Policies+and+Procedures+2016-2017



Loma Linda Pediatric Emergency Medicine Fellowship Policies & Procedures  2017-2018 ** Introduction ** This webpage outlines our operating policies and procedures. The purpose of this document is to provide a convenient reference for our operations. This webpage will be updated based on changes in the educational needs of the fellows, our institutional policies here at Loma Linda as determined by the Graduate Medical Education Office, accreditation requirements as determined by the Accreditation Council for Graduate Medical Education (ACGME) and the associated Review Committee, state and federal laws, and other rules and regulations from appropriate institutions and governing bodies. Every effort has been made to make this webpage compliant and aligned with all of these entities. Once discovered, discrepancies will be dealt with on a case-by-case basis by the Program Director. The timing of updates to this document will be based on the actions of outside entities and the discovery of changes that affect our operations.

Our Curriculum is a “Living” Document
Our curriculum has many facets. We have a 3-year curriculum for graduates of pediatrics residencies and a 2-year curriculum for graduates of emergency medicine residencies. Each fellow's curriculum is an individualized “living” document. Each fellow is responsible for knowing their requirements and meeting them in a manner they feel best meets their own needs. As each fellow's curriculum develops, we use several guiding concepts to help us make the most appropriate decisions possible:

=== We support and follow the mission of Loma Linda University Medical Center and Children's Hospital to "make man whole." === === We strive to understand adult learning theory and implement learning activities that are practical, valuable, meaningful, and appropriate for adult learners taking into account the importance of: === === The 6 competencies from the ACGME Outcome Project (Patient Care and Procedural Skills, Medical Knowledge, Interpersonal and Communication Skills, Professionalism, Practice-based Learning and Improvement, and Systems-based Practice) are incorporated into the fabric of our curriculum and are not separate from it. Our focus for fellowship is to __confirm and enhance__ competence in Interpersonal and Communication Skills, Professionalism, Practice-based Learning and Improvement and Systems-based Practice AND focus on __developing__ subspecialty specific competence in Patient Care and Procedural Skills and Medical Knowledge. We will monitor and assess fellow progress according to the ACGME approved pediatric emergency medicine milestones. ===
 * knowing why we are learning something
 * learners being responsible for their own decisions
 * learners accessing faculty knowledge and experience to enhance their learning
 * recognizing different learning styles in fellows and faculty
 * subspecialty board examination preparation
 * fellows appropriately, clearly, and in a timely fashion expressing their opinions regarding the format of their training program
 * valuing and relying on fellows past and ongoing experience
 * recognizing that one of the richest source of learning for the fellows resides within them
 * fellows and faculty avoiding mental habits, biases, and presuppositions that can cause us to close our minds to new ideas, fresh perceptions, and alternative ways of thinking
 * focusing on learning things fellows need to know and be able to do in order to care for acutely ill and injured children in an emergency department
 * anchoring much of our learning on the patient experiences the fellows have had so that we have case-based or problem-centered learning
 * recognizing that the most potent motivators for adult learners are internal, not external
 * didactic and clinical education having priority in the allotment of fellows' time and energy
 * faculty and fellows collectively sharing the responsibility for the safety and welfare of patients
 * self-directed learning and individual learning plans
 * self-reflection as a key to lifelong learning and continual self-improvement

=== Non-clinical Curriculum  === Our non-clinical activities are anchored around the first Wednesday and the third Wednesday of each month.

**The first Wednesday of each month** consists of a morning conference that is organized and run by the fellows. This morning conference consists of 3 hours of presentations from 8am - 11am. 30 minutes (and occasionally one hour) is dedicated to a required lecture by a second year emergency medicine resident who is mentored by a designated fellow. The remainder of the time is scheduled and arranged by the fellows. There is a good deal of flexibility in how this time can be used. Short lectures, long lectures, panel discussions, guest lecturers, case presentations, radiology reviews, audio-visual presentations, selected materials from the internet, and other didactic formats may be used. Fellows typically in their second or third year of training take primary responsibility for "hosting" or "emceeing" the morning conference on a rotating schedule as follows (for the 2017-2018 academic year):

(Click the icon to see the lecture schedule)

**The first Wednesday** morning session is immediately followed by a seminar lasting from 11am - 3pm (sometimes as late as 5pm depending on the activities included in the "afternoon" component). The afternoon conference is cooperatively organized by the fellows and faculty. Faculty and fellows contribute to the planning and the content of this seminar. Each fellow is responsible for contributing to the educational content of every "afternoon" session they attend.

**The third Wednesday** consists primarily of 4 didactic courses and additional learning activities. The first session starts at 8am, but the order in which the courses are conducted may vary. A SITE review (a "board review"-type course) is held to assist fellows in performing well on the Subspecialty Inservice Training Exam (SITE) which is typically held each spring. Of course, this review also prepares graduating fellows for the subspecialty board examination (the same test is used by the American Board of Pediatrics and the American Board of Emergency Medicine). The second didactic course is a research methods learning experience that prepares fellows for the research component of the SITE and the subspecialty board examination, assists the fellows in enhancing their ability to critically read the medical literature, and assists the fellows in preparing and advancing their scholarly activity project. The third activity will be an imaging in pediatric emergency medicine course that will help the fellow to interpret common imaging studies ordered in the emergency department. The last activity will be a technical skills session.

