2.2 Compliance Requirements Policy

Purpose and Scope
The School of Medicine’s clinical affiliation agreements with healthcare facilities providing clinical training as part of the medical education program, contractually obligates the School of Medicine to ensure that all students in clinical training meet compliance requirements to ensure patient safety. The School of Medicine is contractually prohibited from sending a student to clinical educational facilities if the student is non-compliant with these requirements. Allowing a non-compliant student to see patients in a clinical setting violates the School of Medicine’s contractual obligations, compromises the safety of the patients, could expose the school to lawsuits and permanently damage the school’s reputation within the WWAMI healthcare community.

Policy Statement
All matriculated medical students, including those enrolled in concurrent degree programs, on an approved expansion of the medical education program and those on a leave of absence, must achieve and maintain compliance with the School of Medicine’s essential compliance requirements policy, procedures and guidelines through the entirety of their tenure in the medical school program.

Essential compliance requirements include the following:

• Basic Life Support (BLS) Certification
• Criminal Background Check (CBC)
• Universal Precautions/Infection Control Training
• Immunizations
• Data Stewardship and HIPAA Training

Students who are non-compliant with essential compliance requirements will cease to be in good standing, at which point they may be disenrolled from clinical coursework and will not be allowed to train in patient care settings until they have regained compliant status and have met with the appropriate dean. Non-compliant students may need to reschedule coursework and training, resulting in an expansion of the medical education program. Non-compliant students may have their financial aid withheld and registration holds applied to prevent enrollment. Non-compliance with essential compliance requirements may be considered by the Student Progress Committee when a student’s record is under committee review.

Compliance Requirements, Procedures and Guidelines
Students are expected to track their own compliance due dates and update items needing renewal prior to the six-week block in which they expire. Students’ compliance status is monitored by the Academic Affairs Office, and students are notified when they need to update their status. Students who maintain a record of timely compliance throughout medical school will be awarded the Personal Accountability and Commitment to Patient Safety Certificate of Recognition.

Basic Life Support Requirements, Procedures and Guidelines

Completion Frequency: Every two years, at minimum

Students must be certified in CPR at the level of Basic Life Support (BLS) for Healthcare Providers (American Heart Association approved training) prior to matriculation and again before entering the clinical curriculum. BLS cards expire every two years and students are responsible for keeping their certification current throughout their medical school training. To retain current certification, students in concurrent degree programs and students who have expanded their medical education must track this two-year certification process based on calendar year, not necessarily their year in school.

Students must provide a copy of the current BLS certification to the Academic Affairs Office.  The Academic Affairs Office will upload the certification to uploaded to E*Value. Students are responsible for accessibly maintaining the original certification card in their own personal files.

The School of Medicine does not accept ACLS certification or online-only BLS/CPR training courses as an alternative for this requirement. AHA endorsed online courses must also include an in-person skills test.

The American Heart Association has a course locator function that students can use to find local and convenient class options. Cascade Training Center in Seattle frequently trains medical students and provides a discount to UW students who call in their registration.

Criminal Background Check Requirements, Procedures and Guidelines

Completion Frequency: Every two years, at minimum

Students must complete and maintain a two-part criminal background check (CBC). The first part of the CBC is the national criminal background check, which is completed online for a fee through the School of Medicine’s third party vendor. The second part of the CBC is the Washington State Patrol (WSP) background check, required by Washington State Law.  The WSP CBC is mandatory for all UW students, regardless of their state of residence or Foundations Phase campus and is initiated through the UW Request for Criminal History Information Self-Disclosure, Consent, and Release of Information form, as required by the Washington State Child and Adult Abuse Information Act (RCW 43.43.830 through 43.43.845) for all individuals who have access to children under 16 years of age, developmentally disabled persons, or vulnerable adults and requires disclosure of information concerning crimes and offenses against these populations. By signing the Self-Disclosure and Consent form, students authorize the Academic Affairs Office to conduct future background checks and allow the office to report the student’s status to the clinical sites to which they are assigned.

At minimum, students must complete the two-part CBC in compliance with the following timing and frequency requirements:

• Upon admission,
• in January of their second year,
• in January prior to graduation, regardless of the completion date of the previous criminal background check; and
• if expanding the medical education program, no less than every two years while in status as a matriculated student.

Students will be notified via email by the Academic Affairs Office when their CBC renewal date is approaching.

Students will be required to meet with the Associate Dean for Student Affairs to discuss any findings disclosed in the CBC. Depending on the nature of the CBC findings, the student may be subject to a misconduct review or hearing conducted within the School of Medicine by the Student Progress Committee or through the Community Standards and Student Conduct (CSSC) Office at the University of Washington. As a result of these reviews or hearings, the student may be subject to sanctions, including probation, and in serious cases may include dismissal from the medical education program. Notification of CBC findings are reported to entities for which the School of Medicine is legally or contractually obligated to inform (e.g. The National Resident Matching Program and/or residency programs).

