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2012-2013 Annual Institutional Review Report Graduate Medical Education Robert C. Fore, EdD, FACEHP, CCMEP Associate Dean and Designated Institutional Official November 21, 2013

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Page 1: 2012-2013 Annual Institutional Review Report Graduate ... · Annual Institutional Review Report Graduate Medical ... 2012 – 2013 Annual Institutional Review Report Graduate Medical

2012-2013 Annual Institutional Review

Report Graduate Medical Education

Robert C. Fore, EdD, FACEHP, CCMEP Associate Dean and

Designated Institutional Official

November 21, 2013

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2012 – 2013 Annual Institutional Review Report Graduate Medical Education

INDEX

Topic Page Rationale ....................................................................................................................................1 Description of the Sponsoring Institution and Organizational Structure ...................................1 Program Leadership ...................................................................................................................2 Institutional and Program Accreditation ....................................................................................4 Continued Support and Accomplishments.................................................................................7 Graduate Medical Education Filled Positions..........................................................................11 Graduate Medical Education Committee .................................................................................12 ACGME General Competencies ..............................................................................................14 Internal Reviews ......................................................................................................................15 Resident Supervision ...............................................................................................................15 Resident Responsibilities .........................................................................................................17 Resident Evaluation .................................................................................................................18 Duty Hours ...............................................................................................................................19 Patient Care ..............................................................................................................................19 Patient Safety and Quality Improvement .................................................................................20 Office of Research ...................................................................................................................24 Annual Research Methods Nuts and Bolts Symposium ..............................................25 Annual Research Week and Awards............................................................................25 Resident Stipends and Benefits ................................................................................................26 Strategic Planning and Goals Clinical ................................................................................................................................28 Educational .........................................................................................................................28 Research ..............................................................................................................................29 Community .........................................................................................................................29 Attachments Institutional Organizational Chart........................................................................ Appendix 1 Accreditation Grid – Current Accreditation ........................................................ Appendix 2 Accreditation Grid – Categorization of Citations ................................................ Appendix 3 Faculty Development Activities .......................................................................... Appendix 4

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Office of Graduate Medical Education 960 East 3rd Street, Suite 104

Chattanooga, TN 37403 Phone: (423) 778-7442. Fax: (423) 778-3673.

Website: www.utcomchatt.org

2012 – 2013 Annual Institutional Review Report on Graduate Medical Education University of Tennessee College of Medicine Chattanooga

November 21, 2013 Robert C. Fore, EdD, FACEHP, CCMEP Associate Dean for Academic Affairs and

Designated Institutional Official (DIO)

Rationale Pursuant to the Accreditation Council for Graduate Medical Education (ACGME) Institutional Requirements, the following information is submitted as an Annual Institutional Review Report from the Designated Institutional Official (DIO) for academic year July 2012 – June 2013. The existing ACGME Institutional Requirements state that the “DIO and/or the Chair of the GMEC must present an annual report to the Organized Medical Staff(s) (OMS) and the governing body(s) of the Sponsoring Institution. This report must also be given to the OMS and governing body of major participating sites that do not sponsor GME programs. This annual report will review the activities of the GMEC during the past year with attention to, at a minimum, resident supervision, resident responsibilities, resident evaluation, compliance with duty-hour standards, and resident participation in patient safety and quality of care education.” Description of the Sponsoring Institution and Organizational Structure The University of Tennessee Health Science Center and its College of Medicine sponsor a Statewide Graduate Medical Education (GME) System with training sites in Memphis, Jackson, Nashville, Knoxville, and Chattanooga. Due to the size of the programs and their distances from the main medical school in Memphis, the Chattanooga and Knoxville sites are separately accredited to sponsor Residency education by the Accreditation Council for Graduate Medical Education (ACGME). The University of Tennessee College of Medicine Chattanooga (UTCOMC) has been a major component of the University of Tennessee College of Medicine since 1973. The UTCOMC is an academic center that has been accredited as the sponsoring institution for medical education programs at its major affiliated training site, Erlanger Health System – the area’s recognized leader in health care. Other participating sites include Memorial Hospital, Parkridge Medical Center, Hospice of Chattanooga, Athens Regional Medical Center, Siskin Hospital for Physical Rehabilitation, Siskins Children’s Institute, and SkyRidge Medical Center. All participating hospitals have continued to maintain accreditation by the Joint Commission for Healthcare Institutions. The UTCOMC mission is to provide quality medical education, patient care, research, and community service, emphasizing the following: Medical Student Education, Graduate Medical Education, Continuing Medical Education, patient care and quality improvement, evidence-based medicine, patient safety, research and scholarly activity, and community service. The UTCOMC is the sponsoring institution for a total of 13 accredited Residency and Fellowship programs and two non-accredited Fellowships in Minimally Invasive Gynecologic Surgery and Orthopaedic Trauma Surgery. 457 paid and clinical (volunteer) faculty are involved in training and supervising Residents and Medical Students. [Appendix 1 is an updated institutional organizational chart detailing the structure of the UTCOMC.]

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2012-2013 UTCOMC Annual Report for GME

The 2012-2013 programs have trained 173 individual Residents and Fellows. The chief executive officer for UTCOMC is the Dean, David C. Seaberg, MD, FACEP. David C. Seaberg, MD, FACEP, CPE, UTCOMC Dean, has continued to serve as an integral part of Erlanger Health System’s key leadership groups: Executive Team, Medical Executive Committee, Executive Leadership Council, and Officers Council. He also serves on the governing board of the Southside/Dodson Avenue Community Health Centers. Deans at each campus (Memphis, Knoxville, and Chattanooga) report to the Executive Dean for the statewide College of Medicine, and ultimately report to the University of Tennessee Health Science Center (UTHSC) Chancellor. The Chattanooga Associate Dean for Academic Affairs, Robert C. Fore, EdD, FACEHP, CCMEP, also serves as the Designated Institutional Official (DIO) for Chattanooga and reports directly to the UTCOMC Dean. Working with the Dean and DIO to provide oversight for medical education programs are the Director of Graduate and Medical Student Education, Pamela D. Scott, and the Graduate Medical Education Committee (GMEC). Louis Lambiase, MD, Assistant Dean for Clinical Affairs, also reports to the Dean in Chattanooga. UTCOMC Chairs report directly to the Dean in Chattanooga. Chairs either serve as Program Directors or appoint separate Program Directors, with the approval of the Dean, Associate Dean for Academic Affairs, and GMEC, for their accredited Residency and Fellowship programs. Program Leadership 2012-2013: Department Program Chair Program

Director Associate Program Director

Emergency Medicine Emergency Medicine Residency

James H. Creel, Jr, MD, FACEP, Interim Chair, Department of Emergency Medicine (also serves as Chief Medical Officer for Erlanger) [Note: Dr. Seaberg has been appointed Chair of the Department of Emergency Medicine for 2013-2014.]

Sudave Mendiratta, MD

Benjamin Smith, MD

Family Medicine Family Medicine Residency

J. Mack Worthington, MD, FAAFP

Stephen M. Adams, MD

James W. Haynes, MD

Medicine Internal Medicine Residency

Mukta Panda, MD, FACP

Lisa J. Staton, MD

Jennifer Dooley, MD, and Victor Kolade, MD

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2012-2013 UTCOMC Annual Report for GME

Program Leadership (Continued) Department Program Chair Program

Director Associate Program Director

Medicine Hospice/Palliative Care Fellowship

Mukta Panda, MD, FACP, (Chair, Department of Medicine)

Robert W. Goldmann, MD

Obstetrics/Gynecology OB/GYN Residency Paul G. Stumpf, MD, FACOG (through June 27, 2013) [Note: Garrett Lam, MD, was appointed Chair effective November 1, 2013.]

William Gist, MD

Obstetrics/Gynecology Minimally Invasive Gynecologic Surgery (approved by the Association of American Gynecologic Laparoscopists)

Paul G. Stumpf, MD, FACOG (through June 27, 2013) [Note: Garrett Lam, MD, was appointed Chair November 1, 2013.]

Stephen Rich, MD

Orthopaedic Surgery Orthopaedic Surgery Residency

Richard G. Alvarez, MD

W. Michael Tew, MD

Orthopaedic Surgery Orthopaedic Trauma Fellowship (accredited by the Orthopaedic Trauma Association)

Richard G. Alvarez, MD

Pete Nowotarski, MD

Pathology None Richard Hessler, MD

Pediatrics Pediatrics Residency Alan Kohrt, MD, FAAP

Janara J. Huff, MD

Marielisa Rincon, MD

Plastic Surgery Plastic Surgery Residency

Larry A. Sargent, MD, FACS, FAAP

Mark A. Brzezienski, MD

Jason Rehm, MD

Radiology None R. Kent Hutson, MD

Surgery Surgery Residency R. Phillip Burns, MD, FACS

Joseph B. Cofer, MD, FACS

Richard A. Moore, MD, PhD, FACS; Ben Dart, MD, FACS; Heath Giles, MD

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Program Leadership (Continued) Department Program Chair Program

Director Associate Program Director

Surgery Colon and Rectal Surgery Fellowship

R. Phillip Burns, MD , FACS (Chair, Department of Surgery)

Richard A. Moore, MD, PhD, FACS

Daniel Stanley, MD, FACS

Surgery Surgical Critical Care Fellowship

R. Phillip Burns, MD , FACS (Chair, Department of Surgery)

Robert A. Maxwell, MD, FACS

Surgery Vascular Surgery Fellowship

R. Phillip Burns, MD, FACS (Chair, Department of Surgery)

L. Richard Sprouse, MD, FACS

Free-Standing Program

Program Sponsors Program Director Associate Program Director

Transitional Year Residency

Internal Medicine and Pediatrics

Mukta Panda, MD, FACP

Jennifer Whitley Dooley, MD

Institutional and Program Accreditation (ACGME) Institutional Accreditation Previously, the Chattanooga Campus was awarded Continued Accreditation in the December 16, 2011 letter from the ACGME’s Institutional Review Committee (IRC). The IRC granted the “maximum accreditation cycle of five years until the next institutional site visit (approximately October 2016) and commended the institution for its demonstrated substantial compliance with the ACGME requirements for Graduate Medical Education without citation.’” Due to changes in the ACGME accreditation system, called the “Next Accreditation System” (NAS), institutional site visits are being transitioned to self-study site visits, and ours is tentatively scheduled for October 2023 (a maximum 10 year cycle). Program Accreditation All 2012-2013 Residency and Fellowship programs are ACGME-accredited with the exception of the Minimally Invasive Gynecologic Surgery and Orthopaedic Trauma Surgery Fellowships, and ACGME accreditation is not required for those subspecialties. All programs have Continued Accreditation with none on probation. [Appendix 2 is an accreditation grid denoting the current accreditation information for each program, and Appendix 3 is a grid categorizing all current citations as reported by the Institutional Review Committee.] All programs are funded through Erlanger and the UT College of Medicine except:

• Hospice and Palliative Care Fellowship funded by Hospice of Chattanooga and • Orthopaedic Trauma Surgery Fellowship funded by the American Orthopaedic

Association - Synthes, Inc.

