Resident Academic Action Policies

Evaluation, Promotion/Reappointment & Completion Policy

GMEC approved: March 2007
GMEC updated and approved: September 2011
GMEC updated and approved: March 2015

Purpose

The ACGME requires that the sponsoring institution have a policy that requires each of its ACGME-accredited programs to determine the criteria for promotion and/or renewal of a resident’s appointment. Programs must maintain clear criteria for advancement and competence that are detailed and explicit to the resident. Careful records must be kept to evaluate resident progress. Detailed documentation of performance is critical and the importance of this cannot be overstated.

Policy

Evaluation
All programs sponsored by the GME Committee, including those not accredited by ACGME, are required to utilize the residency management software to create evaluation systems to assess Resident performance. As part of the Common Program Requirements (V.), supervising faculty must evaluate the resident’s performance in a timely manner during each rotation or similar educational experience or assignment, and document the evaluation at the completion of the assignment. The resident’s performance evaluation must include an objective assessment of competence using ACGME competencies based on the specialty-specific Milestones, use evaluations by multiple evaluators, and document progressive Resident performance improvement appropriate to educational level.

Promotion/Reappointment
Programs must clearly delineate, in writing, requirements for promotion/completion of residency/fellowship training, in addition to specialty specific Residency Review Committee (RRC) requirements. The requirements must include but are not limited to:

  1. Satisfactory completion of all training components per PGY-level as determined by the ACGME
  2. Satisfactory performance evaluations
  3. Full compliance with the terms of the residency agreement of appointment
  4. Documentation of passage of appropriate licensing examinations

Program appointment, advancement, and completion are not assured or guaranteed to the resident. Promotion to the next level of training is based on the achievement of program-specific competence and performance parameters via evaluation, including specialty specific Milestones, as determined by the program director and/or Clinical Competency Committee (CCC). Unsatisfactory resident performance can result in required remedial activities, temporary suspension from clinical duties, reappointment without promotion, non-renewal of appointment, or dismissal from theresidency program. A resident must be notified with a written notice of intent of the decision for non-renewal of appointment, reappointment without promotion or dismissal. Residents may be reappointed for a period of not more than one(1) year.

Completion of Program
The program director must provide a Summative Evaluation for each resident upon completing/leaving the program. This evaluation must be based on recommendations of the CCC and specialty-specific Milestones must be used as one of the tools to ensure residents are able to practice core professional activities without supervision upon completion of the program. This evaluation must:

  • Become part of the resident’s permanent record maintained by the institution, and must be accessible for review by the resident
  • Document performance during the final period of education
  • Verify that the Resident has demonstrated sufficient competence to enter practice without direct supervision.

Resignation from the Program
Residents who desire to voluntarily leave the program prior to completion necessary for certification of the specialty are expected to discuss this action with the program director at the earliest possible time, preferably by January 1 of the current training year. In this circumstance, residents are expected to complete the training year of their current appointment, unless and earlier resignation is mutually agreed upon by the resident and the program director.

Procedure for Promotion/Reappointment/Completion of the program

  • After conferring with the residency program CCC, the program director will make the final determination of the resident’s readiness for advancement/completion of the program.
  • Program directors will notify the residents and the GME office in writing of the final determination of the resident’s readiness for advancement/completion of the program by March 1st of the current academic year.
  • In the case of non-renewal of appointment, reappointment without promotion or dismissal, the program will provide the resident with notice of intent promptly and in the most expeditious manner possible. The program director must meet with the resident and present the notification letter to the resident. The letter will contain the reasons for the non-renewal of appointment, reappointment without promotion or dismissal.
  • The GME office with prepare all necessary human resource documents including preparation of the agreement of appointment or completion certificate.
  • Documentation of renewal of licenses (Michigan ELL & CSL), certifications (BLS, ACLS, ATLS as required) must be uploaded into the residency management software.