Emergency Department Continuous Quality Improvement meetings are held **every other month** and fellow attendance is expected when not on PICU, OB, Pediatric Forensics, Pediatric Anesthesia, NICU, or out of town electives. Fellows should strive for 100% attendance.


 * The fourth Friday** of every month will be **PEM Write Club**. On this day, we will meet at SACHS at 9:00 am to work on our academic projects. This will be a dedicated time for fellows and faculty to sit down and work towards completion of their scholarly activities. There will not be planned didactics for this day. When questions arise, help will be available from the group. Fellows should consider this to be one of the 3 days per month required to be spent on administrative and research-related activities. Lunch will be provided. This activity will typically end at 3:00 pm.

__ Our key educational dates for 2017-2018 __ July 1 - New Fellow and Resident Orientation by Loma Linda Graduate Medical Education Office July 5 - PEM First Wednesday Seminar July 18- PEM Orientation July 19 - PEM Third Wednesday Seminar July 26 - EM CQI and Cadaver Lab

August 2 and 16 September 6 and 20 October 4 and 18 November 1 and 15 December 6 and 20 January 3 and 17 February 7 and 21 March 7 and 21 April 4 and 18 May 2 and 16 June 6 and 20

EM CQI: July 26 September 27 November 29 January 24 March 28 May 23

Clinical Curriculum **Supervised Clinical Learning Experiences** (See the “Block” Schedule )

**Graduates of Pediatrics Residencies** **PGY4 Year** Pediatric Emergency Department* – 6 months Adult Emergency Department* – 2 months Obstetrics – 1 month Pediatric Anesthesia – 1 month PICU -- 1 month Elective -- 1 month

**PGY 5 Year** Pediatric Emergency Department* – 6 months Adult Emergency Department* – 2 months (includes EMS training) Elective – 4 months

**PGY6 Year (Junior faculty year)** Pediatric Emergency Department – 12 months (approximately 45% clinical time, 55% non-clinical/research time)

**Graduates of Emergency Medicine Residencies** **PGY4 Year** Pediatric Emergency Department* – 6 months Pediatric Intensive Care Unit – 1 month Neonatal Intensive Care Unit – 1 month Pediatric Subspecialty Clinics – 2 months Pediatric Anesthesia -- 1 month Elective - 1 month

**PGY5 Year** Pediatric Emergency Department* – 6 months Forensic Pediatrics - 1 month Elective – 5 months

*When assigned to the Pediatric Emergency Department, fellows will be scheduled for 15 clinical shifts (10 hours each). When assigned to the Adult Emergency Department, fellows will be scheduled for 13 clinical shifts (10 hours each). Of the shifts in the Pediatric Emergency Department each month, at least 5 are "nights" that will end at or after 2 am. Fellows are expected to spend at least 3 additional days per month on administrative and research related activities.

Throughout the year pediatrics trained fellows in the PGY 4 and PGY 5 year will be assigned to the adult emergency department during the 2nd and 4th Wednesday mornings from 7 am to 2 pm while the emergency medicine residents are in conference. These dates will be coordinated with the emergency medicine schedulers and will take into account the fellows' clinical and nonclinical fellowship obligations. These partial shifts are not counted in any other tally of shift totals (e.g., as indicated above).

Elective requests are due __**three months prior to the elective month**__ (except during the first three months of fellowship). The Program Director acknowledges that learning needs of individual fellows vary. The above numbers of clinical shifts are typical. The Program Director encourages fellows to avail themselves of additional clinical learning experiences as the opportunities arise. In particular, when a paucity of other learners are scheduled to learn in the pediatric emergency department, fellows should discuss with the trainee scheduler opportunities for additional shifts in the pediatric emergency department to supplement their clinical learning. In addition, fellows may request more than the minimum number of shifts per month to enhance the volume of their clinical learning experiences. The Program Director may assign additional clinical time as part of a formal improvement plan, remediation, or probation and this assigned additional clinical time may replace elective time if deemed appropriate by the Program Director.