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2012-2013 Site Visits Two programs participated in site visits by the ACGME during 2012-2013:

1. Colon and Rectal Surgery Fellowship (October 25, 2012) The program is a one-year program requiring at least five prior years of training. Effective February 22, 2013, the Colon and Rectal Surgery Fellowship received Continued Accreditation for one fellow with a four-year cycle until the next site visit (February 2017). The RRC “commended the program for its demonstrated substantial requirements ACGME requirements for Graduate Medical Education”. The RRC “commended the program for the active involvement of the resident in a quality improvement project focused on PICC-associated DVTs. The RRC identified this learning activity as a potential notable practice and requests the Program Director’s permission to include it in a notable practices database available on the ACGME website.” Two citations were identified, and a progress report was requested by August 8, 2013. Due to accreditation changes under NAS, the regular site visit in 2017 will be replaced by a Self-Study Visit in September 2020.

2. Transitional Year Residency (October 24, 2012). The program is a one-year residency at the PGY-1 level for residents planning to enter advanced residency specialties including Anesthesiology, Dermatology, Neurology, Ophthalmology, Pathology, and Radiology. Effective May 02, 2013, the program received Continued Accreditation for up to eight residents with the maximum five-year cycle until the next site visit (May 2018). The RRC identified three documentation citations (one regarding the Transitional Year Education Committee responsibilities; one regarding documentation faculty credentials; and one regarding documenting an evaluation process for residents’ competence in communicating with team members in the hand-over process). The RRC did acknowledge that the program has established formal hand-off mechanisms and had already included a question about competency in transitions of care in each end of rotation evaluation instrument. Due to accreditation changes under NAS, the regular site visit in 2018 will be replaced by a Self-Study Visit in May 2023.

Other RRC Accreditation Letters Received during 2012-2013

• OB/GYN Residency (Site Visit - January 31, 2012) The official RRC Notification Letter for the four-year OB/GYN Program was received October 17, 2012, in which the program received Continued Accreditation with a four-year accreditation cycle. This represented incredible efforts from the program, University, and hospital leadership since the program had been on probation prior to the site visit in early 2012. The program was approved for 16 residents, effective May 17, 2012, with the next site visit scheduled for May 2016. The RRC “commended the program for its demonstrated substantial compliance with the ACGME requirements for Graduate Medical Education … The Committee commended the program for a 100% Board pass rate for program graduated over the past five to six years. The Program Director and Chair have done a remarkable job addressing the concerns that led to a probationary status, changing the culture of the Program and improving the residents’ morale.” The RRC identified three citations regarding procedural experience and education in spontaneous deliveries, abdominal

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2012-2013 UTCOMC Annual Report for GME

hysterectomies, and abortion procedures. Due to accreditation changes under NAS, the regular site visit in 2016 will be replaced by a Self-Study Visit in June 2020.

• Hospice and Palliative Medicine Fellowship (Site Visit - February 2, 2012) Hospice and Palliative Medicine received Continued Accreditation for one Fellow with a four-year accreditation cycle. The program is a one-year fellowship. The RRC “commended the program for its demonstrated compliance with the ACGME requirements.” The RRC identified two citations (faculty scholarly activity documentation and a structured core curriculum conference to augment the fellow’s clinical experience. The next site visit was projected for May 2016; however, due to accreditation changes under NAS, the regular site visit in 2016 will be replaced by a Self-Study Visit in June 2021.

• Plastic Surgery (Site Visit - May 24, 2012) Plastic Surgery received Continued Accreditation in the RRC letter of December 4, 2012, with approval for five residents in the three-year program (effective October 11, 2012) with the maximum five-year accreditation until the next site visit 2017. The RRC “commended the program for its demonstrated compliance with the ACGME requirements.” The RRC identified one procedural documentation citation. Due to accreditation changes under NAS, the regular site visit in 2017 will be replaced by a Self-Study Visit in October 2020.

All Program Information Forms (PIFs) and documentation, including results from ACGME Annual Online Resident and Faculty Surveys were reviewed by the Dean, Associate Dean/DIO, and Director of Graduate and Medical Student Education prior to submission to the individual RRC’s. All correspondence between programs and RRC’s has also been reviewed by the GMEC. As required by the ACGME, the GMEC has approved all appointments for new Program Directors, new programs, progress reports, requests for changes in complement, etc. Program Leadership Changes in 2012-2013 New Program Directors

• Mark Brzezienski, MD, Plastic Surgery Residency • William Gist, MD, OB/GYN Residency • William Goldmann, MD, Hospice and Palliative Care Fellowship • Sudave Mendiratta, MD, Emergency Medicine Residency

Chair After the successful site visit for the OB/GYN Program Paul G. Stumpf, MD, FACOG, Professor and Chair of the Department of Obstetrics and Gynecology, resigned at the end of June 2013 in order to join his family in New Jersey. Garret Lam, MD, was appointed Interim Chair in August 2013 and was named Chair of the Department on November 1, 2013. Associate Program Directors

• Jennifer Dooley, MD, Internal Medicine Residency (Inpatient Medicine) • W. Heath Giles, MD, Surgery Residency • Victor Kolade, MD, Internal Medicine Residency (Outpatient Medicine and Research) • Jason Rehm, MD, Plastic Surgery Residency • Benjamin Smith, MD, Emergency Medicine Residency

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2012-2013 UTCOMC Annual Report for GME

Continued Support and Accomplishments • Successful accreditation decisions for all programs. • Participated in the main medical school accreditation preparation for LCME and SAC

accreditation visits in 2013. • Established a non-accredited Neuro-Interventional Surgery Fellowship to begin July

2013. • Received approval to establish a Transitions to Practice in General Surgery Fellowship,

approved by the American College of Surgeons, as one of seven pilot programs nation-wide to augment general surgery training for recent graduates. The first “fellow/faculty” has begun the one-year training in July 2013.

• Organized a successful 5th annual Faculty Development Retreat (Fall 2012) to focus on team-based learning.

• Increased the number of diversity of institutional and departmental faculty development opportunities in addition to routine didactics, Ground Rounds, and Morbidity/Mortality conferences. [Appendix 4 denotes the overview of faculty development activities.]

• Successfully renovated and relocated the Medical Library into the same building as the Dean’s Office and Department of Internal Medicine (3rd Floor Whitehall Building) with increased electronic resources, study space, meeting rooms, and computer access for Medical Students, Residents, Fellows, and Faculty.

• Continued University funding has been provided for the Dean, David Seaberg, MD, and Associate Dean, Robert C. Fore, EdD, FACEHP, CCEMP, to participate in the American Medical Association Section on Medical Schools.

• Continued funding has also been provided for the Director of Graduate and Medical Student Education, Pamela D. Scott, to participate in the Association for Hospital Medical Education and its Council for Administrative Directors of Medical Education.

• The Dean has continued to conduct regular leadership meetings with the Business Manager, Chairs, and Program Directors to ensure communication and oversight.

• Continued regular meetings with the Dean, Associate Dean/DIO, and Director of Graduate and Medical Student Education with Medical Students and Residents (Bi-Monthly Medical Student Lunch with the Deans and Quarterly Residents Lunch with the Deans).

• Research – o $2.4M National Children’s Study grant awarded o $2.1M in grants in Nanomedicine, Surgery, Internal Medicine o $3.8M in grants to submitted: R13, R18, R34 o Currently have over 256 active studies on the Chattanooga campus o Improved Scientific Review Committee o Hired new Research Compliance Officer: Amy Hutcherson, PhD o Developed new algorithms for Research Grant and Contract processing o Additional grants submitted –

CMS Innovations Center: Transitions of Care in the Emergency Department: Creating the Medical Neighborhood - $2,700,000

Arthur Vining Davis Foundation: FUTureDocs Programs: A Proposal from the University of Tennessee College of Medicine Chattanooga - $230,691

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AHRQ: Tran PAR-09-071: Comprehensive Care Coordination for the Complex Patient - $487,000 – pending

o Conducted the Annual Research Nuts and Bolts Symposium o Working with Erlanger to establish Clinical Trials Center

Hired Director of the Clinical Trials Center: Dr. Severance Hired 2 Research Coordinators for the Clinical Trials Center

• Continued to offer all required rotations for junior and senior medical students from Memphis and to senior students from other US and international schools. UTCOMC hosted 110 UT students and 59 visiting students for a total of 398 student block rotations.

• The “Healthcare Principles in Practice” (HPP) series provide both an institutional core curriculum for residents and fellows as well professional development for faculty. These are held the second Tuesday of each month, Noon – 1 PM, in Erlanger Probasco Auditorium. Topics focus on non-specialty focused ACGME General Competencies (Patient Care, Interpersonal and Communication Skills, Practice-Based Learning and Improvement, Professionalism, and Systems-Based Practice) and include teaching and mentoring skills, recognizing and addressing fatigue and sleep deprivation, physician impairment, medical-legal issues, malpractice, evaluation models, medical ethics, patient safety, etc.

• The Alper endowment funded the guest speaker for the 6th Annual Harold Alper, MD, Humanitarian Series and Award on April 12, 2013. The special guest speaker was Porter Storey, Jr, MD, FACP, FAAHPM, Executive Vice President, American Academy of Hospice and Palliative Medicine, and Palliative Care Physician for Colorado Permanente Group. His topic was, "Palliative Care Is Whole Person Care." Nine Residents and Fellows in their final year of training at the UTCOMC were nominated for the award:

o Jacob Dowden, M (Surgery, PGY-6 Chief Resident) o Sean Huang, MD (Internal Medicine, PGY-3 Chief Resident) o Michael Malandra, MD (Pediatrics, PGY-3 Senior Resident) o Ryan Moore, MD (Transitional Year, PGY-1 Resident) o Kristin Salter, MD (OB/GYN, PGY-4 Chief Resident) o Vanessa Slots, MD (Pediatrics, PGY-3 Senior Resident) o Bryan Vance, MD (Emergency Medicine, PGY-3 Senior Resident) – Dr.

Vance was named the recipient of the 2013 Harold Alper, MD, Humanitarian Award.

o James Wagner, MD (Emergency Medicine, PGY-3 Senior Resident) o Seth Wagner, DO (Internal Medicine, PGY-3 Chief Resident)

• The UTCOMC Chapter of the Gold Humanism Honor Society (GHHS) has continued to be led by Faculty advisors, Drs. Mukta Panda and Robert Fore, and liaison, Pamela Scott. The 5th Annual GHHS induction ceremony was held on May 10, 2013. Nineteen members of the Class of 2014 were inducted into the GHHS Chapter:

o Joshua Nissi Christian Bakke o Andrew Bradley Boucher o Jesse Thornhill Davidson o Ludwig Ivan Francillon o Ashada Freshwater o Kenetra Modessa Hix o Benjamin Allen Jones

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o Christopher Michael Knight o Jacob Ian Lewis o Benjamin James Maddox o Samuel Ray Marcrom o Patrick David McFarland o Robert Hines Mitchell o Zachary Paul Nahmias o Dilan Anil Patel o Donald Lee Pierce o Charles William Schlappi o Dawn Elizabeth Scott o Abigail Lynn Smith

• Continued to sponsor a one-year Pre-Med Course for six pre-med students at the local University of Tennessee at Chattanooga.

• The Clinical Skills and Simulation Center provided inter-disciplinary medical training in a high-fidelity simulated environment. The focus has not only been on the procedural skill education, but has included training for communication, teamwork, patient safety, and infection control skills among various healthcare providers. Simulated code training can be managed in the Simulation Center and has been conducted within Erlanger on patient floors and supervised by faculty.

• Monthly training sessions for the UTCOMC website maintenance have continued to be provided for administrative staff and Faculty from individual departments. These have been conducted by Pamela Scott, Director for Graduate and Medical Student Education. In addition, Ms. Scott had also been available for training sessions twice each month for administrative staff who manage Residency information, including duty hours, demographics, and evaluations, via the web-based software, New Innovations Residency Management Suite.

