Faculty and Clinical Affairs

Series 500 Policies

Wright State University Boonshoft School of Medicine
Sponsored Graduate Medical Education Programs
Resident Manual

Item 501 Risk Management
Item 502 Discrimination and Harassment
Item 503 Impaired Resident
Item 504 Academic and Professional Standards / Due Process
Item 505 Residency Closure and/or Reduction
Item 506 Complaints and Grievances
Item 507 Dress Code
Item 508 Disaster
Item 509 Accommodation for Disabilities
Item 510 Resident Transfers
Item 511 Social Media
Item 512 Patient Handoff Communication
Item 513 Communication and Documentation

Item 501
Risk Management

Revised July 1996

All "incidents" related to patient care should be reported promptly to the hospital's Department of Legal Affairs and Risk Management, or its equivalent. Consult the hospital director of medical education for specific direction in this regard.


The term "incident" includes:

  1. any happening which is not consistent with the routine or commonly accepted care of a patient, including an accident or a situation which might result in an accident
  2. actual or alleged injury that results from providing professional services when proper diagnostic or therapeutic procedures dictate
  3. actual or alleged injury that results from failing to provide professional services when proper diagnostic or therapeutic procedures dictate
  4. a claim that no informed consent was obtained from a patient or legal guardian
  5. failure to carry out a Medical Staff Committee appointment in a prudent manner

Sensitive Legal Matters

The resident should be sensitive to and report

  1. threats of legal action
  2. a patient's and/or attorney's request for medical records
  3. subpoena for appearance or records
  4. request of an attorney to talk to you or any other employee about an "incident" or any potentially litigious issue


The reporting of an actual or alleged incident should be in typed or handwritten letter form and include the following information:

  1. physician's name, address, and specialty
  2. patient's name, address, and number
  3. narrative with specific details of the incident and resulting injury, including time and date
  4. identification of any witnesses to the occurrence
  5. status of patient post incident
  6. any other comments by physicians relevant to the incident

After discussion with the risk manager, the letter should be sent to the risk manager or equivalent within 48 hours of the incident in an envelope marked "Personal and Confidential." These reports will remain in a locked file and they will not become part of the patient's medical record.

While written documentation is important as potential legal defense in an investigation, some situations may be better handled personally by contacting the Department of Legal Affairs and Risk Management.

Sensitive Medical Issues

Discuss privately with the supervisory physician and program director medical care issues such as

  1. unexpected poor result
  2. therapeutic misadventures
  3. significant misdiagnosis including failure to diagnose

Risk Management Principles

Use risk management principles to minimize the potential for a liability claim. Effective principles include:

Preventing Claims

  1. Maintain good rapport and effective communication with the patient.
  2. Keep a well-documented medical record, containing all material information relevant to optimum health care services. This point must be emphasized. Always maintain timely, clear and complete records but be particularly precise and attentive when a patient has had an unexpected adverse response.
  3. Report immediately any malfunctioning equipment so that it can be repaired. Malfunctioning medical equipment poses substantial risk to patients. Because it is important that the evidence of malfunction is preserved, do not send the equipment back to the manufacturer without approval of the risk manager.
  4. Refer all requests for product evaluation from sales representatives of medical equipment companies to the hospital's purchasing department. The purchasing department has established guidelines for evaluating equipment that greatly reduce the potential for liability. If a resident accepts equipment that later injures a patient, the resident could be held liable for that injury.
  5. Do not accept newly purchased equipment. All new equipment should be processed through materials management to assure that it is operating properly before being used. Contact the purchasing department if there are questions.

NOTE: The Patient Relations Department with support from the medical center attorney handles risk management at Kettering Medical Center.

Handling Claims

  1. Direct requests for records or information concerning a claim or claimant to the risk manager or equivalent. Never release any medical information regarding a claimant without the authorization of the Department of Legal Affairs and Risk Management or the Medical Records Department.
  2. Direct any correspondence from a claimant, claimant's attorney, or claimant's insurance company immediately to the Department of Legal Affairs and Risk Management.
  3. Do not discuss a claim with the claimant or the claimant's representative except as authorized by the Department of Legal Affairs and Risk Management.
  4. Deliver correspondence received from a patient alleging substandard medical care immediately to the Department of Legal Affairs and Risk Management. The Department of Legal Affairs and Risk Management must review all responses to inquiries because a resident's response may exacerbate the situation.
  5. Send request or subpoena for appearance for deposition or hearing to the Department of Legal Affairs and Risk Management.
  6. Forward a Summons and Complaint received by a physician naming the physician as a defendant immediately to the Department of Legal Affairs and Risk Management.

Item 502
Discrimination and Harassment

Revised June 2006

Discrimination is any distinction drawn regarding any aspect of an individual's employment or education solely because of that individual's race, gender, color, religion, ancestry, national origin, age, disability, veteran status, or sexual orientation. Harassment is conduct that substantially interferes with an individual's work or educational performance or creates an intimidating, hostile, or offensive working or educational environment. Such conduct may constitute harassment even if done under the guise of humor.

No member of the academic community may discriminate against or harass any other member of the academic community on the basis of the latter person's race, gender, color, religion, ancestry,national origin, age, disability, veteran status, or sexual orientation. This policy is consistent with all state and federal regulations.

Sexual harassment includes, but is not limited to, unwelcome advances, requests for sexual favors, or other verbal or physical conduct of a sexual nature when:

  • submission to such conduct is made -- either explicitly or implicitly -- a term or condition of an individual's employment or education status;
  • submission to or rejection of such conduct by an individual is used as the basis for an employment or educational decision affecting such an individual; or
  • such conduct substantially interferes with an individual's work or educational performance or creates an intimidating, hostile, or offensive working or educational environment.

Following are examples of sexual harassment, although the list is not all-inclusive:

  1. Verbal: sexual innuendo, suggestive comments, insults, humor and jokes about sex or gender-specific traits, sexual propositions, threats.
  2. Non-verbal: suggestive or insulting sounds, leering, whistling, obscene gestures.
  3. Physical touching: pinching, brushing the body, coerced sexual intercourse, assault.


Residents who feel that they or others are subjects of discrimination or harassment should contact a faculty member.