Graduates of emergency medicine are required to spend 2 months rotating in pediatrics outpatient clinics. These will be spent with a variety of pediatric sub-specialists. Due to the diversity of clinic schedules and locations, fellows will be required to complete a faculty sign in sheet documenting attendance that should match their logged duty hours.
 * Pediatric Subspecialty Clinics **

** Vacation (Paid Leave) ** Loma Linda recognizes 8 official holidays per year. These include:
 * Independence Day (July)
 * Labor Day (September)
 * Thanksgiving (2 days - one taken in October and one in November)
 * Christmas (December)
 * New Year's Day (January)
 * Presidents' Day (February)
 * Memorial Day (May)

During these months, fellows will be scheduled for one less clinical shifts per month (to a minimum of 11 shifts). At least 5 shifts per month are "nights" that end at or after 2am and this remains true even during holiday months. Because of the learning opportunities available during the actual holidays and the importance of our 24 hour/365 day coverage of the pediatric emergency department, fellows should expect to be assigned clinical shifts during holidays in a manner similar to faculty members. The decrease in the number of shifts does not imply or indicate that fellows will have the actual holiday off. **All fellows will work some official and unofficial (eg, Mother's Day) holidays each year.**

Fellows are expected to attend all seminars. **Vacations should be arranged around these dates.** Excessive absences from seminars will be dealt with on a case-by-case basis.

We follow the Loma Linda University Medical Center Operating Policy GMEC-21 regarding paid leave. According to the Graduate Medical Education Office policies, fellows are allotted 20 days of vacation per year. Fellows may take up to 5 days of vacation in any one month and should plan to take vacation during pediatric emergency medicine months (in a maximum of 3 months in any one year) and elective months. According to the Graduate Medical Education Office policies, **vacation may not be taken during the first or last months of training**. Given the importance of the learning opportunities in the pediatric emergency department, the Program Director encourages fellows to take vacation during elective months. When vacation time is taken, fellows will use a combination of clinical shifts and research time such that the minimum number of clinical shifts assigned for any one month in the pediatric emergency department is 11. For every 5 days of vacation taken, 3 days will be used to decrease clinical shifts and 2 days will be used to decrease administrative/research time. 5 vacation days (3 clinical and 2 administrative/research) must be used each quarter, and may be distributed within the three months of the quarter at the discretion of the scheduler. Vacation may not be used to decrease any additional clinical time assigned by the Program Director as part of a formal improvement plan, remediation, or probation. **All vacation requests must be submitted in writing on the appropriate form and approved by the Program Director three months prior to the vacation time (with the exception of the second and third months of the fellowship for new fellows)**.

The PGY6 fellow is a faculty member and teaching physician. Their schedule is integrated into the faculty schedule by the faculty scheduler and follows the rules of Loma Linda Faculty Medical Group and the Department of Emergency Medicine like other faculty.

Schedule requests are due 3 months in advance. PGY4 and PGY5 fellows will make their requests to the faculty member responsible for the trainee schedule. PGY6 fellows will make their requests using Tangier scheduling software to the faculty scheduler, Dr. James Moynihan on or before the due date each month. Late schedule requests have a low priority and may not allow for the granting of specific requests. Late schedule requests will be handled on a case-by-case basis. Excessive numbers of requests or requests deemed inappropriate by the schedulers will be dealt with on a case-by-case basis by the Program Director.

**Supervision** At least one fellowship trained pediatric emergency medicine attending staffs the pediatric emergency department at all times and is available to supervise the fellows. Additional supervision in the pediatric emergency department may be provided by emergency medicine attending physicians. Supervision on other services is provided by attending physicians in the corresponding specialties and subspecialties.

**Progression of responsibility within the fellowship** - Fellows are expected to spend at least the first two months in the pediatric emergency department presenting cases to the attending physician before submitting orders or initiating medical treatment or intervention. After this initial "orientation" time, and if deemed appropriate by the faculty member clinically supervising the fellow, the fellow may then formulate a diagnostic and management plan __and implement it__ prior to presenting to the attending physician. This timeline may be shortened for residents from the Loma Linda emergency medicine or pediatrics residencies. At the start of the PGY5 year, all fellows in good standing are expected to formulate diagnostic and management plans and implement them prior to presenting to the attending physician for all stable patients. Unstable patients will be managed cooperatively with the involvement of the attending physician early in the patient encounter. **All patients seen in the pediatric emergency department are to be presented to the attending physician prior to disposition.** All supervision in the emergency department is direct supervision or indirect supervision with direct supervision immediately available.

Transfer calls taken during the PGY4 year will typically be staffed by faculty prior to the completion of the call. Similarly, radio runs in the PGY4 year will typically be taken by faculty in the radio room. Fellows progressing into the PGY5 year in good standing are expected to handle transfer calls and radio runs with faculty assistance as needed.

To aid in progression of responsibility and preparation for a faculty supervision role, the final pediatric emergency medicine month of the PGY-5 year may optionally be structured as a "pre-attending" month, in which the fellow chooses faculty shifts to attend (with one specific faculty member each time), and is not part of the trainee schedule. During these shifts, the fellow takes presentations from residents and medical students that would normally go directly to the specified attending. The faculty member oversees care through the fellow and provides the fellow with feedback on his or her trainee supervision. The number of shifts should be equal to the number of shifts that the fellow would have had on a typical trainee month in the pediatric emergency department (ie, base of 15, minimum of 11 based on holidays and vacation taken). The decision to pursue this option will be made by the fellow with input from the program director. The fellow should review resources related to this month on the wiki. The fellow will submit a copy of the month's faculty schedule to the program coordinator with the chosen shifts circled.