• Two Program Directors, Drs. Joseph Cofer (Surgery) and Mukta Panda (Transitional Year), have served on national taskforces to develop and beta test Milestones in each of their respective programs in advance of the Next Accreditation System.

• Increased involvement in the Institute for Healthcare Improvement (IHI) Open School Chapter as a joint effort between the University and Erlanger. Attendance at the monthly session averages 50-75, led by the DIO, Dr. Robert Fore; Resident Leader, Dr. Paul Courtwright (Emergency Medicine); and representatives from each UT department and hospital quality improvement/patient safety staff, and allied health providers. An Open School Steering Committee meets monthly to plan the Open School activities and includes attendance by faculty, residents, Erlanger Chief Quality Officer, Chief Medical Officer, and Chief Nursing Officer.

• Established an Annual Patient Safety/Quality Improvement Day to recognize ongoing PS/QI activities and projects beginning May 2014.

• The Department of Internal Medicine has successfully developed, through partnership with hospital case managers and documentation specialists, the first dashboards for the Chattanooga Campus for Internal Medicine and Transitional Year Residents and faculty (e.g., LOS, DRG, core measures).

• Following the death of longtime Internal Medicine faculty member, Winston Caine, MD, the Department of Internal Medicine and its Internal Medicine Education Foundation established

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a Winston P. Caine, Jr, Lectureship Series in his honor. Dr. Caine was an inspirational teacher and role model as a physician, serving as an attending physician at Erlanger since 1969, and Professor in the Department of Internal Medicine from 1975 – 2012. For many years he also served as the Medical Director for Continuing Medical Education for the Chattanooga Campus, and also established and directly weekly MKSAP (Medical Knowledge Self-Assessment Program) review sessions for residents and faculty from 1979 until his death.

• Joseph Cofer, MD, was recognized as a Public Health Champion for 2012 by the Tennessee Medical Association. In 2013, Dr. Cofer was appointed Chair of the American Board of Surgery, the national certifying board for general surgeons and related subspecialties (28,000 member association). He is the first Chattanooga faculty member and surgeon to be named to this post.

• Robert Fore, EdD, FACEHP, CCMEP, served multiple times during 2012-2013 as a special reviewer for the Accreditation Council for Continuing Medical Education. He has also represented the UT Health Science Center and College of Medicine at several AMA conferences.

• Alan Kohrt, MD, FAAP, was honored as the Tennessee Chapter of the American Academy of Pediatrics as “Pediatrician of the Year” at the July 2012 TAAP Annual Awards Gala for his exceptional contribution to children and child health advocacy.

• In its 2013-14 Top Hospitals edition, U.S. News & World Report has recognized Dr. Louis Lambiase, Professor and Assistant Dean for the UT College of Medicine Chattanooga and physician with Erlanger’s Academic Gastroenterology practice, as among the top 1% of gastroenterologists in the nation. Before his arrival at Erlanger in 2009, Dr. Lambiase served as Chief of Gastroenterology at University Medical Center in Jacksonville, Florida.

• Mukta Panda, MD, FACP, received the Alexander Hamilton Award for the Legal Health partnership June 2012. She is the project faculty for the $2 Million HRSA grant for Nurse Education, Practice, Quality & Retention Project for the Coalition for Inter-professional Geriatric Care ( 2012). Dr. Panda was the recipient of the Mahatma Gandhi Pravasi Gold Medal 2012 award, presented at the House of Lords London in October 2012 by the government of India to non-resident Indians for their outstanding services, achievements and contributions in their respective professions and fields. She was one of only a few physician leaders selected to attend the Gateway Retreat by the Center for Courage and Renewal in September 2012. Dr. Panda was also invited by the ACGME to assist in planning and facilitation the Courage to Teach and Lead Awardees retreat in Chicago (2012). She was also a recipient of the 2012 Woman of Distinction award given by the American Lung Association in Tennessee. The award is given to 10 women who represent the Chattanooga area's most accomplished women who have distinguished themselves within their family, career, and community. Dr. Panda was a recipient of the Hind Rattan Award 2012 awarded by the government of India to non-resident Indians for their outstanding services, achievements and contributions in their respective professions and fields.

• Marielisa Rincon-Subtirelu, MD, and Mihail Subtirelu, MD, pediatric endocrinologist and pediatric nephrologist respectively, were awarded Diplomate status by the American Board of Clinical Lipidology (ABCL). They are part of an elite group – only a handful of Pediatric subspecialists who have achieved this certification. Both of core faculty members in the Department of Pediatrics, and Dr. Marielisa Rincon-Subtirelu is also Associate Program Director for the Pediatrics Residency.

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• Mark Rowin, M.D., Associate Professor in the Department of Pediatrics and Pediatric Intensivist at T.C. Thompson Children’s Hospital, has been selected as one of the recipients of the Presidential Citation by The Society of Critical Care Medicine for his extraordinary contributions of time, energy and resources to the SCCM during 2012. The Society established the Presidential Citation Award in 1995 to honor SCCM members who have made outstanding contributions to the organization. This is the second consecutive year Dr. Rowin has been selected for this prestigious honor.

• David Seaberg, MD, completed his tenure as President of the American College of Emergency Physicians, giving 67 media interviews, and several meetings at the White House with CMS leadership and the Vice President. He established national taskforces on sedation, transitions of care, delivery system reform, quality, and PA curriculum. Dr. Seaberg gave major presentations at the ACEP Scientific Assembly and Leadership and Advocacy Conferences. He was appointed Chair of the Board of the American College of Emergency Physicians and has continued in a leadership role as Immediate Past President of ACEP. Dr. Seaberg Served on Board of Directors and Chaired the ACEP Foundation has continued to serve on the Board of Directors for the Emergency Medicine Foundation; the AMA Section on Medical Schools; and has recently been appointed to the AAMC Group on Regional Medical Campuses and AAMC Research Group on Regional Medical Campuses.

Graduate Medical Education Filled Positions

• 2003-2004: 138 Residents and Fellows • 2004-2005: 141 Residents and Fellows • 2005-2006: 141 Residents and Fellows • 2006-2007: 146 Residents and Fellows • 2007-2008: 147 Residents and Fellows • 2008-2009: 152 Residents and Fellows • 2009-2010: 157 Residents and Fellows • 2010-2011: 164 Residents and Fellows • 2011-2012: 168 Residents and Fellows • 2012-2013: 173 Residents and Fellows

Breakdown of filled positions by program (2012-2013) Program FTE’s Colon/Rectal Surgery 1 Emergency Medicine 19 Family Medicine 19 Internal Medicine 30 Hospice and Palliative Medicine (program funded by Hospice of Chattanooga)

Unfilled

Obstetrics and Gynecology 15 Minimally Invasive Gynecologic Surgery (paid as faculty) 2 Orthopaedic Surgery 15 Orthopaedic Trauma Surgery (Fellow funded by Synthes) 1 Pediatrics 25 Plastic Surgery 5 Surgery 32

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Program FTE’s Surgical Critical Care 2 Transitional Year 6 Vascular Surgery 2 As evidenced by the table above, UTCOMC Graduate Medical Education Programs have continued to grow, primarily due to funding and support from both the University and Erlanger. The 2012-2013 recruiting season was extremely successful. Programs filled all available positions via the National Resident Matching Program and Specialty Matching Programs. The new policy of the NRMP requires an “all in” policy – programs seeking applicants for first year positions are no longer permitted to offer positions outside the Match until official results are released in mid-March. More than a third of the incoming 2013-2014 Residents and Fellows were recruited applicants who rotated in Chattanooga as students during their last two years of medical school. The University continues to acknowledge Erlanger financial support for Resident recruiting, particularly for primary care Residency programs (Family Medicine, Internal Medicine, and Pediatrics). Graduate Medical Education Committee The ACGME requires that an administrative system be in place in each sponsoring institution that includes a Graduate Medical Education Committee (GMEC) to provide oversight for its Residency and Fellowship programs. The Chattanooga GMEC meets ten times each year to fulfill these responsibilities. The GMEC is chaired by the Associate Dean/DIO. Department Chairs and Residency Program Directors from each department or program (listed above) are members. Other members include:

• Dean • House Staff Association Officers (Residents) • Peer-selected Resident or Fellow representatives from each department • Erlanger Chief Medical Officer • Erlanger Administrative Representatives (President/CEO and Senior Vice President for

Planning or Chief Nursing Officer) • Erlanger Chief Quality Officer • Director of Graduate and Medical Student Education • Associate General Counsel for the University of Tennessee (ex-officio) • Business Manager (Faculty and Finance) (ex-officio) • Director of Research (Ex-Officio)

Participation of Erlanger Administration, Chairs of ancillary clinical departments (e.g., Radiology), and Resident representatives from each program supports communication and provides appropriate hospital administrative representation and Resident involvement in policy decisions. The GMEC has carried out its responsibilities as required by the ACGME:

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• Establish and implement policies and procedures regarding the quality of education and the work environment for the Residents in all ACGME-accredited programs.

• Review annually and make recommendations to the Sponsoring Institution on Resident stipends, benefits, and funding for Resident positions to assure that these are reasonable and fair.

• Establish and maintain appropriate oversight of and liaison with Program Directors and assure that Program Directors establish and maintain proper oversight of and liaison with appropriate personnel of other institutions participating in ACGME-accredited programs of the Sponsoring Institution.

• Establish and implement formal written policies and procedures governing Resident duty hours in compliance with the Institutional and Program Requirements.

• Develop and implement procedures to regularly monitor Resident duty hours for compliance with the Sponsoring Institution's policies and the Institutional and Program Requirements.

• Develop and implement written procedures to review and endorse requests from programs prior to submission to an RRC for exceptions in the weekly limit on duty hours up to 10 percent or up to a maximum of 88 hours.

• Assure that ACGME-accredited programs provide appropriate supervision for all Residents that is consistent with proper patient care, the educational needs of Residents, and the applicable Program Requirements.

• Assure that each program provides a curriculum and an evaluation system to ensure that Residents demonstrate achievement of the six general competencies listed in Section III.E and as defined in each set of Program Requirements.

• Establish and implement formal written institutional policies for the selection, evaluation, promotion, and dismissal of Residents in compliance with the Institutional and Program Requirements.

• Review all ACGME program accreditation letters and monitor action plans for the correction of concerns and areas of noncompliance.

• Review the Sponsoring Institution's Letter of Report from the IRC and develop and monitor action plans for the correction of concerns and areas of noncompliance.

• Conduct internal reviews of all ACGME-accredited programs including subspecialty programs to assess their compliance with the Institutional Requirements and the Program Requirements of the ACGME Residency Review Committees.

• Review and approve the following prior to submission to the ACGME: o all applications for ACGME accreditation of new programs and subspecialties; o changes in Resident complement; o major changes in program structure or length of training; o additions and deletions of participating institutions used in a program; o appointments of new Program Directors; o progress reports requested by any Review Committee; o responses to all proposed adverse actions; o requests for increases or any change in Resident duty hours; o requests for "inactive status" or to reactivate a program; o voluntary withdrawals of ACGME-accredited programs; o requests for an appeal of an adverse action; and, o appeal presentations to a Board of Appeal or the ACGME..

