In hospitals participating in a professional graduate education program(s), the organized med...

(1)

The organized medical staff has a defined process for supervision of each participant in the program in carrying out patient care responsibilities by a physician with appropriate clinical privileges.

(2)

The organized medical staff and hospital staff receive written descriptions of the roles, responsibilities, and patient care activities of graduate education program participants.

(3)

The written descriptions of the roles, responsibilities, and patient care activities of graduate education program participants include identification of mechanisms by which the supervisor(s) and graduate education program director make decisions about each participant’s progressive involvement and independence in specific patient care activities.

(4)

Organized medical staff rules and regulations and policies delineate the participants in professional education programs who may write patient care orders, the circumstances under which they may do so, and what entries, if any, must be countersigned by a supervising physician.

(5)

There is a mechanism for effective communication between the committee(s) responsible for professional graduate education and the organized medical staff and the governing body.

(6)

There is responsibility for effective communication with the medical staff and governing body, whether training occurs at the organization that is responsible for the professional graduate education program or in a participating local or community organization or hospital, as follows: - The professional graduate medical education committee(s) (GMEC) communicates with the medical staff and governing body about the safety and quality of patient care, treatment, and services provided by, and the related educational and supervisory needs of, the participants in professional graduate education programs. - If the graduate medical education program uses a community or local participating hospital or organization, the person(s) responsible for overseeing the participants from the program communicates to the organized medical staff and its governing body about the patient care, treatment, and services provided by, and the related educational and supervisory needs of, its participants in the professional graduate education programs. Note: The GMEC can represent one or multiple graduate education programs depending on the number of specialty graduate programs within the organization.

(7)

There is a mechanism for an appropriate person from the community or local hospital or organization to communicate information to the graduate medical education committee about the quality of care, treatment, and services and educational needs of the participants.

(8)

Information about the quality of care, treatment, and services and educational needs is included in the communication that the graduate medical education committee has with the governing board of the sponsoring hospital.

(9)

The medical staff demonstrates compliance with residency review committee citations. Note: Graduate medical education programs accredited by the Accreditation Council on Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), or the American Dental Association’s Commission on Dental Accreditation are expected to be in compliance with the requirements in this standard; the hospital should be able to demonstrate compliance with any postgraduate education review committee citations related to this standard.