actions regarding terms and conditions of employment will be subject to provisions of the Agreement between ROWAN and the CIR
  2. Routine Corrective Action
    Whenever an PGY 1  – TR/RESIDENT/FELLOW engages in, makes or exhibits acts, statements, demeanor or professional conduct, either within or outside of the medical center, and the same is or is reasonably likely to be detrimental to patient safety or to the delivery of quality patient care, disruptive to medical center operations or an impairment to the community's confidence in the medical center and/or its PGY 1  – TR/RESIDENT/FELLOW training program, corrective action against the PGY 1  – TR/ RESIDENT/FELLOW may be initiated by any University administrator, officer of the medical staff, by the Chief or Program Director of any Department, by the Chief Executive Officer of the corporation, Administrator of the Division, or corporate officer.
    1. Requests and Notices
      1. All requests for corrective action must be in writing, submitted to the Associate Dean for Graduate Medical Education, and supported by references to the specific activities or conduct which constitutes the grounds for the request.  The Associate Dean for Graduate Medical Education will promptly notify the Dean, ROWAN-SOM and the representative of the hospital (Chief Medical Officer or Program Director).
    2. Investigation
      1. The Dean (or his/her designee) will conduct, or order to be conducted, an investigation concerning the grounds for the corrective action request.  The investigation is not a "hearing," but may include a discussion with the person(s) initiating the request, and with other individuals who may have knowledge of the events involved.  The PGY 1 – TR/RESIDENT/FELLOW is entitled to make a personal appearance before the investigative person(s) at a time scheduled to discuss the matters pertaining to his/her standing.  During that appearance before the investigative person(s), the PGY 1  – TR/ RESIDENT/FELLOW may be accompanied by one fellow PGY 1  – TR/ RESIDENT/FELLOW and one or two other faculty members or personnel of the ROWAN-School of Osteopathic Medicine.  Upon completion of the investigation, a written report will be prepared for the Dean.  The Dean may then direct subordinates to proceed with action as provided below.
        1. Recommend rejection of the request for corrective action.
        2. Recommend admonition in the form of a formal letter.     
        3. Recommend a warning in the form of a formal letter.
        4. Recommend a probationary period.
        5. Recommend a period of suspension that must be remediated during or after the conclusion of the residency.
        6. Recommend termination of the PGY 1 training.
        The PGY 1 – TR / RESIDENT/FELLOW may appeal the decision of the investigation to the Dean.  During that appearance, the PGY 1 TR / RESIDENT/FELLOW may be accompanied by one fellow PGY 1 TR / RESIDENT/FELLOW and one or two other faculty members or personnel of the ROWAN-School of Osteopathic Medicine.
        The decision of the Dean or his designee is final.
    3. Records
      1. Following investigation, any corrective measures listed under Article 9.2-2 (c-f) shall become a part of the PGY 1  – TR’s,  RESIDENT/FELLOWS's permanent Credentials File and are subject to disclosure as presented in Articles 8.1 to 8.6 of these Rules and Regulations.
      2. A second or subsequent admonition (9.2-2 (b) will also become part of the PGY 1 – TR’s/RESIDENT/FELLOWS's permanent credentials file.
  3. Summary Suspension
    Whenever an PGY 1  – TR’s/RESIDENT/FELLOWS's conduct requires that immediate action be taken to protect the life of any patient or to reduce the substantial likelihood of injury or damage to the health or safety of any patient, employee or other person present in the medical center, the Associate Dean for Graduate Medical Education, Director of Graduate Medical Education,  Manager of Postdoctoral Training, Chief of Service, Track Coordinator/Program Director, Chief Medical Officer, or their respective designated representative has the authority to summarily suspend the PGY 1  – TR’s/RESIDENT/FELLOW.  A summary suspension is effective immediately upon imposition, and the person imposing the suspension is to give prompt notification of the suspension to the PGY 1 -TR/RESIDENT/FELLOW, Associate Dean for Graduate Medical Education, Director of Graduate Medical Education, Manager of Postdoctoral Training, Chief of Service, Track Coordinator/Program Director, and the Chief Medical Officer.  The procedure for further action on summary suspension is set forth under sections 9.2-1 through 9.2-3 above.