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ACGME General Competencies Residents are considered both trainees and students of the Graduate Medical Education Program and are required to demonstrate competency in the six General Competency areas required by the Accreditation Council for Graduate Medical Education:

• Patient Care • Medical Knowledge • Practice-Based Learning and Improvement • Interpersonal and Communication Skills • Professionalism • Systems-Based Practice

Residents must meet the following in order to continue in the program and successfully complete Residency training:

• Incremental increase in competency in Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health; competency to perform all medical and invasive procedures considered essential for the area of practice (including identifying and performing invasive and non-invasive medical procedures; gathering critical information and data, whether in the form of History and Physicals or diagnostic testing; interpreting results; and knowledge of protocols);

• Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care and a willingness to teach and supervise others;

• Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care;

• Clinical judgment (including synthesizing data gathered from appropriate sources and applying the information and medical knowledge to a particular patient care situation, and the ability to respond to unpredictable treatment situations);

• Technical skills necessary to perform diagnostic, medical and surgical procedures and to deliver other forms of medical treatment;

• Interpersonal and Communication Skills (humanistic skills such as interacting with patients, peer Residents, Faculty, and other medical staff) that result in effective information exchange and teaming with patients, their families, and other health professionals. Receptivity to feedback and corrective action from Faculty and peers; and demonstrating concern for patients' well-being;

• Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population (including attendance, punctuality, availability, and enthusiasm);

• Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system for health care and the ability to effectively call on system resources to provide care that is of optimal value (including adherence to institutional standards of conduct, rules and regulations, including program standards and hospital and clinic rules with respect to scheduling, charting, record-keeping, and delegations to medical staff).

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Re-appointment and promotion to the subsequent year of training requires satisfactory, cumulative evaluations by program Faculty. Programs have been directed by the ACGME and UTCOMC leadership to continue to adapt educational rotation goals and objectives by level of training and identify specific competencies that correlate with each individual learning objective, as well as teaching methods and evaluation tools. All programs have completed the initial revision to include specific competencies with each objective, but this is an ongoing process as rotations and educational methods change and improve. Internal Reviews Under the ACGME accreditation system, internal reviews have been required at the approximate midpoint between site visits and within the overall cycle projected by the institution. Reports from internal review panels were discussed and approved by the GMEC. None of our programs were scheduled for Internal Reviews during 2012-2013; however, a special, focused mini review was conducted prior to establishing a non-accredited Neuro-Invasive Surgical Fellowship. The Fellowship was established July 2013. The Mini Review Panel was chaired by the Associate Dean/DIO. A member of Erlanger Administration (Administrator for Erlanger Surgery Operations) and the Director of Graduate and Medical Student Education also served on the panel. Under the NAS requirements, internal reviews will only be required between official site visits if a significant problem is identified when reviewing Annual Program Evaluations (APEs) which are self-studies conducted by each program. Resident Supervision The institution has continued to enforce its Resident Supervision Policy and is compliance with the ACGME Common Program Requirements: In this policy, the term “Faculty Member” refers to a physician who has been appointed to the Faculty of the University of Tennessee College of Medicine Chattanooga, is a member of the Medical Staff of the affiliated hospital facilities in which our Residents/Fellows train, and serves as an attending physician for given patients. The four classifications/levels of supervision for Residents and Fellows are:

• Direct Supervision • Indirect Supervision with Direct Supervision IMMEDIATELY available • Indirect Supervision with Direct Supervision available • Oversight/General Supervision

General Policy: Each ACGME accredited training program is required to follow this institutional GME Policy and develop a written, program-specific supervision policy consistent with its individual Residency Review Committee (RRC) requirements.

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The Chair of the Department to which the Resident/Fellow is assigned and/or the Program Director is responsible for supervision of the Resident/Fellow. Responsibility for specific supervision may be assigned to a Faculty member supervising the Resident/Fellow on various academic rotations. For many aspects of patient care, the supervising physician may be a more advanced Resident or Fellow. Supervision may be exercised through a variety of methods. Some activities require the physical presence of the supervisor. Other portions of care provided by a Resident or Fellow can be adequately supervised by the immediate availability of the supervising Faculty or advanced Resident or Fellow, either in the institution, or by means of telephone or other electronic modalities. In some circumstances, supervision may include post-hoc review of Resident or Fellow delivered care with feedback as to its appropriateness. Residents/Fellows are not members of the hospital’s Medical Staff but are recognized as health care providers who will be involved in patient care under the supervision of an appropriate Medical Staff/Faculty Member, as defined in the hospital’s Medical Staff Bylaws and Rules and Regulations. Residents/Fellows may provide assistance in the care of patients of physicians on the service to which they are assigned. All patients receiving care at the participating hospital facilities are assigned to a member of the hospital’s Medical Staff, designated as that patient’s attending physician. The attending physician responsible for the care of patients with whom Residents/Fellows are involved will provide the appropriate level of supervision based on the nature of the patient’s condition, the likelihood of major changes in the management plan, the complexity of care, and the experience and judgment demonstrated by the Residents/Fellows being supervised. The Medical Staff/Faculty Member, within the limits of his clinical privileges and with continued supervision, may extend specific patient care responsibilities to the Resident/Fellow, commensurate with the Resident’s/Fellow’s demonstrated competence. As part of the training programs, Residents/Fellows will have the privilege of progressive responsibility for the care of patients and may act in a teaching capacity and provide supervision to less experienced Residents and Medical Students. It is the decision of the Faculty member, with advice from the Program Director, as to which activities the Resident/Fellow will be allowed to perform within the context of the assigned levels of responsibility, based on the needs of the patient and the skills of the Resident/Fellow. The overriding consideration must be the safe and effective care of the patient. To ensure oversight of Resident and Fellow Supervision and graded authority and responsibility for patient care, each Program must use the following classifications/levels of supervision:

• Direct Supervision means that the supervising physician is physically present with the Resident and patient.

• Indirect Supervision with Direct Supervision IMMEDIATELY available means that the supervising physician is physically within the hospital or other site of patient care, and is IMMEDIATELY available to provide Direct Supervision.

• Indirect Supervision with Direct Supervision available means that the supervising physician is not physically present within the hospital or other site of patient care, but is IMMEDIATELY available by means of telephone or other electronic means, and can be available if required for Direct Supervision

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• Oversight/General Supervision means that the supervising physician is available to provide review of procedures or the encounter with feedback after care is provided but the procedure or care does not warrant physical presence of the attending.

In particular, PGY-1 Residents should be supervised either directly or indirectly with direct supervision immediately available as described in the levels of supervision above, unless the patient care activity or procedure is denoted as warranting Oversight/General Supervision. In an emergency, defined as a situation where immediate care is necessary to preserve life or prevent serious impairment, Residents are permitted to initiate whatever care is necessary and reasonable to save a patient from serious harm even if an attending physician is not immediately available to supervise. The appropriate Medical Staff member should be notified as soon as possible. Supervising physicians may be more advanced Residents or fellows. Documentation of supervision will be by progress note, signature, additional evaluation note by the attending physician, or may be reflected within the Resident’s/Fellow’s progress notes of notification and will be consistent with the management plan previously agreed upon with the attending physician at a frequency appropriate to the patient’s condition. Annually, the UT GME Office obtains a Resident Exemption from license for each Resident/Fellow from the Tennessee Board of Medical Examiners – unless the Resident or Fellow already has a full and unrestricted license from the Board. As part of the training program, Residents/Fellows should be given progressive responsibility for the care of patients and to act in a teaching capacity themselves and provide supervision to less experienced Residents/Fellows and students. It is the decision of the Medical Staff/Faculty Member, with advice from the Program Director and/or Chair, as to which activities the Resident/Fellow will be allowed to perform within the context of the assigned levels of responsibility. The overriding consideration must be the safe and effective care of the patient. Fee for Teaching Physician Services: In those instances in which the attending physician may submit a bill for services as the teaching physician, supervision must be provided in keeping with the HCFA (CMS) Final Rule and its subsequent revisions. Individual Resident procedures and supervision level information are available in real time to Residency programs, Erlanger Medical Staff, Nursing, and other Erlanger staff via a web-based application system (New Innovations). The information has been entered as communicated by individual Residency programs and can be updated by Residency Coordinators. The information has continued to be monitored for the GMEC by the Director of Graduate and Medical Student Education. Resident Responsibilities The institution has identified the following as Resident responsibilities in Graduate Medical Education programs. These are included in the Resident Initial Letter of Appointment signed by each Resident and the institution upon appointment:

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• Develop a personal program of self-study and professional growth with guidance from the teaching staff.

• Pass Step 3 of the United States Medical Licensing Examination (USMLE) [or the osteopathic equivalent if appropriate] to be eligible for re-appointment beyond the PGY-2 level in any UTCOMC program.

• Participate in safe, effective, and compassionate patient care under supervision, commensurate with their level of advancement and responsibility.

• Participate fully in the educational and scholarly activities of their program and, as required, assume responsibility for teaching and supervising other Residents and students.

• Participate fully in institutional programs and activities involving the medical staff and adhere to established practices, procedures, and policies of the Graduate Medical Education Program and policies of all affiliated hospitals, including the timely completion of medical records.

• Participate fully in institutional committees and councils, especially those that relate to patient care review activities.

• Participate fully in evaluation of the quality of education provided by the program. • Develop an understanding of ethical, socioeconomic, and medical/legal issues that affect

graduate medical education and how to apply cost containment measures in the provision of patient care.

• Apply cost containment measures in the provision of quality patient care. • Refrain from and not engage in any outside remunerative employment of any sort without

the prior approval of the respective department Chair or other designated departmental official.

• Abide by the instructions, orders, and directives of the department Chair under whom the Resident’s services are performed.

Resident Evaluation The sponsoring institution has approved and implemented policies on Resident evaluation (including Resident evaluation of Faculty, rotations, and the overall program). These policies meet the standards stipulated by the ACGME. In addition, each program is required to have program specific policies regarding these areas and adherence to these policies is closely monitored by the GMEC in periodic program internal reviews conducted between site visits. A formative evaluation form or instrument is required for each Resident which documents progress of the Resident in demonstrating competence in each of the six General Competencies specified by the ACGME. Written summary evaluations are documented at least twice annually for each Resident. A final summative evaluation covering the final training period is also required as the Resident completes training and is recommended for board certification. These elements are reviewed in Resident files during internal reviews by the panel members and should also be reviewed by program leadership during annual department review. In addition, the ACGME requires that Residents must be provided the opportunity to confidentially evaluate their Faculty, rotations, and the overall program (at least twice each year) in a system that is free from intimidation. The UTCOMC requires all programs to utilize the web-based New Innovations software system to provide online, totally anonymous evaluations for Residents to submit regarding Faculty and rotations. Program evaluations are completed semi-annually by Residents and Fellows and include 14 common questions about all programs.

