House officers
and the University


2016- 2017


Graduate Medical Education at the University of New Mexico is conducted by the Health Sciences Center to ensure that this institution:

  • Provides a critical part of the continuum of educational experiences for students engaged in medical education;

  • Assists the State of New Mexico in meeting the statewide need for skilled and competent practicing physicians, as well as attempting to help meet work force needs regionally and nationally;

  • Meets the accreditation standards for graduate medical education placed for the graduates of UNM SOM and assists in the professional and team training required of the entire health sciences center;

  • Provides interdisciplinary graduate training experiences to

    those specialties that require them, e.g. Emergency Medicine, Family Medicine, Internal Medicine, and Pediatrics;

  • Assures resident education improves the quality of patient

    care and patient safety;

  • Encourages the continual review of current strategies in education and patient care through research endeavors that include residents in GME programs;

  • Assures compliance with all regulation requirements for reimbursement by federal and state programs of educational expenses and other specific requirements are also met;

  • Assures training programs provide educational experiences that are sensitive to the unique multicultural environment of New Mexico while meeting or exceeding the standards of professionalism.

Table of Contents





























































403(b ) PLAN 30



ATTORNEY CONTACT (Attorneys Not Representing UNM) 31




FALSE CLAIMS ACT (Deficit Reduction Act) 39

compliance.htm l 39















Consensual Relationships and Conflicts of Interest 50

(See UNM Policy 2215

policies/2000/2215.html) 50












Respectful Campus 56

(see UNM Policy 2240 http s:/ / p o lic y.un m .e d u / un ive rsity

p olic ie s/ 2000/ 2240.h tm l) 56





USMLE & C o m p le x 57


































The University of New Mexico, through the Office of the Associate Dean for Graduate Medical Education, contracts with the Houseofficers of the University of New Mexico School of Medicine training programs. All Houseofficers are required to have a current signed agreement on file in the Office of Graduate Medical Education before entering the University of New Mexico training program. Salary and fringe benefit coverage cannot be extended until a signed agreement is on file and appointment criteria have been met.

Houseofficers scheduled for duty who are unable to report will be responsible for informing the appropriate individual in the department and the specific rotation. If the Houseofficer is rotating at the VA, and the leave is for any extended length of time, the Houseofficer must sign in at the VA Human Resources. If this is not carried out, it may be necessary to charge this time to Leave Without Pay or a Departmental Account. Houseofficers failing to comply with the terms of their contracts may be suspended without pay until such time as compliance is achieved or the contractual agreement with the University is terminated.



UNM HSC Houseofficers care for both adult and pediatric patients.

Interns are required to have appropriate training for medical emergencies prior to beginning residency. Certification courses in ACLS and PALS are available in the BATCAVE. Fellows and off-schedule residents will be required to have the training appropriate for the specialty prior to entering training at UNM HSC or will obtain such training within 30 days of their start date.


Houseofficers who regularly participate on cardiac resuscitation teams will be required to obtain and maintain ACLS certification. Appropriate training and courses are offered through the BATCAVE. Interns are required to complete ACLS prior to their start date.

Specialties which are required to receive initial ACLS certification are: Anesthesiology, Dermatology, Emergency Medicine, Family Medicine, Internal and Preliminary Medicine, Neurology, Neurosurgery, Otolaryngology, Ob/Gyn, Orthopaedics, Surgery, and Urology.


Current training in BLS includes basic airway and cardiac management, including the use of Automatic External Defibrillators. The principles and skills involved in BLS are those which can support a patient in any clinic, private physician’s office, or in a public place until more advanced ACLS providers are available. The Institution believes all Houseofficers should be capable of providing this initial care.

Specialties which are required to receive initial BLS certification are: Anesthesiology, Dental, Emergency Medicine, Family Medicine, Internal and Preliminary Medicine, Neurology, Neurosurgery, Otolaryngology, Ob/Gyn, Orthopaedics, Pathology, Psychiatry, Radiology, Surgery, and Urology.


Houseofficers who may be required to participate in resuscitation of infants and children on a regular basis are required to maintain their PALS certification.

Specialties which will receive initial PALS certification are: Anesthesiology, Emergency Medicine, Family Medicine, Neurosurgery, Orthopaedics, Otolaryngology, Pediatrics, Surgery, and Urology.

Certification for ACLS, BLS, or PALS can be obtained through the BATCAVE at no cost to the Houseofficer. Please call the BATCAVE at 272- 0494 for registration. Certificates will be awarded through AHA or ASHI.


    • BATCAVE — various departments make use of the facilities offered by the human simulation lab including training in ACLS, BLS, PALS, and ATLS. In addition, various simulation modalities are available including Full Fidelity Human Patient Simulation and simulation of endoscopy procedures.

    • GME Web Based Curricula — In order to provide all Houseofficers’ curricula designed to address specific ACGME Competencies, web based modules

      have been developed in Ethics, Evidence Based Medicine, Patient Safety/Clinical Quality Improvement, Research Design, and Wellness.

      These curricula and information on how to use Learning Central can be found here:

      Note: this is different from your Novell username and password. If you aren’t sure about your UNM Net ID, contact the HSLIC help desk at 272-1694 or check the e-guide:

      All UNM Houseofficers must successfully complete all web based curriculum during their first year of training at UNM. The completion of this curriculum is a requirement to be promoted beyond the HO II level and obtain a certificate of completion from the institution. If a program wishes to deviate from the 1 year requirement, the program must file a learning plan with the GME office. Those individuals who have successfully completed these curricula during their UNM residency program will not be required to repeat the curricula during any subsequent fellowship training at UNM.

      The GME Office will monitor the completion of the curricula, and each department will be required to provide reports on the progress of their trainees. The Program Directors will be responsible for assuring completion of the curricula by their trainees before requesting institutional certificates of completion of residency or fellowship training.

    • Office of Medical Educator Development — The Office of Medical Educator Development (formerly part of the Office of Teacher and Educational Development), as a service to the School of Medicine, offers seminars designed to assist and improve Houseofficers’ teaching skills and abilities.

    • Healthcare System and Resources — The Center for Community Partnership in conjunction with GME offers Practice Management seminars (part of the ACGME Competency of System Based Practice) at the departmental level for Houseofficers who are completing their programs.

    • Bio-statistical support for Resident Physicians is provided. To schedule an appointment email, and include project title, that you are a GME resident, HRRC# or RIB#. Houseofficers have unlimited hours.


      Houseofficers should be familiar with information on the following Web pages:

      Campus safety website:

      HSC Policies including Hand Hygiene https:



      Human Subject Research


      Med Staff By Laws:

    • Administration

    • Treatment

    • Medical Records

      RRC Requirements Safety Health & Environ Affairs UNM Medical Group

      Up to Date

      Each program will provide trainees information regarding their respective specialty boards. For additional information, see your Program Coordinator.



      The same health care coverage described under health insurance is available to Houseofficers, their spouses, and dependents for up to 18 months after termination, if the insured has no other health care coverage (i.e., COBRA must be the only health care coverage you have). The entire premium must be paid on the 1st of each month by the policyholder for desired coverage. Dependents removed from a Houseofficer’s policy (e.g., by divorce) may elect to obtain COBRA coverage for up to 36 months. It is the Houseofficer’s responsibility to notify any such dropped dependents of the availability of COBRA coverage.


      Dental coverage for Houseofficers and their dependents is provided through Delta Dental and managed by UNM Employee Benefits located on UNM’s main campus. HR Benefits can be reached at 505-277-6947.

      In order to have coverage you must meet the benefits eligibility requirements and satisfy a 15-day waiting period before you are eligible to elect benefits. Upon completion of the 15-day waiting period, you will have 31 calendar days to make your benefit elections online. After your initial 31 days to elect benefits as a new hire or newly benefits-eligible employee, you will only be able to make changes or elections to your benefit coverage during Open Enrollment period. Premiums are paid by the individual through payroll deduction. Coverage is effective the first day of the month following the month of your hire date.


      In accordance with Accreditation Council on Graduate Medical Education (ACGME), requirements to provide access to coverage for disabilities resulting from activities that are part of their educational program, UNM provides Long Term Disability insurance coverage. Premiums are shared between the institution and the trainee. Insurance is currently provided to the Houseofficer through The Guardian Life Insurance Company. The Houseofficer must be employed as a Houseofficer for one year and disabled for 90 days before coverage may begin. If requirements are met, the policy pays 60% of the monthly salary until age 65, up to the policy maximum. The policy may be converted to an individual policy at the end of training. Contact the carrier office several months prior to leaving the program to arrange a conversion.


      All Houseofficers, their spouses, qualifying domestic partners, and dependent children are offered health care coverage through a group policy. For additional information on how a domestic partner qualifies, please visit

      All Houseofficers must enroll in the health insurance plan or provide documentation of coverage under another plan. Enrollment in the health insurance plan requires a monthly payment by the Houseofficer for single or family coverage. This portion of the premium will be made through an authorized payroll deduction. An identification card is issued to the policy holder. 169800 is the group number. Any additions to the policy (spouses, domestic partners, and children) after open enrollment must be reported on the proper forms within 31 days of marriage, birth, adoption, or other qualifying event along with proof of that event.

      If delayed past 31 days, the carrier may not add coverage until the next open enrollment (mid-June –July 1st); family members of a Resident Physician cannot be covered under more than one Houseofficer Health policy.

      The plan must be used as described in the certificate booklet or Houseofficers will be responsible for additional charges. Houseofficers are requested to choose a designated primary care provider and referrals from the PCP are required for specialists. All incurred health care expenses not covered by insurance will be the responsibility of the Houseofficer. Additional information is available in the certificate of coverage booklet. Extra copies of the booklet are available in GME. Houseofficer health insurance is managed by the Office of GME.

      Exiting Houseofficers and dependents may elect continuation of health care coverage through COBRA (see COBRA section).


      To protect Houseofficers against the special risks to which they may be exposed in fulfilling their patient care duties (including provision of medical care during air transport) the University provides group Life Insurance and Accidental Death and Dismemberment coverage. Life insurance in the amount of $75,000 is currently covered by Guardian. There is a double indemnity accidental death and dismemberment clause. Enrollment forms must be completed with a beneficiary named. Additional coverage is available at competitive rates directly from ING. Please contact the Office of GME for the forms.


      Pre-Tax Insurance Premium Plan is available to all Houseofficers. This allows your health and benefit coverage to be deducted from your gross salary before computing taxes. Participation in the plan is automatic. If the Houseofficer does not wish to participate they must decline within 30 days of the employment date. Those who wish to make changes after that date can do so during open enrollment.


      Professional Liability of the Houseofficer is provided by the State of New Mexico for the period of training. Professional Liability Insurance of the “per

      occurrence” & “tail coverage” type will be provided for the Houseofficer in accordance with that policy. This policy covers only activities that occur in conjunction with residency training.

      No liability insurance is provided for professional activities outside the training program unless such activity is negotiated with UNM HSC SOM Locum Tenens Program.


      Vision coverage for Houseofficers and their dependents is provided by Vision Service Plan and managed by UNM Employee Benefits located on UNM’s main campus. HR Benefits can be reached at 505-277-6947.

      In order to have coverage you must meet the benefits eligibility requirements and satisfy a 15-day waiting period before you are eligible to elect benefits. Upon completion of the 15-day waiting period, you will have 31 calendar days to make your benefit elections online. After your initial 31 days to elect benefits as a new hire or newly benefits-eligible employee, you will only be able to make changes or elections to your benefit coverage during Open Enrollment period (typically held mid-April thru mid-May, exact dates will be emailed as period approaches). Premiums are paid by the individual through payroll deduction. Coverage is effective the first day of the month following the month of your hire date.


      Treatment of occupational injuries is covered under Workers’ Compensation Insurance. Injuries must be documented within two weeks through the submission of a Workers’ Compensation Form and incident report to Risk Management. Forms are available on the UNM website. Residents working outside of the institution may also call the Occupational Health Services, UNMH at 272-2517.


      The use of any leave may require make-up time for the purpose of Board eligibility, which is determined by the specific policy for each Board specialty and should be discussed with each individual Program Director, or designee. Houseofficers remain responsible for meeting the requirements for the residency program and of the specialty Board. Leave for annual contracts of less than one full academic year will be calculated on a pro rata basis.


      Annual leave provides the Houseofficer with time for rest and restoration for an extended period in order to return to Residency with renewed vitality. This is beneficial for patient safety and Houseofficer well-being.

      All Houseofficers will receive 21 days of annual leave which will be based on a five day work week consisting of 15 week days and 6 weekend days during the academic year. Annual leave which is unused will not be carried forward to the new training year.

      Annual leave must be requested in writing through the home department on approved leave request forms in accordance with the home program’s established procedure. No annual leave will be scheduled and paid during the week at the beginning of the contract. Blocks of seven days are encouraged for Houseofficers to have a period of adequate rest. Annual leave may not be taken in increments of less than one week without the approval of the Houseofficer’s Program Director; for off service rotations, vacations of less than one week must be approved by the Program Director of the off service department. No rotations should be off limits to vacation and Programs need to be aware they must provide appropriate coverage to allow this. Leave requests may be denied if it places undue burden on the service. The maximum time off on any rotation for which credit will be given is two weeks. Houseofficers who have difficulties scheduling annual leave on a rotation should contact their Program Director for assistance. The GME Office can be an additional resource.

      Houseofficers have the responsibility to schedule leave in a timely manner. The later the request the more difficult it may be for it to be granted. Normal requests should receive notification of confirmation or denial within 10 days of initial request from the home Program Coordinator.


      Program Directors should grant Houseofficers vacation in proportion to the number of Houseofficers that are received on that service. For example, if

      you have one Houseofficer per month for one year, you would have to grant 21

      days of annual leave on your service. No rotation should be off limits to vacation. Leave requests may be denied if it places undue burden on the service.

      Requests for vacation on services other than the Houseofficer’s home service should be received a minimum of sixty days in advance of the requested annual leave. Requests without the sixty day notice will be at the discretion of the service on which vacation is requested. Each program may have its own policies on the timetable for requesting vacation. Program

      Coordinators should communicate these timetables to off service coordinators who’s Houseofficers may rotate on their service. The request for vacation would be initiated with the Program Coordinator in the home service. The home Program Coordinator would verify the amount of annual leave remaining for that Houseofficer and obtain the proper signature and permission of the Program Director. The home Program Coordinator would communicate the vacation request by e-mail to the off service Program Coordinator. The communication cycle, discussion, and definitive approval or denial of the request should be concluded within ten days of the initial e-mail communication of the request. Approval or denial of the request should be communicated by e-mail to the initiating home Program Coordinator.


      The Houseofficer initiates the vacation request to the home Program Coordinator.

      Home Program Coordinator verifies remaining annual leave and obtains any required signatures or permissions for the home service.

      At least 60 days prior to the date of the requested annual leave, the Houseofficer’s home Program Coordinator will e-mail the annual leave request to the off service Program Coordinator, including name of Houseofficer, rotation dates, and requested leave.

      The off service Program Coordinator should e-mail the home Program Coordinator a definitive approval or denial of the request within 10 days of the initial e-mail request.

      The home Program Coordinator will notify the Houseofficer of their approved leave.


      Housofficers are granted three paid days per contract year for bereavement leave for immediate family members as defined by University policy. Houseofficers do not have the option of carrying unused leave from one contract year to another. Due to extenuating circumstances such as distance to be traveled, settling of the estate, the Houseofficer, upon request to the Houseofficer’s Program Director, shall be able to use annual leave, if available, to extend bereavement leave beyond three (3) days or may be granted a leave of absence without pay.


      A catastrophic illness and/or injury is defined as a medical or psychological event experienced by an employee, or an employee’s dependent (spouse, domestic partner, or child), which is likely to require the Houseofficer to be absent from training for a prolonged period of time. Catastrophic leave is to support those unusual or catastrophic illnesses or injuries that leave the Houseofficer without salary between the duration of their paid sick and annual leave and the qualifying period of the long-term disability coverage (90 days). Houseofficers do not have the option of carrying unused sick and annual leave from one contract year to another.

      Catastrophic leave must be requested in writing, through the Houseofficer’s Program Director to the Associate Dean for Graduate Medical Education. The Associate Dean for GME approves such leave. A request for catastrophic leave may require an attending physician statement. It is to be used only after the Houseofficer has exhausted all available sick leave and a minimum of 15 days of annual leave. Catastrophic leave cannot typically exceed sixty (60) days. Requests for extension of an additional 30 days of catastrophic leave may be requested by a Program Director to the Associate Dean of GME. The additional 30 days of catastrophic leave would require the approval of the Executive Dean of the School of Medicine. Catastrophic leave is available as a one-time event per duration of training. Any additional leave falls into the category of unpaid leave of absence. Make up time for purposes of board eligibility is determined by the specific policy of each specialty board and should be negotiated with the Program Director.