Most incidences of discrimination or harassment are resolved without initiating a formal complaint. However, procedures for filing a complaint are detailed in the Complaints and Grievances Policy.

Depending on the involved parties, either WSU or institutional policies, or both, may apply.

Item 503
Impaired Resident

Revised July 1996

1. Residents are not permitted to participate in any residency or fellowship program activities while under the influence of any substance which impairs the ability to practice.

2. The Boonshoft School of Medicine (BSOM) intends to comply completely with federal, state, or local laws related to the sale, possession, use or distribution of drugs or alcohol. Any violations by a participant will be interpreted as failure to comply.

3. Failure to comply with (1) and (2) may result in:

  • referral to an approved treatment center,
  • disciplinary action by the program including suspension, termination, or non-reappointment,
  • notification to civil authorities of the violation, or
  • notification to the Ohio State Medical Board.

4. Under the Ohio Revised Code, physicians are required to report physician colleagues, whom they suspect to be impaired, to the Ohio State Medical Board unless they enter treatment voluntarily. Program directors should not report impaired residents who enter treatment voluntarily. Program directors must report impaired residents who refuse to enter treatment. A list of approved treatment providers should be obtained by the program director from the Board. (Contact the State Medical Board, 77 South High Street, 17th Floor, Columbus, Ohio 43266-0315; telephone number 614-466-3934). An impaired physician is one who cannot practice according to acceptable and prevailing standards of care because of habitual or excessive use or abuse of drugs, alcohol, or other substances that impair the ability to practice (ORC 4731.22 (B)(19),(26)). Upon probable cause the Board may mandate a mental or a physical examination of any physician. Failure to submit to examination constitutes an admission of the allegations. If a physician is found to be impaired after the examination, the physician will be required to submit to treatment as a condition for initial, continued, reinstated or renewed medical licensure.

5. All professionals who have concerns about a resident's compliance with Items (1) and (2) above are encouraged to report to the program director in accordance with the following conditions:

  • if the resident's behavior and/or physical appearance suggest substance abuse;
  • if the resident does not practice according to acceptable and prevailing standards of care;
  • if a violation of a federal, state or local law related to the sale, possession, use or distribution of drugs or alcohol becomes known;
  • if information is requested by the program administrators; and
  • when required by applicable codes of professional conduct. It is the ethical responsibility of any physician who knows of an apparent problem in a colleague to take assertive action, to seek treatment or rehabilitation for the fellow physician.

6. Consultation Process

a. After observations, consideration of related reports and assessments, and confidential discussion with the director of medical education (DME) of the sponsoring hospital, the residency program director makes a decision whether consultation for a resident is necessary. This decision can include the temporary relief of the resident from training and institutional duties.

b. The case is referred in confidence to a standing Resident Effectiveness Subcommittee of the Graduate Medical Education Committee (GMEC) comprised of:

  • the director of the Psychiatry Residency Program (or designee) as chair
  • a member of the GMEC designated by the GMEC chair
  • a senior resident on the GMEC designated by the GMEC chair

c. In each individual case, the Resident Effectiveness Subcommittee will be augmented by three specific members:

  • the chair of the Physician Effectiveness Committee of the sponsoring hospital
  • the chair of the Physician Effectiveness Committee of the occurrence hospital
  • the senior resident preferably from the sponsoring hospital in a program that is different from that of the reviewed resident

d. The review and consultation of the subcommittee will produce specific recommendations that will be transmitted in confidence from the chair of the subcommittee to the reviewed resident's program director.

  • Administrative details of the rehabilitation program will be the responsibility of the residency program director.
  • Rehabilitative details and monitoring of the remedial program will be the responsibility of the subcommittee chair.
  • Compliance of the reviewed resident in the rehabilitation program will eliminate the need for discovery outlined in items 3 and 4 above. Failure to comply as determined jointly by the subcommittee and the resident's program director will mandate a report of the case to the State Medical Board.

e. The above consultation procedure may also be implemented for a resident whose function is impaired by physical, mental or emotional disability.

7. A resident may be given a leave of absence or may utilize sick leave while under the care of an approved treatment center on the same basis as other illnesses.

8. In affiliated hospitals, the directors of medical education are responsible for interpretation of their institution's policies related to the consumption of alcohol on premises. Residents having questions about the institution's policies should contact the DME.

Item 504
Academic and Professional Standards / Due Process

Revised October 2013


The primary purpose of the Boonshoft School of Medicine (BSOM) residency and fellowship programs is to provide high quality graduate medical education, patient care, experience in teaching, and the opportunity to conduct research. The procedures contained in this document concerning the academic standards and the professional standards are intended to further these fundamental goals.


These procedures and standards are applicable to residents in all BSOM sponsored graduate medical education programs.

Residents are also subject to additional standards of conduct and performance adopted by hospitals participating in the educational program. To obtain a copy of a hospital's standards of conduct, contact the medical education office.

The Office of Faculty and Clinical Affairs and the Director of Medical Education for the employing institution shall be consulted before the implementation of any due process.

Academic Standards

  1. The resident must demonstrate the competence, efficiency, and maturity necessary to assume increasing responsibilities for teaching and supervising other residents, fellows, and students.
  2. The resident must acquire appropriate cognitive medical knowledge.
  3. The resident must competently obtain thorough medical histories, perform complete physical exams, develop rational differential diagnoses, and implement appropriate management plans for treatment of patients appropriate to his or her level of responsibility.
  4. The resident must assume appropriate responsibility for patient.
  5. The resident must demonstrate approved creativity in the advancement of patient care and medical knowledge appropriate to his or her level of responsibility.

Violations of one or more of the above academic standards constitute sufficient grounds for academic suspension, academic demotion, academic non-promotion, academic non-renewal or academic termination.

Professional Standards

  1. The resident must perform all responsibilities as a resident competently, efficiently, and maturely.
  2. The resident must refrain from engaging in any conduct that is grounds for (a) refusal to grant or (b) revocation of a certificate to practice medicine in Ohio as provided by the Ohio Revised Code Section 4731.22.
  3. The resident must refrain from habitual or excessive drug or alcohol use or any combination thereof.
  4. The resident must refrain from obstructing or disrupting medical care and hospital activities.
  5. The resident must obey all provisions of the American Medical Association Principles of Medical Ethics.