    1. As soon as possible, however no longer than within 72 non-weekend/non-holiday hours after a summary suspension is imposed, the Dean (or his respective designee) will discuss and recommend continuation, modification, or termination of the suspension.
    2. Unless the recommendation is to terminate or modify the suspension to one of lesser sanctions (i.e., 9.2-2 (a-d)), the PGY 1 – TR/RESIDENT/FELLOW will remain suspended until the investigation as described in Article 9.2-2 is completed
    3. Actions then follow in accordance with Article 9.2-2 and 9.2-3.
  4. Automatic Suspension
    Automatic suspensions occur: (1) after first offense (when warned of failure to comply with timely preparation and completion of medical records, or logs, or evaluations; unexcused absences from service or call schedule; improper conformity to dress code; conduct; attitude; or availability or completion of PGY 1 – TR’s/RESIDENT/FELLOWS responsibilities as outlined in Article 4.1 to 4.10), or (2) the second offense.
    1. Corrective Action:
      1. First offense:  The GME – TR/RESIDENT/FELLOW may not continue to the next rotation and a warning will be given in writing to the PGY 1  – TR/RESIDENT/FELLOW by the Chief Medical Officer, Track Coordinator/Program Director, Chief of Service, Associate Dean for Graduate Medical Education, Director of Graduate Medical Education or Manager of Postdoctoral Training and will become a part of the PGY 1  – TR’s - RESIDENT/FELLOW's Credentials File.  The Associate Dean for Graduate Medical Education will receive a copy of the warning for placement in the PGY 1  - TR's / RESIDENT/FELLOW file.
      2. Second offense:  The PGY 1 – TR RESIDENT/FELLOW will be automatically suspended.  The PGY 1 – TR/RESIDENT/FELLOW will be required to meet with the Associate Dean for Graduate Medical Education, Director of Graduate Medical Education, Manager of Postdoctoral Training, and/or the Chief Medical Officer.  After such interview, further corrective action may be imposed and may include suspension, termination of the PGY 1  – TR/RESIDENT/FELLOW, or other measures as outlined in 9.2-2 (b - f). These actions shall become a part of the PGY – 1 TR/RESIDENT/FELLOW's Credentials File.
      3. All corrective action obligations must be fulfilled before the PGY 1 – TR/ RESIDENT/FELLOW will receive the official certificate of the PGY 1 – TR/  RESIDENCY training.
  5. Specifics
    1. Attendance Requirements
      1. Failure to meet the attendance requirements of the formal training program(s) including call schedule and lectures shall be remediated in a manner established by the Associate Dean for Graduate Medical Education, Director of Graduate Medical Education, Manager of Postdoctoral Training, the Chief Medical Officer and Program Director.  Unapproved absences from a service obligation or on-call will be considered as a first offense for possible dismissal from the program as noted in 9.4 (a-c).  These obligations will be fulfilled before the PGY 1 – TR/RESIDENT/FELLOW will receive the official certificate of notification of completion of the PGY 1 – TR/RESIDENCY Training.
    2. Medical Records
      1. Medical Records for patients assigned to PGY 1 – TR/RESIDENT/FELLOW must be completed in a timely fashion.  Failure on the part of the PGY 1 – TR/  RESIDENT/FELLOW to fulfill his/her medical record obligations within the time frame outlined in this document, shall result in the actions as outlined under Article 9.4 (a-c).
    3. Logs and Evaluations
      1. Service logs and evaluations of service and faculty must be completed in a timely fashion. Failure on the part of the PGY 1 – TR/RESIDENT/FELLOW to fulfill his/her logs/evals obligations within the time frame outlined in this document, shall result in the actions as outlined under Article 9.4 (a–c).
    1. Dress Code-Proper Conformity
      1. Failure of the PGY 1 – TR/RESIDENT/FELLOW to abide by the stated dress code   policy (4.2 c) shall result in the same corrective  action as outlined under Article 9.4 (a-c)
    2. Conduct, Attitude, Availability
      1. Failure of the PGY 1 – TR/RESIDENT/FELLOW to abide by the standards of conduct, attitude and availability as set forth, shall be subject to the same corrective action as outlined under Article 9.4 (a-c)
  6. PGY 1   Evaluation (Remediation)
    Evaluations of PGY 1 – TR/RESIDENT/FELLOW performance will be completed by clinical faculty within fifteen days (15) of completion of each month's service or block.  The Program Director shall have ultimate responsibility for review of the evaluation with the PGY 1 – TR/RESIDENT/FELLOW.  Any remedial recommendations must be fulfilled in a timely fashion by the PGY 1 – TR/RESIDENT/FELLOW. All incomplete or remedial work must be completed to the satisfaction of the Chief of Service, Program Director, Director of Medical Education, and the Associate Dean for GME before an official certificate of PGY 1 – TR/RESIDENT/FELLOW training is presented to the PGY 1 – TR/ RESIDENT/FELLOW.