      Educational activities including but not limited to presenting papers, taking state and national examinations, or attending educational seminars may be allowed, with pay, with advance approval of a Houseofficer’s Program Director. The annual educational leave allowance shall be five (5) days. At the discretion of the Program Director, Houseofficers shall be permitted to split educational leave time or use it as a whole unit. Educational leave cannot be carried over from one academic year to another. Educational leave should not be used for conducting CIR business.


      Houseofficers shall be entitled to seven holidays off per year with pay. The following holidays will be considered holidays with pay: New Year’s Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Christmas

      Day, and New Year’s Eve. Holidays falling on a Saturday shall be observed on the preceding Friday. Holidays falling on a Sunday shall be observed on the following Monday in accordance with UNM Policy.

      Houseofficers who are required to perform duty, or to be on-call, on a holiday shall be granted either alternate time off commensurate with the amount of time worked up to a maximum of eight (8) hours, or time-and-a-half pay up to a maximum of eight (8) hours for the time worked. The Houseofficer’s Program Director shall approve all requests for alternate time off or additional pay, and determine which option is granted. In the event the Houseofficer is granted time off, the time off must be taken within the Houseofficer’s training period and need not be granted in the same academic year in which the holiday falls. The alternative leave arrangement may not be compounded. For example, a Houseofficer whose shift requires them to work on both Thanksgiving and the day after Thanksgiving will receive eight (8) hours of alternative leave or additional pay, not sixteen (16) hours.

      Since Houseofficers may participate in training at multiple institutions, The Office of Graduate Medical Education strongly encourages alternative leave arrangements to be granted by Program Directors in the same rotation in which it occurs. It is permissible for alternative holiday leave to occur prior to the holiday if it is within the same rotation period.


      The Program Director may grant leaves of absence, at their discretion, for periods of short duration. Time for such activities as personal courtroom appearances or personal business must be taken as leave without pay or annual leave. In such instances, Houseofficers would be responsible for paying the full cost of their health, vision, and dental premiums. Insurance premiums are charged at full institutional cost to those working fewer than fifteen calendar days per month. Leave of absence without pay may, at the discretion of the Program Director, be extended up to a maximum of one month. Make up time for purposes of board eligibility is determined by the specific policy of each specialty board. Contact your Program Director for specific requirements for your specialty. Houseofficers whose leave of absence extends beyond twelve months will be required to reapply for admission to their UNM residency or fellowship program should they wish to resume their GME training at UNM.


      In compliance with the federal Family and Medical Leave Act (FLMA), The University of New Mexico provides eligible employees with up to twelve (12) weeks of job protected leave within a twelve (12) month period for eligible family and medical reasons and/or up to twenty six (26) weeks for Military Family Leave subject to the conditions outlined in the act. This leave is hereafter referred to as FMLA leave. FMLA leave is an addition of any paid annual or sick leave an employee may have taken. The University will comply with all provisions of the Act for eligible employees.

      Houseofficers returning from family leave may be required to complete missed rotations in order to become Board eligible. Should a department require a Houseofficer to complete missed rotations, UNM shall compensate the Houseofficer at his or her current Post Graduate (“PGY”) level and provide malpractice coverage and all other applicable benefits.


      UNM Graduate Medical Education programs recognize the legitimacy of integrating child-bearing and adoption into the years of graduate medical training. Return to work after pregnancy and pregnancy-related conditions is to be determined by the Houseofficer’s personal physician. Houseofficers receive 14 days of paid maternity/paternity leave for the birth or adoption of a child. Paid time off may be extended with available sick/annual leave to a maximum of 28 days. Houseofficers may take leave any time within the first year of a child’s birth or adoption. If both parents are Houseofficers at UNM, both Houseofficers shall be eligible to take maternity/paternity leave at the same time or separately. Leave of absence without pay may be extended to bring time off (the sum of paid and unpaid leave) up to a maximum of four months.

      Upon request, any Houseofficer who is pregnant shall be assigned electives and rotations appropriate to her condition, to the extent possible. This shall include but not be limited to being relieved of exposure to disease, radiation, and chemicals, which may be harmful to the fetus and the mother, limited night call duty, and time off to attend personal medical visits as appropriate. Such requests shall be in conformity with the rules of the Houseofficer’s specialty board and within the constraints of the program.

      The Office of Graduate Medical Education pays a portion of the health insurance premium as a benefit during this approved Family Leave. Make up time for purposes of board eligibility is determined by the specific policy of each specialty board and should be negotiated with the Program Director.


      Paid military leave shall be granted upon presentation of official orders at a rate of three (3) weeks per academic year, consisting of fifteen (15) week days and six (6) weekend days per. Military leave is defined as leave for service into the United States Army, Air Force, Navy, Marine Corps, Coast Guard, National Guard, Air National Guard, or reserve component thereof.

      In the event a Houseofficer is called to active duty by the military as defined above, the Houseofficer’s position within his or her training program shall be held until the Houseofficer can return to work duty at UNM HSC.


      Professional leave is available to Houseofficers for the purpose of interviewing for employment, residency, or a fellowship. Houseofficers are allowed up to 5 days of such leave during the course of a residency or fellowship program. Leave for such purposes beyond the five days must be taken as annual leave or leave without compensation. No payment will be made for unused time.


      All Houseofficers receive twenty one days of paid sick leave (which will be based on a five day work week consisting of 15 week days and 6 weekend days) may be used during the contract term for the purpose intended. Sick leave must be documented in writing through the Department on approved leave request forms. The sick leave policy is established in order to protect the Houseofficer from threats to their own health, for bona-fide medical conditions, and to prevent patient exposure. Absence from work to care for an ill or injured member of one’s immediate family (spouse, domestic partner, children, parents, and grandparents) may be charged to sick leave and should be done in advance of the leave if possible. A doctor’s note may be required at the discretion of the Program Director. Unused sick leave may not be carried forward to the next training year nor will any payment be made for unused time.

      Use of sick leave may require make up time for purposes of Board eligibility which is determined by the specific policy of each Board specialty and should be discuss with the Program Director.

      Houseofficers diagnosed with or suspected of having the following infectious diseases should return to work through Employee Occupational

      Health Services for medical clearance before returning to work: acute viral conjunctivitis, acute diarrheal disease and Salmonella infection, acute hepatitis A, vaccine-preventable viral diseases, pertussis, influenza, scabies, Group A streptococcal infection, tuberculosis, herpetic whitlow, varicella and shingles. Note: This list is not comprehensive. Certain diagnoses may preclude working with immunocompromised patients. Houseofficers should contact Infection Control at 272-0131 or Infection Prevention Manager 24 and after hour’s pager 951-3000. Special provisions may apply to Houseofficers with acute or chronic Hepatitis B and HIV (see page HIV/Hepatitis C/Hepatitis B). The University reserves the right to request a physician statement of fitness to return to work.



      Houseofficers are required to receive the influenza vaccination yearly. Beginning in October, influenza vaccinations are available at Employee Occupation Health Services and locations to be announced in University Hospital and at the VAMC.


      These vaccines are offered at no cost to Houseofficers. All Houseofficers must have had proof of being immune to Hepatitis B and Varicella (i.e. titres) in accordance with UNM HSC requirements. Houseofficers must be up to date on all immunizations including and not limited to measles, mumps, rubella, pertussis, tetanus, and diphtheria. Houseofficers must also be immune to varicella through documentation of vaccination (two doses for adults) or with serology performed after vaccination or clinical varicella. Houseofficers are required to maintain appropriate immunizations. This must be up to date prior to starting clinical work at UNM and its affiliated hospitals and clinics.


      Houseofficers must be medically cleared to begin clinical work. This must be completed by orientation. This will be done by the Employee Health Office. Until notification is received from the Employee Health Office that the Houseofficer has been cleared, they will not be allowed to begin clinical work. This is in accordance with HSC policy.

      Houseofficers are also required to document immunity to Hepatitis B and varicella via titres. A history of having varicella is not sufficient documentation of immunity. Additionally, all Houseofficers must be up to date on their immunizations prior to and during residency training.


      Houseofficers should be aware that state law governs the practice of physicians with HIV and varies from state to state. CDC recommendations concerning the practice of physicians with chronic Hepatitis B and C must be followed. As yet, no state has elected to regulate the practice of physicians with Hepatitis C. The Centers for Disease Control and Prevention recommend strict adherence to Standard Precautions as outlined in the OSHA Blood borne Pathogen Standards as the best way to prevent transmission of blood borne pathogens from infected health care workers to patients as well as the infected patient to providers.

      In New Mexico, HIV-seropositive physicians who perform “exposure- prone procedures” must report their HIV status to the New Mexico Board of Medical Examiners. Consultants from the Department of Health, the physician’s specialty, and Infectious Diseases will then review the physician’s practice and clinical status and determine whether he/she may continue practicing as before or should be restricted in the scope of his/her practice. “Exposure-prone procedures” are defined as procedures which create a risk of the provider sustaining an injury and bleeding into the patient, such as palpation of a needle tip in a body cavity. Such procedures may occur in, but are not limited to, surgical and dental fields.

      Houseofficers who are HIV-positive should seek advice from their HIV physician as to whether it is appropriate for them to disclose their HIV sero- status to their Program Director based on their clinical status, training program, and need for practice modification under State Law. Houseofficers with chronic Hepatitis B and C who perform invasive procedures should seek expert consultation with Hospital Epidemiology pager 951-3000, coordinated through their residency Program Director, on how to prevent the transmission of disease to patients.

      In the event of an acknowledgment of an infection such as HIV and Hepatitis C, the Houseofficers should be expected to be counseled as to career effects; limitations, precaution, options, expectations, liabilities and position of the Department and Institution. This counseling will be provided by a committee that is to include the Program Director, a mentor/advocate (selected by the Houseofficers) and the Infection Control Physician for the Institution. The Chair of the Committee will be the Associate Dean of GME or his delegate.


      The State of New Mexico requires annual tuberculosis testing for all health care personnel. New Houseofficers will receive this test during their orientation day activities. All Houseofficers will be sent reminders for annual tuberculin skin testing, which is performed at Employee Occupation Health Services. Only Housestaff with proof of prior positive TST’s are excluded from this requirement, but they will be required to complete an annual symptoms survey from EOHS.

      N-95 respirator training and fit-testing is provided at new Houseofficer orientation for all first and second year Houseofficers, as well as first year fellows. Thereafter, respirator fit-testing is required yearly. Program Coordinators will be responsible for ensuring all Houseofficers comply with yearly fit-testing. Yearly respirator fit-testing will be provided through group sessions or individual appointments arranged by the residency coordinators. New Houseofficers not medically cleared or fit-tested at orientation may contact Employee Occupational Health at 272-8043.



      Monitored and secured callrooms are available in University Hospitals and in the Barbara and Bill Richardson Pavilion. Callrooms will be located near bathroom and shower facilities and readily accessible to patient care areas. Callrooms will be equipped with computers with intranet and internet access or intranet terminals and telephones.

      Callrooms will be cleaned and provided with adequate linens by housekeeping staff seven days per week. Houseofficers must recognize they share responsibility for living and working conditions in the on-call rooms and will cooperate in keeping the environment clean, free of unnecessary clutter, and otherwise attractive for themselves and their colleagues.

      Houseofficers who have disabilities, as defined by EEO (and University Policy 3110), can obtain access to the handicapped callroom by contacting the Office of GME in person.


      The Meditation Room is available to all Houseofficers on 3 Middle in the main hospital. The Meditation Room is meant to be a quiet space away from

      clinical areas. Yoga mats are available for those who wish to make use of the floor space. The room has a badge entry access. Houseofficers must recognize they share responsibility for living and working conditions in the Meditation Room and will cooperate in keeping the environment clean, free of unnecessary clutter and otherwise attractive for themselves and their colleagues.


      The hospital has renovated the 6 Middle spaces in the main hospital to be a gym facility open to Houseofficers 24 hours per day. Access is by badge entry access. All who use the Houseofficer Gym must first sign a waiver available at the GME office and at the Houseofficer Gym.

      Houseofficers must recognize they share responsibility for living and working conditions in the Gym and will cooperate in keeping the environment clean, free of unnecessary clutter and otherwise attractive for themselves and their colleagues. Towels will be provided in the shower room and in the gym room.


      A variety of computer services are offered to the university community through Computer and Information Resources and Technology (CIRT). Services include on campus facilities with access to shared-system computers, international computer networks and microcomputers. Houseofficer are expected to comply with UNM Computer Use Policy #2500. Computer training and services are available through University Hospital. You can contact 272- 3282 or Educational and Consulting Services at 272-3356.

        1. ail accounts (Outlook) are established as a part of orientation for those who start at a scheduled orientation date. Others who start on a date which is not a scheduled orientation time will be required to obtain an e-mail account through their Program Coordinator. University e-mail is the primary means of electronic institutional communications with Houseofficers, including communications from the Office of Graduate Medical Education. Houseofficers are expected to regularly check their University e-mail accounts for such institutional communications. To establish an e-mail account or information on services available on the medical campus, contact the Health Sciences Center Computer Services Help Desk, 272-1694. The office is located in the in the Lobby of the HSC Library.


          The University recognizes that residency may be an increasingly stressful time. Support is available through the following resources:

    • Program Director of your department.

    • GME Office — 272-6225

    • Outcomes, Inc. – 243-2551. Provides counseling, education, conflict resolution, and other services for Houseofficers. Additional information is available at

      • CARS — 272-6868

      Counseling, Assistance and Referral Service functions directly or through referral system for counseling and support.

    • Relationship Coaching – New Mexico Relationship Center at 505-999-1179.

    • Department of Psychiatry faculty is available for Houseofficers counseling at 272-2223.

    • Resident Council OMBUDSPERSON

      The Resident Council Ombudsperson is a confidential forum for expressing concerns and for exploring options that might be available for addressing those concerns. The Resident Council Ombudsperson is a Chairperson of the Resident Council who provides neutral, impartial, and independent support, education and dispute resolution to the SOM community. The Ombudsperson can be reached through the GME Office at 272-6225.


      Educational achievement issues around learning disabilities, board preparation, or test taking may be addressed by services available through the University as requested by Program Directors or Houseofficer through Student Learning Support at 272-8028.

      • CAPS — 277-7208

      The Center for Academic Progress Support is available to help assess difficulties in test-taking, time management and study skills. Online Wellness training resources are available in Learning Central for all Houseofficers.

    • Fitness equipment is available 24/7 in the 6th floor UNMH callroom (please see Houseofficer Gym).

    • Also see Leisure Activities.


      Houseofficers are eligible for membership in the Nusenda Credit Union, which has a branch not far from University Hospital. Your UNM check will be electronically deposited at your banks’ checking or savings accounts.


      Each clinical department has education funds for Houseofficers. Houseofficers will receive a minimum of $450 for the use of books, journals, CD ROMS, state mandated medical licenses, audio visual tapes, DVD’s, compact disks, cassettes, personal data assistance, computer and digital equipment including hand held devices and tablets which may be approved at the discretion of each department, educational/professional software, board review programs, conference registration and travel, and work related medical equipment.

      Any computer or digital device purchased with UNM funds must comply with UNM HSC IT Security Policies. It is the responsibility of each individual to follow the standards and requirements established by their department as well as all data owners regarding the handling and protection of HSC information assets. HSC IT Security Policies can be found at under Productivity and following the links for the HSC and UNMH Policies and Procedures.

      Unused funds may be carried forward from one year to the next. Program Directors must approve the specific utilization of educational funds. If approved by the department all of the above educational equipment shall be retained by the Houseofficer on completion of residency, provided the purchase price of any individual item does not exceed one thousand dollars ($1,000).


      Emergency loans are available to Houseofficers under signed contracts for up to $500 through the Alumni Association 272-3748. Contact GME for additional information 272-6225.


      All requests for verification related to credit applications, mortgage loans, loan deferment and educational training should be directed to the Office of Graduate Medical Education to expedite their return. The Associate Dean for GME on behalf of the institution delegates the responsibility for all verification of training dates, as well as other verification of resident data, to the Administrative Director of GME. (See back cover for mailing address).


      Houseofficers may participate in UNM’s Flexible Spending Account by setting aside part of their pay on a before-tax basis to set up: a) a medical reimbursement account to pay certain qualified medical, dental, prescription, vision, and hearing care expenses for eligible employees or their eligible dependents that are not covered by insurance plans, or b) a dependent’s care spending account to reimburse the Houseofficer for dependent care at a licensed facility, services from unrelated individuals, care at dependent care centers, and other qualified dependent care expenses thus reducing taxable income. The FSA program is a fringe benefit authorized by the IRS. The FSA program year begins January 1st. This is set up by UNM HR and Payroll; forms are available in those offices or here


      Food is available 24 hours per day/7 days per week through the cafeteria, on call refrigerators, vending machines or through private vendors. For information about the location of the refrigerators in on call rooms please contact the departments Program Coordinator or Chief Resident.