Violations of one or more of the above standards relating to professional conduct constitute sufficient grounds for disciplinary suspension, disciplinary termination, or disciplinary non-renewal of the resident's appointment.

Continued Appointment / Promotion
The above academic and professional standards must be met for continued appointment and/or promotion.

Adverse Actions

  1. If the above academic standards or professional standards are not met, the program may act to demote, not promote, not renew, or terminate the resident's appointment. A written notice of the action shall be transmitted to the resident and shall include:
    • the program's intended action,
    • a summary of the reasons for the intended action, and
    • the right of appeal as described in this policy.
  2. Written notice of intent to not renew, not promote or terminate a resident's appointment must be provided to residents no later than 120 days (four months) prior to the end of their current contract if the primary reason occurred prior to the last 120 days of the contract.

    When professional standards are not met, the program director may immediately suspend the resident with pay for a maximum of 60 days. Within five working days of taking this action, the program must notify the resident in writing stating the reasons for the action and the program's intention to reinstate or terminate the resident's appointment at the end of the suspension period.
  3. The program director will meet with the resident to discuss the program's intended action and to attempt resolution of any disputed issues.

Due Process

  1. Within five working days after receipt of the written notice or within five working days after the conference with the program director, whichever is later, the resident may request in writing a review of the program's intended action. The review will not be granted if requested after the five-day period has expired except under extenuating circumstances.
  2. Within 60 calendar days after the receipt of the request for the review, the Designated Institutional Official (DIO) or designee must convene a hearing to review the intended action.
  3. Review panel membership
    • Panel membership will consist of three faculty members, who are knowledgeable of the program's academic content. The panel members will be appointed jointly by the dean of the BSOM and the employing institution's chief executive officer/commander. One of the three members will also be appointed as chair.
    • One member of the three will be nominated by the resident. Within five working days of requesting the review, the resident may submit a list of three to five faculty nominees as a member. One nominee will be selected from the list by the dean and the chief executive officer/commander to serve on the panel.
    • If the resident is on active duty with the United States Air Force, at least one member of the review panel must be an active duty medical officer stationed at the Wright-Patterson Medical Center (see #6).
  4. The purpose of the review is to determine if there is substantial evidence to support the program's intended action.
    1. The program or resident may have an attorney present as an observer but may not be represented by the attorney at the hearing.
    2. The hearing will be recorded by the Boonshoft School of Medicine, and a transcript made available to the resident upon request.
    3. If the resident fails to appear for the scheduled hearing, the program's decision shall be affirmed.
    4. The program director
      • will present the basis for the intended action,
      • may call witnesses if a 15 calendar day advanced written notice is provided to the resident, and
      • may question the resident or any witnesses called by the resident.
    5. The resident
      • may appear and speak on their own behalf,
      • has the opportunity to respond to the program director's presentation,
      • may question the evidence, the program director, or any witnesses that have been called by the program,
      • may present evidence including testimony of witness,
      • will be responsible for questioning any witnesses that the resident has asked to attend, and
      • may be assisted by a faculty advisor chosen by the resident. This advisor may give advice to the resident or may speak on the resident's behalf.
    6. The hearing panel
      • may question any witnesses that have been called by either the program director of the resident and
      • will not consider any information related to the resident's performance after the program's decision.
  5. Within ten working days following the conclusion of the review, the panel must submit a written recommendation to the dean and the employing chief executive officer/commander. The panel must reach their decision by a majority vote based on the evidence presented. The recommendation can be to
    • affirm the program's intended action,
    • take revised action against the resident, or
    • not affirm the program's intended action.
  6. Within 15 working days of the receipt of the review panel's recommendation, the dean of the BSOM and the employing institution's chief executive officer/commander must jointly decide and notify the resident in writing of the decision. The decision can be to
    • affirm the program's intended action,
    • take revised action against the resident, or
    • not affirm the program's intended action.
  7. Within ten working days of receipt of the notice of the decision, the resident may appeal the decision to the provost of the university. The appeal must be made in writing and must contain the action the resident requests and reasons in support of that action. Within 15 working days of receipt of the appeal, the provost of the university must notify the resident in writing of the decision to affirm or not affirm the action.
  8. In the case of military residents, once the recommendation of the review panel is finalized, Wright-Patterson Medical Center may conduct hearings according to USAF rules and regulations regarding the individual's military status. Final approval by HQ AFPC/DPAME is required.

The dean and the chief executive officer/commander at their discretion may modify time lines as may be appropriate to ensure fairness and realities of scheduling.

Item 505
Residency Closure and/or Reduction

Updated: August 2008

In the event of reduction or closure of a Wright State University program, the Designated Institutional Official (DIO) will inform the Graduate Medical Education Committee (GMEC) and all affected residents as soon as possible.

In the event of a reduction or closure, every effort will be made to reduce entry-level positions through decreased recruitment.

In the event of such a reduction or closure, every effort will be made to allow residents already in the program to complete their education.

For residents who are displaced by such a reduction or closure, every effort will be made to assist the resident(s) in enrolling in a program in which they can continue their education.

In the event of a reduction, the DIO and the GMEC will abide by all ACGME requirements.

Item 506
Complaints and Grievances

Revised: August 2014

Complaints and Grievances

We are committed to providing an educational environment in which residents and fellows may raise and resolve issues without fear of intimidation or retaliation.

Residents should try to resolve issues through the appropriate channels in their own program. However, if a resident or fellow feels that they have a concern that they would like to have addressed in a protected and confidential manner, they are welcome to use the following procedure.

This procedure is designed to promote a prompt resolution of complaints and grievances, while at the same time preserving the right of each resident to have their concerns addressed in a protected and confidential manner. All deliberations and discussions relating to a complaint or grievance shall be treated with confidentiality by all parties. The procedure is divided into informal and formal systems.

Residents who need to appeal a decision for academic suspension, academic demotion, academic non-advancement, academic non-reappointment, or termination should consult the Due Process Policy (Item 504).

Informal System

After oral presentation of the grievance or complaint to a third party (a Director of Medical Education or an institutional staff member), a mediator will be assigned. The resident should identify that he/she is implementing the informal complaint system when making the oral presentation.

