GUIDELINES FOR GME ROTATIONS OUTSIDE WFUBMC
Introduction
These guidelines are provided as an internal process for review and approval of graduate medical education (GME) rotations outside the Medical Center.
While “outside” rotations have traditionally been under the control of the Residency Program Director, increasing institutional issues with Medicare compliance related to “supervisory physicians,” accurate cost reporting, restricted Federal Government financial support and risk management make a complete institutional inventory and review of residency rotations which occur outside of the Accreditation Council for Graduate Medical Education (ACGME) sponsoring institution necessary.
Three types of “outside” rotations are utilized to educate resident physicians:
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Rotations which have undergone formal Residency Review Committee (RRC) evaluation and have received specific approval separate from listing in the Program Information Form at the time of ACGME Accreditation Review. An RRC letter contains specific reference to this rotation and/or the institution at which the rotation occurs is listed as a major participating institution for the Residency Program because of this rotation.
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Specific RRC required educational experiences which are unavailable at Wake Forest University Baptist Medical Center (WFUBMC) or its subsidiaries or affiliated practice sites. Such Educational Experiences are by definition limited in duration to less than a full time experience, and accommodate the continuing participation of the resident in educational experiences at WFUBMC such as conferences and continuity clinics.
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Resident rotations which have been authorized by the Residency Program Director which preclude continued participation in WFUBMC clinics, on-call responsibilities or conferences.
Guidelines:
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ALL rotations away from WFUBMC require an appropriate letter of agreement (per ACGME) with the Residency Program and the rotating site including length of rotation, goals and objectives, supervising physician, stipulation of “non-billing” for resident physician services etc. A Business Associate Agreement is also required for HIPAA purposes. Such documentation must be available for institutional review at the time of inauguration of the rotation, for the Graduate Medical Education Committee (GMEC) Internal Review of the program, and at the time of an ACGME site survey.
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When WFUBMC Departmental or Institutional strategic actions are considered which would result in the loss of a WFUBMC clinical educational site which provides the basis for more than 3 months of a residency’s RRC required educational experiences, plans to replace the lost educational experience with an outside rotation(s) must be approved by the GMEC.
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Residency positions initially proposed to be supported with “outside funding” (grants, etc) will only be approved by the GMEC if establishment of the position is viewed as optimal for the institution’s long term strategic plan. Loss of outside funding requires review of the residency position in terms of the current strategic plan and educational resources.
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All new “outside” rotations (those established after January 1, 2005) of any type, and research rotations require approval of the Director of Physician Services and the Chair of the GMEC.
Criteria for Institutional Approval of an Outside Rotation
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The rotation provides an educational experience designed to fulfill Residency Review Committee requirements or Specialty Board Certification requirements and/or the educational experience is recommended by the Residency Program Director to complete an individual resident’s self-directed learning program.
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Completion of the rotation will not increase the resident’s length of training beyond the time period stipulated in the resident’s most recent training agreement.
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The educational experience is unavailable at the Medical Center, OPD/Downtown Health Center, NCBH subsidiaries including Aegis practices or Wake Forest University Physicians’ Clinics.
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An appropriate ACGME-required letter of agreement has been completed between the Residency Program and the rotation site, and a business associate agreement for HIPPA compliance has been executed.
Funding Arrangements
A complete inventory of all resident rotations or educational experiences which occur outside of WFUBMC/ OPD/Aegis/WFUP practices, Downtown Health Plaza or other NCBH subsidiaries will be maintained. Departments must be responsible for providing accurate reports of the location of the resident’s educational activates on a monthly basis to the House Staff Office. Rotations will be reviewed and assigned one of the following categories:
Category 1 (RRC specific rotations):
The resident’s salary, fringe benefits and malpractice insurance for these rotations will be funded by NCBH since they have been subject to rigorous scrutiny by the ACGME for their educational contribution to the program. In some instances they form an integral structure to the residency program (e.g. OB at FMC). Wherever appropriate, funding should be sought by NCBH to cover the costs of these rotations if they are performed at participating healthcare institutions with the ability to include residents on Federal cost reports.