  1. On satisfactory completion of an PGY 1 – TR/RESIDENCY / FELLOWSHIP training program, Sponsoring Institution/ROWAN-SOM OPTI shall award the certificate of completion. All PGY 1 – TR trainees will be issued a letter of completion for the AOA approved PGY 1  – TR year, in the appropriate specialty by ROWAN-SOM OPTI, for licensing purposes. This letter will be provided at the end of the first year. The certificate letter shall confirm the successful fulfillment of the program requirements, the starting and completion dates of the program, the name(s) of the training institution, program director(s) and the ROWAN-SOM OPTI. Such certificate letters will be granted to the PGY 1 – TR only after the following requirements have been met.

* All programs who are granted initial/full accreditation during the Single Accreditation process will immediately follow granting of certificate guidelines set forth by the ACGME.

    1. PGY 1 – TR/RESIDENCY/ FELLOWSHIP Performance Evaluations are received and satisfactorily document all training in accordance with AOA/ACGME Training Program regulations.
    2. Any remediation recommended on PGY 1 – TR/RESIDENT/FELLOWS Performance Evaluations has been satisfied, verified by the Program Director and reported to the Office of Graduate Medical Education.
    3. Any remediation required for attendance at Core Lecture or Departmental progress is satisfied and reported to the Office of Graduate Medical Education
    4. Any corrective action measures taken have been satisfied and reported to the Office of Graduate Medical Education.
    5. Any fair hearing proceedings have been completed and corrective actions satisfied and reported to the Office of Graduate Medical Education.
    6. All service evaluations by the PGY 1 – TR/RESIDENT/FELLOW, faculty evaluations by the PGY 1  – TR/RESIDENT/FELLOWS, and all logs are completed and submitted to the Office of Graduate Medical Education.
    7. All University and medical center supplies, materials, equipment, books, beepers, passes, and records have been satisfactorily returned and verified.
    8. All medical records for patients assigned to the PGY 1 – TR/RESIDENT/FELLOW have             been satisfactorily completed at each division of the medical center.
    9. The PGY 1 – TR must sit for Part III of the COMLEX.


    1. The base institution, DME, and program directors must make every attempt to avoid scheduling excessive work hours leading to sleep deprivation, fatigue or inability to conduct personal activities.
      1.  The Sponsoring Institution policy must be reported in the house staff manual and available for review at all program site reviews.
      2. Evidence of review of PGY 1 – TR /RESIDENT/FELLOW duty hours by the graduate medical education committee (GMEC) must occur quarterly.
    2. The trainee shall not be assigned to work physically on duty in excess of 80 hours per week averaged over a 4-week period, inclusive of in-house night call and any allowed moonlighting. No exceptions to this policy should be permitted.
    3. The trainee shall not work in excess of 24 consecutive hours.
      1. Allowances for already initiated clinical care, transfer of care, education debriefing and formal didactic activities may occur, but shall not exceed 4 additional hours and must be reported by the RESIDENT/FELLOW in writing with rationale to the DME/Program Director and reviewed by the MEC. These allowances are not permitted for PGY 1  trainees.
      2. RESIDENT/FELLOWs shall not assume responsibility for a new patient or any new clinical activity after working 24 hours.
    4. The trainee shall have 48-hour periods off on alternate weeks, or at least one 24-hour period off each week and shall have no call responsibility during that time.
    5. Upon conclusion of a 20-24 hour duty shift, trainees shall have a minimum of 12 hours off before being required to be on duty or on call again.
    6. Upon completing a duty period of at least 12 but less than 20 hours, a minimum period of 10 hours off must be provided.