** Learning ** Fellows are responsible for creating their own electronic written curriculum for each month of training during the PGY 4 and PGY 5 years. Fellows will be trained at the start of their PGY4 year in the creation of goals, learning objectives and assessment tools. Fellows are expected to write goals, learning objectives and assessment tools for each month of training and document them on their personal curriculum page of the wiki. During periodic self-assessment, based on direct feedback from faculty, and in coordination with the fellowship program director, fellows are expected to identify knowledge and performance deficits and address them in their monthly curricula. Eight months of the year will be devoted to curricular elements focusing on Patient Care and Procedural Skills and Medical Knowledge. The other 4 months will be dedicated respectively to the other 4 competencies. These curricular elements will be assessed by the Program Director periodically and their quality will factor into the overall evaluation of each fellow. During the PGY 6 year, the fellow is responsible for developing a written curriculum for each quarter year. The PGY 6 fellow is responsible for writing a curriculum that focuses on all 6 competencies appropriate for a new faculty member and acceptable to the Program Director. Monthly curricula on the wiki will be reviewed and evaluated during semi-annual evaluations or more frequently as deemed appropriate by the Program Director.

**Duty Hours** We follow Loma Linda University Medical Center Operating Policy [|GMEC-12] regarding resident duty hours. Fellows must not voluntarily or involuntarily violate the resident work hour guidelines. The fellows and the program director share responsibility for identifying areas in which work duty hour guidelines have been, might have been, or at risk for being violated. Circumstances in which the fellow suspects that resident work duty hour guidelines have been, might have been, or are at risk for being violated must be brought to the attention to the Program Director in a timely fashion.

**Vacation during the PGY6 year:** The PGY6 fellow is a member of the medical staff and therefore employed by Faculty Medical Group. The typical allotment of clinical time for PGY6 fellows is 18 hours per “week” based on a 40-hour workweek. A “week” is defined as 5 weekdays (Monday – Friday) in any given month. Many months are 4.2 or 4.4 “weeks.” This calculation is the same as that used by the faculty for their schedules. The clinical “load” for a PGY6 fellow compares favorably to that of a new Assistant Professor who typically has clinical duties of 32 hours per week with 8 hours of academic/administrative time. Vacation time is subtracted from the 18 hours per week requirement. For example, if 5 days of vacation (ie, one “week”) is taken in a given month, the clinical expectation for that fellow is decreased by 18 hours for the month. PGY6 fellows must take 5 vacation days per quarter. This process, if changed, will do so in conjunction with overall changes in faculty vacation policies.

**Moonlighting** We will follow Loma Linda University Medical Center Operating Policy GMEC-26 regarding moonlighting. Moonlighting is professional and patient care activity external to the graduate medical education program. Fellows are to inform the program director in writing **prior to** moonlighting. This written notification must be renewed at the beginning of each academic year (July). A form is provided at the beginning of the fellowship and the beginning of each academic year for this purpose. Fellows are expected to report their moonlighting hours in an accurate and timely manner in New Innovations. Fellows on probation may not moonlight. Fellows must never allow moonlighting to cause them to violate work duty hour restrictions as defined in Loma Linda University Medical Center Operating Policy GMEC-12. Fellows must arrive to their fellowship activities (both clinical and non-clinical) ready to work and learn (ie, don't moonlight all night and then go to seminar the next day).

**Email** Each fellow will be given an email account through the medical center. These email addresses are typically of the format fellow@llu.edu. According to Loma Linda University Medical Center Operating Policy GMEC-28, this is the official means of communication to the fellows from the Graduate Medical Education Office and a vital communication tool for the fellowship program. Fellows are responsible for the information sent to this email address and are expected to check this email account at least three times per week.

PEMOSATS are pediatric emergency medicine objective structured assessments of technical skills. We use PEMOSATS checklists as tools for learning key technical skills and for documentation of competency in these skills as required by the ACGME. Fellows are expected to have completed all PEMOSATS by the end of their PGY 5 year. These are accessible on Canvas. Progress towards completion of PEMOSATS will be reviewed by the Program Director at each semi-annual meeting.
 * Competency Documentation **

Fellows will document number of key PEM procedures performed in New Innovations.

As required by ACGME PEM program requirements, fellows will document clinical experiences in cardiopulmonary resuscitation; trauma; disaster and environmental medicine; transport; triage; sedation; emergencies arising from toxicologic, obstetric, gynecologic, allergic/immunologic, cardiovascular, congenital, dermatologic, dental, endocrine/metabolic, gastrointestinal, hematologic/oncologic, infectious, musculoskeletal, neurologic, ophthalmic, psychosocial, and pulmonary causes; renal/genitourinary and surgical disorders; and physical and sexual abuse. A form to facilitate this can be found on the wiki under monthly paperwork. An updated form must be submitted to the program coordinator prior to each semi-annual evaluation.

