• The attending is required to co-sign all charts.
   

• Residents rotating on Ambulatory Care block rotations and Chief Residents participate in the collaborative practice for resident’s clinic.  Collaborative practice reports through the hospital QA process QIC (Quality Improvement Council) and PIC (Performance Improvement Council).

Emergency Department
 

• All patients not admitted from the Emergency Department (ED) must have the disposition reviewed by the ED physician.
   

• A periodic sampling of ED records of patients not admitted are sent to the Department of Medicine Program Director (PD) for review of appropriateness of care and appropriateness of involvement of the resident by the ED.

In-patient Teaching Service
 

• All patients admitted must be reviewed by an attending within 24 hours.  Seriously ill patients must be seen at least daily by an attending.
   

• Residents and attendings on the in-patient teaching services attend collaborative practices for the various nursing stations.
   

• Chief Resident(s) are assigned to the hospital-wide Quality Improvement  Committee that deals predominantly with in-patient issues.
   

• When questions arise about quality issues the case is formally referred to the PD for review and action.  These are reviewed with the involved trainees and attendings.  A formal response results and, when appropriate, notation appears in the residents file.

Morbidity and Mortality (M&M)
 

• All deaths must be reported to the PD.
   

• Autopsies are encouraged and rewarded financially, the resident should have a low threshold for requesting an autopsy.
   

• M&M Conference is held regularly and various cases are selected for formal review.
   

• Residents are required to attend autopsies on cases in which they are involved.  A mechanism completed by the residents goes with the expired patient to the pathology department for notification of the involved resident(s) when the autopsy is performed.
   

• Formal review of methods to aid a higher autopsy rate are presented to residents.
   

• Medical records are currently always available for review and reviews of various topics and problems including mortality are encouraged.
   

• The State Medical Examiner discusses and presents cases that have been on the teaching services when requested.