The mediator will communicate with the resident to identify the subject of the grievance. The mediator's communication with other involved parties will attempt to clarify sources of conflict and identify possible avenues of resolution. The mediator will also seek information concerning policies, procedures, directives, and regulations relevant to a satisfactory resolution.

The mediator shall give a response in writing to the aggrieved resident within ten working days, unless an extension is mutually agreeable to the mediator and the aggrieved resident.

Formal Grievance System

In the event the grievance is not settled in the informal grievance system, the formal grievance system may be pursued.

Within ten working days of the mediator's response, the aggrieved resident shall submit their written, detailed complaint to the Designated Institutional Official (DIO).

Within 30 days after the receipt of the formal grievance, a panel shall be convened to review the complaint. The panel will examine the grievance, and make recommendations, while assuring fair treatment for all parties.

The panel will consist of three members, who must be faculty, staff or residents associated with a GME program. The sponsoring and/or the employing institutional chief executive officer(s) will appoint the panel members jointly. One of the three members will also be appointed as chair.

The resident will nominate one member of the three. Within ten working days of requesting the review, the resident may submit a list of two to five nominees. One nominee will be selected from the list by the chief executive officer(s) to serve on the panel.

If the resident is on active duty with the United States Air Force, at least one member of the review panel must be an active duty medical officer stationed at the Wright-Patterson Medical Center.

The panel shall conduct a formal closed hearing, providing the aggrieved resident and other parties ample opportunity to introduce evidence, and to examine and cross-examine witnesses. Any party to the case can be represented by another individual who is a GME faculty or staff member. The panel shall render a recommendation in writing to all parties, including the appropriate program director, within ten working days of the conclusion of the hearing.

In the event any party to the grievance is dissatisfied with the recommendation of the panel, he/she has thirty days to appeal that recommendation. The chief executive officer(s) shall take such action as is deemed necessary to assure that all parties have been afforded due process and have received fair treatment. The panel recommendation can be confirmed, an alternative decision rendered, or the case remanded back to the panel for further hearing.

The timeline may be modified by the DIO.

In the case of military residents, once the appeal decision is finalized, Wright-Patterson Medical Center may conduct hearings according to USAF rules and regulations. Final approval by HQ AFPC/DPAME is required.

Item 507
Dress Code for All Dayton-Area Residents

Adopted: October 2005

The purpose of this policy is to assure that all interns, residents, fellows and teaching faculty portray a professional image in carrying out their clinical and educational duties. Physicians should wear appropriate clothing suitable to the professional health care environment and safety and infection control principles should be considered when selecting work attire.

These standards are considered the minimum standard. Most Dayton-area hospitals have dress code policies that should be adhered to while working at those institutions. Program or hospital-specific policies would supersede these guidelines.

Implementation of this policy is up to the Program Director or the hospital officials where the resident is rotating.

In areas where scrub attire or standardized uniforms are not necessary, the following guidelines should be followed:

Name Badges: Identification badges must be worn above the waist at all times with the resident's name and photograph clearly visible

Shirts: Shirts with collars, such as golf-type shirts, are approved. Long or short sleeved shirts and sweaters are approved. No t-shirts, sweatshirts, tank tops or muscle shirts, unless worn under other garments.

Pictures and Logos: Clothing (including buttons and accessories) with words, pictures or logos having commercial, sexual, political, and/or negative connotations are not permitted.

Skirts and Dresses: All skirts and dresses should be of appropriate length.

Dresses/Blouses: Dresses/blouses with low tops, bare shoulders or bare backs are not appropriate in the healthcare environment, e.g. evening/party or sun dresses, unless worn with a jacket/lab coat. No bare midriff garments will be allowed.

Pants and Slacks: Pants and slacks should not be too tight fitting (body contouring). Pants should be at least ankle-length. Extremely baggy pants are not to be worn. Jean pants (of any color denim) are not appropriate. Jogging suits, sweatsuits, warm-ups, shorts and stretch (Lycra®) clothing, leggings/tights, stirrup pants are not appropriate.

Shoes: Hose or socks and shoes appropriate for patient care areas must be worn. Flip-flops, sandals and house slippers are prohibited.

Hats: Hats, caps, and head covers should not be worn while on duty unless they are part of a uniform or safety/sanitation gear.

Scrubs: Surgical scrub clothing is not to be worn outside the procedure/clinical area except in emergencies. Fresh scrub clothing must be put on prior to re-entering the operating room whenever old ones have been worn outside that area. Scrubs worn while on-call are acceptable. It is not appropriate to wear hospital-issues scrubs outside of the hospital.

Inappropriate attire

  • Inappropriate tattoos
  • Excessive jewelry
  • Visible body piercing (with exception of ears)
  • Artificially or excessively lengthened nails
  • Excessive fragrances or smell of smoke
  • The obvious absence or presence of undergarments
  • Clothing which is sheer and/or revealing


Reasonable accommodations may be made on an individual basis for employees with properly documented religious needs. Requests with supporting documentation should be discussed with the individual's program director.

Deviation from this policy for a medical condition will require a physician's statement that includes a time period for the exception.

Item 508
Disaster Policy

Adopted: July 2008


This Disaster Planning Policy and Procedure is intended to protect the well being, safety, and educational experiences of the residents/fellows, hereby referred to as trainees, enrolled in Wright State University Graduate Medical Education (GME) training programs.

It provides guidelines for communication with trainees and program leadership to assist in reconstituting or restructuring the trainee's educational experiences as quickly as possible after the disaster, or determining need for transfer or closure in the event of being unable to reconstitute normal program activity.

It provides general information and procedures to support Wright State University GME training programs and trainees in the event of a disaster or interruption in their educational experience.


A disaster is defined herein as an event or set of events causing significant alteration to the trainees' experience of a Wright State University GME training program.

This policy and procedure document acknowledges that there are multiple types of disaster including but not limited to acute disaster with little or no warning (e.g. tornado, bombing), and the insidious disruption or disaster (e.g. pandemic event). This policy and procedure will address disaster and disruption in the broadest terms.


This policy applies to all GME training programs sponsored by Wright State University Boonshoft School of Medicine.