      Meals for Houseofficers will be provided at the University Hospital, Mental Health Center, and at the Veterans Administration Hospital as a benefit. University hospital meal funds are electronically distributed using the UNM HSC ID badge magnetic strip and are for use by Houseofficers only and no other allied workers. The credit can be redeemable at the cafeteria located on the 2nd floor of University Hospital.

      Cafeteria funds will be allotted in annual sums and may roll over from one year to the next. Prorated amounts will be allocated to those working less than an academic year. Vending machines located in the cafeteria lobby are available for after hours. Refrigerators in the resident lounge on the 6th Floor, 4 West conference room, and ER Conference room of University Hospital shall be stocked with adequate frozen meals seven days per week for those on call

      overnight who were not able to access food in the cafeteria. A minimum of

      $200 per year will be applicable regardless of assignment.

      Meals at the VA are located in the 5th floor conference room, or may be preordered each day by the individual Houseofficer.

      Graduate Medical Education and Program Coordinators are not responsible for lost or stolen identification badges once they have been distributed to Houseofficers.


      UNMH offers a couple of lactation station for Houseofficers, as well as UH employees, to continue breast feeding children after their return to work. Locations can be found at with other areas of interest.


      Houseofficers have access to health and fitness facilities through UNM’s Johnson Gym, exercise equipment in the UH Houseofficer Gym, and the Workout Room in the basement of the Biomedical Research Facility.


      Living quarters, routine meals, and laundry are not provided. See section on Callrooms.


      Loans from various sources are available to Houseofficers:

      UNM SOM Alumni Association …………………………………………. (505) 272-5700

      American Medical Student Association/Foundation…… (800) 767-2266 National Association of Residents and Interns…………….. (800) 221-2168 Nusenda Credit Union…………………………………………………………. (505) 889-7755

      Physician Services Association…………………………………………. (800) 241-6905

      MILEAG E

      The mileage rate that may be claimed when using a privately owned vehicle for university Business is set by the New Mexico Per Diem and Mileage Act. Houseofficers who are required to use their personal vehicles for rotations outside of the Albuquerque area may claim so much per mile when driving to and from their training sites for business purposes. Houseofficers may not claim mileage reimbursement for other incidental travel within the location of their training site. Mileage will be determined using the UNM standard travel distance between cities. Program Directors will approve travel reimbursement.


      Each Houseofficer will be provided with a long range text messaging pager during employee orientation or within the first week of employment by their department. All pagers shall be returned to UNM at the end of training with UNM.


      All Houseofficers are provided safe and secure parking by University Hospital at the Lomas Parking Structure. Houseofficers are allowed to park on the 2nd level ramp and levels above of the designated parking structure in parking spaces for “employee and SOM parking”. Residents on clinical rotations at CTRTC or OSIS may park in Land’s West Parking off University Blvd. Applications for University of New Mexico parking lots are available at Parking Services, located on 1129 University NE behind Carrie Tingley Hospital. For directions, call Parking and Transportation at 272-4074. Payment is made by lump sum at a discounted rate of $40 per year. The parking area is equipped with security cameras as you enter and exit the facility. Emergency response/panic kiosks are located on each floor near the stairwells. If you need an escort to your vehicle after-hours please call UH Security at 272-2160. The University of New Mexico and University Hospital closely monitor parking.

      You are strongly encouraged to park in the designated areas. Failure to do so will result in parking tickets and possible towing. Parking tickets should be handled at once in a professional and responsible manner before the situation escalates to booting and/or towing. University parking lots are paid parking only. Individuals parked in lots without an appropriate visible permit may be fined and towed.

      Parking at the Veteran Administration Medical Center is administered by the VA facility. Houseofficers are allowed to park on the East parking lot, and if already full in the South parking lot behind the Air Force Clinic and clinic parking lot. The South parking lot is for daytime parking only. If the Houseofficer is staying past 5pm, then they must move their car to the East lot or a City of Albuquerque parking ticket may be issued. A parking sticker must be present on the vehicle to park in these lots. There are “on call” placards that may be used by Houseofficers who are on call. These placards allow the Houseofficer to park in designated parking spots in the East lot. The placards may be obtained from the Program’s VA Administrator.

      When a Houseofficer works an outside or away rotation that does not provide free parking to employees, UNM shall, upon presentation of a receipt(s) from the parking garage of the medical facility, reimburse the Houseofficer for all parking expenses accrued during the rotation. Receipts and the rotation schedule must be submitted in a timely manner in order to receive parking reimbursement.


      New Mexico state law prohibits the University of New Mexico from making payroll advances.


      The University of New Mexico believes that all Houseofficers have the right to pursue their religious beliefs during their medical residency training. UNM Programs should attempt to reasonably accommodate these beliefs and practices by making adjustments to schedules that honor the Program’s commitment to the integrity of its educational curriculum and patient care, and does not burden the faculty or affect the general residency population involved in that educational activity. The Houseofficer, who is excused from a scheduled educational activity because of religious observance, will be required to make it up at another time. Each institution may have its own policies on the observations of religious practices and accommodates. Residents are subject to the rules of each institution in which they may rotate.


      UNM HSC and the affiliated hospitals will make efforts to provide a safe and secure work environment. Callrooms at the VAMC and UH are equipped with panic buttons in each sleeping room. The callrooms on the 6th floor of UH

      are accessible by the swipe bar on the back of your UNM HSC ID badge. The hallways are monitored and the callrooms are located away from patient and visitor areas. Escorts to your automobile are available after hours by calling UH Security at 272-2160. Suspicious activities at UH should be reported to security at 272-2160, campus police (designated as part of the city police department) at 277-2241, or by dialing 911 if appropriate. UH Security is located on the ground floor of UH behind the Welcome Desk.

      UNM shall make safety training available to all Houseofficers who work at a UNM facility, and/or web based on-line safety training. Houseofficers who staff the Emergency Rooms and Psychiatric Emergency Room shall receive training on how to de-escalate violent patients. University Hospitals Code Silver is available at the following link under Administration then General:

      Personal protection equipment including masks, gloves, gowns, goggles, safety leads, and other appropriate equipment shall be available to each Houseofficer, to use as needed. Houseofficers shall be integrated into UNM’s infection control program. The literature, seminars, and other educational tools prepared by this program, when appropriate, shall be made available to the Houseofficers. The protocols for blood borne pathogens, developed by the infections control program, shall be given to the Houseofficers.


      Many loans which Houseofficers received as students may be deferred for periods of time while in an accredited training program. Contact your lender to request the appropriate forms. All forms requesting deferment should be directed through the Office of Graduate Medical Education for authorized signatures.


      Regular full-time Houseofficers shall be eligible for reimbursement of tuition at the University of New Mexico for up to 8 credit hours per semester (4 credit hours in summer) based on main campus graduate student rates. Tuition reimbursement may be used toward furthering medical academic education in the UNM HSC Masters in Clinical Research program, Masters in Public Health, Masters in Business Administration, Masters in Education or any course approved by the institution which demonstrates or adds to the knowledge base of any of the ACGME general competencies (Patient Care,

      Medical Knowledge, Professionalism, Interpersonal and Communication Skills, System Based Practice and Practice Based Learning and Improvement) and which lead to the successful completion of an ABMS certification.

      To be eligible for reimbursement, Houseofficers must successfully complete these courses for academic credit toward a terminal or advanced degree in a health related field, or be ACGME Clinical competency courses as outlined above. Reimbursement will be provided through submission of receipts as soon as signup for the courses occurs. GME will make a good faith effort to reimburse Houseofficers within thirty days. If the Houseofficer does not complete the course, they will reimburse the Office of GME within a week of non-completion. Proof of successful completion of the course shall be provided to GME. Those who do not provide documentation of successful completion of coursework will not be eligible for further reimbursement until they comply. Benefits do not extend to spouses or dependent children.


      White coats and laundry of these coats will be provided. The linen room is on the second floor of the University Hospital. Scrubs are available to all Houseofficers at the Central Distribution Unit, 2nd floor of UNMH. The alternative site for Houseofficers working in the OR is the OR, Obstetrics is OB.


      Application forms for benefits under the GI Bill are available in the Office of Graduate Medical Education. The certifying official is also in this office.

      403(b )PLAN

      In order for Houseofficers to begin developing their personal retirement funds, the University has a number of tax deferred plans, which include IRA and IRA Roth accounts, available. For information regarding participating plans and enrollment instructions, please contact the Office of Graduate Medical Education 272-6225 or the UNM Payroll Department at 277-2353. Funds are not matched by employer.



      Houseofficers shall have the right to access and review all documents in their academic, departmental, and employment files during the term of their appointment, excluding pre-employment references. Request for copies of files must be made to the Office of the Associate Dean for Graduate Medical Education. Copies of files will be provided within three (3) days of written request by the Houseofficer where reasonable need has been established.

      Houseofficers shall have the right to review all materials placed in his or her file at any time, both by appointment and at a regularly or specifically scheduled evaluation or counseling session with program faculty. The Houseofficer may place in his or her file a response to any file entries or report and may withdraw his or her response at any time. Any adverse documents not made available to the Houseofficer may not be considered in any disciplinary or arbitration hearing during employment at UNM. In addition, any adverse documents not made available to the Houseofficer shall not in any way be considered in any form of evaluation or communication by UNM during employment at UNM or regarding any other employment, including but not limited to future employment following training at UNM.

      Written evaluations of Houseofficers shall be performed regularly after each rotation, by an attending physician who has direct, continuous contact with the Houseofficer. Evaluations shall be conducted in a timeframe and format acceptable to the Residency Review Committee, specialty board, or other accredited/accrediting body and disclosure in advance to the Houseofficer. A copy of any evaluations shall be accessible to the Houseofficer online and place in his or her file within a reasonable time after completion or after rotation.


      If you are served with a summons. complaint, or a subpoena regarding medical malpractice, employment issues or other issues that are within the scope and duty of your responsibilities as a Houseofficer at UNM, notify your Program Director, GME Office, Division Chief, and Department Chair and the Office of University Counsel (“OUC”) immediately. Your supervisors will make the necessary contacts with the appropriate Dean, or Vice President to approve the involvement of the OUC in the matter. All requests for information made by attorneys or investigators outside of UNM should be directed to Office of University Counsel at 272-2377. Do not engage in discussions with outside attorneys without first contacting OUC.


      In the event a complaint is lodged by a patient or staff regarding a Houseofficer, the GME Office is charged with the obligation to investigate and report back to the appropriate authority (UNMH, VAMC, SOM, Department) any findings and recommendations. This responsibility may be delegated to Program Directors, Chief Residents, and/or designees. This is a Medicare requirement.


      The University Of New Mexico School Of Medicine is committed to providing its learners with a secure learning environment that reflects courtesy, civility, and respect. A respectful learning environment exhibits and promotes:

      • Professionalism;

      • Respect for individual rights, diversity, and differences;

      • Confidentiality and trust;

      • Protection of civil discourse without fear of retaliation;

      • Freedom from bullying or intimidation.

        Other specific professionalism attributes have been defined by the UNM HSC Medical Staff through an inclusive and iterative process. Those attributes are covered in a document entitled Medical Professionalism: A Statement from the UNM HSC Medical Executive Committee

        Interactions between teachers and evaluators (on the one hand) and learners (on the other) in the education programs offered by the SOM or taught by SOM fellows, residents and faculty members are guided by principles of mutual trust, respect, ethics, and professionalism. All learners have the right to study, learn, and work in an environment free from harassment, threats, intimidation, or bullying.


        Mistreatment of learners can occur in a variety of ways that may impair learning. Examples of mistreatment of learners include – but are not limited to

        – a repeated pattern or a single egregious instance of public humiliation or

        belittlement, criticism or other actions that reasonably can be interpreted as demeaning or humiliating, unwarranted exclusion from reasonable learning opportunities, unwelcome sexual comments, jokes, innuendos, or taunting remarks about one’s body, attire, age, gender, ethnicity, sexual orientation, marital status, intentional physical contact such as pushing, shoving, slapping, hitting, tripping, throwing objects at, or aggressive violation of personal space.

        For purposes of this policy, the following terms have the meanings indicated.

    • ‘Teacher’ means a full-time or part-time faculty member or any other person who is responsible for evaluating the performance of one or more students, residents, fellows, or other learners. Fellows and residents are also considered “teachers” of medical students.

    • ‘Resident’ or ‘fellow’ means any full-time or part-time resident or fellow at the School of Medicine.

    • ‘Learner’ means any person enrolled in a course, clerkship, or other educational program offered by the SOM or taught by a resident, fellow or member of the faculty in an SOM department.

    • A teacher occupies a ‘position of authority’ if he or she is responsible for evaluating the academic performance including clinical skills, or professionalism of a learner.

    • ‘Abusive conduct’ means behavior that is intended by the actor to create an intimidating environment and that is likely to interfere with an individual’s work or education. Abusive conduct can be verbal, visual, physical, or communicated in writing or electronically. Such conduct is typically directed against a particular individual or individuals. Examples of conduct that may be considered abusive include but are not limited to repeated patterns of or a single egregious episode of:

      • Threatening or intimidating behavior or words (written or oral);

      • Obscenities/profanities (verbal or gestures) directed at a person;

      • Threatening or obscene gestures, jokes or cartoons;

      • Degrading a person or a group on the basis of a racial, religious or cultural characteristic or sexual orientation;

      • Taunting, jeering, mocking or humiliating another person through acts or words;

      • Screaming and/or yelling at or around others;

      • Insulting a person with the intent to embarrass, humiliate or aggrieve that person, especially in the presence of others;

      • Endangering the safety of an individual or group of individuals;

      • Inappropriate or unprofessional criticism that is primarily intended to belittle, embarrass, or humiliate.

        It is a violation of this policy for any teacher knowingly, deliberately or intentionally to engage in abusive conduct directed at a learner. A teacher who violates this policy may be subject to discipline as outlined in the procedure below.


        A complaint that the behavior of a faculty member, resident or fellow has

        been in violation of this policy may be made to an appropriate individual, including – but not limited to – one or more of the following:

        • Faculty members (including Program Director or Depart. Chair);

        • Associate Dean of Students;

        • Associate Dean for GME;

        • Associate Dean for UME;

        • Associate Dean for Clinical Affairs;

        • Members of CAPE;

        • Clerkship directors

        Informal resolution may be pursued by the person receiving the complaint, based on an assessment of the nature of the complaint and/or the wishes of the learner. Informal resolution may be achieved by direct discussion and/or mediation with the alleged offender. When a learner has exhausted the possibility of resolving a situation of abuse or mistreatment using informal mechanisms, he/she either acting alone or in conjunction with the initial recipient of the complaint may contact the Professionalism Improvement Committee (see below) and give a verbal or written description of the circumstances leading to the complaint.


        The Professionalism Improvement Committee was created by the Executive Vice Dean (EVD) to promote professionalism among learners, including students, residents, and other learners, and residents, fellows and members of the SOM faculty. The functions of the PIC are:

    • to receive and evaluate complaints from individual learners and refer them with recommendations to the Chair of the Department and the EVD;

    • to receive results from block, course, clerkship, and other formal evaluations that identify individual faculty members, residents, fellows or academic units that are alleged to be in violation of policies related to professionalism, including the UNM Respectful Campus Policy. ;

    • to conduct regularly scheduled meetings to ensure dissemination of policies and to track learning environment issues in the School of Medicine.

      The membership of the Professionalism Improvement Committee is as follows:

      • Director, HSC Office of Professionalism (Chair)

      • Associate Dean for Clinical Affairs and/or Medical Staff representative

      • Associate Dean for Graduate Medical Education

      • Associate Dean for Student Affairs

      • Associate Dean for Academic Affairs

    The above members may, at their discretion, include other ad-hoc members when they judge this to be prudent or necessary.

    A complainant must be willing to be identified to the person against whom a complaint is directed. It is strongly preferred that the complainant document the complaint in a written statement to the PIC. The complainant may submit a complaint to any member of the Professionalism Improvement Committee.

