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Policies and Procedures

The following are the Policies and Procedures for the Department of Neurosurgery which are adhered to in conjunction to the GME’s Resident and Fellow Policies and Procedures. Both manuals are given to each resident yearly.

Evaluations:  There are numerous evaluation methods and tools utilized throughout the academic year which carefully measures the competency based outcome for each resident. Overall evaluations of the residents are completed by the faculty twice a year at the end of each semester along with oral examinations to prepare for their specialty board exam. At the end of each rotation, members of the faculty from the rotation will complete an evaluation of the resident based on the goals and objectives outlined in this manual.

Advancement to the next level of training is based on satisfactory achievement of the established objectives and competencies, as determined by the Resident Oversight Committee.

The resident will have the opportunity to review the evaluations and discuss the results with the program director. At any time during the year, the residents may request verbal feedback from the faculty. They may also review their evaluations in the coordinator’s office during regular business hours. Finally, if they would like to discuss a specific evaluation with a faculty member, this will be promptly facilitated by the program director.

Details of the evaluation tools utilized are:

  • Bi-annual evaluations – overall evaluations based on core competencies and procedure techniques completed online utilizing New Innovations evaluation program twice a year.
  • 360 / Peer / Self evaluations – residents are evaluated by non-neurosurgery professional staff, nursing staff, their peers and themselves. Comparisons will be made between their own thoughts of themselves versus how their peers view them. 
  • Observed Exams – the resident will perform a full history and physical and have discussions with the patient under the direct observation of a faculty member and evaluated accordingly.
  • Post-exam/feedback cards – to be used following the observed exam for the patient care rendered during the visit. Feedback cards will also be placed in the clinic units to be available to the patients, patient’s families and nursing staff for both positive and negative comments of the resident.
  • Ethics and Journal Club with statistics - a formal review of a topic directed by each of the residents once per semester with the residents providing a brief recap of the presentation for inclusion in their portfolio.
  • Set new/evaluate old GOALS - residents will be required to enumerate at least 3 goals for each of the 6-month periods and then at the same time evaluate progress made on the prior three goals.  This would be submitted as a formal one-page report and included in the portfolio.
  • Case Logs - residents will be expected to record their surgical cases within the ACGME case log database and produce logs every six months as part of the six-month evaluation process.
  • Yearly scholarships logs – residents will be required to provide a summary of all scholarly activity including abstracts, papers, posters, etc, once every year at the end of the academic year in June.
  • Quality Improvement (QI) Project – this will entail residents working in teams of two on projects selected during M&M conference. A particular problem would be analyzed in a series of meetings with appropriate staff and ancillary personnel. A six month interim project report will be submitted for their portfolio and also at year end.
  • Project Professionalism/AMA Virtual Mentor – this will be a presentation and discussion performed by each of the residents every six months. The subject selected would be from the aforementioned sources dealing with both professionalism as well as socioeconomic topics. The resident will then prepare a one-page summary for inclusion in his or her portfolio.
  • AANS/SNS online education courses - Residents are expected to complete all of the online modules by the conclusion of their fourth year. Assessment results will be reviewed by the program director and results filed in the resident portfolio.
  • SANS Life Long Learning -  a CNS online self-assessment examination tool for the resident. The program director/faculty will randomly request the residents to complete the in-service examinations, usually once a year and the results will be filed in their portfolio.

Resident Advancement/Disciplinary Action:  Residents will undergo evaluations every six months by means of various tools including the core competency, technical proficiency, “360” evaluation, oral exam, observed exam and the results from various QI , journal club and ethics projects. These evaluations will be placed in the resident portfolios and reviewed by the members of the Resident Oversight Committee which will determine the status of each individual resident for the next six month period. These status designations follow a three-color code format. Residents given a “green” are in good standing with no concerns regarding behavior or performance. A “yellow” indicates a concern with which the committee wishes to formally communicate to the resident, but does not require any specific remedial action. A “red” indicates a serious concern by the committee regarding behavior or academic performance and automatically necessitates a remediation plan, as outlined by the Program Director and approved by the committee. The committee will decide the time duration of this remediation, and at the conclusion of this time period determine whether the resident will: 1) be returned to good standing or 2) continue on a program of remediation for a time interval designated by the committee or 3) is to be terminated.