Following declaration of a disaster by the ACGME, the Designated Institution Official (DIO), Graduate Medical Education Committee (GMEC), hospital leadership, and other sponsoring institution leadership will strive to restructure or reconstitute the educational experience as quickly as possible following the disaster. The overall objective is the continuity of training.

In order to maximize the likelihood that trainees will be able to complete program requirements within the standard time required for certification in that specialty, steps will be taken to transfer the affected trainees to other local sites, if necessary. If leadership determines that the sponsoring institution can no longer provide adequate educational experience for its trainees, the sponsoring institution will, to the best of its ability, arrange for temporary transfer of trainees to programs at other sponsoring institutions until such time as the sponsoring institution is able to resume providing the educational experience. Preference will be given to the closest geographic location with the most appropriate training required for trainees.

The Program Director will give the trainees, who temporarily transfer to other programs as a result of a disaster, an estimated time that relocation to another program will be necessary. Should that initial time need to be extended, the Program Director will notify the trainees by written or electronic means identifying the estimated time of the extension.

If the disaster prevents the sponsoring institution from re-establishing an adequate educational experience within a reasonable amount of time following the disaster, then permanent transfers will be arranged.

The Wright State University DIO will be the primary institutional contact with the ACGME, program specific RRC's, and the Institutional Review Committee Executive Director regarding disaster plan implementation and needs within the sponsoring institution.


Communication between the DIO, the GME Office, the program directors, and the trainees is critical in the event of a disaster to assess the impact of that disaster on education and the health and well-being of the trainees.

The DIO will identify an institutional designee to act in the DIO's absence or in case the DIO is incapacitated. If neither the DIO nor the designee is available, the Executive Associate Dean of the SOM will appoint an interim DIO.

The GME office will routinely maintain updated contact information to include home phone numbers, cell phone numbers, pager numbers, and WSU email addresses for its program directors. The program directors will gather and maintain current contact information to include the home phone numbers, cell phone numbers, pager numbers, and email addresses for trainees and faculty. GME Administration will maintain an email list-serve and list of phone and pager numbers for core residency Program Directors, program coordinators, and key faculty (associate program directors) which will be transferred to a memory stick and kept in a separate geographic location.

Data and Document Recovery
Trainee's demographic documentation is stored in Residency Management Suite (RMS) by New Innovations, which is a web-based relational database management system. Data and documents stored in RMS are stored on two IIS servers and two SQL servers at each data center in separate cities. Data from each server is copied to the other server every hour. The servers also have full backups run every night and the backups are located on a backup sub-system own and operated by another company.

Programs are responsible for establishing procedures to protect the academic and personnel files of all trainees from loss or destruction by disaster. This should include at least a plan for storage of data in a separate geographic location away from the sponsoring institution.

A disaster recovery plan which includes management and maintenance of information systems will be critical to maintaining a business continuity plan for GME. Protection of data is paramount to maintaining operations. Therefore, the GME Office, affiliated hospitals, and programs should employ a data protection system that includes electronic capture and storage of all data. Previous data that is still being maintained and stored, whether paper or microfilm, will be protected in an off-site and climate controlled space in order to maintain access to this information after a disaster.

During and/or immediately following a disaster, Wright State University and the employing institutions will make every effort to ensure that the trainees continue to receive their salary and fringe benefits during any disaster event recovery period, and/or accumulate salary and benefits until such time as utility restoration allows for fund transfer.

Longer term funding will be determined on the basis of the expected operations of the teaching sites, Centers for Medicare and Medicaid Services (CMS) and governmental regulations, and the damage to the infrastructure of the finance and hospital operations.

Legal and Medical-Legal Aspects of Disaster Response Activity
Trainees serving under the direction of their program in disaster response efforts will be covered by their employing institution's liability insurance company. Trainees who act as emergency responders under an executive order issued by the governor of Ohio are immune from damages for their good faith acts/omissions in rendering emergency care, advice or assistance under emergency plans.


1. Disaster Response: 0-72 hours after occurrence

Designated Institutional Official (DIO)
The DIO is the primary institutional contact with the ACGME, RRCs, and Institutional Review Committee (IRD) Executive Director regarding disaster plan implementation and needs within the sponsoring institution. The DIO is responsible for maintaining communications between the various Program Directors, the hospital Directors of Medical Education, and the Office of Graduate Medical Education to assess the impact of a disaster on any and all areas of GME and maintaining business and educational continuity. The DIO consults with hospital leadership as needed and may decide to convene a planning meeting to work through important details in managing the situation. The DIO assessment will include the following:

  • Immediate contact and discussion with program directors to determine the availability of trainees and faculty to aid in disaster response.
  • The feasibility of continuing on-site training within the training site(s).

The immediate email communication to all parties will go out through Graduate Medical Education Administration, hereby referred to as GME Administration.

If email communication is not possible, then GME Administration will contact the core residency Program Directors by phone or pager. Fellowship Directors should contact the Program Directors of their core residency program with fellowships to determine next steps.

The DIO will notify the ACGME Executive Director of the disaster and, if appropriate, request a declaration of disaster. The ACGME will post a notice on its website, www.acgme.org.

Program Director
First point of contact. The Program Directors will immediately assess the impact of a disaster on their own programs and on the health and well-being of the trainees within that program. This will be done by the following:

  • Contacting trainees in the program to gather information
  • Referring affected trainees to available resources for care
  • Assessing the functionality of the facilities and operations in the institution that supports that particular educational program
  • Identifying and arranging for alternative clinical/training sites for residents as may be needed

If necessary, the Program Directors will develop a recovery strategy and timetable and a written plan to address response, recovery, and resumption of education and services. They are responsible for getting communications out to their trainees and if necessary to their fellowship directors.

Residents/Fellows (Trainees)
Initially they are expected to report to their originally assigned hospital/clinic location. In the event the hospital/clinic is affected by the disaster and unable to operate in the usual fashion or if the patient load is skewed by the disaster, some or all of the trainees may need to be reassigned by the DIO after discussion with the Program Director and approval of the DIO with the hospital officials.

2. Disaster Response: 3-30 days after occurrence
Institutional Assessment and Decision-making on Program and Institution Status
Resident Transfer

DIO (GME Administration)
The DIO will communicate in writing a formal initial report with the ACGME regarding the nature, extent, and impact of the disaster.

