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Updated: November 26, 2012

Graduate Medical Education Policies – Section 1

A.  Institutional Statement of Commitment

B1. Organizational Chart

C. Accreditation Standards

D. Educational Affiliations – Rotations, Program Letters of Agreement and Master Affiliation Agreements

E. Roles and Responsibilities of DIO

F. Completion of Training and Final Verification

G. Financial Support and Allocation of Training Positions

H. Licensing of House Staff

I. Supervisions


K. Clinical Observerships at UPHS

  • Clinical Observerships at UPHS Checklist

  • Clinical Observerships at UPHS Terms and Conditions

Graduate Medical Education Policies – Section 2

A. House Staff Compensation and Benefits

B. Appropriate Treatment of House Staff

C. Professional Liability for Housestaff

D. House Staff Code of Conduct

E. Vacation and Leave for House Staff

F. House Staff Impairment

G. Prohibited Harassment of House Staff including Sexual, Racial and Gender Discrimination

H. Accommodation for House Staff with Disability

I. House Staff Discipline, Non-renewal and Dispute Resolution

J. Ombudsperson for House Staff

K. House Staff Work Environment

L. House Staff Evaluation and Promotion

M. Roles and Responsibilities of House Staff

N. House Staff Involvement in Performance Improvement

O. House Staff Involvement in Hospital Affairs

Q. Advanced Cardiac Life Support Certification

R. Parking

S. Counseling Psychological Support Services

Graduate Medical Education Policies – Section 3

A. Graduate Medical Education Committee (GMEC)

C. Internal Review Process

D. Duty Hours

E. Requests for Duty Hours Exceptions

F. House Staff Moonlighting

G. House Staff Onboarding

H. Sponsorship of New Training Programs

I. Training Program Closure or Reduction in Size

J. House Staff Agreement

K. House Staff Eligibility

L. Roles and Responsibilities of Program Directors

Any printed copy of this policy is only as current as of the date it was printed; it may not reflect subsequent revisions.  Refer to the on-line version for most current policy. Use of this document is limited to University of Pennsylvania Health System workforce only.  It is not to be copied or distributed outside the institution without administrative permission.”

Administrative Policies

Employee Photo Identification Badges

Standards of Professional Appearance

Employee-Health Service

Hospital Provided Scrubs

Identification & Treatment of Impaired Employee

Creating a Workplace Free of Prohibited Harassment

Substance Abuse

Violence in the Workplace

Participation in Incident/Occurrence Reporting Process

Avoidance of Sexual Harassment in the Workplace

Pre-Employment Background Investigation

Pre-Employment Drug Screening

Occurrence Assessment and Intervention

Medical Record Documentation Practices

Records Leaving Medical Record Services Department

Management of Ethical Issues

New and/or revised Administrative policies are posted on the Intranet once approved by the Administrative Policy Review Committee. New and/or revised policies effective from May 2003 and onward will not showactual signatures; rather, the designated signature(s) will be typed, preceded by /s/ . However, if needed, signed copies of the policies are available.

HIPAA Policies

Patient's Right To Access, Inspect Or Copy Their Protected Health Information (PHI)

Patient's Right To Request An Accounting Of Disclosures Of Protected Health Information (PHI)

Patient's Right To Request Amendment Of Their Protected Health Information (PHI)

Business Associates

HIPAA Complaint Resolution

Patient Requests To Receive Protected Health Information (PHI) By Alternate Means Or At Alternate Locations

Disclosures Of Protected Health Information (PHI) With Patient Authorization

Disclosures Where No Form Of Patient Permission Is Required

Disclosure Of Information From The Patient Information System

Disclosure Of Protected Health Information (PHI) To Family And Friends

Development (Fundraising) Activities

Marketing And Other Related Health Care Communications

"Need To Know" Determination (Minimum Necessary Requirements) For Pennsylvania Hospital (PAH)

Prohibition On Intimidation Or Retaliatory Actions

Policy On Notice Of Privacy Practices

Access To Protected Health Information (PHI) By Personal Representatives

HIPAA Policy And Procedure For Research

Patient Requests For Restrictions Of The Use And/Or Disclosure Of Protected Health Information

Workforce Training For HIPAA

Uses And Disclosures Of Protected Health Information (PHI) For Treatment, Payment, And Healthcare Operations


Infection Control Policies

Standard Precautions

Exposure Control Plan for Bloodborne Pathogens

Blood Culture Collection

Central Venous Catheter Insertion

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