At all times the program will follow the Academic Improvement Policy as noted in the Allegheny General/Institutional Resident Policy and Procedures manual.

Any allegations of misconduct by a resident will be handled in accordance with the GME Misconduct Policy in the Allegheny General/Institutional Resident Policy and Procedures manual.

The Termination/Suspension process is set forth in the Allegheny General/Institutional Resident Policy and Procedures Manual

CGME Grievance Policy: The Neurosurgery Residency program adheres to the Grievance/Due Process Policy detailed in Allegheny General’s Resident Policy and Procedures Manual

Duty Hours/Fatigue: The neurosurgery program acknowledges the effects of prolonged work periods that can cause extreme fatigue which can be detrimental to the surgeon’s health and to patient care.   Our program recognizes the signs, symptoms and impact of sleepiness and fatigue on the resident and therefore adheres to the GME Resident Fatigue policy outlined in the AGH/Institutional Resident Policy and Procedure Manual. If resident fatigue becomes an issue, the resident should notify the chief resident or the program director and appropriate action will be taken.

Specifically, our program adheres to the 80-hour work week averaged over four weeks with one in seven days free of clinical activities averaged over a four-week period. Residents should have at least 10 hours off between duty periods. Call is restricted to no more than 24 consecutive hours. 

The institution and department offer several conferences throughout the year addressing the issues related to sleep deprivation and fatigue. At a minimum, residents will be required to attend one of these lectures.

Moonlighting: The resident is not required to do moonlighting. Any moonlighting must be expressly authorized in writing by the program director and the duty hour rules must be strictly adhered to.

Supervision Policy:  All residents will have appropriate supervision for all patient procedures by attending staff. The attending physician will be available and accessible to instruct, supervise and consult with the residents to provide a learning environment in which the residents will be able to assume increasing responsibility of all aspects of patient care.

The department follows the same supervision policies as the institution which can be found on the intranet website at: http://home.wpahs.org/agh/AGHGME/neurosurgeryguidelines.htm

Ventriculostomy policy:  The performance of all bedside ventriculostomies will be done in observance of the following regard to sufficient training of the operator:

All junior level residents new to the neurosurgery service will require the supervision of at least ten (10) ventriculostomies prior to them achieving the status of performing these procedures by themselves.

This supervision is to be carried out by a more senior resident already qualified or by the attending staff.

A listing of the patients on whom the procedure was performed as well as the initials of the supervising resident/staff will be provided to the resident coordinator. The coordinator will then post the resident's name on the intranet site which provides guidance throughout the hospital on who is qualified to perform which procedures. It will also be posted in the New Innovations Residency Suite program.

Twist-drill SDH drains policy:  Residents must first be certified to perform ventriculostomies prior to Twist-drill Drain certification. Similar to the ventriculostomy guidelines:

  • Junior residents must be supervised in the performance of five (5) twist-drill drain procedures with appropriate documentation prior to achieving independent status for these procedures.

A listing of the patients on whom the procedure was performed as well as the initials of the supervising resident/staff will be provided to the resident coordinator who will then post the resident's name on the intranet site which provides guidance throughout the hospital on who is qualified to perform which procedures.

Additional procedures - the chief will observe the resident performing the following procedures during their PGY1-PGY2 year and will certified them upon competency:

♦Lumbar puncture ♦ Central line placement ♦ Arterial line placement ♦ Lumbar spinal drain.

These procedures will also be listed on the intranet and the New Innovations program.

Conflict of Interest Guidelines: In accordance with AGH GME policy, the Department of Neurosurgery requires all residents to follow these guidelines at all times, whether on or off-site. Any questions on interpretation of these guidelines should be directed to the program coordinator, program director and/or Department Chair.  These guidelines can be found at:  https://services.aamc.org/Publications/showfile.cfm?file=version114.pdf&prdid-232

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