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Summary reports of these Faculty and rotation evaluations are available to the Residency Coordinator and should be used in annual department reviews as well as Faculty evaluations. Problems identified by the Associate Dean/DIO are handled individually with the appropriate program leadership, maintaining the anonymity of the Residents providing ratings and comments On behalf of the GMEC, the Associate Dean/DIO and the Director of Graduate and Medical Student Education have continued to monitor these reports. Residents have indicated through feedback to the Dean, Associate Dean/DIO, and GME Office that they are assured that the system is confidential and protects their anonymity, encouraging them to provide honest feedback. Evaluation instruments in most programs more accurately reflect rotation goals and objectives per level. Duty Hours The institution’s Duty Hours Policy is in compliance with the ACGME Common Program Requirements. Overall, residents at any level cannot exceed 80 hours per week, averaged over a four week period. First year residents cannot be assigned to duty more than 16 consecutive hours. Residents at other levels cannot be assigned more than 24 consecutive hours, but are permitted to remain up to four additional hours for patient transitions of care, conferences, and clinical documentation. All residents should have at least 10 hours between duty assignments and must have one day in seven completely free from duty (averaged over a four-week period). Compliance is monitored by both the programs and the institution through the Associate Dean/DIO and Director of Graduate and Medical Student Education. Web-based New Innovations Residency Management software continues to provide an excellent mechanism for logging and monitoring each Resident's work hours. Residents are required to enter hours worked, denoting them as “regular duty," “in-house call,” “post-call,” “home called – called in”, “home call – not called in,” or “vacation/sick leave.” Reports are easily retrieved by Residency Coordinators so problems can be quickly identified regarding work hour violations. Compliance has been very good among Residents and programs. Few violations of the 80-hour week are reported PGY-1 Residents working more than 16 consecutive hours. Compliance has also been excellent regarding one day in seven free from duty and call no more frequently than every third night. The most frequent problems noted have continued to be ensuring that each Resident has at least 10 hours free (must have eight hours) between each work assignment. Duty hour questions are also included in the rotation and program evaluations for each program. Although compliance with duty hours can be especially difficult at times in the surgical fields, overall compliance has been good throughout programs. To assist programs in overall evaluation, the Director of Graduate and Medical Student Education prepared “mock” ACGME Resident Surveys to document improvement from the previous year’s official survey. The GMEC has reviewed all ACGME Resident Survey results as they are released during the year. Patient Care Residents and Fellows are involved in the majority of both inpatients and outpatients treated at Erlanger, including both Baroness Erlanger and Children’s at Erlanger, under supervision of attending physicians who are members of the Erlanger Medical Staff and hold UT faculty

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appointments. Any patient care problems involving Residents and Fellows are addressed by the appropriate Medical Quality Improvement Committees and Program Directors. Only a few of the existing RRC program citations involve patient care, procedures, and transitions of care – and none involved actual quality of care issues: Family Medicine, OB/GYN, Pediatrics, Plastic Surgery, and Transitional Year. All are being appropriately addressed and monitored by the GMEC. Patient Safety and Quality Improvement An institutional GME Policy on Patient Safety and Quality Improvement has been established to ensure compliance with accreditation requirements and to promote quality, safe patient care. The institution, GMEC, and individual programs have reviewed and incorporated several ACGME Common Program Requirements into each program’s overall educational curriculum regarding patient safety and quality improvement:

• IV.A.5.c).(4) systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement;

• IV.A.5.f).(5) work in inter-professional teams to enhance patient safety and improve patient care quality; and,

• IV.A.5.f).(6) participate in identifying system errors and implementing potential systems solutions.

In addition, the DIO and Director of Graduate and Medical Student Education have reviewed all Milestones to identify common themes related to patient safety and quality improvement competencies in an effort to assist programs in developing appropriate curriculum in these areas. Currently, three programs have the most robust, defined PS/QI curriculum and requirements (Internal Medicine, Pediatrics, and the Transitional Year); however, other programs are also working to enhance their educational activities in these areas (Emergency Medicine, Family Medicine, Orthopaedic Surgery, Plastic Surgery, Surgery, and surgical fellowships). The sponsoring institution, UTCOMC, provides supervised, safe quality patient care at Erlanger and ensures that formal quality improvement (QI) activities are conducted involving Residents, Faculty, and other health care personnel:

• Reviewing patient complications and deaths through conferences including Mortality and Morbidity (M & M) and other QI activities (e.g., Resident and Faculty participation in departmental and hospital committees) and special initiatives.

• Conducting program-specific educational activities that deal with QI and performance improvement such as Grand Rounds, didactic lectures, and a review of complications and deaths at M & M conferences. Quality improvement and medical care processes are discussed during these conferences and are a required component of the overall GME system. Changes in current practices or protocols are frequently altered as a result of these discussions.

In order to ensure appropriate institution-level involvement and oversight, the Dean and Associate Dean/DIO participate through several key hospital committees and councils that deal with peer review and QI activities:

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• Erlanger Executive Leadership Council (Dean), Medical Executive Committee (Dean) • Erlanger Quality Oversight Committee (Associate Dean) • Erlanger Joint Conference and Accreditation Committee (Dean) • Hospital Authority Board meetings (Dean) • Medical Ethics Committee (Associate Dean). • Departmental Medical Quality Improvement Committee (MQICs) • Children’s Hospital at Erlanger includes both Pediatrics Faculty and Residents in its

Clinical Quality Oversight Committee • Resident Orientation and Healthcare Principles in Practice Series include topics related to

patient safety, medical ethics, and quality improvement. • Erlanger Process Improvement Core Measures groups including a Best Demonstrated

Practices Steering Committee (Faculty and Residents) • National Surgical Quality Improvement Program (NSQIP) – Erlanger and our Surgery

Residents, Fellows, and Faculty have continued to participate in this national project sponsored by the American College of Surgeons as one of 250+ hospitals nationwide. This project involves collection of more than 135 data points for general and vascular surgical patients to monitor outcomes and direct quality improvement. Surgery Residency Program Director, Joseph Cofer, MD, has continued his leadership in Tennessee for NSQIP.

o Erlanger’s semi-annual NSQIP report data is presented to residents to demonstrate Erlanger’s mortality and morbidity compared to national data.

o Semi-annually, Faculty see their individual M & M data compared to other faculty.

o Quarterly, Surgery Residency reviews with residents the cumulative complication rate in NSQIP data base on patients on whom they operated or were involved in care.

• Erlanger Chief Quality Officer and UTCOMC DIO have begun meeting with each individual program (faculty and residents) to give an overview about the NAS, CLER Visits, and how residents can and should fit into the hospital’s overall QI plans and projects.

• They have also met with Erlanger Nursing leadership to emphasize the importance of their involvement in overall QI and PS initiatives with residents and faculty and how to work together.

• Meetings have also begun with the Dean, DIO, Director of Graduate and Medical Student Education and the Erlanger C-Suite (including CEO, CFO, CQO, CMO, etc.) to educate them about the Clinical Learning Environment Review (CLER) six focus areas:

o Patient Safety o Quality Improvement o Transitions of Care o Supervision o Duty Hours/Fatigue Mitigation o Professionalism

• Formed a CLER C-Suite Task Force to prepare hospital administration for CLER Visits. • Established a Program Directors Subcommittee to assist in developing a worksheet to

maintain CLER focus area data (and identify team leaders for each focus area) in preparation for CLER visits.

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• Specific Internal Medicine and Transitional Year PS/QI activities: o Residents have access to Inpatient Medicine Disease Management Score cards

including three identified indicators: Acute MI, Congestive Heart Failure, and COPD.

o Residents have access to Outpatient Medicine Score Cards with quality indicators including: LDL < 100 mg/dL - - NQF004 Vision Exam Annually- NQF0055 Annual Urinalysis with Microalbumin measurement - NQF0062 Annual Foot Exam with monofilament testing - NQF0056 Smoking Cessation - NQF0028A BP <140/90 mmHg in pts with HTN - NQF0013 Aspirin therapy (if appropriate) - NQF0068 Colonoscopy at age 50 and per Guidelines * - NQF0034 Screening mammography for women ages 40-69 (within 24 months) - NQF0031 Depression Screening - AHRQ Tool Influenza Vaccinations for Population >50 yrs old (Sept thru Feb) - NQF0041 Pneumonia vaccination for patients >=65 - NQF0043

o Residents have access to Meaningful Use - Outpatient Based Score Cards (abbreviated) Code – Measure Description Core 1 – CPOE for Medication Orders Core 1A – CPOE for Medication Order Report 2 Core 1B – CPOE for Medication Order Report 3 Core 3 – Maintain Problem List Core 4 – Permissible Prescriptions Core 5 – Active Medication List Core 6 – Medication Allergy List

o The UMA clinic is pursuing a systems-based approach to quality and safety via the EMR to developed systems to facilitate availability of quality indicators and prompts in real time with access to data.

o We have integrated quality care evaluation and quality improvement through utilization of the American Board of Internal Medicine Practice Improvement Modules.

o Implementation of high value, cost conscious curriculum (Dr. Mukta Panda). o Residents evaluate the chronic disease management and preventive health care

they deliver using the Comprehensive Unit-Based Safety Program (CUSP), a five – step program designed enhances workplace quality. Upon collection of panel data from their own continuity panel, residents make comparisons with standards of care and evidence-based guidelines, and develop an improvement plan. They identify systems available for evaluation of quality patient care.

o Multidisciplinary teams which include physician champions, staff and residents and management will continue to champion process to transform our patient care.

o Faculty are members of the Medical Quality Improvement Committee which meets monthly to review the quality and core measure initiatives of the hospital, documented incident reports and "near misses” or unplanned events that can result in unsatisfactory outcomes, including Risk Pro Incident reporting and monthly hospital-wide case review for internal medicine.

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o Morbidity and Mortality – monthly quality improvement lectures are conducted using the Institute of Medicine and ACGME guidelines as the basis for case discussion. The format used is the "Health Care Matrix" which is a conceptual framework supported by the Institute for Health Improvement that assess episodes of health as an interaction of six core competencies and the Institute of Medicine dimensions for quality to determine if care was safe, timely, effective, efficient and patient centered care.

o To fulfill their involvement in the quality improvement component of their educational portfolio (self-reflection), resident participation on hospital and university committees is supported and facilitated by the Department of Medicine. Residents report their participation on their bi-annual learning portfolio

and are asked to report monthly at the business meeting. Emphasis on Professionalism and personal development. Malakoff, G,

Payne, C, Staton, L, Kolade, and Panda, M. Professionalism Can it be Quantified. (In progress).

o Regular structured didactics on quality improvement are provided at scheduled noon conferences, core curriculum lectures, and mentored hands-on experience.

o Residents and faculty participate in various quality improvement committees, locally and nationally: Code Committee, Best Practice Leadership, Care Transitions, VTE Prevention, Cauti Prevention, International Conference on Communication in Health Care.

• Institute for Healthcare Improvement (IHI) Open School Chapter for Health Professionals (led by Robert Fore, EdD, DIO; Alan Kohrt, MD, Faculty, and Paul Courtwright, MD, Emergency Medicine PGY-3 Resident, and attended by Faculty, Residents, Fellows, Medical Students, and Erlanger health professionals)

• Sleep and Fatigue Education in Residency (SAFER) – presented annually as part of the Healthcare Principles in Practice Series (required for all first – third year Residents and encouraged for all Faculty)

• UTCOMC Clinical Simulation Center (available to all Residents, Fellows, Faculty, Medical Students, and Erlanger healthcare staff) – The Sim Center has continued to conduct mock code sessions that can be carried out in the Sim Center as well as in the hospital using the high-fidelity SimMan 3G mannequin in order to train Residents, Faculty, and Nursing staff in requisite patient care and safety skills involved in a mega code. Sessions can be recorded and critiqued to optimize feedback in real time and to significantly impact adult learners.