Category 2 (RRC required educational experiences):
The resident’s salary, fringe benefits and malpractice insurance for these rotations will be funded by NCBH since they are utilized by the residency program to fulfill specific RRC requirements and the educational resources or specific practice characteristics (e.g. “community based,”) are unavailable at WFUBMC. Since such rotations are individually limited to less than 30 days time over the course of an academic year, the majority of the resident’s concurrent educational experience remains at the Medical Center or within its subsidiary practices and clinics.
In some circumstances, NCBH may seek funding for resident support from contracting agencies such as community Mental Health Centers. Expenses incurred in support of rotations to Veterans’ Administration facilities will be billed by WFUHS.
Category 3 (not RRC required)
If a Residency Program Director wishes to offer a rotation to a resident which will involve the full time participation of the resident in an educational experience removed from WFUBMC or its subsidiary facilities or professional practices, WFUHS will seek funding from the healthcare entity or organization where the resident will rotate for the educational experience. WFUHS will be responsible for funding the resident’s salary, benefits and professional liability costs for the rotation in the absence of identification of another funding source.
International Education
Professional liability issues preclude institutional funding for international educational experiences. It is recommended that residents seek a Leave of Absence or utilize vacation or personal leave to participate in international educational missions and assure financial support and funding for professional liability through the entity which sponsors the resident’s participation.
Research
The ACGME and RRCs have in recent years imposed requirements for research on both the Sponsoring Institution and individual residency programs. With the introduction of the ACGME Common Program requirements, institutions which sponsor Graduate Medical Education programs are required to assure that there is an active research component in each residency program. Some of the programs have requirements for a structured research component while others address research as a scholarly activity Resident salary and benefits during required research time, structured in accordance with individual RRC requirements, will be funded by NCBH. Faculty supervision for research, supplies, resources, equipment, etc. is the responsibility of the department.
Subspecialty Training (Fellows)
Previous financial agreements exist between NCBH and WFUHS which address funding of subspecialty residency (fellow) positions. These pre-existing agreements supersede the recommendations of this work group related to funding of outside rotations and research
Procedure for requesting approval of an outside rotation.
The House Staff Office will assure that residents on outside rotations continue to receive stipends, benefits and ACGME-compliant educational experiences.
Program Directors may be obligated to notify their RRC when they contemplate sending a resident on an outside rotation and are definitely obligated to notify the Chair of the GMEC and the Director of Physician Services when such consideration is given.
RRC:
Program Directors should notify their RRC’s (after approval by the GMEC) to obtain prospective approval of the rotation, if required, and then follow guidelines established by the RRC. Program Director also should assure that the rotation is for the educational advancement of the resident.
GME OFFICE:
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Notify the House Staff Office in writing or by email of the intent to assign a resident to an outside rotation at least 4 months in advance of the start of the rotation.
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Notify the House Staff Office of the source of funding for stipends, benefits and malpractice insurance.
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Assure the House Staff Office that the off-site rotation will comply with ACGME guidelines regarding duty hours.
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Assure the House Staff Office that the resident’s rotation will not place other residents at jeopardy for excessive work.
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Complete and send the House Staff Office a copy of the completed Letter of Agreement.
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Assure the House Staff Office that the Program Director will receive evaluations of the resident’s performance and of the rotation.
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Inform the resident of the procedure for reporting work-related injuries. If NCBH is paying the stipend, then NCBH covers the resident’s workers compensation. If a resident is injured in a work-related incident, the resident should seek medical attention and initial treatment from NCBH if possible. If medical attention and treatment is sought at the site of the outside rotation, the resident must report the injury within 48 hours to the Program Director and the House Staff Office as soon as possible. Payment for services provided cannot be made until this step is completed.
Please contact the House Staff Office with any questions or concerns.