** Administrative Experiences ** Fellows are expected to participate in six administrative experiences per year of training. Administrative experiences can consist of attending meetings with departmental administrators, reviewing QI cases with the QI director, completing a QI project with the QI director, and active participation as an interviewer on applicant interview days (a maximum of 2 per year). At least one of these activities per year must be a case review with the QI director that is presented in emergency medicine QI conference. Administrative experiences will be documented on the fellows personal administrative page on the wiki.

Click here for a monthly administrative meetings list:

Fellows are expected to complete the IHI Patient Safety course by December of their PGY-4 year. Instructions can be found by following the link. A certificate of completion will be submitted by email to the Program Coordinator.
 * Patient Safety Modules **

Fellows are expected to participate in a minimum of 3 teaching/education experiences per year. These can include co-leading/organizing an emergency medicine residency PGY-2 PEM small groups session, an emergency medicine residency simulation teaching session, a medical student acute care skills evaluation (ACSE) session, a pediatrics residency noon conference, or a PEM board review session as a PGY-6 fellow. Other activities may qualify but should be approved by the program director. These activities will be documented on the fellow's personal administrative page on the wiki.
 * Teaching Experiences **

** Electronic Devices (iPads) ** Fellows will be expected to have their iPads with them for all required fellowship activities both clinical and nonclinical. iPad use within the program will be dictated by the program leadership including the Program Director. Fellows are expected to learn how to use their iPad appropriately for all required program activities. Fellows are responsible for the care and security of their iPad. The iPad must be password protected at all times. Fellows are expected to replace lost, damaged, poorly functioning, or unusable iPads at their own expense and in a timely fashion if the loss or breakage of the iPad was due to dishonesty, a willful act, or gross negligence. The Program Director considers removing the iPad from the provided protective Otter Box as a willful act.

** Fellowiki ** Each fellow is expected to check the fellowiki for announcements and events listed on the official calendar at least three times per week. Fellows are responsible for information communicated through the fellowiki.

**New Innovations** Each fellow is responsible for completing items within New Innovations in a timely fashion. Fellows are expected to log all procedures, duty hours, and moonlighting hours in New Innovations in a timely manner (this will be checked monthly by the program). Failure to do so will be dealt with on a case-by-case basis by the Program Director, but may result in corrective action.

** Policy on Admissions ** **Selection** - Fellows will be selected for our program based on faculty and fellow reviews of letters of recommendation, the program from which the fellow graduated from or is expected to graduate from, USMLE or comparable scores, personal interviews, interpersonal communications during the interview process, personal statement, stated career plans, assessment of overall fit with our program and its resources, assessed ability to fulfill the mission of the institution, demonstrated past self direction and motivation, and overall fit with the field of pediatric emergency medicine. **Promotion** - Fellows will be promoted from one post graduate year to another based on satisfactory performance in the six competency areas as determined by direct observation during clinical care, multi-source feedback (including from families/patients, nurses, the program coordinator, on service and off service faculty, the Program Director), successful and appropriate progress in any formal improvement plans, remediation or probation, and active participation in required fellowship activities, timely submission of required materials. **Renewal** - Fellows will have their contract renewed if they meet the criteria for promotion. Fellows may have their contracts renewed, but may not be promoted if their deficiencies in performance are determined to be remediable by the Program Director and additional time has been arranged for the fellow to meet expectations for promotion. **Termination** - Fellows may be terminated from the fellowship for unprofessional behavior, loss of California medical license, criminal behavior, dishonesty, failure to successfully complete the requirements of probation, deficiencies in performance in any of the six competency areas deemed unremediable by the Program Director, or on a case-by-case basis as determined by the Program Director in consultation with the Graduate Medical Education Office.

** Advanced Degrees During Fellowship ** The Program Director reserves the right to determine the appropriateness of simultaneous pursuit of an advanced degree (e.g., MBA, MPH, MPA) for any individual fellow. The Program Director reserves the right to deem the simultaneous pursuit of an advanced degree inappropriate for any fellow at any point in time. Once the fellow starts an advanced degree program, the Program Director reserves the right to deny a fellow permission to continue in an advanced degree program if the fellow is not performing acceptably in fellowship or is undergoing any disciplinary action (including Formal Improvement Plans). These decisions will be made on a case-by-case basis by the Program Director.

**Health Information (Medical Records)** It is the expectation of the program that medical records will be completed in a timely and appropriate fashion. To develop good charting habits, fellows should complete their charting for all emergency department shifts during or immediately following the shift. All charting must be completed within 24 hours of the patient encounter. Failure to do so will be dealt with one a case-by-case basis, but may result in corrective action.

**Attire** We will follow Loma Linda University Medical Center’s Dress & Appearance Policy. During times in which the fellow will be visible to patients and families, appropriate attire must be worn. Scrubs that are “child friendly” are acceptable. The fellow must not wear scrubs, lab coats, or other items from other institutions, particularly if the logo, name, or other identifiers are visible.