The UTCOMC Institute for Healthcare Improvement (IHI) Open School Chapter for Health Professions is an inter-professional educational community that gives students the skills to become change agents in health care improvement. These skills include proficiency in quality improvement, patient safety, teamwork, leadership, and patient-centered care. Our Chapter involves Residents and Fellows from all specialties, Medical Students, nursing, University and Erlanger administration, and Faculty. Lectures have been presented on process improvement methodology using FOCUS-PDSA cycles. Residents have also presented quality improvement projects that they have completed using this methodology. Through its website (www.ihi.org),

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the IHI provides online courses and resources to guide physicians and health care workers committed to safe, patient centered, quality medical care. Courses include

• PS 100: Introduction to Patient Safety • PS 101: Fundamentals of Patient Safety • PS102: Human Factors and Safety • PS 103: Teamwork and Communication • PS 104: Root Cause and Systems Analysis • PS 105: Communicating with Patients after Adverse Events • QI 101: Fundamentals of Improvement • QI 102: The Model for Improvement – Your Engine for Change • QI 103: Measuring the Improvement • QI 104 Putting It All Together – How Quality Improvement Works in Real Health Care

Settings • QI 105: The Human Side of Quality Improvement • QI 106: Level 100 Tools.

In cooperation with Erlanger Patient Safety and Quality Improvement leadership, we have identified and distributed a list of the hospital-wide patient safety and quality improvement projects and initiatives denoting contact names and emails for individuals leading these efforts in order that students, residents, fellows, and faculty can readily identify and collaborate to facilitate issues already ongoing within the hospital. The Open School leadership has planned a campus-wide, Annual Patient Safety and Quality Improvement Day to highlight and recognize projects. The first PS/QI Day is already scheduled for the second Friday in May (May 16, 2014). Office of Research The 2012-2013 Office of Research and its Institutional Review Board (IRB) reports more than 270 currently open and approved research studies and projects, and the majority of these involve Residents and both clinical and paid Faculty. Office of Research Staff include:

• Director of Research (Gregory Heath, DHSc, MPH, Professor in the Department of Medicine and UTC Guerry Professor of Health and Human Performance and Assistant Provost for Research and Engagement)

• IRB Chair (Manoo Bhakta, MD, Associate Professor, Department of Pediatrics, Division of Pediatric Hematology/Oncology)

• IRB Administrator (Stacey Hendricks, CIM) • Scientific Review Committee (Chaired by Jimmy Waldrop, MD, Plastic Surgery Faculty) • Research Compliance Officer (Amy Hutcherson, PhD)

The IRB reports 256 research studies are currently open and approved, and the majority of these involve Residents and both clinical and paid Faculty. Funded grants are included in the list of major accomplishments in this report. Numerous Faculty and Residents are involved in

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research projects, publications, and presentations at regional, national and international meetings.

Annual Research Methods Nuts and Bolts Symposium The Annual Research Methods Nuts and Bolts Symposium was conducted at the UTC Student Center on August 24, 2012. G Topics and speakers included: Mentoring from the Physician’s Perspective (Shauna Lorenzo-Rivero MD, Surgery) The IRB from the Chair’s Perspective (Manoo Bhakta, MD, Pediatrics) Research from an Investigator’s Perspective: Using Evidence-Based Medicine to Create

Clinical Trials (Francis Fesmire, MD, Emergency Medicine) Research from a Data Perspective - Survey instrument use and development; How to test

attitudes, behaviors, practices; Importance of interdisciplinary teams (Kim Mason, PharmD and Eric Heidel, PhD, UT Graduate School of Medicine)

2012 Annual Research Best Research Presentation, “Improving Risk Stratification in Chest Pain Patients: The Erlanger HEARTS Score” (presented by Francis Fesmire, MD, Faculty Mentor for Erik Mitchell, MD, EM Resident)

Scientific Review Committee Research Fundamentals - Starting your Research Project; Asking the right question; Research criteria (feasible, interesting, novel, ethical, relevant); Recommended proposal format; Legitimate authorship (moderator: Eric Gratias, MD, Chair, SRC, Pediatrics)

Writing Workshop Part 1: Research Submissions (Victor Kolade, MD, and Greg Heath, DHSc (Internal Medicine)

Writing Workshop Part 2: Case Study Submissions (Victor Kolade, MD, and Greg Heath, DHSc (Internal Medicine)

Annual Research Week Forty-two abstracts were submitted for consideration at the 31st Annual Research Week, held April 15 – 19, 2013. The Scientific Review Committee selected twenty-two for presentations: Seven research presentations and fifteen case reports for poster presentations. Judges for the event included: Amar Singh, MD, Clinical Assistant Professor, Department of Surgery; David Stern, MD, Executive Dean, UTHSC College of Medicine (Memphis); and Mel Twiest, MD, Associate Professor, Department of Surgery, UTCOMC, and Past Chief Medical Officer for Erlanger. Dr. Coddington, the first Associate Dean for the Chattanooga campus and for whom the event and awards were named, attended this year’s awards dinner and assisted Dean Seaberg and Dr. Fore in presenting awards. Awards were presented to the following: Research Projects (both posters and oral presentations)

• Best Overall Research Presentation and Winner of the Robert C. Coddington, MD, Award for Research Excellence: Joshua Worthington, MD, Department of Surgery. “Outcomes of Elderly Patients Undergoing Elective Abdominal Surgery”

• 2nd Place: Jared Shell, MD, Department of Emergency Medicine (Co-Author, Bryan England, MD). “Pre-hospital Creatinine Decreases Door-to-CT Times But Not Door-To-Treatment Time in Stroke Patients Undergoing Acute Interventional Therapy”

• 3rd Place: Bryan England, MD, Department of Emergency Medicine (Co-Author, Jared Shell, MD). “Patients with Middle Cerebral Artery Thrombotic Strokes Have a Worse

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Outcome When Associated with Coexistent Ipsilateral Thrombosis of the Internal Carotid Artery”

• 4th Place: Alex Lemons, MD, Department of Orthopaedic Surgery. “Arthroscopic biceps tenodesis in the lateral position. An osseous tenodesis technique integrated into rotator cuff repair”

Case Report Posters

• 1st Place: Jared Shell, MD, Department of Emergency Medicine (Co-Author, Bryan England, MD). “Usefulness of CT Perfusion Scan in Treatment of an Acute Stroke Patient with Unknown Time of Symptom Onset”

• 2nd Place: Matthew Higgins, Department of Orthopaedic Surgery. “Total Knee Arthroplasty with Distal Femoral Autograft Patellar Reconstruction with Allograft Tendon Augmentation in a Previously Patellectomised patient with multiple Quadriceps Tendon Disruptions: A Case Report”

• 3rd Place: Benjamin Lambert, MD, Department of Emergency Medicine. “Fatal Anaphylactic Following Copperhead Envenomation”

Resident Stipends and Benefits Resident stipends and benefits are approved annually by the GMEC at each campus (Memphis, Knoxville, and Chattanooga). The University works to remain competitive with other institutions in the Southern Region of the Council of Teaching Hospitals (COTH) of the Association of American Medical Colleges. The 2012-2013 Resident Stipend Scale is listed below as well as the scale approved for 2013-2014. The figures for 2013-2014 represent an approximate 1% increase at each level for the Chattanooga Campus. The UT College of Medicine Chattanooga stipend scale is less than the scale used by both the Memphis and Knoxville Campus. Our Campus is below the 50th percentile in the Southern Region; however, many of the UTCOMC resident benefits exceed those offered in Memphis and Knoxville.

PGY Level 2012-2013 Stipend 2013-2014 Stipend PGY-1 $46,150 $46,850 PGY-2 $47,800 $48,510 PGY-3 $49,450 $50,200 PGY-4 $51,100 $51,860 PGY-5 $52,750 $53,550 PGY-6 $54,400 $55,210 PGY-7 $56,050 $56,900

Benefits provided to Residents and Fellows:

• Health, dental, life, and disability insurance. • Relocation reimbursement for new Residents moving to Chattanooga (up to $500) • Annual professional development funding to reimburse for travel to national conferences,

educational books or electronic/web learning tools, USMLE Step 3 fees, etc., including up to $250 to reimbursement for a smart phone or PDA:

o $500 maximum for PGY-1 Residents o $750 maximum for PGY-2 Residents o $1,000 maximum for PGY-3 and above Residents and Fellows

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• Alpha/digital pagers provided by the hospital at no charge. • Monogrammed lab coats (three initially and two each subsequent year). • Funding for meals in the hospital cafeteria up to $20 per day. • Parking in the hospital garage at no charge. • Annual vacation (Three weeks including days during the Christmas – New Year’s

season). • Annual sick leave (up to 21 working days annually – not cumulative). • Educational leave for external conferences (typically up to one week). • 24 hour access to the Medical Library. • Copying in the Library at no charge. • Web-based access to Erlanger Medical Library electronic databases at no charge,

including Epocrates, Up-to-Date, and Visual DX. • Web-based access to the UTHSC Medical Library electronic databases. • Interlibrary loans for resources not available within the Library (no charge). • Call quarters and lockers within the hospital. • Tax deferred income plan participation (401K and 403b without matching funds). • Residents/Fellows may download UT licensed software for personal home use for

minimal fees (e.g., Microsoft Office, SAP, SAS, SPSS, Thomson Reuters [EndNote], Wolfram Research, Inc., etc.).

• A state-of-the art Medical Surgical Skills Lab and Human Patient Simulation Center is available for all Residents/Fellows. Particular emphasis is on surgical and procedural practice and developing teamwork skills.

• Web email accounts for both Erlanger and UTHSC provided at no charge. • No charge for Notary Service for personal or educational related needs. • No charge for parking in the Erlanger parking garage. • No charge for Hepatitis B immunizations, annual TB skin testing, and flu vaccines. • Availability of on-site child care at E-Kids (an Erlanger child care center). • An active Resident/Fellow Organization (House Staff Association). • Resident Assistance Program for counseling, legal, and financial issues at no charge

(ENI). • An Aid to Impaired Residents Program offers intervention and assistance to

Residents/Fellows who admit impairment and comply with recommended treatment. Given compliance with treatment guidelines, every effort is made to allow a resident or fellow to continue residency training and benefits.

• Exercise room in Erlanger at no charge. Also available -- University of Tennessee at Chattanooga Aquatic and Recreation Center (ARC)-fee $125 per six months. Discounts at several local gyms.

• Residents/Fellows are eligible for UT employee discounts, including car rental (Budget, Hertz, & National Enterprise), wireless phones (AT & T, Sprint/Nextel, & Verizon), & Tennessee State Parks.

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Strategic Planning and Goals for 2013-2014 Clinical • Continue to make progress with the Faculty Practice Plan, particularly regarding moving

physicians into the plan, undertaking strategic and fiscal planning, and demonstrating fiscal progress.

• Continue to cooperate with UTHSC and Erlanger leadership as Erlanger works to improve its financial situation and stabilize its operations in order that the University remains part of the decision making process.

• Recruit a new Division Chief for Cardiology. • Implement the first Patient Safety/Quality Improvement Day in May 2014.

Education • Working in close cooperation with the new Erlanger CEO, complete the affiliation

agreement between UT and Erlanger so funds will flow appropriately, and mission support/academic payments and other critical issues are addressed.

• Provide institutional support from the hospital administration, the Dean, DIO, GMEC, and Director of Graduate Medical Education for correction of all program citations and meeting both institutional and program requirements.

• Continue demonstrated progress in educational missions for all programs despite difficult financial constraints from our primary clinical training site, Erlanger Health System.

• Prepare for upcoming ACGME Clinical Learning Environment Review Visit revolving around six focus areas of collaboration between the sponsoring institution (UTCOMC) and the primary clinical training site (Erlanger).

• Continue to provide support to the statewide College of Medicine regarding preparation for both LCME and SAC accreditation, demonstrating uniformity and comparability in student services, experiences, learning and curriculum among the campuses. These entities will require the COM to demonstrate that the three main campuses provide a diversity of experiences, and that there is a high level of educational value and standardization whenever possible.