    Upon receipt of a complaint the Professionalism Improvement Committee will, in a timely manner, evaluate the complaint and determine whether the best initial action is a further attempt at resolution by the Professionalism Improvement Committee or whether the complaint requires immediate referral to the EVD. The Professionalism Improvement Committee’s evaluation may include other ad hoc members with expertise to address matters involving substance abuse/recovery, gender/sexual orientation and minority issues, mental health, clinical specialty issues, or other matters. The subject of the complaint and his/her Department Chair will be informed of the complaint and the evaluation that has been undertaken. The resident, fellow or member of the faculty will have the opportunity to address the PIC as part of its evaluation of the matter. After completing its evaluation, the Professionalism Improvement Committee will make a recommendation to the relevant Department Chair and the EVD regarding a process for resolution, further investigation, or other actions. The Professionalism Improvement Committee will inform the complainant of the recommendations.

    The Department Chair will decide what additional actions, if any, are indicated and appropriate. The Chair will inform the PIC and the EVD within a month of the action taken. The EVD may choose to refer the complaints to other institutional offices, including but not limited to the Office of Clinical Affairs, the Office of Graduate Medical Education, the Office of Undergraduate Medical Education, the Dean of the College of Nursing, the Dean of the College of Pharmacy, the Dean of the College of Arts and Sciences, the Office of Equal Opportunity or the UNMH Human Resources Department. The PIC will track the outcomes of the process and provide feedback to appropriate entities.

    Remedies could include, but are not limited to, review of this policy signed by the individual, required attendance at one or more educational or training programs, an apology to the complainant, an oral or written warning, loss of discretionary funding, and the like. In cases of especially serious violations of this policy, sanctions up to and including termination of

    employment may be imposed. While counseling is not considered a remedy, it may be offered in combination with one or more remedies. Additional actions will, when appropriate and indicated, follow established processes – including but not limited to – those in the UNM Faculty Handbook, UNM Policies and Procedures Manual (“Big Red”), the Medical Staff Bylaws, and the Graduate Medical Education Handbook.


    All individuals involved in the process should know and understand the need for confidentiality. Written documents will be provided to others only when the Professionalism Improvement Committee refers the matter to the Department Chair and the EVD. In all cases, written material will be kept in confidential files maintained by the chair of the Committee. At the end of each fiscal year, the Committee will submit an annual report to the EVD, summarizing the nature of cases and issues considered during the previous



    The School of Medicine provides ongoing education to its community

    concerning its commitment to providing a positive learning environment that is respectful of all individuals. Reference to this policy is included in the student and resident handbooks and posted on the SOM website; the topic and this policy should be addressed at the time of matriculation and at the beginning of the third year of medical school. The policy will be reviewed by the Professionalism Improvement Committee and the EVD on a regular basis; suggested modifications will be recommended to the Dean. A letter will be sent on a regular basis from the Dean or his/her designee to all residents, fellows and members of the SOM faculty (including voluntary faculty) reminding them of the School’s statement on supporting an abuse-free environment, of this policy, and of the existence of resources for resolution.


    In case of a disaster, UNM HSC has developed an emergency operations plan, which can be found on the UNM Hospital Emergency Management webpage ( Please refer to this webpage for information on procedures related to disasters. Additionally, in the event of a disaster, all updates as to which personnel are to report to work will be posted on this page.

    Since the 2005 Hurricane Katrina disaster, the need for such a plan has become apparent and is a Joint Commission and Accreditation Council of Graduate Medical Education requirement. The UNM Hospital Chief Executive Office, UNM HSC Physician in Chief, and the Vice Chancellor for Health Sciences, in conjunction with the Emergency Operations Director will declare a state of emergency at UNM HSC.

    In the case of a disaster in which UNM HSC is still a functioning hospital system, residents and fellows must be expected to perform according to the professional expectations of them as physicians, taking into account their degree of competence, level of training, and context of the specific situation. Residents will get further instruction from their residency program leadership as to changes in schedule as a result of the disaster. These updates will also be posted to the Emergency Management webpage. Clinical affairs may reassign physicians and residents through the Emergency Operations Director based on clinical needs. Residents who are fully licensed in the State of New Mexico may be able to provide patient care independent of supervision in the event of an extreme emergent situation. Residents are also trainees/students. Residents and fellows should not be first-line responders without consideration of their level of training and competence.

    In the case of a disaster requiring evacuation of the UNM HSC, but in which services and communication are intact, all communications will be conducted via the Emergency Management Webpage. Additionally, alerts will be sent to all HSC staff, including Houseofficers, via the emergency paging system, LOBOalerts, UNM Emergency Management Webpage, and UNM HSC Emergency Management Webpage.

    UNM affiliated hospitals such as Presbyterian Hospital and the Albuquerque VA Hospital will also activate the Emergency Operations Center at UNM HCS. Instructions for response by Houseofficers will also be posted on the UNM HSC Emergency Management webpage in these circumstances.

    In the event of a devastating disaster, which renders UNM HSC non- functional, has developed a partnership with the University of Arizona to provide information, support, and communications in case such resources become unavailable due to the disaster. In the case of loss of our communication system and evacuation, we will partner with the University of Arizona to post information on their GME website and work together to find accommodations for our residents. We would also set up a connected administrative structure in Tucson at the University of Arizona. We would similarly help to provide accommodations to the University of Arizona should a disaster requiring evacuation befall them.

    Conrad Clemens, MD from the University of Arizona is the coordinator of the University of Arizona GME communications plan with the help of his staff.


    Betty Chang, MD, from the University of New Mexico, is the coordinator of UNM GME communications plans with the help of her staff. – 505-272-6225

    Thus, our GME Disaster Plan is the following:

        1. Notification –

          The UNM Vice Chancellor of Health Sciences will declare a disaster and begin the implementation of the HSC Disaster Plan, including activities of the Emergency Operations Center. Residents will be expected to respond as part of their appropriate departmental response per the HSC Disaster Plan. Notifications will be via UNM Emergency Management pager messages, LOBO Alerts, and UNM and UNM HSC Emergency Management webpage updates.

        2. Communication – The UNM HSC Emergency Management Webpage will be used to communicate with all Housestaff, students and faculty. The HSC website will be responsible for providing timely updates. In case the HSC website becomes inoperable, the University of Arizona GME website will be utilized to provide information to all UNM residents and students. Residents and students will be instructed concerning this backup mechanism at orientation. As soon as possible the UNM and UNM HSC websites will be reactivated for communications. UNM will provide a similar back-up system for University of Arizona Health Sciences Center in case of a disaster at that campus.

        3. Relocation (if required) – Residents will initially be accommodated in Tucson at the University of Arizona. After assessment of the extent of the disaster, other long-term accommodations may be necessary. The Associate Dean for Graduate Medical Education and staff will accompany residents to Tucson. Similarly, UNM will accommodate University of Arizona residents and students in the case of a disaster in Tucson.

        4. Placement Assistance – If placement of residents became necessary, the UNM GME offices will contact the ACGME within 10 days of the disaster to ask for assistance in the placement of residents with the least disruption to the training programs depending upon the anticipated length of time for the resolution of the disaster situation.

    If the disaster affects a subset of the residency programs at UNM, as determined by the Program administration and the UNM GME office, then notification of the ACGME for specific programs will occur.

    FALSE CLAIMS ACT (De fic it Re d u c tio n Ac t)

    Training of the Federal False Claims Act and the NM Medicaid False Claims Act is required pursuant to the Deficit Reduction Act of 2005 (DRA). Both Statutes cover fraud involving federally funded contracts or programs (i.e., Medicare and/or Medicaid) and establish liability for any person who knowingly presents or causes to be presented a false or fraudulent claim for payment. The Qui Tam (“whistleblower”) provisions encourage people, with actual knowledge of allegedly false claims, to come forward and report the misconduct. Whistleblowers are protected from retaliation by both statutes, as well as, by UNM Business Policy 2200, Reporting Misconduct and Retaliation. You may anonymously report internally using the toll-free 24/7 contracted HSC Compliance Hotline at 1-888-899-6092.

    For more information on the DRA, please review the PowerPoint presentation entitled “Deficit Reduction Act of 2005 (DRA)” on the HSC Compliance web page at:


    This procedure pertains to disciplinary action including probation, suspension, termination based on academic, professional (as defined in the Code of Professional Conduct policy in this Manual), or clinical performance or competency, or non-renewal of contract. Please see the most recent CIR/SEIU Collective Bargaining Agreement for guidance regarding grievances for discipline issued for reasons other than academic, clinical, or professional (as defined in the Code of Professional Conduct policy in this Manual) matters.

    1. Purpose: The purpose of this procedure is to secure, at the lowest possible level, equitable solutions to individual grievances which may arise regarding terms and conditions of a Houseofficer’s participation in a training program.

    2. Definitions:

      1. A grievance shall mean a complaint by a Houseofficer, and/or Houseofficer and the CIR/SEIU, alleging that action or inaction

        by the University has, in a substantial way, adversely affected his or her progress in the educational program, threatened their intended career development, wrongfully deprived him or her and of the compensation owed by the University under this Agreement, is related to the Houseofficer’s academic or clinical environment, or related to the Houseofficer’s training program or faculty.

      2. The term “grievance” as pertains to this grievance procedure shall not be construed to apply in the following instances:

        1. Questions about whether or not a University policy or practice is good, bad, wise, unwise, etc. Concerns about such matters must be pursued by other means.

        2. Matters beyond the authority or control of the University, or beyond the University’s ability to provide a remedy.

        3. Termination or suspension due to the exhaustion of funds as determined by the Dean of the School of Medicine (see section on Resident Reduction/Closure).

        4. A Houseofficer’s being placed on remediation under the terms of this Manual.

        5. Discipline or dismissal for alleged administrative misconduct. Please see the Collective Bargaining Agreement

          between the University of New Mexico and the Committee

          on Interns and Residents/SEIU under such circumstances.

        6. Referrals to the New Mexico Monitored Treatment Program, referrals to an emergent psychiatric assessment pursuant to the Mandated Behavioral Assessment and Counseling policy herein, or referral to a drug screening.

    3. Preliminary Procedure: No matter shall be submitted for the grievance procedure unless informal resolution has been attempted between the Houseofficer and the Houseofficer’s Program Director. If the Program Director is personally involved in the matter, then the Associate Dean for Graduate Medical Education or their designee shall be substituted for the Program Director. The parties shall make a good faith effort to resolve the grievance in an informal manner. If the grievance is not resolved, the Houseofficer may proceed to Step 1 of the grievance procedure.

    4. Step 1.

      1. The grievance shall be submitted within ten (10) calendar days following the grievable event, or within ten (10) calendar days after the Houseofficer becomes aware of such event, whichever is longer. Any deviation from the 10 day time limit must be agreed upon by all parties.

      2. The grievance shall be in writing and must contain a statement of the grievance, the facts upon which it is based, information describing the attempt to resolve the matter in accordance with Section 3 of this policy, and the remedy sought.

      3. The grievance shall be filed with the Associate Dean for Graduate Medical Education or designee.

      4. The grievance shall be heard by a committee (voting members) consisting of

        1. an uninvolved Houseofficer appointed by the Resident Council,

        2. two training Program Directors from other programs who have not been involved in the dispute, or, if one or both Program Directors are not available, substitute faculty member(s) involved in medical education shall be appointed in the alternative. Alternate faculty appointee(s) must be SOM faculty in the field of clinical medical practice and must be mutually acceptable to the other members of the committee. The Associate Dean for Graduate Medical Education shall be the Chairperson of the committee, shall attend to the administrative matters of the grievance, may participate in the deliberations, but shall not have a vote.

          The grievant’s Program Director or their designee will be

          present at the committee hearing, but shall not vote. The committee may be advised by faculty members who specialized in fields which would be of assistance to voting members. Those providing advice are non-voting members. If the committee has not been formed within ten (10) days of the filing of the grievance, the Senior Executive Vice Dean of the School of Medicine shall make the necessary appointments as soon as practicable.

      5. The committee shall hear the case as promptly as is practicable with due notice to all parties. The parties are required to exert their best efforts to commence the hearing within twenty-one

        (21) calendar days after the grievance is filed or as soon thereafter as is practicable. The parties to the grievance may submit evidence and argument in writing, in person, or both. Either party may employ attorneys or other advisers to assist them in the presentation of the case, but such attorneys or other advisors shall act in an advisory capacity only, and shall have no right or opportunity to advocate directly to the committee on that party’s behalf. The purpose of the meeting will be to obtain factual information from the Houseofficer. The grievant Houseofficer shall present his/her case and stand for questioning. The committee shall keep a record of the case and may, in its sole discretion, make or arrange to have made an

        audio, video, transcriptional, or other recording of any oral presentation made before it.

      6. The committee shall decide whether the subject is grievable pursuant to the terms of his policy. At such time as the committee decides that the matter is not grievable, the Houseofficer shall be so notified and the proceedings stopped and/or the grievance summarily denied.

        The decision of the committee in this regard is final.

      7. The committee is authorized to decide the grievance and to provide for a remedy to carry out its decision.

      8. The grievance shall be decided by a majority vote of the voting committee. The decision shall be rendered in writing and, once rendered in writing, shall be delivered immediately to the Houseofficer in person or, if he or she is not immediately available, a copy of the decision shall be sent by Certified Mail to the Houseofficer’s last known address of record kept at the School of Medicine.

    5. Step 2.

      1. If the Houseofficer or the Program Director is dissatisfied with the decision of the committee in Step 1, he or she may appeal the decision to the Senior Executive Vice Dean of the School of Medicine. Appeals are limited to 1) alleged violations of the Houseofficer’s rights as provided for in this grievance procedure or 2) new information potentially applicable to the decision that was not available to the Houseofficer at the time the committee rendered the decision.

      2. The Houseofficer shall submit the notice of appeal in writing to the Senior Executive Vice Dean and a copy thereof to the Office of GME within five (5) calendar days following the decision in Step 1. That written notice shall state the basis for the requested appeal as provided for in Section 5(a) of this Grievance Procedure.

      3. The Senior Executive Vice Dean shall review the record of the case as presented to the committee in Step 1. The Dean may call for further evidence or argument at his/her discretion.

      4. The Senior Executive Vice Dean may affirm, reverse, or modify the decision. The decision of the Senior Executive Vice Dean is final.


    HIPAA training and certification is required annually of all Houseofficers physicians for each location they are assigned in accordance with the

    institutional policy. UNMH HIPAA training is online at

    Violation of HIPAA requirements through viewing of protected patient information that is not part of a patient care activity may result in discipline, up to and including termination from Graduate Medical Education programs and is a violation of professionalism standards.


    HSC Identification badges are the official photo identification for all Houseofficers. UNM HSC ID badges must be worn at all times when training or when representing UNM HSC. Houseofficers are expected to display appropriate photo ID when on duty. UNM Hospital Security will assess a replacement fee of $15 for all lost cards. Stolen cards should be reported to Hospital Security (272-2160) immediately.

    HSC ID Cards with a Lobo card code allows Houseofficers to take advantage of the following at a discounted rate:

    • University tennis courts

    • Medical Library — North Campus

    • Zimmerman Library and satellite libraries

    • Johnson Gymnasium facilities (spouse/dependent cards are available from Leisure Services at the gym and a minimal charge per semester)

    • North Golf Course

    • HSC Lockshop Key Service




    (See Workers’ Compensation under insurance)

    All exposure to blood or other potentially infectious materials (needle sticks, splash to mucous membranes or exposure to non-intact skin) must be evaluated and treated as soon as possible, preferably within two hours of exposure. Trainees must be released immediately to seek treatment. Houseofficers should fill out an incident reporting form with their supervisor’s signature and a Workmen’s’ Compensation form (available on all floors or on the GME website) and then report to the appropriate clinic or Emergency Department.


    All injuries or infectious disease contacts by disease of human blood or

    prevention exposure of Houseofficers while on duty must be reported to the

    Workers’ Compensation Office, 277-0312 and the Employee Occupational Health Services, 272-8043 on the appropriate incident report forms. Accidents must be reported to the Program Director and Program Coordinator as well as the above two listed departments. The form is available in the clinics, nursing stations, emergency room, operating rooms, and online at

    Houseofficers with puncture wounds must follow appropriate procedures for UNM HSC, VAMC, or Lovelace Medical Center. For additional information contact your Program Director and see the UNM HSC policy on Blood & Body Fluid Exposure (Needlestick) at


    All Houseofficers receive training on basic infection control at new Houseofficer orientation, including the principles of Standard Precautions, patient isolation, and hand hygiene. Houseofficers temporarily unable to perform routine hand hygiene in the course of patient care should be reassigned to non-patient care duties.

    Houseofficers may be contacted by Infection Control regarding the potential exposures from patients and are expected to comply with prompt follow-up and treatment at Employee Occupational Health Services. Houseofficers are encouraged to report potential exposures to Infection Control/Hospital Epidemiology.

    Questions or concerns regarding isolation, nosocomial infections, exposure, or diseases reportable to the State Department of Health may be addressed to Infection Control staff at UH at 272-0131 or VAMC 265-1711 ext. 4945, as well as Hospital Epidemiologist at pager 951-3000.