**Legislated Leaves** We will follow Loma Linda University Medical Center and Children’s Hospital Operating Policy I-69 regarding legislative leaves such as those associated with the Pregnancy Disability Act or the Family & Medical Leave Act.

**Fatigue** Our program strives to prevent and counteract the potential negative effects of fatigue on patient care and learning. If the supervising faculty member deems a fellow to be sufficiently overly fatigued to preclude continuing participation in patient care or learning activities, the fellow will be excused from that activity and asked to rest and find a safe way to get home. It is the fellow’s responsibility to notify the program director that such an excusal has occurred. The fellow must notify the program director in a timely fashion. The program director will investigate the situation. If a structural problem with the pediatric emergency medicine fellowship is identified, a corrective plan of action will be initiated. Other cases will be dealt with on a case-by-case basis by the program director. Depending on the identified cause (e.g., out “partying” too late), corrective action may be indicated.

**Honesty** At the heart of all of our professional relationships is honesty. Instances in which a fellow is accused of, suspected of, or discovered to be dishonest will be dealt with on a case-by-case basis by the program director. Formal action leading to probation, suspension, or termination may be indicated.

**Sick Leave** For PGY4 and PGY5 fellows, we follow Loma Linda University Medical Center Operating Policy GMEC-21 regarding sick leave. For PGY6 fellows, we follow the sick leave policies of the Department of Emergency Medicine and those of Loma Linda Faculty Medical Group. Ten days of paid sick leave per year are provided to fellows. Fellows must notify the assigned service, the program director’s office and the Graduate Medical Education Office if they are unable to work (clinically or academically) due to illness. Sick leave is not to be used as additional “vacation.” Sick leave is not to be used when anyone other than the fellow is sick. Sick leave is not transferrable from one fellow to another. Sick leave up to 5 days may be used for paternity leave according to Loma Linda University Medical Center Operating Policy GMEC-21. The program director may ask the fellow to present themselves to the adult emergency department for evaluation during sick leave if the program director is concerned that the fellow is seriously ill or if the program director suspects the fellow is using sick time as “vacation” time.

Circumstances for which fellows who have an illness require more time off work than is available in their annual sick leave allotment will be dealt with on a case-by-case basis. Fellows are responsible for notifying the program director of such an illness as soon as possible.

**“Make Ups”** Any clinical or non-clinical educational activities that are missed are potentially subject to a “make up.” Each of these instances will be dealt with on a case-by-case basis by the program director. Fellows are responsible for appropriately balancing competing demands for their time and energy. When two or more learning activities cause a scheduling conflict, the priority is for clinical learning and for the individual learning needs of each fellow. The fellow is responsible for communicating their choices to the Program Director in a timely fashion.

For cases in which a fellow misses or will miss a substantial number of educational activities (e.g., for maternity leave), the program director will determine an appropriate course of action that meets the objectives missed and is in compliance with ACGME requirements, institutional policies and all applicable regulations and laws. According to the American Board of Pediatrics, absences in excess of 1 month/year of training must be made up.

**Scholarly Activity/Research and the Scholarship Oversight Committee** Each fellow will be required to undertake and satisfactorily complete a Scholarly Project during fellowship. Each fellow will be assigned to a Scholarship Oversight Committee to guide and oversee the fellows’ progress toward completing the Scholarly Project. The program director does not sit on any of the Scholarship Oversight Committees, but may attend their meetings. The chair of all Scholarship Oversight Committees is responsible for selecting appropriate faculty to serve on each fellow’s Scholarship Oversight Committee, providing a semiannual report to the program director on each fellow’s progress toward completion of a Scholarly Project, and providing a report to the program director when a fellow has completed their Scholarly Project satisfactorily. The chair is also responsible for bringing to the attention of the program director any fellow deemed by their Scholarship Oversight Committee to be at risk for failing to complete a Scholarly Project during the fellowship. Remediation or corrective action may be appropriate for those fellows failing to meet deadlines or other requirements established by their Scholarship Oversight Committee.

For graduates of programs in pediatrics who anticipate obtaining subspecialty board certification in pediatric emergency medicine through the American Board of Pediatrics, a personal statement is required. This personal statement is a comprehensive document written by the fellow that is integral to the requirement for scholarly activity. The document should be several pages in length and comment on the fellow’s intended career path upon entering fellowship and reasons for choosing a specific area of scholarly activity. This document should describe the scholarly activity and the fellow’s role in each aspect of the activity, as well as any preparation beyond the core fellowship curriculum needed to ensure successful completion of the project. The personal statement should describe how the scholarly activity furthers the fellow’s career development plan, and should reflect upon the educational value of the pursuit of the project.

For graduates of programs in pediatrics, the requirement for scholarly projects as outlines by the American Board of Pediatrics "//Fellows are expected to complete projects in which they develop hypothesis or in projects of substantive scholarly exploration and analysis requiring critical thinking. Specifically, abstracts, book chapters, and review articles would not be expected to meet the requirement for Scholarly Activity.// In addition, the scholarly project AND the personal statement are due to the program coordinator **NO LATER than May 1** of the year of graduation.