    7. All off-duty time must be totally free from clinical, on-call and education activity.
    8. Rotations in which a trainee is assigned to Emergency Department duty shall ensure that trainees work no longer than 12 hour shifts with no more than 30 additional minutes allowed for transfer of care and shall be required to report in writing to the DME/Program Director for review by the GMEC, only any time exceeding the 30 additional minutes, for monitoring individual RESIDENT/FELLOWs and program.
    9.  In cases where a trainee is engaged in patient responsibility which cannot be interrupted at the duty hour limits, additional coverage shall be provided as soon as possible by the attending staff to relieve the RESIDENT/FELLOW involved. Patient care responsibility is not precluded by the duty hours policy.
    10. The trainee shall not be assigned to in-hospital call more often than every third night averaged over any consecutive four-week period. Home call is not subject to this policy, however, must satisfy the requirement for time off.  Any time spent returning to the hospital must be included in the 80 hour maximum limit.
    11. At the trainee’s request, the training institution must provide trainees with comfortable sleep facilities to trainees who are too fatigued at shift conclusion to safely drive.
    12. Any trainee who works 24 consecutive hours may spend additional time of no more than 30 minutes providing transfer of care / patient sign-out to receiving physicians and staff without the need to report this time to the DME/Program Director.  Any other activity or longer timeframe will require a written report.
    13. RESIDENT/FELLOWs are permitted to return to the hospital while on home-call to care for new or established patients.  Each episode of this type of care, while it must be included in 80-hour weekly maximum, will not institute a new “off-duty” period.  Faculty must be aware of the home-call responsibilities of their PGY 1 – TR/RESIDENT/FELLOWs recognizing fatigue and sleep deprivation.  They must alter schedules and counsel PGY 1 TR/RESIDENT/FELLOWs as necessary.
    14. The Sponsoring Institutions work hour policy is subject to review and revision on an as needed basis.

    1. Any professional clinical activity (moonlighting) performed outside of an official residency program will only be conducted with the permission of the program administration (DME/program director) and must not interfere with the RESIDENT/FELLOW’s didactic or clinical performance.
      1. A written request by the RESIDENT/FELLOW must be approved or disapproved by the program director and DME and be filed in the institution’s RESIDENT/FELLOW file.
      2. This policy must be published in the institution’s house staff manual. Failure to report and receive approval by the program may be grounds for terminating a RESIDENT/FELLOW’s contract.
    2. If moonlighting is permitted, hours shall be inclusive of the 80 hour per week maximum work limit and must be reported and monitored by the MEC.
    3. PGY 1 trainees shall be prohibited from moonlighting.
    1. Faculty must be educated in recognizing early fatigue and sleep deprivation and to alter schedules and counsel PGY 1-TR/RESIDENT/FELLOWs as necessary, while maintaining continuity of patient care.



  1. The American Osteopathic Association/American Council for Graduate Medical Education requires DME’s and Program Directors to implement training, and Program Evaluators to assess, the AOA/ACGME Core Competencies in all AOA/ACGME training programs.
    1. Osteopathic Philosophy Principles and Manipulative Treatment
      1. PGY 1-TR/RESIDENT/FELLOWs are expected to demonstrate and apply knowledge of accepting standards in OPP/OMT appropriate to their specialty.  The educational goal is to train a skilled and competent osteopathic practitioner who remains dedicated to life-long learning and to practice habits in osteopathic philosophy and manipulative medicine.
    2. Medical Knowledge and Its Application Into Medical Practice:
      1. RESIDENT/FELLOWs must demonstrate and apply integrative knowledge of accepted standards of clinical medicine and OPP in their respective osteopathic specialty area, remain current with new developments in medicine, and participate in life-long learning activities, including research.
    3. Patient-Care
      1. PGY 1-TR/RESIDENT/FELLOW(s) must demonstrate the ability to effectively treat patients, provide medical care that incorporates the osteopathic philosophy, patient empathy, awareness of behavioral issues, the incorporation of preventive medicine, and health promotion.
    4. Interpersonal and Communication Skills in Medical Practice:
      1. PGY 1 TR/RESIDENT/FELLOW(s) are expected to demonstrate interpersonal and communication skills that enable them to establish and maintain professional relationships with patients, families, and other members of health care teams.