Within ten days after the declaration of a disaster by the ACGME, the DIO will contact the ACGME to discuss the timeframe and dates pertinent to maintaining the education of the trainees within affected programs, including

  • To submit program reconfigurations to the ACGME, and
  • To inform trainees of any transfer decisions. The due dates for submission shall be no later than 30 days after the disaster unless other due dates are approved by the ACGME.

The DIO will monitor progress of both healthcare delivery and functional status of GME training programs for their educational mission during and following a disaster. They (or their designees) will work with the ACGME to determine the appropriate timing and action of the options for disaster impacted institution and/or programs:

  1. Maintain function and integrity of program(s),
  2. Transfer trainees temporarily until program(s) reinstated, or
  3. Transfer trainees permanently, as necessitated by program or institution closure.

Information and decision communications will be maintained with Program Directors and trainees, as appropriate to circumstances of the individual disaster event.

Program Director
The Program Director(s) will communicate with their appropriate Review Committee(s) (RRC) regarding the impact of the disaster and, if necessary, with the specialty board(s) regarding any break in resident training and ensuring compliance as directed by the board. The ACGME website provides instructions for changing trainee email information in the ACGME Web Accreditation Data System.

The Program Director is responsible for:

  • Providing direction and working with others as appropriate to locate and arrange for office space for residency faculty and staff, supplies and equipment, etc. as may be needed.
  • Informing hospital affiliates, volunteer faculty and others associated with the program in a timely manner.
  • Providing oversight, direction and assistance to residents to ensure a quality educational experience throughout the duration.
  • Informing and providing updates as appropriate for the Department Chair about the alternative arrangements, quality of training experiences, issues, progress, etc.

The trainees should call or email the appropriate Review Committee Executive Director with information and/or requests for information. On its website, the ACGME will provide instructions for changing trainee email information on the ACGME Web Accreditation Data System.

ACGME (from ACGME Policies and Procedures)
When warranted, the ACGME Chief Executive Officer, with consultation of the ACGME Executive Committee and the Chair of the Institutional Review Committee, will make a declaration of a disaster. A notice of such will be posted on the ACGME website with information relating to ACGME response to the disaster.

If within the ten days the ACGME has not received communication from the DIO or designee, the ACGME will attempt to establish contact with the DIO(s) to determine the severity of the disaster, its impact on training, and next steps.

The ACGME will assist with communications during any declared disaster. The ACGME will maintain phone numbers and email addresses for emergency communications with disaster-affected institutions.

  • The DIO will call or email the IRC Executive Director with information or requests for information.
  • The program directors will call or email the appropriate RRC Executive Director with information and requests for information.
  • Trainees will call or email the appropriate RRC Executive Director with information and requests for information.

The ACGME will provide and periodically update its website with information relating to the disaster. The ACGME will provide instructions on its website so that a trainee can change his/her information on the Web Accreditation Data System. In the event of a disaster, the Graduate Medical Education Office will communicate directly with program directors and trainees via all available communication techniques to provide guidance for the affected trainees. These communications will include the Graduate Medical Education Office website, the DAGMEC website, and the ACGME website.

The ACGME will establish a fast track process for reviewing (and approving or not approving) submissions by programs relating to program changes to address disaster effects, including, without limitation, (a) the addition or deletion of a participating institution, (b) change in the format of the educational program, and (c) change in the approved trainee complement.

Once information concerning a disaster-affected program's condition is received, the ACGME may determine that one or more site visits is required. Prior to the visits, the DIO will receive notification of the information that will be required. This information, as well as information received by the ACGME during these site visits, may be used for accreditation purposes. Site visits that were scheduled prior to a disaster may be postponed.

New ACGME policy will supersede these current policies as they become enacted.

Resident/Fellow (Trainee) Transfer
As soon as feasible and to the extent that it is possible, the DIO, the GME Office, and the program directors will determine whether the disruption of each program's ability to maintain the educational experience is temporary or permanent.

At the outset of a temporary transfer, a program must inform each transferred trainee of the minimum duration and the estimated actual duration of the temporary transfer and continue to keep each trainee informed of such durations. In the event that the transfer will continue, the program must inform the trainee who has transferred.

In the event that the DIO in conjunction with the program directors determines that a program can no longer provide an adequate educational experience for the trainees, the program directors and the DIO will do the following:

  • Arrange for temporary transfers to available programs to complete the educational experience on an interim basis, or
  • Assist the trainees to achieve permanent transfers to other programs or institutions, if necessary

If more than one program/institution is available for temporary or permanent transfer of a particular trainee, the preferences of each trainee must be considered by WSU. Programs must make the keep/transfer decision expeditiously so as to maximize the likelihood that each trainee will complete training in a timely fashion.

Offering to Accept Transfers
If offering to accept temporary or permanent transfers from programs affected by a disaster, the DIO will complete the form found on the ACGME website. Upon request, the ACGME will give information from the form to affected programs and trainees, and post the information on its website, upon authorization.

The ACGME will expedite the processing of requests for increases in trainee complement from non-disaster affected programs to accommodate trainee transfers from disaster affected programs. The RRC will expeditiously review applications and make and communicate decisions.

3. Post-Disaster

Plans will be made with the participating institutions to which trainees have been transferred for trainees to resume training at Wright State University.

Appropriate credit for training will be coordinated with the ACGME and the applicable Residency Review Committees and

Decisions as to other matters related to the impact of the disaster on training will be made.

Item 509
Accommodation for Disabilities Policy

Adopted: August 2008

Extending the opportunities of higher education to people with disabilities and making reasonable accommodations which will enable its employees to perform the essential functions of their positions are high priorities at Wright State University.

The Wright State University Boonshoft School of Medicine supports the reasonable accommodations which will enable its residents and fellows with a disability to perform the essential functions of their positions.

Each institution that is fiscally responsible for a WSU sponsored GME program and/or site where training occurs will determine what, if any, reasonable accommodation will be made based upon its individual policy.

Residents/fellows with disabilities are responsible for requesting reasonable accommodations. They should consult with their program directors and/or employing Human Resources office to initiate the request.