• Provide faculty development and resources as we move into a New Accreditation System and evaluation of individual Residents against specialty and level specific “Milestones.” Ensure successful implementation and integration of the Milestones in all Phase 1 programs (Emergency Medicine, Internal Medicine, Orthopaedic Surgery, and Pediatrics) during 2013-2014.

• Continue to facilitate inter-disciplinary training programs in the Simulation Lab, working to incorporate Basic Life Support and Advanced Cardiac Life Support education for Residents and Fellows.

• Continue recruitment of excellent Residents and Fellows, particularly in primary care Residency programs.

• Maintain continued accreditation with limited or reduced federal and state funding. • Cooperate with Erlanger to move the Medical Library from the main hospital to the

Whitehall Building, increasing digital resources and provided needed space at Erlanger for surgical facilities expansion.

• Continue to enhance Medical Student activities in Chattanooga. • Transfer the Medical Library as a UT resource.

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• Increase funded GME residency slots for the Chattanooga Campus. • Secure State funding for our Family Medicine Residency Program. • Secure increased State/Orange dollars and tuition support for the Chattanooga Campus. • Secure accreditation approval to begin fellowships in Gastroenterology (sponsored by the

Department of Internal Medicine) and EMS (sponsored by Emergency Medicine). • Develop a non-accredited fellowship in Emergency Medicine Ultrasound. • Continue to plan and development potential fellowships in Cardiology and Oncology. Research • Increase NIH/federal grants and funding (targeting $3M in grant support). • Continued progress in encouraging research and scholarly projects. • Develop mechanism for F & A rate and indirect rate. • Continue to develop the UT – Erlanger Clinical Trials Unit.

o Hire three more Research Coordinators. o Receive and start six major clinical trials. o Receive and start two federal research projects. o Establish research fund.

• Enhance Translational Research efforts. • Develop Pediatric Obesity Research Center. • Develop Neurosciences Research Centers of Excellence. • Institute Computerize IRB forms.

Community Service/Foundations • Coordinate development and fundraising activities for UTCOMC. • Continue the Medical Library preservation project. • Evaluate feasibility of a local Health Science Center (HSC) Advisory Board. • Create one endowed Chair. • United Way Campaign - add 25 faculty to Silver Circle or above. • Continue involvement in community service projects (e.g., Annual Bench Press

Competition to “Press Out Domestic Violence”). DCS:RCF:PDS

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Organizational Chart

University of Tennessee

College of Medicine Chattanooga Appendix 1

Effective 11/01/2013

UT College of Medicine Chattanooga Dean: David C. Seaberg, MD, CPE, FACEP

Major Teaching Institution Affiliation

Erlanger Health System (Erlanger Medical Center and

Children’s Hospital at Erlanger)

President/CEO: Kevin M. Spiegel, FACHE

CMO: James H. Creel, MD

COO: Robert Brooks, FACHE

CFO: Britt Tabor

CNO: Jan Keys

CQO: W. Woods Blake, MD

Assistant Dean for Clinical Affairs Louis R. Lambiase, MD

IRB and SRC IRB Chair: Manoo Bhakta, MD

IRB Coordinator: Stacy Hendricks, CIM

SRC Chair: Jimmy Waldrop, MD

Research Compliance: Amy Hutcherson, PhD

Medical Library Manager: Rachel Bohannon

Graduate Medical Education Committee (GMEC)

Continuing Medical Education Statewide Director: Bill Reynolds, MBA

Business/Faculty/Finance/Admin Business Manager: Jane H. Clay

Research Director: Gregory Heath, DHSc, MPH

University of Tennessee Board of Trustees

UT Health Science Center Chancellor: Steve Schwab, MD; Executive Dean: David Stern, MD

University of Tennessee President: Dr. Joseph A. DiPietro

Organized Medical Staff Chief of Staff: Daniel Fisher, MD

Family Medicine Mack Worthington, MD, FAAFP, Chair Stephen Adams, MD, Residency Program Dir

Internal Medicine Mukta Panda, MD, FACP, Chair

Lisa Staton, MD, Residency Program Director

Obstetrics/Gynecology Garrett Lam, MD, Chair

William Gist, MD, Residency Program Director

Pediatrics Alan Kohrt, MD, FAAP, Chair

Janara Huff, MD, Residency Program Director

Plastic Surgery Larry Sargent, MD, Chair

Mark Brzezienski, MD, Residency Program Director

Transitional Year Mukta Panda, MD, FACP

Residency Program Director

Surgery R. Phillip Burns, MD, FACS, Chair

Joseph Cofer, MD, FACS, Residency Program Director

Orthopaedic Surgery Richard Alvarez, MD, Chair

Channappa Chandra, MD, Vice Chair W. Michael Tew, MD,

Residency Program Director

Orthopaedic Trauma Fellowship (Orthopaedic Trauma Association Approved)

Pete Nowotarski, MD, Fellowship Director

Medical/Surgical

Skills and Sim Lab Ben Dart, MD FACS, Med Dir

Richard Cook, PA

Skills Lab Director

Surgical Critical Care Robert Maxwell, FACS, MD

Fellowship Director

Vascular Surgery Richard Sprouse, FACS, MD

Fellowship Director

Emergency Medicine David Seaberg, MD, CPE,

FACEP, Chair Sudave Mendiratta, MD

Residency Program Director

House Staff President and

Resident Representatives

from each department

Designated Institutional Official and

Associate Dean for Academic Affairs Robert C. Fore, EdD, FACEHP, CCMEP

Hospice/Palliative Care (sponsored by IM) Robert Goldmann, MD, Fellowship Director

Colon & Rectal Surgery Richard Moore, MD, PhD,

FACS

Fellowship Director

MIGS Fellowship (AAGL Approved)

Stephen Rich, MD

Fellowship Director

Radiology

R. Kent Hutson, MD

Chair

Graduate and Medical Student Education Director: Pamela D. Scott

Transitions to

Practice - Surgery (American College of

Surgeons Approved)

R Phillip Burns, MD FACS

Fellowship Director

Neuro-Interventional

Surgery

(Non-Accredited) Blaise Baxter, MD

Fellowship Director

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Appendix 2

Rev 11/21/2013

Accreditation Grid

Institution Current Status Site Visit Date

Date of Accreditation Decision

Decision Cycle Length # Citations Progress Report ? Self Study Date NAS Cycle

UTCOMC Continued Accreditation 3/1/2011 10/18/2011 5 yrs 0 10/1/2023 12 yrs

Program Current Status Site Visit Date

Date of Accreditation Decision

Decision Cycle Length # Citations Progress Report ? Self Study Date

Colon and Rectal Surgery Continued Accreditation 10/25/2012 2/22/2013 4 yrs 2 8/8/2013 9/1/2020 7 yrsEmergency Medicine Continued Accreditation 9/16/2011 3 yrs 7 N/A 2/1/2017 6 yrsFamily Medicine Continued Accreditation 5/21/2012 5 yrs 8 N/A 5/1/2022 10 yrsInternal Medicine Continued Accreditation 5/12/2011 5 yrs 1 N/A 1/1/2021 10 yrsObstetrics and Gynecology Continued Accreditation 1/31/2012 5/17/2012 4 yrs 3 N/A 6/1/2020 8 yrsOrthopaedic Surgery Continued Accreditation 6/18/2010 5 yrs 3 N/A 6/1/2022 12 yrsPediatrics Continued Accreditation 10/23/2011 3 yrs 7 N/A 7/1/2017 6 yrsPlastic Surgery Continued Accreditation 5/24/2012 10/11/2012 5 yrs 1 N/A 10/1/2020 8 yrsSurgery Continued Accreditation 2/1/2012 6/21/2012 5 yrs 0 N/A 6/1/2021 9 yrsSurgical Critical Care Continued Accreditation 6/23/2011 5 yrs 1 N/A 6/1/2021 10 yrsVascular Surgery Continued Accreditation 6/23/2011 5 yrs 0 N/A 6/1/2021 10 yrsHospice and Palliative Care Continued Accreditation 2/2/2012 5/21/2012 4 yrs 1 N/A 1/1/2021 8 yrsTransitional Year Continued Accreditation 10/24/2012 5/2/2013 5 yrs 3 N/A 5/1/2023 10 yrs

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PrintINSTITUTIONAL REVIEW DOCUMENT - PART IIATTACHMENT 1A - PROGRAM SPECIFIC CITATION CATEGORY SUMMARY

470490 - University of Tennessee College of Medicine-Chattanooga(corresponding to Institutional Requirements, effective July 1, 2007)

Please note that not all citation categories are reported on Attachment 1A. Therefore, it may appear that several of the program citations are missing from Attachment 1B. The IRC will only focus on these citations categories.

Note: The shaded areas represent major headings.Citation Category Number of Citations Specialty/Subspecialty Receiving Citation

1. Institutional Support A. Institutional Support-Sponsoring Institution B. Institutional Support-Program Director C. Institutional Support-Participating Institution D. Facilities-Educational Space Including Library E. Facilities-Clinical Space F. Medical Records Retrieval G. On-call Rooms H. Appropriate Food Services I. Safety/Security J. Patient Support Services2. Resident Appointment Issues 1 ORS 3. Faculty A. Qualifications of Program Director 1 ORS B. Responsibilities of Program Director 4 CRS, EM, FM C. Qualifications of Faculty (including # of faculty) 4 EM, FM, PD, TY D. Responsibilities of Faculty 2 EM, HPM E. Other Program Personnel 1 IM F. Resources 3 CRS, PD 4. The Education Program A. Progressive Resident Responsibility B. ACGME Competencies 1 CCS C. Patient Care Experience 2 FM D. Procedural Experience 4 OBG, PS E. Service to Education Imbalance 1 PD F. Scholarly Activities 3 EM, ORS G. Supervision 1 FM H. Duty Hours and Working Environment H.1. 80 Hours per week H.10. Transitions of Care 1 TY H.11. Maximum Frequency of In-House Night Float H.2. 1 day in 7 free H.3. Minimum Time Off Between Scheduled Duty Periods H.4. Maximum Duty Period Length 1 PD H.5. In-House Call Frequency H.6. Moonlighting H.7. Other 1 PD H.8. Oversight H.9. Culture of Professional Responsibilities5. Evaluation A. Evaluation of Residents 1 PD B. Evaluation of Faculty C. Evaluation of Program 1 TY D. Performance on Board Exams6. Experimentation and Innovation

Page 1 of 6

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SCOTTPD
Typewritten Text
Appendix 3 -Annual Report
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Appendix 4-Faculty Development Activities UT College of Medicine ChattanoogaMost Recent 12 Month PeriodReport Date: 11/21/2013

ActivityInstitution-Wide or Department Special Notes Numbers

IHI Open School Meetings Institution-Wide

Monthly sessions for faculty, residents, medical students, and hospital staff focusing on quality improvement and patient safety skills, education, and how to improve these areas. Online courses and modules regarding Quality Improvement and Patient Safety are reviewed at each meeting. Leaders and Steering Committee include faculty from each department and resident representatives: IHI Open School Chapter Leader (Robert Fore, EdD, DIO); Resident Chapter Leader (Paul Courtwright, MD, Emergency Medicine Resident); Emergency Medicine Faculty Representative (Sudave Mendiratta, MD); Pediatrics Faculty Representative (Alan Kohrt, MD); Pediatrics Resident Representative (Tara Kuschel, MD); Family Medicine Faculty Representative (Michael Shepherd, MD); Family Medicine Resident Representative (Philip Sutherland, MD); Internal Medicine Faculty Representative (Mukta Panda, MD); Internal Medicine Quality Coordinator (William Crowe, CNP); Internal Medicine Resident Representative (John Lewis, DO); Surgery Faculty Representative (W. Heath Giles, MD); Surgery Resident Representative (Anna Royer, MD); OB/GYN Faculty Representative (Jeanie Dassow, MD); Erlanger Chief Quality Improvement Officer (W. Woods Blake, MD); Erlanger Chief Nursing Officer (Jan Keys); Erlanger Chief Patient Safety Officer (Debbie Reeves, RN); Erlanger Chief Safety Officer (Debbie Shepherd); and GME Director (Pam Scott). [Chapter meetings are held the 1st Tuesday of each month, one hour sessions.]