    1. If a UNM GME Program Director or designee, in their sole discretion, identifies the need for a mandatory behavioral assessment of a Houseofficer, the Program Director or designee will notify the Houseofficer, make an emergent referral of the Houseofficer to the Psychiatry Faculty Practice for emergent assessment, and will remove the Houseofficer from clinical responsibilities until the initial assessment has been completed and a report has been received of that assessment. As part of this assessment a drug screen may be required, and referral to the New Mexico Monitored Treatment Program may result.

    2. The Houseofficer shall be seen by a mutually agreed on psychiatrist as soon as arrangements can be made, preferably within 48 hours of the emergent referral.

    3. The psychiatrist(s) performing such assessments will

      1. Meet with the Houseofficer

      2. Clearly notify the Houseofficer of the psychiatrist’s dual reporting responsibility to the Houseofficer and the University (i.e., reporting both to the Houseofficer and to the referring Program Director or designee)

      3. Provide an initial psychiatric assessment, focusing on the presence or absence of psychiatric illness that might interfere with the Houseofficer’s ability to be safe at work and provide safe patient care.

        1. If the Houseofficer is determined not to have such a psychiatric illness:

          1. The psychiatrist will notify the Program Director what, if any, conditions should be placed on the Houseofficer to return to duty, including, as appropriate, recommended time limitations for these conditions.

          2. If the Program Director feels such conditions are inappropriate in the context of the Houseofficer’s training, the matter should be referred to the Associate Dean for GME for resolution.

          3. The psychiatrist performing the initial assessment may recommend additional evaluations/treatment to the Houseofficer. Should the psychiatrist make recommendations, they will help identify available resources for such evaluations or treatment, and will assist with those referral(s).

          4. Ongoing psychiatric care will not be provided by the psychiatrist making the emergent assessment under this policy.

          5. As necessary, the psychiatrist performing the mandated assessment will develop a “behavioral contract”, with input from the referring Program Director, which the Houseofficer must sign as a condition for returning to duty.

        2. If the Houseofficer is determined to have a psychiatric condition which compromises the safety of the Houseofficer or of patients and other members of the health care team, the psychiatrist:

          1. Will notify the Program Director and the Office of GME that such a condition exists. If the resident requires leave, the resident must communicate this with the Program Director;

          2. May recommend additional evaluations/treatment to the Houseofficer, will help identify available resources for such evaluations or treatment, and will assist with those referrals, but will not be the provider of such evaluations or treatment; and

          3. Will provide re-assessments as necessary.

      4. Will document all assessments in accordance with UNM HSC Bylaws for medical documentation.

      5. If the assessing psychiatrist suspects substance abuse, will notify the Program Director. The Program Director, in their sole discretion, may then refer the Houseofficer for testing and/or to the New Mexico Monitored Treatment Program.

          1. If, in their sole discretion, the Program Director mandates the Houseofficer to participate in an emergent referral as provided under this policy, the Houseofficer will not be subject to any out-of-pocket cost for such mandated behavioral assessments. Such assessments may be provided by the UNM Department of Psychiatry or, in the case of a Psychiatry Resident, a designated community psychiatrist mutually agreed-to by the Psychiatry Department and the UNM Office of GME. The costs of any additional evaluations or treatment recommended as a result of a mandated emergent referral and behavioral assessment made under this policy will be the

            financial responsibility of the Houseofficer. The Office of GME will be

            available to assist the Houseofficer with processing medical insurance claims and with identifying other available resources (including financial resources) for such additional evaluations or treatment.

          2. As a condition of returning to their training program, Houseofficers will instruct any individuals or agencies providing additional evaluations or treatment outside of the initial emergent referral and behavioral assessment, including ongoing behavioral care, engaged in as a consequence of or directly related to a mandated behavioral assessment made under this policy, to notify, as appropriate, the Houseofficer’s Program Director that the Houseofficer is ready for re-assessment of their ability to work and any recommended conditions on or limitations to the Houseofficer’s ability to perform the essential functions of their positions that may be required.

          3. Houseofficers may request medical leave as a consequence of or directly related to an emergent referral or behavioral assessment made pursuant to this policy. Such requests must be made pursuant to the policies in this Manual. Houseofficers whose medical leave is granted as a consequence of or directly related to an emergent referral or behavioral assessment made pursuant to this policy that extends beyond 12 months will be required to reapply for admission to their UNM residency or fellowship program should they wish to resume their GME training at UNM following the completion of such leave.

          4. Failure to comply with any provision of this policy, including but not limited to failure or refusal to comply with a referral to an emergent assessment, failure or refusal to comply with a referral to the New Mexico Monitored Treatment Program, or failure or refusal to timely communicate with the Program Director and/or GME of compliance with such referrals, may result in disciplinary action up to and including dismissal from the Houseofficer’s training program.


    The Federal Government requires annual training of all personnel who may be exposed to blood borne diseases. New Houseofficers receive this training as part of their orientation day activities. All Houseofficers must complete annual certification. Web based OSHA training is available at both UNM and VA sites. The UNM online training resides under Learning Central on the main UNM HSCL website The VA online training resides on the VA Internet under “Clinical”, then under “Computer Based Training” as “Physician OSHA Bloodborne pathogens (with test)”. Upon completion of the web-based training, Houseofficers may print out a certificate of completion and forward it to the GME Office. Houseofficers taking the refresher training should log in after the third week in July to ensure that they are entered in the online training system. Houseofficers who are not in compliance may be suspended from duty without pay until they provide documentation of having taken the training.


    (See University Policy 2200 )



    Each ACGME program will provide trainees with a written policy in compliance with its Program Requirements concerning the effect of leaves of absence, for any reason, on satisfying the criteria for completion of the residency program, and information relating to access to eligibility for certification by the relevant certifying board.


    Contracts for Houseofficers are awarded annually and do not extend beyond an academic year. Houseofficers who begin a training program at the University of New Mexico may reasonably expect to complete their training at this institution provided their academic progress and performance is satisfactory, moral and ethical behavior is appropriate, and funds are available.


    Interactions between teachers/evaluators and learners in medical education programs sponsored by the University of New Mexico School of Medicine are guided by mutual trust, confidence, and professional ethics. Professional teacher/learner relationships have a power differential between the teacher and the learner; personal relationships between those who teach and evaluate and those who learn carry a number of risks: conflict of interest, breach of trust, abuse of power, perception of favoritism, and breach of professional ethics. When any of these occur, there is disruption of the dynamics of the health care team, with consequent potential loss of quality patient care and medical education. Those interactions with power differential include, but are not limited to faculty/student, faculty/resident, faculty/fellow, fellow/resident, supervising resident/subordinate resident, resident/student. For the purpose of this policy, those in the position of greater power will be termed teacher and those who are in the position of lesser power will be termed learner.

    1. Definitions

      1. Faculty, for the purposes of this policy only, is defined as full or part- time faculty and all other personnel who evaluate resident/fellow performance.

      2. Residents/fellows are all full time or part time residents/fellows.

      3. Medical Student refers to any student enrolled in a course approved by the School of Medicine.

      4. A consensual relationship is any dating, romantic, sexual, or marriage relationship.

      5. Position of authority includes situations in which the teacher is responsible for an evaluation of the performance of a learner.

    2. Policy

      Teachers shall not engage in consensual relationships with learners whenever the teacher has professional position of authority with respect to learner matters which involve teaching or evaluation of learners’ performance, as part of the medical education program. Should a consensual relationship develop, or appear likely to develop, while the teacher is in a position of authority, the teacher and/or the learner shall terminate the position of authority. Even when the teacher has no professional responsibility for a learner, the teacher should be sensitive to the perceptions of other learners, that a learner who has a consensual relationship with a teacher may receive preferential treatment from the teacher or the teacher’s colleagues. This policy will apply to relationships between teachers and learners during residency rotations/experiences in which the performance of the resident/fellow as part of their approved curriculum is being evaluated, and during all graduate medical education rotations/experiences.

    3. Procedures

      When a consensual relationship, as defined above, exists or develops, the teacher should avoid or terminate his/her position of authority with respect to the learner. Avoidance or termination includes, but is not limited to, the evaluation being performed by another qualified teacher; the position of authority being assumed by an alternative teacher; transfer of the learner to another rotation, etc.

    4. Non-Compliance with Policy

      Any credible allegation of a teacher’s failure to avoid or terminate a position of authority with regard to a learner while in a consensual relationship obligates the Department Chair, Program Director or other responsible person to conduct a prompt and thorough inquiry to determine whether the allegation is true. Where it is concluded that a position of authority in a consensual relationship exists and the involved person refuses to terminate the position of authority, the Department Chair or Program Director shall terminate the position of authority and can impose sanctions against parties involved.

    5. Sanctions

    Persons in violation of this policy shall be subject to sanctions ranging from verbal warnings to dismissal or termination. Persons who

    knowingly make false allegations that consensual relationship overlaps with a position of authority shall be subject to the same sanctions.

    Co n se n su a l Re la tio n sh ip s a n d C o n flic ts o f In te re st

    (Se e UNM Po lic y 2215 h t t p s:/ / p o lic y.u n m .e d u / u n iv e rsit y-p o lic ie s/ 2000/ 2215.h t m l)


    In the event of a termination, transfer, or reduction in size of a residency program UNM will follow all ACGME guidelines and assist in placing affected Houseofficers in other accredited residency programs of the same specialty. The sponsoring institution will inform the GMEC, DIO, and the Residents as soon as possible and residents as soon as possible when a reduction in size or closure occurs. In addition, at the time UNM informs residents of a termination, transfer, or reduction of residency program, UNM shall provide resources including but not limited to contact names, addresses, and phone numbers which may be helpful in a Houseofficer’s search for placement. In such event, UNM shall continue to pay the salaries of displaced Houseofficer for the remainder of the residency year or until said Houseofficers are placed in other salaried and accredited residency programs at another facility if such placement is within the residency year.

    For Houseofficers continuing in a program for which accreditation is lost, UNM will maintain levels of training, continue to provide rotations required for certification, and add ancillary and professional staff to cover losses in Houseofficer coverage. UNM shall take reasonable steps to try to gain full accreditation for the program, to encourage Houseofficers to remain in the program, and to balance the service needs of the department with the professional goals of the Houseofficer involved.


    Drug screening (pre-rotation) is required at some hospitals under affiliation agreements with the University of New Mexico. Compliance is mandatory for those rotations. Forms and information can be obtained through the GME Office. So long as the Houseofficer complies with the drug screening requirements of the affiliated healthcare facility, and so long as the Houseofficer’s screen results are negative, GME will send a letter to the affiliated hospital stating that the Houseofficer has met the drug screening eligibility requirements of the affiliated hospital.

    Drug screens may also be required of any Houseofficer as part of an investigation of impairment as per the Physician Impairment policy in this

    Manual, as part of an emergent psychological review as per the Mandated Behavioral Assessment and Counseling policy in this Manual, as part of an investigation into allegations of a Houseofficer’s misconduct or behavior, or as part of an investigation of allegations of missing narcotics. In the event of allegations of missing narcotics during a Houseofficer’s rotation at the University of New Mexico Hospital or its associated or affiliated clinics or an affiliated hospital or healthcare facility, the Houseofficer is subject to that hospital’s or healthcare facility’s policies and procedures for drug testing. Any allegation of impairment or involvement in an investigation into missing narcotics may result in a referral to the New Mexico Monitored Treatment Program.

    In the event that drug screening is mandatory, whether as part of an affiliation agreement with a healthcare facility, as required by a Houseofficer’s Program Director, as a part of an investigation of narcotics at a hospital or healthcare facility, or for any other reason, failure to comply with any part of such drug screening process may result in disciplinary action, up to and including the withdrawal of employment offer or dismissal from the Houseofficer’s training program. Failure to comply with a referral to the New Mexico Monitored Treatment Program may result in disciplinary action up to and including dismissal from the Houseofficer’s training program. A Houseofficer’s failure to properly and/or timely notify their Program Director or GME of their compliance with a referral to a drug screening or a referral to the New Mexico Monitored Treatment Program may be interpreted as non- compliance with the referral and may therefore result in disciplinary action up to and including dismissal from the Houseofficer’s training program.


    Houseofficers are required to fully participate in the teaching programs and in the educational activities of their individual departments under the guidance and direction of the Department Chairman, Program Director and the Chief of Service to which they are assigned. Houseofficers should develop a personal program of learning to foster professional growth under guidance of teaching staff, participate in institutional and departmental committees which affect their education and patient care, and participate in educational activities developed and supported by the institution. The educational experience should not be compromised by excessive reliance on residents to fulfill non- physician service obligations.


    To be eligible for a training position, a physician must be a graduate of an LCME accredited medical school in the United States or Canada or an AOA

    accredited osteopathic school in the United States. Graduates of international medical schools must hold a currently valid ECFMG certificate, or possess a full and unrestricted license to practice medicine in the state of New Mexico, or have completed a Fifth Pathway program in an LCME accredited medical school. Physicians who are not U.S. citizens must have a valid work authorization on a J-1 visa. All J-1 visas are sponsored by the Educational Commission for Foreign Medical Graduates. No other visas are accepted for training at UNM in Graduate Medical Education. This requirement is consistent with the AAMC guidelines for Graduate Medical Education programs. Houseofficers who are unable to obtain sponsorship or renewal of a J-1 visa through the ECFMG within sixty (60) days of their start date or renewal date may be released from their training program. Eligibility for training at UNM does not guarantee future eligibility for granting of an unrestricted professional license by the New Mexico Medical Board.


    University standard and federal law requires all Houseofficers to be investigated through the US Department of Health and Human Services Office of Investigator General (OIG) and Government Services Administration (GSA). The OIG and the GSA have the authority to exclude individuals and businesses who have engaged in fraud of Medicare, Medicaid, or other Federal health care programs from receiving payment or reimbursements from a Federal health care program. Federal programs include NIH, Medicare, Medicaid, Tricare, Veteran Programs, and others. Cases for exclusion include: convictions for program related abuse, patient abuse, licensing board actions, and default on health education assistance loans.

    Houseofficers must be eligible for employment as verified by the US Department of Health and Human Services Office of Inspector General (OIG) and the Government Services Administration (GSA). Individuals on the OIC/GSA Exclusion List will not be considered for hire. Once hired, periodical checks will be made for eligibility of continued employment. Houseofficers who appear on the list after the initial hiring will be excluded from the UNM HSC training programs. Houseofficers will have the right to the appeal process developed by the US Department of Health and Human Services Office of Investigator General.

    The Office of Graduate Medical Education will be responsible for the initial check on OIG/GSA and EPLS databases. Thereafter, a periodic list of Houseofficers physicians will be provided to the HSC Compliance Office. The Houseofficers Physician Contract will include an acknowledgement by the Houseofficers that they have not been disqualified from the CMS list of physicians.


    Fingerprinting for the purpose of background checks will be required of all Houseofficers in accordance with New Mexico Medical Board(s). Failure to comply or receive clearance for work from the New Mexico Medical Board(s) may result in the withdrawal of an employment offer or the termination of employment. UNM GME reserves the right to consider information revealed from background checks in making its hiring decisions, as allowed by law.

    Residents who rotate to the VAMC will be subject to the fingerprinting process for purposes of a federal criminal background check. Compliance is mandatory for VAMC rotations.

    Other information regarding background and current status may be required which is needed to comply with University, state or federal regulations and/or contractual agreements with affiliated institutions.


    The institutional DEA number assigned to Houseofficers covers all training program activities. UNM HSC, VAMC and all other training sites institutional DEA numbers have separate prefixes and cannot be used interchangeably. For activities outside the training program (i.e., moonlighting) Houseofficers must secure an individual DEA number. Houseofficers, without an unrestricted professional license, should write prescriptions only for patients with a medical record and with a note to that record. Prescriptions for controlled substances may not be written using the institutional DEA number for faculty members, family members, friends, themselves, or individuals with whom they are having a sexual relationship. Violations of appropriate use of the institutional DEA number will constitute a violation of the professionalism standard requirement. Inappropriate use of the DEA number is considered professionalism misconduct and may be investigated by UNM, the Board of Pharmacy, or the New Mexico Medical Board.

    Applications for individual DEA numbers are available on line at the DEA website


    The level of appointment within a training program is determined by the Program Director upon review of application’s relevant qualifications and the

    requirements of the Residency Review Committee, as well as a request to the appropriate RRC or certifying board of the specialty of pursuit.


