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MUSC GME Resident Handbook

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Graduate Medical Education  2016-2017

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Resident Handbook Introduction

Letter of Commitment/
Accreditation Status Disclaimer

Administration & Governance - Graduate Medical Education Programs

Policies & Procedures

Salaries & Benefits

MUSC Policies

Appendix 1 - Resident Agreements (Medical and Dental)

Appendix 2 - Evaluation Forms

Appendix 3 - Forms

Appendix 4 - Scopes of Practice

Appendix 5 - Program Director/Program Coordinator Resources



Graduate Medical Education

The GMEC oversees all educational programs and implements the policies and procedures for residents and residency programs within MUSC ensuring high-quality education for its residents. The GMEC ensures programs are adhering to the policies and procedures of the ACGME while maintaining their educational commitment to the residents. (This committee will actually have four resident representatives. Three will be elected and the fourth position will be the President of the House Staff Council.)

Chaired by Dr. Ben Clyburn
Staff Contact:  Ann Ronayne
2nd Thursday of every month
4:00 p.m. – 5:00 p.m., 628 CSB

  • Dr. Kendall Brewer, Pathology (House Staff Council President)
  • Dr. Maggie Gray, Peds Cardiology
  • Dr. Christopher Stem, Pediatrics
  • Dr. Sarah Yale, Pediatrics

Annual Program Evaluation (APE)

The APE Committee ensures all ACGME-accredited residency programs are in compliance with ACGME Institutional and Program Requirements.   This committee will have two residents that will serve a full academic year (July – June).

Chaired by Dr. Leonie Gordon
Staff Contact:  Ann Ronayne
3rd Thursday of every month
2:00 p.m. – 4:00 p.m., 601 CSB

  • Dr. Lloyd Felmly, CT Surgery
  • Dr. Ashley Feeman, Anesthesiology

Medical Executive (MEC)

The MEC is the professional policy board of the hospital and is responsible for supervision and enforcement of all professional policies, rules and regulations. Its purpose is to ensure high quality, patient-centered, cost effective care throughout MUSC's clinical enterprise.

Chaired by Dr. Brenda Hoffman
Staff Contact:  Michele Weatherford
3rd Wednesday of every month
7:30 a.m. - 8:30 a.m., 628 CSB

  • Dr. Mark Siegel, Pediatrics

MUSC Ethics

The Ethics Committee works to improve patient care within an ethical framework. Committee

functions include clinical consultation, policy development and review, and ethics education.

Chaired by Dr. David Schenck
1st Wednesday monthly -- Full committee 3:30 p.m. - 5:30 p.m., Room 247 North Tower
2nd & 4th Tuesdays each month -- Ethics Consultation Service, 4:00 p.m. - 5:30 p.m., Admin Conference Room MH-295 (next to library bridge)

  • Dr. Michelle Greene, Pediatrics

Blood Utilization Review (BUR)

The BUR committee monitors the use of blood and blood components at the MUSC Medical Center.

Chaired by Dr. Jerry Squires
Staff Contact:  Karen Garner
3rd Thursday of the month, quarterly
3:00 p.m. – 4:00 p.m., 204 Children's Hospital

  • Dr. Vanessa Fabrizio, Pediatrics

Hospital Infection Control (ICC)

The ICC investigates and controls nosocomial infections and monitors the MUHA Infection Control program. It is a Medical Staff Committee responsible for the development and implementation of policies and practices to decrease healthcare-associated infections in patients and staff.

Chaired by Dr. Cassandra Salgado
Staff Contact:  Linda Formby
4th Tuesday of every month
2:00 p.m. – 3:00 p.m., 803 CSB

  • Dr. Elizabeth Schulz, Neonatology

Health Information Management Committee (HIM)

The HIM committee oversees the policies and procedures of the governance and functioning of all parts of the medical record.

Chaired by Dr. Baron Short
Staff Contact:  PJ Floyd, RN, BSN, MBA, NE-BC, CCA
3rd Thursday of every month
7:30 a.m. - 8:30 a.m., RTA 104

  • Dr. Trisha Marshall, Pediatrics

Quality Operations (QOC)

The QOC reports and reviews all new and ongoing quality efforts in the clinical enterprise.