Item 510
Resident Transfers Policy

Adopted: August 2008

Before accepting a resident who is transferring from another program, the program director must obtain written or electronic verification of previous educational experiences and a summative competency-based performance evaluation of the transferring resident.

For residents who leave the program prior to completion, the program director must provide timely verification of residency education and summative performance evaluations.

Item 511
Social Media Policy

Adopted: June 2011


Online social networks such as Facebook, LinkedIn and Twitter have taken on increasing importance in both personal and professional life. These social media offer unique opportunities for people to interact and build relationships and have great potential to enhance interpersonal and professional communication. As health care professionals with unique social and ethical obligations, medical students, resident physicians and medical school faculty must be keenly aware of the public nature of social media and the permanent nature of its content.

This policy has been developed to ensure that actions taken on the social Internet by members of the Boonshoft School of Medicine community reflect the school’s core values of professionalism, compassion, accountability, integrity, honor, acceptance of diversity and commitment to ethical behavior.

Scope & Definitions

This policy applies to all resident physicians in residency and fellowship programs of the Boonshoft School of Medicine, including contractors acting on its behalf, and covers all interaction with social media.It incorporates all Wright State University and Boonshoft School of Medicine policies relating to professional conduct, ethical behavior and online communications, including but not limited to the Boonshoft School of Medicine Code of Faculty Behavior, the Medical Student Professional Honor Code, HIPAA and Responsible Use of Computing Resources. Resident physicians should follow these guidelines whether participating in social networks personally or professionally, or using personal or university-owned computing equipment when doing so.

The terms social media, social web and social networks comprise Internet- and mobile-based tools for sharing and discussing information based on user participation and user-generated content. Examples include social networking sites like LinkedIn and Facebook, social bookmarking sites like Del.icio.us, social news sites like Digg, Twitter, Youtube and other sites that are centered on user interaction. Social media content may take the form of blogs, social networks, social news, wikis, videos and podcasts.

Official School Business

Only resident physicians authorized by the medical school administration may use social media to portray themselves as representing the medical school or to conduct official business in the name of the school or one of its units. Use of any social media in an official context should have the approval of the school’s Office of Marketing and Communications or the Office of the Dean. University or school logos may not be used on any social media site without the express written approval of Marketing and Communications.

Individual Use

Postings within social network sites are subject to the same professionalism standards as any other personal interactions.Resident physicians of the Boonshoft School of Medicine should routinely monitor their own Internet presence to ensure that the personal and professional information on their own sites and, to the extent possible, content posted about them by others, is accurate and appropriate. Professionalism standards are outlined for students in the Principles of Medical Ethics and for faculty in the Code of Faculty Behavior.

Resident physicians of the Boonshoft School of Medicine who participate in a social media site, whether in a personal or official capacity, should:

  • Take steps to ensure that they have implemented appropriate privacy settings to avoid inadvertent dissemination of personal information to audiences outside their control. This includes making an effort to ensure that you are not “tagged” in images posted by others that might be seen as portraying you in an unprofessional manner.
  • Include a disclaimer with any posting that relates to their role as a member of the Boonshoft School of Medicine community clearly stating that all opinions belong to the poster alone and do not necessarily reflect the views of the Boonshoft School of Medicine or Wright State University.
  • Refrain from violating standards of patient confidentiality or communicating about patients in a manner that could in any way convey a patient’s identity, even accidentally. Patients with rare diagnoses, unusual physical appearances and/or in specific locations within the community may be easily identifiable even in the absence of names and medical record numbers.1
  • Not express defamatory comments about employees, students, health professionals or patients associated with the medical school or its affiliates, post images that would denigrate anyone they come into contact with in the course of carrying out their roles as students or employees of the school or depict other students or employees engaging in unprofessional behavior.
  • Not interact with or “friend” individuals through social networks when they are or have been in a physician-patient or similar relationship.


University administrators may look up profiles on social networking sites and may use the information in informal or formal proceedings without providing notice to the individuals involved. The same standards of professional conduct apply to social networking as to any other ethical or professional breach up to and including dismissal from the school or termination of employment.


Regardless of whether students, resident physicians, faculty, or staff are conducting official school or personal business, they are ambassadors for the school and the medical profession. In online social networks, the lines between public and private, personal and professional are blurred. Just by identifying oneself as WSU resident physician, those affiliated with the school portray an impression of the institution for those who have access to their social network profiles or blogs. Each member of the Boonshoft community should ensure sure that all content he or she is associated with is consistent with his or her position at the school and with the school’s values and professional standards.


  1. “If the information that is shared is generic enough that nobody can identify a patient in the course of reading (Berkman, Massachusetts Medical Law Report, Social Networking 101 for Physicians, 2009), the post is permitted and is a valuable tool for physicians to share information and skills with other physicians faster than ever before.” From “Social Networking and the Medical Practice: Guidelines for Physicians, Office Staff and Patients,” published by the Ohio State Medical Association.


The American Medical Association adopted the following policy on Nov. 8, 2010

AMA Policy: Professionalism in the Use of Social Media

The Internet has created the ability for medical students and physicians to communicate and share information quickly and to reach millions of people easily. Participating in social networking and other similar Internet opportunities can support physicians’ personal expression, enable individual physicians to have a professional presence online, foster collegiality and camaraderie within the profession, provide opportunity to widely disseminate public health messages and other health communication. Social networks, blogs, and other forms of communication online also create new challenges to the patient-physician relationship. Physicians should weigh a number of considerations when maintaining a presence online:

  1. Physicians should be cognizant of standards of patient privacy and confidentiality that must be maintained in all environments, including online, and must refrain from posting identifiable patient information online.
  2. When using the Internet for social networking, physicians should use privacy settings to safeguard personal information and content to the extent possible, but should realize that privacy settings are not absolute and that once on the Internet, content is likely there permanently. Thus, physicians should routinely monitor their own Internet presence to ensure that the personal and professional information on their own sites and, to the extent possible, content posted about them by others, is accurate and appropriate.
  3. If they interact with patients on the Internet, physicians must maintain appropriate boundaries of the patient-physician relationship in accordance with professional ethical guidelines just, as they would in any other context.
  4. To maintain appropriate professional boundaries physicians should consider separating personal and professional content online.
  5. When physicians see content posted by colleagues that appears unprofessional they have a responsibility to bring that content to the attention of the individual, so that he or she can remove it and/or take other appropriate actions. If the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities.
  6. Physicians must recognize that actions online and content posted may negatively affect their reputations among patients and colleagues, may have consequences for their medical careers (particularly for physicians-in-training and medical students), and can undermine public trust in the medical profession.