    5. Professionalism in Medical Practice:
      1. PGY 1-TR/RESIDENT/FELLOW(s) are expected to uphold the Osteopathic Oath in the conduct of their professional activities that promote advocacy of patient welfare, adherence to ethical principles, collaboration with health professionals, life-long learning, and sensitivity to a diverse patient population. RESIDENT/FELLOW(s) should be cognizant of their own physical and mental health in order to care effectively for patients.
    6. MedicalPractice-Based Learning and Improvement:
      1. PGY 1-TR/RESIDENT/FELLOW(s) must demonstrate the ability to critically evaluate their methods of clinical practice, integrate evidence-based traditional and osteopathic medical practices into patient care, show an understanding of research methods, and improve patient care practices.
    7. System-Based Medical Practice
      1. PGY 1-TR/RESIDENT/FELLOW(s) are expected to demonstrate an understanding of health care delivery systems, provide effective and qualitative osteopathic patient care within the system, and practice cost-effective medicine.
      The core competencies shall be taught and assessed throughout training by a variety of methods as indicated in the ROWAN-SOM OPTI Core Competency Plan.


  1. In the event of a discontinuation of a training program, the Sponsoring Institution agrees that it will make every effort to place displaced House Staff  in another appropriate Sponsoring Institution program, or if necessary, a program outside the Sponsoring Institution.
  2. The training institution shall immediately notify the AOA, ACGME, its OPTI and its trainees of a program closure or reduction in positions, which would impact trainees prior to program completion.
  3. If a training institution reduces in size or closes a program, every attempt should be made to permit the current PGY 1 -TR/RESIDENT/FELLOW(s) enrolled in the program to complete their training prior to such action.
  4. In the event of a hospital or program closure or reduction in positions, which would impact trainees prior to program completion, the Sponsoring Institution shall immediately notify the all OPTI members to aid in placement of the enrolled PGY 1 -TR/RESIDENT/FELLOW(s) in other AOA, ACGME approved programs within the OPTI structure.
  5. Severance pay shall be provided for two months when institutional program closure or reduction decisions prevent the PGY 1 -TR/RESIDENT/FELLOW(s) from program completion in that or another geographically proximate program arranged by the Sponsoring Institution and/or the OPTI.


  1. Policy
    The Graduate Medical Education (GME) department shall provide a grievance procedure for house staff officers who wish to appeal a notice of non-renewal of the house staff officer’s contract.  The Graduate medical Education department shall provide for the appointment of an Ad Hoc Non-Renewal Committee to conduct the grievance procedure, and all such committees shall review non-renewal appeals in accordance with the standards set forth in this policy.
  2. Procedure
    1. A house staff officer may appeal a Program Director’s decision not to renew the house staff officer’s contract for the following academic year by submitting a written request to the Department Chair within five (5) working days of receipt of notice of the decision.
    2. If the house officer submits timely notice of appeal, the Department Chair shall convene a Non-Renewal Committee to consider the appeal.  The Non-Renewal Committee shall be composed of either
      1. the Department Chair, the Associate Dean of Graduate Medical Education, or their designees, and one faculty member designated by the Chair of the GME Committee, or 
      2. such other individuals as designated by the GME policies of the School.
  3. The house staff officer will be invited to meet with and make a personal presentation to the Non-Renewal Committee and my be accompanied by a faculty member or fellow house staff officer who may act as an advisor.  The house staff officer may also be accompanied by a representative of the CIR, who shall not participate in the proceedings.  The Non-Renewal Committee may invite the Program Director and any other witnesses to make presentations.  All parties may submit any relevant information to the Non-Renewal Committee prior to or during the hearing.
  4. The Non-Renewal Committee shall consider only whether the non-renewal conforms to the following standards:
    1. the decision was communicated to the house officer in writing;
    2. the decision was communicated in a timely manner, in accordance with the Sponsoring Institutions procedure on non-renewal of house staff contracts; and
    3. the non-renewal decision was not based on reasons prohibited by law or Sponsoring Institution policy.
    If the Non-Renewal Committee determines that the non-renewal decision conforms to these standards, the decision shall be upheld.
  5. Following the hearing, the Non-Renewal Committee shall deliberate and render a writing decision,which shall be communicated to the house staff officer and Program Director.  The decision of theNon-Renewal Committee will be final and binding.
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