    The New Mexico Medical Board, Osteopathic Board, or Dental Board issues a training license to Houseofficers to participate in residency programs. All residents must have a training license application on file with the GME office, unless they have an active, full unrestricted professional license in the State of New Mexico (they cannot have a pending license application). Application questions must be completed in an honest manner and disclosure of misdemeanors, DWI, and other criminal arrest must be declared. This Training License is issued by the Board with the expectation that all requirements of the New Mexico Practice Act related to professional behavior, care of patients, and assurance of competency are adhered to while in training. Due to the commitment of the institution to train Houseofficers to practice in the state of New Mexico, candidates for a training license to train at UNM cannot be ineligible for a full unrestricted license in the State of New Mexico at the end of training.

    For Houseofficers in good standing, all training licenses are renewed annually by the Houseofficer for the duration of the program (not to exceed eight years). NMMB training license online renewal process is located at Houseofficers are expected to maintain the highest level of licensure once they obtain a public service or professional license. For any activity outside the training program (i.e., Locum Tenens, moonlighting), you must have a New Mexico Public Service license, at a minimum, to practice medicine.

    In addition to training licenses, the NM Medical Board grants Public Service and unrestricted professional licenses. An unrestricted license requires two years of graduate training completed in the United States to be eligible. A Public Service license is available to UNM Houseofficers after one year of graduate training and successful completion of USMLE Step III and with the written permission of their Program Director.

    The New Mexico Board of Osteopathic Medicine requires Houseofficers to obtain professional licensure after completing one year of training. Applications can be obtained from the Osteopathic Board by calling (505) 476- 4622.

    The NMMB and NMBOM may report resident issues to the National Medical Practitioner Data Base. Houseofficers must notify the Office of Graduate Medical Education and the DIO of any complaints by patients or others filed with the NMMB and NMBOM.


    Plagiarism is the use of another person’s ideas, words, phrases, sentences, facts, graphics, charts, tables, graphs, graphics, audio-visuals, or other intellectual products without appropriately citing and crediting the original source(s). Plagiarism in any form constitutes academic misconduct and the UNM School of Medicine (UNMSOM) considers plagiarism a breach of resident professionalism, which requires appropriate administrative inquiry and response. Appropriately citing sources brings deserved credit to the work of other writers, indicates the level and quality of research conducted, provides a scientific foundation for scholarship, builds solidarity in the academic community, and facilitates the reader’s ability to validate claims and pursue independent learning.


    The following are considered examples of plagiarism but are not inclusive. It is within the discretion of the School of Medicine faculty member or program director to determine if other actions not listed here also constitute plagiarism.

    • The submission of efforts of others as your own personal or group work, or scholarship.

    • Use of direct quotations without the use of quotation marks and referencing of the source of the quotation.

    • Incorrect paraphrasing information without proper citation of the source.

    • Failure to provide adequate citations for material used.

    • The purchase of a scholarly paper or any other academic product from the Internet or any other commercial sources and submitting it as your own work.

    • Downloading work from the Internet and submitting it without citation.

    • Directly copying and pasting from any source, electronic or written, into any academic assignment without explicit citation of the original source.

    • Inappropriate and unattributed use of the cut/paste functions in electronic medical record documentation of clinical care.


    The UNMSOM considers plagiarism as academic dishonesty that violates the Medical Resident Code of Professional Conduct. The following procedure will be followed when a resident is suspected to have plagiarized.

    1. The faculty member or program director will notify the resident verbally and in writing that there is concern regarding plagiarism.

    2. If it is determined that plagiarism occurred, consequences may include failure of the rotation or other required activity (e.g. research project). The program director may require the resident resubmit the document of concern.

    3. The program director will send a notification of the nature of the plagiarism and the action to the Graduate Medical Education Committee to determine if further action is warranted. The GMEC will review the incident and determine if other penalties are appropriate depending on the seriousness of the plagiarism and the context in which it occurred as well as the resident explanation. Additionally, notification will also go to the Associate Dean for Graduate Medical Education.

    4. Any resident who has a second report of plagiarism will be brought before (GMEC). The GMEC will determine the appropriate action to be taken.


    The UNM Office of Graduate Medical Education functions as a human resource, payroll and benefits office for Houseofficers in the training programs (see rear cover for mailing address and phone number).

    Re sp e c tfu l C a m p u s

    (se e UNM Po lic y 2240 h t t p s:/ / p o lic y.u n m .e d u / u n iv e rsit y-p o lic ie s/ 2000/ 2240.h t m l)


    UNM sponsored programs participate in the National Residency Matching Program and other specialty matches to fill their positions. The University is an Equal Opportunity employer and makes selections based on the preparedness, ability, aptitude, academic credentials, communication skills, and personal qualities such as motivation and integrity.

    Programs do not discriminate with regard to sex, race, age, religion, color, national origin, disability, veteran status, sexual orientation, ancestry, medical conditions or ACGME required status.


    Residents and fellows who transfer to the University of New Mexico from another ACGME program must obtain a release from the Program Director at that institution. The Office of GME will assist in verifying prior training. In order to appoint the transferred trainee at the appropriate level, the Program

    Director at the University of New Mexico must obtain 1) a written verification of previous educational experiences and/or rotations, as well as, 2) a statement regarding performance in the program or copies of performance evaluations prior to the acceptance and appointment at UNM HSC. Trainees who transfer from the UNM HSC to another institution are responsible for providing that institution with verification of educational experiences or completed rotations and a statement regarding performance of the trainee in the program.


    Each program will make call and rotation schedules available to their trainees. All call and rotation schedules must be available through AMION. There must be a process in place by each program will ensure accuracy of the information in AMION.


    National Provider Identifiers are required of all Houseofficers participating in training programs at UNM HSC. The online application is located at

    After the number has been obtained by the Houseofficer, it must be on file with the Office of GME and UNMH.

    USMLE & C o m p le x

    For physicians, GME requires Step II to be successfully completed by the end of the first year of training (HO I) and Step III to be successfully completed by the end of the second year of training (HO II). Completion of USMLE Step III or Complex Step III shall be a requirement for successful completion of the HO II training year. Program Directors in each specialty must monitor Houseofficers’ compliance; however, Houseofficers are responsible for ensuring that they have completed the USMLE or Complex requirements. Houseofficers who are not in compliance shall not be promoted to the next level of training. Houseofficers who join the training program and enter above the HO II level are required to have successfully completed USMLE Step III or Complex Step III prior to acceptance into a UNM GME training program. Upon successful completion of USMLE Step III or Complex Step III, Houseofficers are

    eligible for reimbursement if completed prior to end of their HO II year, and if attempted during employment at UNM in an ACGME residency program.


    The New Mexico Medical Board allows UNM Houseofficers to take USMLE Step III after completing their first year of training. The exam is administered by the Federation of State Medical Boards. The New Mexico Medical Board allows the option for Houseofficers to apply for a NM Public Service license at the same time that they apply to take the exam. Applications for the examination can be obtained online at or calling (817) 868-4041. To obtain a public service application you may FAX your request to the Board at (505) 476-7237. The New Mexico Medical Board requires Step III to be taken within seven years of passing Step II. GME will offer assistance with the forms upon request.


    UNM HSC will strive to provide a safe and healthy work environment and will comply with city, state, and federal health and safety laws.


    (See UNM Policy 3110

    policies/3000/3110.html )


    This policy does not apply to discipline or dismissal for alleged administrative misconduct. Please refer to the Grievance Procedure and Disciplinary Action articles in the current Collective Bargaining Agreement between the University of New Mexico and the Committee of Interns and Residents/SEIU regarding discipline or dismissal for alleged administrative misconduct.

    Houseofficers shall not be disciplined or discharged under the terms of this policy without just cause. Houseofficers shall be given written notice of any disciplinary action to be taken against them, which shall include a description of the disciplinary action taken or contemplated and a description of the reasons for such action. A copy of the notice of contemplated disciplinary action will be presented to the CIR/SEIU representative assigned to UNM as quickly as practicable. Disciplinary action shall not be reported to the New Mexico Medical Board until the discipline is implemented. A Houseofficer’s paycheck shall not be withheld pending contemplated

    discipline. GME must be notified and consulted with for all proposed or contemplated disciplinary actions.

    If the academic performance of a Houseofficer – in domains that include, but are not limited to, clinical skill, medical knowledge, ethics, professionalism, attendance, or compliance with Institutional policies or the law – is unsatisfactory, the Houseofficer may, in the Program Director’s discretion, be placed on remediation. In such cases, the Program Director will notify the Houseofficer in writing of the specific areas of unsatisfactory performance and the expectations for improvement. Remediation is not an adverse action and it is not appealable or grievable.

    If, following a period of remediation, the academic performance of a Houseofficer continues to be unsatisfactory, or, in the case of misconduct wherein remediation is deemed inappropriate, the Houseofficer may be placed on probation for a specified period of time. The Program Director will designate the period of probation and identify the areas of deficiency to be corrected during such period. During the probationary period, the Houseofficer must correct the deficiencies; failure to do so may result in further discipline up to and including dismissal from the Houseofficer’s training program. The probationary period together should not be less than 30 days in length nor should it normally exceed six months. The Program Director will meet with the Houseofficer as regularly as is practicable during this period to formally review progress.

    At the end of the probation period, the Program Director will review the Houseofficer’s progress and determine whether satisfactory improvement has been made. Feedback from various sources may be solicited as required to evaluate the Houseofficer’s performance. Improvement during the probationary period does not result in an automatic reinstatement to non- probationary status. Rather, even if improvement has been satisfactory, the Houseofficer may, in the Program Director’s discretion and in consultation with GME, be continued on probation for a specific period of time not to exceed six months. If the Houseofficer’s performance again becomes unsatisfactory during this period or improvement during the period is unsatisfactory, the Houseofficer may be dismissed without an additional probation period even if the probation extended beyond a contract year.

    To appeal probation, non-renewal of contract, or dismissal, see the grievance procedure as stated in this Manual. Remediation is not a grievable event.


    The University of New Mexico is an environment for the pursuit of its educational mission free of illegal drugs and the illegal use of alcohol.


    Duty hours are defined by the ACGME as all clinical activities related to the residency program, i.e. patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.

    Each program has a written statement concerning the Houseofficer’s duty hours which will be in compliance with their RRC requirements. The ACGME Duty Hours Requirements, which are the minimum duty hour standards for all residency and fellowship programs (unless granted program specific exemptions by the ACGME and by UNM) are as follows:

    1. Maximum Hours of Work per Week – ACGME 80 Hour Rule

      • Houseofficers work week must not exceed eighty hours averaged over a four-week period, inclusive of all in-house call activities and moonlighting.

    2. Mandatory Time Free of Duty – ACGME Day Off Rule

      • Houseofficers must receive one day off in seven from all educational and clinical responsibilities averaged over a four week period, inclusive of call. One day is defined as one continuous 24-hour period free of all clinical, educational, and administrative activities. At home call cannot be assigned on these free days.

    3. Maximum Duty Period Length – ACGME 24+4 Rule

      • Duty hour periods for Interns must not exceed 16 hours in duration.

      • Duty hour periods for HO II and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital. Residents are encouraged to use alertness management strategies in the context of patient care responsibilities. This includes strategic napping after 16 hours of continuous duty and between the hours of 10 PM and 8 AM is strongly encouraged.

      • Transitions of patient care must occur for patient safety and resident education. Residents may be allowed to stay on site for an additional 4 hours to accomplish these tasks.

      • Each program must have a procedure to ensure continuity of patient care if a Houseofficer is unable to attend to assigned patient care responsibilities.

      • Residents must not be assigned additional clinical responsibilities after 24 hours of continuous service.

      • Residents may, in unusual circumstances, on their own initiative, remain beyond their scheduled period of duty to continue to provide care to a single patient. Justification for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family. Under such circumstance the resident must hand over the care of all other patients to the team responsible for their continuing care, and document the reasons for remaining to care for the patient in question and submit that documentation in every instance to the Program Director. The Program Director will forward all such documentation of these instances to the Duty Hour Compliance Task Force and the GMEC. The program must review each submission of additional service and track both individual resident and program- wide episodes of additional duty.

    4. Minimum Time Off Between Scheduled Duty Periods – ACGME Short Break Rule

      • Residents should have 10 hours free of service between daily service rotations, and must have 8 hours scheduled duty periods. An appropriate educational justification must be offered if a resident is unable to meet the “should have 10 hours” requirement.

      • Residents must have 14 hours free of duty after 24 hours of in-house service.

      • Houseofficers in their final years of training must be prepared to enter the unsupervised practice of medicine and care of patients over irregular or extended periods. While it is desirable that these houseofficers have eight hours free of duty between scheduled duty periods, there may be circumstances (as defined by the program’s RRC) when these houseofficers must stay on duty to care for their patients or return to the hospital with fewer than eight hours free of Duty. All instances will be reviewed by the Duty Hour Compliance Task Force.

    5. Maximum Frequency of In-House Night Float – ACGME Night Float Rule

      • Residents must not be scheduled for night float more frequently than six consecutive nights. Night float may be further specified by individual RRC’s.

    6. Maximum In-House On-Call Frequency – ACGME Call Rule

      • HO II and above residents must be scheduled for in-house call no more frequently than every third night when averaged over a four week period.

    7. At-Home Call

      • For call taken from home (pager call), the time the resident spends in the hospital after being called in is counted toward the duty hour limit. The only other duty hour requirement that applies is the ACGME Day Off Rule which requires the day-off to be free of all patient care responsibilities, including at-home call. The ACGME also requires that programs monitor the intensity and workload resulting from at home call, through periodic assessment of the frequency of being called into the hospital, and the length and intensity of in- house activities. Each episode of this type of care while it must be included in the 80 hour work week will not initiate a new off duty period. Residents are responsible for monitoring fatigue after home call and will be relieved of clinical responsibilities following home call if necessary. Faculty physicians will assist in relieving Houseofficers of duty responsibilities after home call.

    At this time, no UNM residency program has been granted exemption from these maximum standards. Specific RRC duty hour regulations (e.g., specialty specific) may be more restrictive than the duty hours standards described above, and those residency programs must have departmental duty hours policy compliant with the standards of their RRC.

    Each program shall distribute a copy of the departmental duty hour policy to all Houseofficer physicians and faculty. It is the primary responsibility of the sponsoring program to assure compliance with RRC duty hour regulations regardless of the Houseofficer’s rotation on or off of the service.

    Houseofficers shall report duty hours honestly, completely, and correctly in accordance with institutional requirements via New Innovations. This must be complete by the end of business on Monday afternoons each work week. Failure to do so will require the resident to appear before the Duty Hour Task Force to explain why the resident cannot comply with institutional policy and procedure.

    Also see (Callrooms, and Taxi Reimbursement Program)

    The duty hour policy promotes the educational environment, supports the physical and emotional wellbeing of Houseofficers, and provides for patient safety.


    All University of New Mexico ACGME accredited programs, as well as the dental program, must achieve and maintain compliance with the resident duty hour regulations for their respective RRC. The Office of Graduate Medical Education will regularly monitor resident duty hours for compliance with the institutional duty hour limitations and RRC regulations by the use of weekly reporting and the review of data by the GMEC. The GMEC has established the Duty Hour Compliance Task Force, which meets monthly, to review compliance in each program. The following policy outlines the procedures that will be used by the institution.

    1. The Office of GME will collect and maintain a file containing all of the individual program policies concerning resident duty hours.

    2. The Office of GME will provide New Innovations as a method for all programs to track resident duty hours, and all programs will be expected to utilize this standard reporting tool. All residents and fellows will be required to input duty hours by Tuesday (end of business on Monday) for all hours worked the previous week (Tuesday to Monday). Reports will be generated by the Office of GME through New Innovations to determine compliance. Failure of any Houseofficer to meet this duty hour reporting requirement will result in the Houseofficer appearing before the Duty Hour Task Force to explain how they will meet the requirement in the future. The second incident will require the resident to appear with his or her Program Director. The third incident of non-reporting duty hourswill result in a letter of reprimand being place into the resident’s file. Program Directors who do no investigate an alleged duty hour violation may be required to attend the following months duty hour task force and offer an explanation. The second occurrence will require the Program Director to appear before the committee accompanied by his Clinical chair. The third offense could result in the program receiving institutional probation or result in a negative score on the compliance for the SOM scorecard. The Duty Hour Compliance Task Force and the GMEC will review on a monthly basis duty hour reports based on any area of violation in the ACGME duty hour regulations. This information will be reviewed monthly by the GMEC for compliance and by the Operations Committee for discussion of specific rotation concerns. No residency or fellowship programs will be exempt fromhaving to track this information without the complied consent of the GMEC and the DIO. The Duty Hour Task Force will review matrixes of alleged duty hour noncompliance in each program. Each Department will be required to investigate the alleged duty hour violation.