Item 512
Patient Handoff Communication Policy
Adopted: June 2013


To provide guidance on, and expectations for the development and implementation of a standardized process for handoff communication to ensure effective information transfer among providers during handoff with the overarching goal of minimizing the potential for medical errors. The primary objective of handoff communication is to provide accurate information about a patient’s care, treatment, and services, current condition, and any recent or anticipated changes.

The Joint Commission requires all health care providers to “implement a standardized approach to handoff communications including an opportunity to ask and respond to questions” (2006 NPSG 2E). The Accreditation Council for Graduate Medical Education also requires that residency programs maintain formal educational programs in handoff and care transitions.


Communication: the process by which information is exchanged between individuals, groups, and organizations. In order to be effective, communication should be complete, clear, concise, and timely.

Handoff (as addressed in this policy): the process of transferring patient information and knowledge, along with authority and responsibility, from one clinician or team of clinicians to another clinician or team of clinicians during routine changes of duty assignment.

Signout: as defined by the Agency for Healthcare Research and Quality (AHRQ) is used to refer to the act of transmitting information about the patient.

Transition of care: Patient movement from one area or level of care to another (e.g. emergency department to inpatient admission, general medical floor to intensive care). Such transitions are addressed in other hospital and program policies.


Patient care responsibilities are shared among many team members including, but not limited to, residents and fellows (hereafter referred to as “residents”). When a resident completes an assigned period of duty or prepares to leave the hospital/clinic to take care of other responsibilities, he/she is expected to “sign out” to the resident or attending assuming care for all assigned patients.

It is understood that specific handoff procedures will vary from one discipline to another and from one practice site to another. This policy outlines general principles and expectations for patient handoff, with the adoption of specific process and form to be determined by each program and site. Although no specific requirements are mandated, The Joint Commission provides guidelines for the development of the handoff process. Each program and site will develop its own standardized process and incorporate The Joint Commission guidelines to include the following:

  1. Interactive communication between the giver and receiver of patient information, including an opportunity for the receiver to ask for clarification of any issues or items presented.
  2. A system for providing updated information regarding each patient’s condition, treatment, and anticipated needs during the coverage period.
  3. A strategy to minimize interruptions during the handoff process.

It is expected that every program will develop the handoff process to include the following items:

  1. To whom each resident will sign out and whether handoff includes transfer of an on-call phone or pager.
    • Intern to intern, senior to senior – handoff phone and code pager
    • Fellow to attending
    • Team to team
  2. A location that will minimize interruptions
    1. For many programs this will be a standard time and location for handoffs
    2. For other programs, a mutually agreed upon time and location that will minimize interruptions to the handoff process
  3. Standardized handoff content (consider inclusion of a standard hard copy [see sample (DOCX)] or electronic “signout form” with discipline-specific details for each patient as written communication may assist the person conveying clinical information in organizing his/her thoughts and presenting important details, and provides the receiving party hard copy information for future reference). The most effective handoff of patient information includes both verbal and written components. Although the exact content may vary from one program to another most will likely include the following:
    1. Demographic information: name, room number, date of birth, medical record number
    2. Code status
    3. Reason for admission and active problem list
    4. Consultants currently involved in care
    5. Current medications (if not readily available from Electronic Medical Record)
    6. Allergies
    7. Selected specific therapeutics: oxygen or ventilator settings, dietary restrictions, NPO status for imaging study
    8. Expected action items (lab results, improvement in symptoms) and intended response. Examples:
      • If 9:00 p.m. Hgb < 7, transfuse one unit PRBC
      • If BP systolic consistently > 180, resume labetalol drip
      • If temperature > 101F, no need for additional cultures
    9. Special family or communication issues. Examples:
      • Minor children – custody or guardian
      • Non-English speaking, available translator
    10. Responsible attending physician, how to contact, and specific expectations for updates

If signout forms are used, they must be maintained in a confidential manner. Examples: specific document in the electronic medical record system, password protected document (Word, Excel, etc.) on a single computer workstation, handwritten hard copy passed directly from one resident to another.

Signout forms must never be:

  1. Sent by unencrypted email, even through a hospital system
  2. Left in a publicly accessible mailbox or other “drop area”
  3. Copied for or sent to unauthorized users
  4. Disposed of in non-confidential trash receptacles

Every program is expected to monitor the handoff process. Faculty should seek feedback from residents to make changes that will enhance the ability to cross-cover residents to deliver care as intended by the primary team. Residents should share ideas that will improve the quality of information delivered so covering residents can more easily adjust therapy based on changes in patient condition. The handoff processes should be revised as needed for ongoing improvement in the quality and safety of patient care.

Item 513
Communication and Documentation Policy
Adopted: May 2015

Physicians are required to document all pertinent information regarding patient care as well as notation of communication with their supervising faculty members in the patient’s medical record. All information is to be documented in a timely manner, as soon as is practical, during or after the care episode. Each clinical site may have its own policies regarding documentation in which case these policies will prevail.

Texting of patient information and/or photos may only take place using the clinical site’s approved and secured application to be installed on the physician’s smart device. Texting of orders is subject to the prevailing policies of clinical sites (see each site’s policy manual for details). Texting does not replace the need for personal interaction, direct supervision, or phone discussion, and should be utilized judiciously. Any storing of texts or photos must occur only on the site’s approved application. Taking and transmitting patient photos requires a patient’s consent. Any pertinent information communicated in text must be entered into the patient’s medical record, and text records are not a substitute for this required documentation.

Whereas physicians may practice at multiple clinical sites that may have different brand applications, physicians who wish to text must install all required applications onto their smart devices. The location of the patient will determine which application is to be used to communicate about him or her.

Failure to comply with this requirement may result in disciplinary action up to and including termination.



Last edited on 09/02/2016.