15 faculty out of 50-75 attendees

Healthcare Principles in Practice Sessions (Institutional Core Curriculum) Institution-Wide

Monthly sessions for faculty and residents regarding Professionalism (including physician impairment and malpractice), Interpersonal Communication Skills (including teaching skills), Practice-Based Learning and Improvement, and Systems-Based Practice. [2nd Tuesday of each month, one hour sessions.]

10 - 25 faculty out of 75-100 attendees

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ActivityInstitution-Wide or Department Special Notes Numbers

Annual Research Nuts and Bolts Symposium Institution-Wide

Faculty and Residents are invited to this annual event to outline how to select research topics, written and oral presentation of case reports, how to write a research abstract, research methods and statistical analysis, Scientific Review Committee and Institutional Review Board Process, and how to select a mentor for projects. Local faculty - usually 6 - 10 -- participate as presenters or moderators. [Typically a one-day seminar in August each year.]

25 faculty, 40 residents, and 25 other physicians and staff

ACGME and AHME Webinars Institution-Wide

Periodic webinars regarding education topics. This year's sessions have focused on accreditation changes, teaching and evaluation, milestones, and quality improvement initiatives. Our campus has participated in 7 this year and faculty are invited.

5 - 20 each session

Annual GME and UME Retreat

Institution-Wide including all UT campuses (Memphis, Knoxville, Nashville, and Chattanooga)

Chairs, Program Directors, Associate Program Directors, Clerkship Directors, as well as medical student and residency program leadership staff attend. Presentations focus on adult learning principles, individual and program evaluation, etc. [Typically 2 days each fall - September.]

21 from Chattanooga

ACGME Annual Education Conference External

Annual Educational Conference sponsored by the ACGME, including educational and accreditation issues. Multi-day meeting in Feb/March each year. One of our Chairs, Mukta Panda, MD, Chair of Medicine, presented a workshop at the March 2013 conference and will present again at the March 2014 conference. The Program Director and Associate Program Director for Plastic Surgery also attended the 2013 conference.

3 faculty and GME Director attended. Two residents presented poster/oral sessions.

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Appendix 4 - UT College of Medicine Chattanooga Faculty Development Page 3

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ActivityInstitution-Wide or Department Special Notes Numbers

Quarterly Faculty SessionsDepartment of Emergency Medicine

Clinical and Core Faculty attend and topics include resident teaching and evaluation. Key teaching articles are reviewed and much discussion has centered around milestones reviews. 8 - 14

Annual Faculty RetreatDepartment of Emergency Medicine

Dean, Chair, Program Director, Associate Program Director, Core and Clinical Faculty, Program Coordinator, and Chief Residents attend these retreats held annually. Topics include resident teaching and advising. [Next retreat is scheduled for October 30, 2013.] 14

Council of Residency Directors (CORD) MeetingsDepartment of Emergency Medicine

Teaching and Management workshops attended by the Program Director, Associate Program Director, and Residency Coordinator at least once each year. Our Coordinator is on the planning committee and is a small group discussion leader at the meetings. 3

American College of Emergency Physicians (ACEP) Annual Meetings

Department of Emergency Medicine

Educational topics include milestones development and assessment workshop

4 faculty and 6 residents

ACEP/EMF Teaching FellowshipDepartment of Emergency Medicine

80 hours course work with academic project over one year. One faculty each year participates. 1

ACEP Ultrasound Course/WorkshopDepartment of Emergency Medicine

One-day course/workshop regarding teaching ultrasound techniques. Next workshop is October 31, 2013.

5 faculty and 15 residents

Family Medicine Inquiry Network Help Desk Answer writing

Department of Family Medicine

Each faculty member will be involved in at least one 5 hour session each year. 7

Family Medicine Inquiry Network Help Desk Answer peer review

Department of Family Medicine

Each faculty member will be involved in at least one 5 hour session each year. 3

Family Physician Inquiry Network eMEDref writing

Department of Family Medicine

Each faculty member will be involved in at least one 5 hour session each year. 1

Family Physician Inquiry Network eMEDref editing

Department of Family Medicine

Each faculty member will be involved in at least one 5 hour session each year. 1

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ActivityInstitution-Wide or Department Special Notes Numbers

Family Physician Inquiry Network HAD workshopDepartment of Family Medicine

Workshop on improving skills in literature review and technical writing. [One day conference.] 7

Family Medicine Board Review SAM modulesDepartment of Family Medicine

Board reviews will be conducted as part of the Noon Conference Didactics approximately four times per year. 7

NCQA/Quality Initiatives integrated into residency program

Department of Family Medicine

These will be integrated into didactics sessions four - six times per year. 7

TMA Physician's Leadership CollegeDepartment of Family Medicine

Involves multiple sessions and ongoing academic requirements over a one-year period. One faculty member each year participates. 1

TMA Physician Relations CommitteeDepartment of Family Medicine

Involves multiple meetings each year (four). One faculty member participates each year. 1

Annual Faculty RetreatDepartment of Family Medicine

Chair, Program Director, Associate Program Director, and faculty meet for a one-day departmental review, including curriculum, resident teaching, and evaluation. [Typically conducted each spring.] 8

Annual Faculty and Resident RetreatDepartment of Family Medicine

Includes all faculty and residents (half day) to review educational goals and objectives, resident teaching topics, supplemental hands-on learning, etc.

4 faculty and 18 residents

Quarterly Faculty SessionsDepartment of Medicine

Includes all core faculty. Topics include curriculum, resident teaching and evaluation, and accreditation education regarding the Next Accreditation System (NAS) and Clinical Learning Environment Review (CLER) Visit. 12

Cross Cultural Training and AcculturationDepartment of Medicine

Includes one-two hour sessions for all faculty and residents over several days. [October 2012]

10 faculty and 30 residents

CPOE (Computerized Physician Order Entry) Training

Department of Medicine July 2013 5-6

Medication Reconciliation TrainingDepartment of Medicine [September and October 2013] 5-6

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ActivityInstitution-Wide or Department Special Notes Numbers

High Value Cost Conscious Curriculum Team-Based Learning

Department of Medicine [August 2013] 5-6

Organizational Development and Strategic Planning

Department of Medicine [January 2013] 5-6

Role of a MentorDepartment of Medicine Electronic resource communication. [October 2013] 5-6

ACP Medicine OnlineDepartment of Medicine [October 2013] 5-6

Transition to ResidencyDepartment of Medicine

Includes Teaching Skills Summary; Orienting Learners; Residents as Team Leaders; Giving Feedback; Teaching Charting; Giving Lectures; and One Minute Preceptor - Microskills for Clinical Teachers] 5-6

Role of the Competency CommitteeDepartment of Medicine

Special training session for members of the Clinical Competency Committee [Slide set] 8

Primary Care Faculty Development InitiativeDepartment of Medicine ABIM Teaching Slides for all faculty 5-6

Primary Care Faculty Development Initiative online and campus meetings

Department of Medicine

Topics include leadership, change management, teamwork, population management, clinical microsystems, and competency assessment. 5-6

Association of Program Directors in Internal Medicine

Department of Medicine

Department Chair, Mukta Panda, MD, presented a faculty workshop at these national meetings. [April 2012 and October 2013.] 2-3

Southern Society of General Internal MedicineDepartment of Medicine

Meetings held semi-annually. Topics include education, evaluation, etc.

5-6 faculty and 4-5 residents

Association of Program Directors in Internal Medicine

Department of Medicine

New Program Director Pre-Course. New Associate Program Directors (2) participated. Department Chair, Mukta Panda, MD, presented a workshop. 3

Weekly OB/GYN Faculty MeetingsDepartment of OB/GYN

A portion of one-two hour weekly OB/GYN faculty meetings are devoted to faculty development regarding teaching, curriculum, mentoring, and evaluation. 6 core faculty

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ActivityInstitution-Wide or Department Special Notes Numbers

Department and Faculty RetreatDepartment of OB/GYN

Chair and core faculty met to establish "who we are as a department." Conducted June 2013. 6 core faculty

Department and Faculty RetreatDepartment of OB/GYN

New Interim Chair, Program Director, and core faculty met to form a mission statement as a department. Several half day meetings were conducted in September 2013. One session included residents to establish an agreement between faculty and residents regarding our goals as a residency program. 6 core faculty

Faculty RetreatDepartment of Orthopaedic Surgery

Annual meeting involving all faculty. Topics include curriculum and program review, evaluation, etc. 12-15

Orthopaedic Educators Course (AAOS)Department of Orthopaedic Surgery One faculty per year participates. 1

Annual AOA ConferenceDepartment of Orthopaedic Surgery

Annual meeting for faculty development of chairs, program directors, and key educators. 3

Annual Program ReviewDepartment of Pediatrics

Half-day faculty sessions regarding overall educational program and curriculum review, resident evaluation and assessment, resident teaching, and accreditation requirements and changes. [June 2012] 20

How to Be a Resident MentorDepartment of Pediatrics One hour session. [April 2013] 20

Introduction to Milestones Evaluations and Changes in RRC Requirements

Department of Pediatrics Three hour session. [May 2013] 20

How to Prepare for the Program Evaluation Committee

Department of Pediatrics One hour session. [July 2013] 20

Remediating the Problem ResidentDepartment of Pediatrics One hour session. [September 2013] 20

MiPass Teaching SystemDepartment of Pediatrics

One hour session regarding a teacher/learner methodology. [November 2013] 20

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Appendix 4 - UT College of Medicine Chattanooga Faculty Development Page 7

Date: 11/21/2013 Page 7 of 7

ActivityInstitution-Wide or Department Special Notes Numbers

IPASS for Patient Handovers and Quality Improvement Teaching Sessions

Department of Pediatrics

Multiple one-hour sessions led by the Department Chair, Alan Kohrt, MD, for faculty. 20

Annual Faculty RetreatDepartment of Plastic Surgery

Annual half-day faculty retreat to review long term goals for the department; plans for additional faculty, resident teaching and educational learning objectives, and enhancing research.

6 faculty, 1 resident, and 1 administrator

Monthly Faculty SessionsDepartment of Plastic Surgery

Review faculty teaching involvement, how to improve evaluation, new assessment tools, and current assessment. (1 - 2 hours)

6 faculty, 1 resident, and 1 administrator

Weekly Faculty Research MeetingsDepartment of Plastic Surgery

Ongoing discussion and review of current research projects, potential projects, and ways to enhance and research scholarly efforts among faculty and residents. (One hour sessions)

2 faculty and 1 Department Research Director

Semi-Annual Faculty RetreatDepartment of Surgery

Chair, Program Director, Associate Program Directors, Faculty, Program Coordinator, and Chief Residents attend these retreats held twice each year. Topics include resident teaching and advising. [One day for each session]

28 faculty and 2 chief residents

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