** Clinical Competency Committee (CCC) ** The Clinical Competency Committee will be responsible for evaluating each fellow's progress in the program with an emphasis on the ACGME approved pediatric emergency medicine milestones. The CCC will report on the fellow's performance with respect to the milestones ultimately focusing on promotion, graduation, dismissal, and remediation. Each fellow will be evaluated at least semi-annually by his/her CCC. A group of at least 3 faculty members will evaluate each fellow and prepare a report for the Program Director to include as part of the fellow's semi-annual evaluation. This report will be prepared by the chair of the CCC and will factor heavily in the Program Director's semi-annual evaluation of each fellow. The Clinical Competency Committee may include the Program Director.

**Interviews and Recruitment of Future Fellows** Typically held on Mondays during September and October (and occasionally early November), we hold interviews for prospective candidates for our fellowship. In order to educate fellows about reviewing applications, interviewing techniques, and selection processes, fellows will be given the opportunity to participate in this process. Not all fellows will participate in all interviews or on all interview days.

** SITE ** Each year in the late winter or spring, the Subspecialty In-Training Examination is held. **All fellows are required to participate in and complete the SITE when offered.** The SITE examination must be taken even if the fellow takes paid leave for the rest of the week the examination is offered.

** Simulation Experience ** The fellows may be required to utilize simulation to demonstrate resuscitation and procedural skills during scheduled learning experiences.

**EMS Training and “Ride Alongs”** Fellows trained in pediatrics have EMS training incorporated into their adult emergency department months. EMS training includes 2 four hour shifts in the radio room; a one hour lecture to an approved first responder group; participation in the annual disaster drill; and 6 8-hour ride alongs from the approved agencies list which can be obtained from the program coordinator.

= NICU rotation = Fellows trained in emergency medicine will spend one month in the neonatal intensive care unit. Fellow scheduling for this month is done by fellowship leadership in conjunction with the NICU coordinator. Fellows are not scheduled by the pediatric chief residents, who handle the scheduling of pediatric residents. Fellows are scheduled for this month in accordance with the goals and objectives for the NICU rotation for pediatric emergency medicine fellows, as agreed upon by PEM and NICU fellowship leadership.

= OB/GYN rotation =

Fellows trained in pediatrics will spend one month in OBGYN at White Memorial Medical Center (WMMC.) Fellows will work at WMMC Monday, Wednesday and Friday throughout the month to gain OBGYN experience. While on the rotation the fellow is not required to attend Wednesday Seminar. Fellows are scheduled for this month in accordance with the goals and objectives for the OBGYN rotation for pediatric emergency medicine fellows, as agreed upon by LLUMC PEM and WMMC OBGYN fellowship leadership.

= Pediatric Anesthesia rotation = Fellows trained in both emergency medicine and pediatrics will spend one month in Pediatric Anesthesiology. Fellow scheduling for this month is done by fellowship leadership in conjunction with the pediatric anesthesiology program coordinator and the pediatric anesthesia chief residents. Fellows are scheduled for this month in accordance with the goals and objectives for the pediatric anesthesia rotation for pediatric emergency medicine fellows, as agreed upon by PEM and pediatric anesthesia rotation fellowship leadership.

**“To Make Man Whole” Project** The motto of Loma Linda University Medical Center, “To Make Man Whole,” summarizes its philosophy that work for the whole person – spiritual, physical, mental and social – is an essential part of the gospel of Jesus Christ. Thus, our goal is the restoration of health on this earth and the reconciliation of man to God, which is the preparation for eternal life. To participate in achieving this goal, each fellow is expected to develop a “To Make Man Whole” project and complete it prior to graduation.

**Pediatric Noon Conference** Fellows are expected to provide occasional lectures to the “noon conference” of the Loma Linda Residency in Pediatrics. These dates are typically listed on our calendar. Fellows should coordinate with pediatrics chief residents regarding choices for lectures.

**Other CME activities** The ACGME Program Requirements for Fellowship Education in the Subspecialties of Emergency Medicine [IV A c)(10)] effective July 1, 2007 state: “[Fellows] must be given the opportunity to teach and participate in undergraduate, graduate, and continuing education activities…” Fellows are expected to participate in available CME activities as the opportunities arise. In recent years this has included a pediatric procedure lab for physicians and lectures to physicians, nurses and paramedics. Documentation of participation must be submitted to the program coordinator and in the fellow’s portfolio.

= Medical Professionalism = Fellows must be familiar with the content of this article on online medical professionalism. Breeches in professionalism are dealt with on a case-by-case basis by the fellowship director.



**Institutional Surveys** **When requested, all fellows are required to complete the ACGME Resident Survey in a timely fashion.** When requested, all fellows are required to complete the annual program evaluation and faculty evaluations. When requested, all fellows are required to complete the John Byrne Survey in a timely fashion.