Chaired by Dr. Danielle Scheurer
Staff Contact:  Tracie Porter
1st and 3rd Thursday of each month (minus holidays)
8:30 a.m. - 10:30 a.m., CSB 300

  • Dr. Trisha Marshall, Pediatrics


The IMPROVE Committee gives guidance and recommendations on all quality projects that have been endorsed by the senior leaders within the hospital and medical staff.  The role is to ensure that the IMPROVE process is followed and that there are relevant and sustained results.  This committee makes the final recommendation on whether projects are appropriate to close or not.

Chaired by Dr. Danielle Scheurer
Staff Contact:  Tracie Porter
Every Wednesday
4:00 p.m. – 5:30 p.m., RTA 104

  • Dr. Ian Osburn, Anesthesiology


The leadership of MUSC Medical Center has established the Accreditation/Regulatory Committee with responsibility to ensure Joint Commission standards, Centers for Medicare and Medicaid Services standards, and other regulatory standards are implemented and monitored across the entire organization. Membership of the committee will be comprised of key people from cross-functional areas who are recognized as formal or informal leaders in regulatory compliance, and have proven their abilities to effect change.

Chaired by Dr. Lois Kerr
Staff contact: Terri Ellis
3rd Wednesday of the month
11:00 a.m. - 12:30 p.m., (usually in 628 CSB)

  • Dr. Lloyd Felmly, CT Surgery

Patient Throughput

The Patient Throughput Committee monitors the flow of patients across the medical center by overseeing flow dashboards and metrics as well as all policies and procedures associated with placement of patients on select units.

Chaired by Dr. Dan Handel
Staff contact: Sarah Cowart
2nd Wednesday of every month
10:00 a.m. – 11:00 a.m., 300 CSB

  • Dr. Libby Barton, Emergency Medicine

College of Medicine Student Progress Committee and Professional Standards Subcommittee

The Student Progress Committee conducts meetings four times a year as well as on an as needed basis.  During these meetings the Progress Committee reviews the academic progress of all students with regard to established progression standards.  Students who do not meet required academic or professional standards are considered individually by the Progress Committee.  If there concern about a pattern of a student’s unprofessional behavior, the student will appear before the professional standards subcommittee.  These meetings are held as needed, but historically there have been about 4-6 of these meetings a year.  The meetings of both the Student Progress Committee and the Professional Standards Subcommittee are usually from 4:30 p.m. - 6:30 p.m., 601 CSB.

Chaired by Dr. Sally Self
Dr. Elizabeth Schulz, Neonatology

  • Dr. Mark Siegel, Pediatrics

Medication Decision Support Subcommittee

The Medication Decision Support Subcommittee is looking for medical representation to help review medication alert build and determine customization of settings, where necessary.  The subcommittee reports to the Decision Support Oversight Committee (DSOC) and the Pharmacy and Therapeutics Committee.  It is responsible for management of medication-related decision support seen by users of the electronic health record (EHR).  The committee is chartered to review, amend, and monitor medication alerts and other decision support tools to improve the overall usefulness and value to the clinicians throughout the organization.  Examples of medication decision support include but are not limited to the following: medication warnings (dose, drug interactions, pregnancy, duplicates), incorporating lab values in the order composer; maximum dose warnings.

Chaired by Dr. Holly Griffin
Date/Time: 3rd Wednesdays; 11:00 am – 12:00 p.m.
Location: Adobe Connect/Conference Call
Committee website: Decision Support Oversight Committee

  • Dr. Nina Asbury, Emergency Medicine

Continuing Medical Education Advisory

Charge to the Committee: The Committee serves to advise and assist the Office of Continuing Medical Education in the planning, organization and conduct of continuing medical education offered by the College of Medicine.  The Committee functions include the following:  Apply criteria for CME accreditation developed by the Accreditation Council for Continuing Medical Education and policies established to govern sponsorship of CME activities; Provide liaison with Departments and Divisions of the College involved in CME activities; Participate in Annual Review of CME program in the College of Medicine; Participate in strategic planning process for the CME; Review and approve documents prepared or revised by the CME staff;  Participate in discussions by individuals who provide important areas of collaboration with the CME program.          

Chaired by Dr. Robert Malcolm, MD
Staff contact:  Shirley Maxwell
3rd Thursday of the month, every other month
12:00 p.m. – 1:00 p.m., location varies

  • Dr. Elizabeth Schulz, Neonatology