Universal Precautions/Infection Control Training Requirements, Procedures and Guidelines 

Completion Frequency: Annual

Students must complete the School of Medicine’s program on universal precautions annually to ensure they are informed of the appropriate handling of blood, tissues, and body fluids. Universal precautions are those that are used with all patients, not just those with known or suspected infectious disease in an effort to reduce disease that are transmitted by proximity, superficial physical contact or more intimate contact with blood or other body substances.

Opportunities for training and review of universal precautions are included in the orientation program, Foundations of Clinical Medicine course and required clerkships. As part of professional development, students are responsible for incorporating these principles into their routine practice while in patient care situations and for understanding the universal precautions at each hospital and clerkship site.

Universal precautions include:

• Immunizations: See Immunization Requirements, Procedures and Guidelines.
• Routine hand washing: Hand washing is performed frequently to protect both patients and healthcare workers. Hands are washed when entering a patient’s room, before touching a patient, performing invasive procedures, when leaving a patient’s room, and before eating; hands are also washed after glove use, working with body substances, and using the toilet. Skin is a natural barrier to infectious agents, and products that protect and promote skin integrity can be used.

Additional precautions that may be required in specific clinical settings include:

Barrier Protection:

• Gloves are worn for anticipated contact with all body substances and are changed between patients and sometimes between contacts with different body sites on the same patient.
• Gowns and/or plastic aprons are used to cover areas of the skin or clothing that are likely to become soiled with body substances.
• Facial barriers, including masks, glasses/goggles and face shields are worn whenever splashing or splatter of body substances into the mouth, nose, or eyes is likely to occur. Specialized masks and individual respiratory devices are also used for certain airborne diseases such as meningococcal meningitis and tuberculosis.
• Other barriers such as hair covers, shoe covers, and boots may be used when extensive exposure to body fluids may occur. (e.g., cystoscopy, vaginal delivery, multiple trauma).

Sharps management: Sharps management refers to safe use of sharp agents, such as needles, scalpel blades, etc. Dispose of them in appropriate rigid, impervious containers, and learn to handle them safely.

Immunization Requirements, Procedures and Guidelines

Completion Frequency: Varies per immunization. Tuberculosis (TB) screening and the influenza vaccine are annual requirements.

Students must provide documentation of immunization for Measles, Mumps, Rubella, Hepatitis B, Tetanus-Diphtheria-Pertussis, Varicella, TB-Screening <PPD or IGRA> (annual), Influenza (annual) and any other immunization requirements as recommended by the Center for Disease Control (CDC).  Immunization requirements may be updated during the course of a student’s tenure in the medical education program.

Documentation of compliance with all required immunizations, including the annual tuberculosis screening, must be documented and confirmed by the Health Sciences Immunization Program (HSIP) via a web-based vendor service, CastleBranch, for compliance tracking. In situations where a specific vaccination is contraindicated, HSIP staff will advise students on the appropriate documentation to obtain from their health care provider.

Students are responsible for sending all immunization documentation, including annual TB symptom survey results and influenza documentation to HSIP via a web-based vendor service, CastleBranch, for compliance tracking. Questions about vaccine requirements can be directed to HSIP at myshots@uw.edu or 206-616-9074 (VM). Questions about compliance status should be directed to CastleBranch. Documentation should be submitted to HSIP via the CastleBranch web portal. It is the students’ responsibility to confirm with CastleBranch that their documentation has been received and their status is compliant. CastleBranch provides compliance reports to HSIP and the School of Medicine.

Data Stewardship and HIPAA Training Requirements, Procedures and Guidelines

Completion Frequency: Annual

Students must complete the Data Stewardship training, HIPAA training  and sign a Privacy, Confidentiality, and Information Security Agreement (PCISA) form prior to matriculation. The Data Stewardship training, HIPAA training and the PCISA form are administered by the Academic Affairs Office. Prior to completion of the PCISA form, students must view a web-based training provided by UW Medicine Compliance,  notifying students of expectations for proper safeguarding of confidential information and compliance with standards for personal accountability for data stewardship.

Examples of violations of the security/confidentiality agreement include, but are not limited to: blogging or otherwise describing or discussing patients and/or patient interactions on social media; accessing the records of patients’ which are not related to student’s job duties; leaving the workstation unlocked and unattended; forwarding email to a non-UW email account; etc. All infractions are taken seriously and will be referred to the associate dean for student affairs for a misconduct hearing process.

Additional HIPAA training may be required by other regional hospitals during clerkship rotations.

Clerkship Site Compliance Requirements
The department clerkship website provides prerequisite requirements for preceptorship and clerkship onboarding. Generally, the department clerkship will facilitate onboarding requirements. Students must comply with requests from departments to complete training site credentialing requirements. Departments may ask students to complete requirements up to 3 months prior to the clerkship start date. In addition to requirements to submit site and department-specific paperwork, students may be asked to provide a copy of their immunization records (available from CastleBranch), BLS cards, HIPAA training certificates, universal precautions training certificates, and other compliance training certificates, which may be found in the Personal Records section of E*Value.

Clinical training sites may ask students to comply with additional immunization, drug testing, criminal background check or other compliance related requirements. Students are advised to check with the department clerkship before completing any of these additional requirements to ensure the additional requirements are aligned with the School of Medicine’s clinical affiliation agreements.