**Semi-annual Evaluations** The Program Director is responsible for a formal semi-annual evaluation of each fellow. The Program Director may assign fellows tasks above and beyond those included in the Portfolio (eg, a self evaluation or personal essay) to bring with them to the semi-annual evaluation meetings.

**Multisource Feedback** Fellows are expected to complete and submit to the Program Coordinator feedback forms in a timely fashion. Each clinical month (either required or elective) fellows are expected to undergo at least 2 face-to-face, documented feedback sessions with faculty members and at least 2 face-to-face documented feedback sessions with patients/families for whom they have cared. Every 3 months in the adult or pediatric emergency department, fellows are expected to undergo at least 2 face-to-face documented feedback sessions with nurses. Every 3 months in the adult or pediatric emergency department, fellows are expected to undergo at least 1 face-to-face documented feedback session with a medical student. Every 3 months or more frequently as needed (as determined by the Program Director), regardless of monthly block rotations, fellows are expected to receive one feedback form from the program coordinator. Fellows are responsible for arranging time for the feedback, completing the forms, and submitting them to the Program Director in a timely fashion. Feedback forms are available here.

**Program Evaluation Committee (PEC)** Fellows will have the chance to evaluate the program formally by surveys at least annually. In addition to this, the program evaluation committee consisting of faculty, fellows, the Program director, and the Program Coordinator will meet at least annually and submit a formal report (the Annual Program Evaluation) to the Graduate Medical Education office. The PEC will be responsible for
 * leading the planning, developing, implementing and evaluation of educational activities of the Program.
 * reviewing and making recommendations for revision of competency-based curriculum goals and objectives.
 * leading the discussion when addressing areas of non-compliance with ACGME standards.
 * reviewing the program annually using evaluations of faculty, fellows, and others.
 * actively ensuring a continual quality improvement process regarding program outcomes

=**Faculty evaluations**= Fellows will evaluate the program and faculty at least annually, typically at the time of the program evaluation committee (PEC) meeting. These evaluations are anonymous and are typically completed electronically using Qualtrics. Thoughtful participation in this process is expected of all fellows. We participate in continuous face-to-face feedback of the faculty by the fellows. In particular, the Program Director, Tim Young, welcomes direct, face-to-face feedback from the fellows regarding any aspect of his interaction with them clinically, academically, administratively or in any other manner.

**Submissions** **to the Program** It is the Program Director's expectation that materials requiring submission to the program will be submitted in a timely fashion. Failure to submit required materials in a timely fashion will be dealt with on a case-by-case basis, but may result in a formal improvement plan, remediation, or probation. A tracking sheet is kept by the Program Coordinator that documents each fellow's submissions. Each fellow is responsible for the contents of this tracking sheet and its accuracy. Fellows should periodically check their tracking sheet with the Program Coordinator and are required to do so approximately 2 weeks prior to each semi-annual evaluation.

**Trades** For clinical shifts in the pediatric emergency department, fellows may only trade shifts with other fellows or second or third year pediatrics or emergency medicine residents. Fellows may not trade with interns or Family Practice trainees.

**NIH Research Training** Fellows are required to complete the research training approved by the Loma Linda Office of Sponsored Research. This can be found online at http://www.citiprogram.org.

**Fluoroscopy** Fellows are required to successfully complete the institutional training for fluoroscopy as soon as possible after starting fellowship. Fellows may not position a patient for fluoroscopy or administer xrays to a patient prior to successfully completing this training. After successful completion of this institutional training, the fellow may position the patient or administer xrays under the supervision of a properly credentialed attending physician. During the first year of fellowship (PGY 4 year) the fellow must register for the examination for the California Department of Public Health Fluoroscopy X-ray Supervisor and Operator certificate test. Before or during the second year of fellowship (PGY 5 year) the fellow is expected to successfully pass the California Department of Public Health Fluroscopy X-ray Supervisor and Operator certificate test. Failure to meet this timeline will be dealt with on a case-by-case basis by the Program Director.

**Formal Improvement Plans, Probation, and Similar Issues** We follow Loma Linda University Medical Center Operating Policy GMEC-29 regarding probation and similar issues. Our processes include Formative Feedback, Formal Improvement Plans, Remediation, Probation, Suspension, and Termination as outlined in this policy. These processes may be contested by the fellow through the “Graduate Medical Education Grievance Policy and Procedure” as presented in Loma Linda University Medical Center Operating Policy GMEC-20. In addition to other actions, the Program Director may assign additional monthly clinical shifts to fellows as part of a formal improvement plan, remediation, or probation.

**Flexibility** The Program Director expects fellows to take an active role in developing their own curriculum. In general, all requests for individual or global changes in any part of the program will be taken seriously. The main constraints involve ACGME requirements, our own institutional rules, requirements of the American Board of Pediatrics, requirements of the American Board of Emergency Medicine, and other similar requirements.

**Accreditation** All fellows are expected to actively assist the Program Director, Program Coordinator, and the faculty in maintaining the accreditation of the fellowship.