    3. The Office of GME will request action plans from individual programs concerning individual rotations or residents that are not in compliance with RRC and institution regulations. The Office of GME will encourage the individual departments to involve residents in the preparation of these plans. The Office of GME will follow up on a monthly basis concerning progress on these action plans until it appears to be appropriately resolved.

    4. Any individual (housestaff or faculty) aware of a violation of the policy mandating that interns work more than 16 hours and PGY 2’s work no more than 24 continuous hours with a 4 hour period to transition care

      (i.e. 28 hours of continuous service) must report the instance to their Program Director immediately. Failure to do so will be considered a breach of professionalism, and may result in disciplinary action. The program must prepare a response plan and provide the Office of GME with an action plan within 72 hours of the report of the violation.

    5. The institution will maintain a confidential web based reporting tool for residents to report duty hour violations or Houseofficers may use the HSC Compliance Hotline (1-888-899-6092). Upon notice of such reporting through a) the institutional web site

      b) a report through an RRC resident survey, or c) a report to the

      institution from the ACGME; The Office of GME will conduct a focus group session with the residents participating in various rotations to assess not only compliance with the resident duty hour regulations but also to assess educational aspects, resident fatigue/stress and quality of life issues. You can also reach the HSC Compliance Office at

    6. The internal review committee will include questions concerning resident duty hours during the reviews of the programs. The institutional annual resident satisfaction survey will solicit information on duty hour compliance. These reports will be included in the summaries submitted to the GMEC. The annual ACGME Resident Survey for each program will be reviewed by the GMEC. The Office of GME, under the direction of the DIO, will submit a report to the Dean of the School of Medicine and the medical staff governing body of each major participating institution annually on resident duty hour compliance.


    Houseofficers may report duty hour violations on any rotation at the following reporting site:

    This site provides complete confidentiality of the Houseofficer who is making the report. Additional resources included the UNM HSC Compliance Hotline at 1-888-899-6092.


    The University recognizes the potential impact of sleep deprivation and fatigue upon Houseofficers. Information on sleep deprivation will be made available to Houseofficers during orientation and through each department.


    Houseofficers who feel they are not able to safely drive themselves home after twenty four hours or more of service may, with notification of the Program Director or attending physician, elect to take a taxi to their designated home. Reimbursement shall include one way or round trip fares not to exceed fifty dollars ($50) in total.


    Each program will have a procedure for evaluation of each Houseofficer’s performance which will be in agreement with the specific Residency Review Committee requirements. The institutional standard for performance evaluations is New Innovations. Formative performance evaluations will be done on a formal basis at a minimum of every six (6) months by an attending physician who has direct, continuous contact with the Houseofficer. Evaluations should be written and must be discussed with and acknowledged by the Houseofficer. Such evaluation shall include:

    1. An evaluation based on the 6 ACGME competences.

    2. A milestone based assessment.

    3. An identification of future goals and learning objectives, as well as a plan for achieving these goals and objectives.

    4. A plan to advance a trainee to a position of higher responsibility will be done annually on the basis of the trainee’s readiness for advancement based on level of achievement of core competencies and specialty milestones. Assessments may be done more often than every six months, particularly if deficiencies are noted. The program will maintain documentation of individual records of written evaluation for each Houseofficer which shall be available and accessible to the trainee. Each

    Houseofficer should be responsible for maintaining a portfolio reflecting professional growth and guidance from the teaching staff.

    Final summary evaluations are performed by each training program at the conclusion of training. The summary evaluation will include the following statement “I verify that, during (his/her) participation in the residency program in (specialty) sponsored by the University of New Mexico School of Medicine, (name of resident/fellow) has demonstrated sufficient professional ability to practice competently and independently in the specialty of (name of specialty).” A copy of the final summative evaluation of competency is retained by the program as well as the Office of GME. The institution strongly supports and endorses the use of New Innovations Electronic Evaluation System. A copy of any evaluation shall be accessible to the Houseofficer online and placed in his or her file within a reasonable time after completion of a rotation. Houseofficers shall have the right to review any evaluation with the Program Director, Chair, or designee of the Houseofficer’s program.


    It is the policy of the institution to prevent and eliminate forms of unlawful harassment in employment and educational settings. The University prohibits harassment of employees by supervisors or co-workers and harassment of students on the basis of race, color, religion, national origin, physical or mental disability, age, sex, sexual orientation or gender identity, ancestry, medical condition, spousal affiliation or other protected status. The University makes special efforts to eliminate both overt and subtle forms of sexual harassment.

    Please refer to the UNM Equal Opportunity and Affirmative Action and Sexual Harassment Policy (Policy 2720) for details.

    UNM Office of Equal Opportunity web site:


    Moonlighting activities, whether internal or external, must be consistent with sufficient time for rest and restoration to promote resident educational experience, well-being, and patient safety. Program Directors will closely monitor moonlighting activities to ensure they do not interfere with the Houseofficer’s ability to achieve the goals and objectives of the educational program. Internal Moonlighting is considered to be moonlighting at all UNM HSC facilities. For example, some departments will allow Houseofficers to take

    extra call or provide extra service in their department and compensate them for it (through special compensation forms). These hours would count toward the 80 hour work week. External Moonlighting is moonlighting at any institution, which is not a required rotation or funding source for UNM GME Programs. External Moonlighting cannot be done at the same institution, which is funding the rotation. External Moonlighting may be done through and paid for by UNM Locum Tenens. These hours would be counted toward the 80 hours work week. All internal and external moonlighting (as defined in the ACGME Glossary of Terms) will be counted toward the 80-hour maximum weekly limit and must be reported. Residents are responsible for reporting moonlighting hours. Failure to do so is consider professional misconduct. Program Directors are responsible for monitoring fatigue which might be a result of this moonlighting. If it is determined that moonlighting affects a Houseofficer’s performance, the Houseofficer’s ability to moonlight may be limited or eliminated.

    Permission forms for moonlighting (both internal and external) are available in the GME Office. This form must be signed annually by the Program Director and must be on file in the GME Office. Individual departments may have specific policies defining and/or denying moonlighting privileges. Moonlighting privileges cannot be used for the formation of one’s own practice. Residents who hold J-1 visas are prohibited from internal or external moonlighting by the sponsor (ECFMG). No trainee can be required to moonlight. Interns are not permitted to moonlight.

    Programs are bound by Residency Review Committee requirements for duty hours and educational content and environment. Because of the educational advantage and mission of the SOM and in compliance with that mission it is advised off site moonlighting experiences be coordinated through the UNM Locum Tenens program. The Locum Tenens program assists the Houseofficer in the process of licensing and credentialing. Professional liability is covered in the institutionally sponsored program. Compensation is paid through the UNM payroll system thus minimizing any unplanned tax liabilities. The Houseofficer’s Program Director must sign each special compensation form prior to payment. The University and the Houseofficer agree to abide by the Association of American Medical Colleges’ statement on moonlighting by Houseofficers (memorandum 74-21, July 1, 1974).


    Graduate medical education should be a full time educational experience. Houseofficers should not be diverted from their primary responsibilities to their own education and to the patients charged to their care by the training

    institution by engaging in extramural professional activities. Therefore, as a matter of general principle, the Association of American Medical Colleges believes that “moonlighting” by Houseofficers is inconsistent with the education objectives of Houseofficer’s training and is therefore a practice to be discouraged. For those institutions that permit moonlighting, great care should be taken to preserve the educational character of their graduate medical education programs. The following general guidelines are recommended as the means by which the primary training institutions should monitor and control this practice.

    1. The hospital governing board or executive committee of the faculty having responsibility for medical standards in the educational setting, should administer the authority to approve or disapprove “moonlighting” in the individual case. This authority may be delegated to the service chief or other individual who controls the content and quality of each training program.

    2. In evaluating the content and quality of the training program for each Houseofficer, consideration should be given to the following:

      1. The capacity of the Houseofficer to fulfill his educational objectives while at the same time pursuing additional work opportunities for income;

      2. The nature of the work opportunity, including its educational value;

      3. The needs of the community; and

      4. The financial need of the individual.

    3. Moonlighting by incumbents of internship and residencies approved by the Accreditation Council on Graduate Medical Education, may be permitted only if those activities are reviewed and approved by the person(s) responsible for the individual’s graduate training program. Houseofficers should be informed of the substance of this provision prior to


    4. The ACGME may take the necessary steps in its process of approval of graduate medical education programs to assure compliance with the above guidelines.


    Houseofficers are not subject to the UNM HSC non-competition clause.


    All Houseofficers shall be notified in writing no less than four (4) months prior to the end of their annual contract year if their contract is to be non- renewed or if they will not be promoted to the next level of training. If primary reason(s) for the non-renewal or non-promotion occur(s) within the four (4) months prior to the end of the Agreement, or in the case of Houseofficers with a contract for less than twelve (12) months, UNM will provide as much written notice of the intent not to renew or not to promote, prior to the end of the contract, as the circumstances will reasonably allow. Determination regarding a decision not to renew a contract will be made by the Program Director in consultation with the Department Chair and the Associate Dean for Graduate Medical Education.


    In the event a Houseofficer becomes impaired during the training program, including but not limited to alcohol, drug, or chemical dependency, the Houseofficer may exhaust accrued annual, sick, and available catastrophic leave for treatment with pay. No Houseofficer will be disciplined or terminated for seeking such treatment. No Houseofficer shall be disciplined or terminated for admitting they are impaired, or seeking medical leave for such treatment. This disciplinary safe harbor does not extend to impairment or dependence discovered other than by self-disclosure, nor does it extend to discipline for conduct, behavior, actions, or omission while impaired or dependent.

    Investigation and disposition of a Houseofficer suspected of impairment, including, but not limited to alcohol, drug, or chemical dependence are outlined in the UNM Physician Impairment and Substance Abuse Policy. If the Houseofficer is rotating at an affiliated hospital, the Houseofficer is subject to the policy and procedures of the affiliated hospital for impaired physicians.

    Any violation of this policy may result in discipline up to and including immediate termination from our GME programs.


    All persons enrolled in UNM Graduate Medical Education programs are responsible for ensuring that patient safety is maintained at all times. UNM and its affiliated hospitals are drug free and alcohol free campuses. This Physician Impairment policy is adopted pursuant to UNM Graduate Medical Education’s obligation to maintain a high standard of patient care and safety

    “Impairment,” “impaired,” “impair,” and any and all forms of the word as used in this Policy includes but is not limited to: alcohol, drug, or chemical dependency, use, or abuse, whether such substance is prescribed for a

    medically recognized physical, mental, or other condition or not; a physical or mental condition that impairs the Houseofficer’s ability to perform his or her duties even to the slightest degree; and any other condition that impairs the Houseofficer’s ability to perform his or her duties even to the slightest degree. In the event a Houseofficer becomes impaired during the training program, the Houseofficer may exhaust any and all accrued annual, sick, and available catastrophic leave to voluntarily seek and participate in a treatment program directly related to such impairment. No Houseofficer will be disciplined or terminated for self-disclosing and seeking such voluntary treatment

    Houseofficers are strongly encouraged to self-disclose impairments to their Program Directors and/or the Office of Graduate Medical Education. Houseofficers, who self-disclose impairments, will be referred for evaluation and development of an appropriate treatment plan. Based on recommendations of the MTP, Houseofficers participating in MTP-designed treatment plans may have their work schedules and training schedules modified depending on the circumstances, the needs of the University to maintain patient care and safety, and whether such modifications present an undue hardship to the University, among other factors to be considered. Failure of a Houseofficer to comply with MTP recommendations, a recurrence of impairment, or failure or refusal to cooperate with the University’s investigation and disposition of suspected impairment (whether or not the non-compliant or non-cooperative Houseofficer is the subject of the investigation) may result in disciplinary action up to and including termination.

    Investigation and disposition of a Houseofficer suspected of impairment are outlined in the UNM Physician Impairment and Substance Abuse Policy herein.


    “Impairment,” “impaired,” “impair,” and any and all forms of the word as used in this Policy includes but is not limited to: alcohol, drug, or chemical dependency, use, or abuse, whether such substance is prescribed for a medically-recognized physical, mental, or other condition or not; a physical or mental condition that impairs the Houseofficer’s ability to perform his or her duties even to the slightest degree; and any other condition that impairs the Houseofficer’s ability to perform his or her duties even to the slightest degree. “Substance abuse” refers to the use or misuse of any substance, licit or illicit, whether prescribed for a medically-recognized condition or not.

    During the training period, if a person detects signs of possible substance abuse and/or impairment in a Houseofficer (including but not limited to behavioral changes, alcohol on breath, display of use of alcohol, marijuana or

    other depressant, stimulant, or mind-altering chemical, discovery of possession or use of illegal or improperly-possessed or used substances, unprofessional or unethical acts or behavior; etc.), the attending physician, Graduate Medical Education, and/or the Department Chairman or Program Director, upon notification of same, will advise the Houseofficer of the situation and will immediately place the Houseofficer suspected of impairment on administrative leave pending investigation into the suspected impairment. Depending on the circumstances, appropriate testing will be arranged. If recommended for testing, the Houseofficer will be accompanied to the testing by appropriate personnel. The individual supervising the immediate investigation will notify the Houseofficer’s Program Director and Department Chairman and the Associate Dean for GME as soon as practical. Failure of the Houseofficer to comply with the recommendation and/or arrangement for testing may result in disciplinary action up to and including termination.

    In the event of a positive test result, the Houseofficer will be referred to MTP for evaluation and development of an appropriate treatment plan. In addition, in the event of a positive test result, the University may conduct an investigation into the suspected impairment, during which time the Houseofficer’s placement on administrative leave may continue. Placement on administrative leave may also, depending on the circumstances, continue until MTP develops an appropriate treatment plan, and the Houseofficer and the University accept such recommended treatment plan. Continuation or resumption of participation in Graduate Medical Education programs will be based on the recommendation of MTP, the result of the University’s investigation into the suspected impairment, the evaluation of patient safety concerns by the Program Director and the Office of GME, and any other relevant parties, in accordance with the hospital’s policies on physician impairment. Failure of a Houseofficer to comply with MTP recommendations, a recurrence of impairment, failure, or refusal to cooperate with the University’s investigation and disposition of suspected impairment (whether or not the non-compliant or non-cooperative Houseofficer is the subject of the investigation) may result in disciplinary action up to and including termination.

    In the case of a negative test result, the Houseofficer’s suspected impairment may be investigated. Failure to comply or cooperate with such investigation may result in disciplinary action up to and including termination. Such investigation may include further testing, a psychiatric evaluation, or other appropriate evaluations. The Houseofficer’s placement on administrative leave may continue throughout the investigation. A determination that the Houseofficer may resume participation in Graduate Medical Education programs will depend upon the health status of the resident, the results of the investigation, the nature of the suspected impairment, and any other relevant factor. Even if the Houseofficer’s test results are negative, the Houseofficer may be subject to disciplinary action up

    to and including immediate termination depending on the circumstances. In the event of a false or malicious accusation of impairment, GME will work with the individual resident and their program to take appropriate restorative measures.

    In situations where a Houseofficer’s physical or mental health or personal safety is a concern or where the Houseofficer presents a safety concern to others, the Houseofficer will be placed on administrative leave and referred for appropriate psychiatric and medical evaluations. Failure or refusal to comply with such referral may result in disciplinary action up to and including termination. At such time that the Houseofficer no longer presents a health or safety concern as determined by the circumstances, the Program Director and the Associate Dean for GME will assess the Houseofficer’s ability to resume participation in Graduate Medical Education programs. Depending on the circumstances, the needs of the University, and any other relevant factor, a modified schedule may be implemented. In parallel, evaluation of the Houseofficer for suspected alcohol and/or substance abuse may proceed pursuant to the procedure provided for herein.

    Houseofficers on administrative leave are expected to comply with the reasonable requests of their Program Director, Program Coordinator, and the GME office in a timely and professional manner. All Houseofficers on administrative leave must make reasonable efforts to maintain communication with their Program Director, Program Coordinator, and the GME office unless reasonable exigent circumstances exist to prevent such communication. In the event a Houseofficer claims that exigent circumstances exist during the Houseofficer’s period of administrative leave that prevent or impede their ability to so communicate, the Houseofficer will be required to provide sufficient proof of such exigent circumstances and propose a plan for which reasonable, timely, and professional communications may occur. A Houseofficer’s failure to maintain such communication while on administrative leave may result in disciplinary action up to and including termination. Should a resident be investigated for impairment, the reason for being put on leave will be recorded as medical or administrative leave on a need-to-know basis, dependent on situation.

    If the Houseofficer’s impairment persists or recurs, the University may:

    • Issue the Houseofficer discipline up to and including termination;

    • Identify treatment options and refer the Houseofficer to such treatment as appropriate;

    • Notify the New Mexico Medical Board; and

    • Take any other action deemed necessary.

    Impairment and substance abuse constitute administrative misconduct as defined in the Collective Bargaining Agreement between the University of New Mexico and the Committee of Interns and Residents/SEIU and are thus subject to the grievance and arbitration procedure set forth in the Collective Bargaining Agreement.


    Houseofficers are responsible for professional conduct in all activities as outlined in the University Of New Mexico Code Of Conduct Policy (Policy 3715) and University of New Mexico HSC policy on Professionalism for students, residents, and faculty (Statement from UNM HSC Medical Executive Committee). Houseofficers are responsible for serving as a role model for medical students and other Housestaff, and understand that their behavior is a powerful means for educating others. Violations of this policy and the policies referred to herein may result in disciplinary action up to and including dismissal from the Houseofficer’s training program. Violations of this policy and the policies referred to herein are subject to the grievance procedure as stated in this Manual. Nothing in this Manual, the University of New Mexico Business Policies and Procedures Manual, or the University of New Mexico HSC Policy on Professionalism shall be construed as granting Houseofficers any rights, benefits, or privileges not explicitly provided for in this Manual or the Collective Bargaining Agreement between the University of New Mexico and the Committee of Interns and Residents/SEIU.


    Houseofficers are expected to dress and appear in a professional manner at all times when on duty. Houseofficers’ dress should present an appearance consistent with their daily activities which engenders a sense of confidence, trust, and meets customer and patient expectations. Houseofficers are expected to comply with professional attire policy of the hospital in which they are rotating. Individual departments may have additional or specific requirements for professional attire. Dress must comply with Joint Commission, OSHA and other federal standards.


    In the event that academic deficiency is noted, the Houseofficer will be informed. Written recommendations will be made identifying measures to be taken in order to correct the deficiency. A time frame will be given within which correction is to be made. If there is question regarding promotion to the

    next level of training, the Houseofficer will be notified in writing at least four

    1. months prior to the contract end date. Written receipt will be required from the trainee.


      For reappointment to the next higher level of training, each Houseofficer must complete a new contractual agreement (UNM SOM GME Agreement) and have been recommended by their department for promotion to the next level of training. Determination regarding a decision not to reappoint will be made by the Program Director in consultation with the Department Chair and the Associate Dean for Graduate Medical Education.


      To receive a certificate of successful completion of a program, a trainee must satisfactorily complete programmatic, administrative, patient care and educational requirements and competency expectations. An appropriate certification shall be issued within one month of each Houseofficer’s satisfactory completion of his or her training program or part thereof.


      Responsibilities of Houseofficers at the University of New Mexico are detailed in the UNM School of Medicine Graduate Medical Education Agreement. They include, but are not limited to: patient services, education activities and seminars, teaching and supervision of other Houseofficers and medical students, orientation, committee participation, providing documentation of good physical health, CPR certification, places and hours of duty, standards of performance, and compliance with rules and policies of training sites. All Houseofficers shall conduct themselves in a manner that justifies the confidence placed in them by the citizens of the State of New Mexico and shall at all times maintain the integrity and ethics in accordance with the high responsibilities of public service. Any changes in the rotation request require a three month prior notice and the permission of all affected parties. Individual programs will have additional specific responsibilities which are to be written and given to Houseofficers at the start of their training. Houseofficers should be familiar with UNM HSC Medical Staff policies and procedures which are online at:

      Each Houseofficer will be provided with a copy of their RRC (Residency Review Committee) Program Requirements by their Department and are provided with goals and objectives for their residency and rotation. The

      information is available for RRC program requirements and are online at


      The University of New Mexico recognizes the benefits of social

      networking; however, materials posted on personal websites may be discovered by others. Houseofficer information concerning individual patients, including records, photos, x-rays, or other materials that include any identifiable individual information, may NOT be posted on websites. Houseofficers shall also recognize that personal information and photos may be discovered by future employers. Medical schools, residency programs, potential employers, and even law enforcement are known to monitor social networking sites for inappropriate materials and behaviors, and it is to be expected that unprofessional information will be held against you in a variety of contexts. As a physician, your ability to maintain a professional image and reputation impacts your career.

      When considering a professional versus personal online profile, prudent disclosure is essential. Keep in mind the following guidelines: Information on online profiling should be kept to a bare minimum on your professional profiles.

      It should include:

      • Professional Profile

      • Name

      • Professional/work contact information

      • Education

      • Links to Professional and job related content

      • Benign Hobbies

      • Professional or benign Profile photo

        The following rules are basic, but essential minimums regarding your online conduct:

      • DO NOT post patient information or pictures of procedures which would be a potential HIPAA violation.

      • DO NOT badmouth colleagues, boss, or the company you work for. (Always assume that this information will reach them. Nothing ever disappears from the internet). Be sure that you are not performing such activities from a University computer or during work hours. (See University Policy # 2500 ).

      • DO NOT complain about lack of motivation, work load, or anything you see as a “waste of your talents”.

      • DO NOT claim to have family emergencies and sick days (Assume you will be time stamped and tagged in all of your friends’ party pictures.)

      • DO NOT talk about illegal activities or even legal but inappropriate activities.

      • ALWAYS ASSUME everyone can see what you’re writing, or that it will make its way to them at some point.

        Check your security setting. They change often. Your career and professional reputation may depend on keeping your privacy protected.


        Careful supervision and observation are required to determine the physician or dentist in training’s (trainee’s) abilities to perform technical and interpretive procedures and to manage patients. Supervision of trainees should be designed to provide gradually increased responsibility and maturation into the role of a judgmentally sound, technically skilled, and independently functioning, credentialed professional.

        It is the policy of the Medical Staff of the University of New Mexico Health Sciences Center to provide guidance to attending UNM HSC Medical Staff members to insure that the patient care provided by trainee physicians under their supervision is appropriate and of the highest quality and safety. Supervision of trainees in a clinical training program requires balancing multiple different institutional missions and goals while at the same time ensuring the progressive acquisition of skills necessary for independent practice at the completion of graduate medical education. Included among these goals are adherence to sound ACGME (Accreditation Council for Graduate Medical Education), and individual RRC (Residency Review Committee) and CDA (Council on Dental Accreditation) educational principles and guidelines for graduated clinical responsibility, adherence to regulatory guidelines as set forth by, but not limited to CMS (Center for Medicare and Medicaid Services) and JC (Joint Commission) (and others), commitment to ensuring patient safety and providing the highest quality care to our patients, and meeting the risk management and financial goals of the institution.


        UNM HSC Medical Staff Rules and Regulations, UNM HSC Documentation of Clinical Activities by Medical Staff and House Staff, JCAHO Medical Staff Standard, MS 6.9, ACGME Accreditation Standards.


        The purpose of this policy is to specify the mechanisms by which trainee physicians and dentists are supervised by members of the University of New Mexico Health Sciences Center (UNM HSC) Medical Staff, and to establish guidelines for medical staff member supervision of trainees for all inpatient and outpatient care. This policy establishes the minimal requirements for trainee supervision at the teaching hospitals of The University of New Mexico Health Sciences Center (UNM HSC). A UNM HSC teaching hospital or individual training program may have additional requirements for trainee supervision as they pertain to that specific hospital or training program.


        The UNM HSC Medical Staff member is responsible for all aspects of the care provided by trainee physicians and dentists to individual patients in both the inpatient and outpatient settings. It is expected that the medical staff member will maintain active personal involvement in the care of each patient under his/her direct or consultative care, and will document according to policy.


        Trainees will be supervised by credentialed and privileged clinical faculty

        who are licensed independent practitioners on the UNM HSC Medical Staff. The medical staff member must be privileged for the specialty care and diagnostic and therapeutic procedures that they are supervising. In this setting, the supervising medical staff member is ultimately responsible for the care of the patient.

        At least annually, each UNM HSC Residency and Fellowship Program Director will review the ACGME specialty procedural requirements and list of trainee clinical activities and make changes to the program’s requirements. Program Directors of ACGME-accredited programs will submit their updated listing of clinical activities to the Office of the Associate Dean for Graduate Medical Education (GME), and to the UNM HSC Office of Clinical Affairs for review. Program Directors of non-ACGME programs will submit their updated listing of clinical activities to the appropriate department chairperson or departmental committee for approval and then submit the approved

        guidelines to the Associate Dean for Graduate Medical Education and to the UNM HSC Office of Clinical Affairs for review.

        The Program Director will ensure that all supervision guidelines are distributed to and followed by trainees and the Medical Staff supervising the trainees. Compliance with the UNM HSC Medical Staff Supervision of Physicians and Dentists in Training Policy will be monitored by the Program Directors.


        All lines of authority for inpatient care delivered by inpatient ward or ICU teams will be directed to a credentialed and privileged medical staff member. The medical staff member has the primary responsibility for the medical diagnosis and treatment of the patient.


        All inpatient consultations performed by trainees will be documented in

        writing, with the name of the responsible medical staff member/consultant recorded. The responsible medical staff member/consultant must be notified verbally by the trainee doing the consult at the time of the consult. The consulting medical staff member is responsible for all the recommendations made by the consultant team.


        All outpatient visits provided by trainees will be conducted under the supervision of a medical staff member who is physically present in the clinic.

        This medical staff member will interview and examine the patient at the

        discretion of the medical staff member, at the trainee’s request, or at the patient’s request. The medical staff member has full responsibility for care provided, whether or not he/she chooses to verify personally the interview or examination.


        The responsibility for supervision of trainees providing care in the Emergency Department (ED) to patients who are not admitted to the hospital will be identical to that outlined for outpatient supervision above. The responsibility for supervision of trainees who are called in consultation on patients in the ED will be identical to that outlined in section III above. Consulting medical staff members should be notified at the time of the ED consultation. Contact of a trainee for the sole purpose of arranging a follow-up

        visit does not require the notification of the medical staff member.



        Operative, therapeutic and diagnostic procedures involving appreciable risk of morbidity or mortality performed by trainees require active Medical Staff member/ involvement. This includes involvement in the pre-procedural evaluation, decision-making, and planning processes, as well as the actual performance of such procedures. This involvement will be documented in the medical record. Appropriate personal supervision based on the trainee’s level of training and experience will be provided during performance of the procedure. At a minimum, this requires Medical Staff member presence/availability within the operative/ procedural suite or Health Sciences Center complex (if immediately available within 5 minutes) during non-key portions of the procedure, and physical presence at the patient’s bedside in the operating room or procedural suite during key portions of the procedure. The level of supervision provided by the Medical Staff member/ will be documented in the procedural note.



        Each Program Director will identify those procedures commonly performed in locations other than Operating or Procedural Suites by trainees in that program. This listing will be submitted to the Office of the Associate Dean for GME, and the UNMH Office of Clinical Affairs as stated in Section I of this policy. Procedures common to many training programs would include, but are not limited to, the following:

        Endotrachael intubation; Cardioversion/defibrillation; Chest tube insertion; Lumbar puncture; Centeses; Incision and drainage; Wound debridement; Peritoneal lavage; Arterial line insertion; Central venous access; Moderate sedation; Adult medical resuscitation; Pediatric medical resuscitation; Vaginal deliver; Laceration repair; Skin biopsies; Sigmoidoscopy.

        Each Program Director will regularly review each trainee’s experience and training in such procedures as part of that trainee’s performance evaluation, and will determine whether that trainee is required to perform each procedure with “direct, physical supervision”, immediate medical staff availability or by general supervision by a responsible attending. “Direct, physical supervision” may be performed by credentialed clinical faculty who are licensed independent practitioners on the medical staff of the UNM HSC teaching hospital, or by other trainees who have been approved to perform such procedures with general supervision by an attending. The procedure specific listing of “minimum level of clinical faculty supervision” for each trainee will be documented and updated at least annually by each GME Program Director, and will be submitted by the GME Program Director to the Office of Clinical Affairs, which will maintain this documentation in a manner that facilitates timely access by other clinicians, consistent with JC guidelines.


        Any additions or exceptions to the requirements of this Medical Staff Policy that a department/division or specialty may require should be

        submitted in writing to the Associate Dean for Clinical Affairs and to the

        Associate Dean for Graduate Medical Education for their review and approval.

        In an emergency situation, a trainee may provide immediate care including the performance of invasive procedures (assisted by available Health Sciences Center staff) necessary to preserve life or prevent serious impairment for any patient under the trainee physician’s care. The appropriate medical staff member will be contacted and apprised of the situation as soon as is practical and possible, and the discussion will be documented in the medical record.


        Houseofficers must be supervised by teaching staff in a way that assumes progressively increased responsibilities throughout the course of training according to their level of education, ability and experience. HO I will be supervised by senior level residents directly available and will not provide care under indirect supervision. Each program must have a policy which outlines the type and level of supervision for each level of training in a program which is consistent with the RRC requirements for the particular program, and ACGME common program requirements. A copy of each department’s policy on graduated levels of supervision must be included in their program manual and a copy must be on file in the Office of Graduate Medical Education.


        Each program will be responsible for the development of a procedure/guideline for patient hand offs to ensure timely, efficient, and safe transfer of patient care. The procedure/guidelines must be available to all Houseofficers at the program level and copies should be on file in the Office of GME. A schedule of attending physicians and residents responsible for each patient’s care must be provided by each program. Also, see Schedules.


        Houseofficers are represented by the GME Resident Council. The Resident Council is a peer selected organization. The Committee meets the first Tuesday of each month with representatives from all programs. The Resident Council

        elects membership to participate in the GMEC and the MEC. Houseofficers interested in joining this or other committees should contact the Office of GME.



        Unpaid clinical activity on behalf of a non-profit organization other than UNM or UNMH. Volunteer activity is not required by the UNM GME program. Volunteer activity must be limited to non-profit organizations and typically

        involves provision of medical services to underserved, vulnerable populations,

        away from the UNM Health Sciences Center or UNM campus.


        The following is a list of current volunteer activities. Any additional

        activities should to be reviewed and approved by the UNM GME office.

      • Clinical activities in non-UNM Facilities (i.e., Healthcare for the Homeless)

      • Sports physicians (ball games)

      • School physicals

      • Camp physician (diabetic, asthma, cancer, etc.)

      • Community Projects


    All resident clinical volunteer activities that will occur under the auspices of the UNM are subject to the following requirements:

    • Approval of activity by the Program Director and the Chair of the resident’s Department.

    • A written description of the resident’s activity, supervision and rationale for inclusion in the resident’s training activity. The written description is to be signed by the Chair of the Department and placed in the resident’s residency file.

    • Appropriate recording of patient care interactions is ultimately the duty of the supervising physician.

    • Compliance with HIPAA regulations.

    • A signature by the resident acknowledging the above summary and agreeing to the limitations specified and agreeing to wear a name tag that identifies the resident as a UNM resident.

    • A designation of a supervising faculty who will be available on-site or by telephone to assist the resident during the volunteer activity. A resident cannot supervise students without a supervising physician in person or available immediately by phone.

    • A copy of this agreement will be sent to: UNM Graduate Medical Education (GME) office, and placed in the resident’s residency file.


    The Graduate Medical Education program is educational and is not designed to replace, nor will it result in the replacement of, employees of the training sites nor will it impair existing contract for services. Houseofficers will not take the place of training sites regular personnel in providing healthcare services to patients and will not provide full and complete technical and or professional direction of patient care but will participate in such care with the medical staff of each training site. Educational experiences will not be compromised by excessive reliance on residents to fulfill non physician service obligations.

    Locked and monitored callrooms equipped with panic buttons are provided at the University Hospital and VAMC. Security is on site at all Health Science Center facilities and the Veteran Administration Medical Center. Houseofficers are encouraged to call hospital security for escort from facility to facility and to the parking facilities.

    The University strives to have the work environment be compatible with and conducive to the educational mission of the GME training program. Houseofficers are to be able to be free of harassment while training. The work environment is drug and smoke free. Equipment is available to meet federal compliance standards including OSHA. Accommodations will be made under the Americans with Disabilities Act.

    Mechanisms are available within the institutions, as outlined in this handbook under Confidential counseling, and other support services, so that you may raise and resolve issues without fear of retaliation. Concerns should be reported to the Program Director, Resident Council, OEO, or the GME Office. Should the Program Director and Chair of a Department be the same individual and the resident have concerns about adverse consequences; the issues can be addressed with the Associate or Assistant Deans of GME. The GME Office has an open door policy and may try to advise or mediate on behalf of the Houseofficers.

    This handbook documents current policies as of 1 July 2016. Changes and additions are subject to unionization changes, and, if not clarified at the time of this publication will be posted on the New Innovations web site at


    Residents at the University of New Mexico HSC are covered under a collective bargaining agreement. Houseofficers are eligible for membership in the Committee of Interns and Residents. For more information please contact your local union representative or 800-CIR-8877 or