Monitoring

The GMEC will monitor compliance with the institutional and program policies through the following venues:

  • Annual Program Evaluation
  • Special Review of the Program
  • ACGME Annual Resident Survey
  • Annual GME Resident evaluation of the program
  • ACGME Annual Faculty Survey
  • Annual GME Faculty evaluation of the program
  • Resident Council
  • Anonymous contact via hotline and/or online complaint form

Grievance for GME Residents

GMEC approved: March 2007
GMEC updated & approved: July 2011
GMEC updated & approved: March 2015

Purpose

The purpose of this policy is to define the usual process at WSU for residents to communicate substantive issues and concerns to the programs and institution’s administration. It also defines the mechanisms for an official, impartial hearing of concerns that are not resolved through usual, initial communications with administration. Existing mechanisms available to all residents through the GME Office are:

Anonymous Complaint Box: The Anonymous Complaint boxes are located in the resident areas of each residency program. The boxes are checked frequently and can only be opened by the GME office administrative staff.

GME Office Open Door Policy: The GME office is a confidential and safe place for residents and fellows to discuss concerns and conflicts. Additional information available on the Graduate Medical Education website homepage ( http://www.gme.med.wayne.edu/ ).

Residency Council and/or DIO: For problems involving program concerns, training matters or work environment, the Resident Quality Council, or the GME DIO should be consulted.

Confidential Complaint Reporting: For concerns involving professionalism, including duty hour violations, Residents may also complete the confidential complaint reporting form online on the GME website (http://www.gme.med.wayne.edu/) or via the Resident Reporting Hotline (248-4575120).

Other confidential venues available: GME Annual Resident Evaluation of the Program, ACGME Resident Survey.

Policy

WSU GME provides an environment in which residents may raise and resolve issues without fear of intimidation or retaliation. The intent is to provide the due process in instances where this is needed.

The Wayne State University School of Medicine GME programs encourage the participation of Residents in decisions involving educational processes and the learning environment. Such participation should occur in formal and informal interactions with peers, faculty and attending staff.

Efforts should be undertaken to resolve questions, problems and misunderstandings as soon as they may arise. Residents are encouraged to initiate discussions with appropriate parties for the purpose of resolving issues in an informal and expeditious manner.

With respect to formal processes designated to address issues deemed as complaints under the provisions of this policy, each program must have an internal process, known to Residents, through which Residents may address concerns. The Program Director should be designated as the first point of contact for this process.

Residents who have concerns or issues related to the interpretation, application, or breach of any policy, practice, or procedure in their educational program, or Graduate Medical Education in general should:

  1. first discuss them with their program director,
  2. if reasonable discussion with the program director does not lead to resolution of the concern the resident(s) should bring the issue to the attention of the Graduate Medical Education office and DIO,
  3. If reasonable discussion with the Designated Institutional Official (DIO) does not resolve the issue, a formal grievance may be sent in written form to the Graduate Medical Education Council (GMEC).

Procedure

  1. Resident(s) wishing to resolve a specific grievance will forward their complaint in writing (addressed to the Graduate Medical Education Council), to the DIO. The resident(s) concerned, or their colleagues representing them – such as the chief resident(s), will then be scheduled to present a summary of the complaint to the Graduate Medical Education Council at its next meeting. Legal representatives will not participate in or be present during Graduate Medical Education Council or subcommittee deliberations.
  2. Upon hearing the summary of the complaint, the Graduate Medical Education Council will nominate a subcommittee to review that specific complaint. The subcommittee must be made up of Graduate Medical Education Council members and include:
    • two residents
    • two faculty (one from the program from which the complaint emanated and one not)
    • a chairperson who cannot also simultaneously fill one of the above positions
    • a non-voting administrative resource person
      The chairperson will be nominated and elected by the Graduate Medical Education Council.
  3. The Grievance Subcommittee will meet within two weeks to consider resolution for the complaint. Residents, program directors, and the DIO will submit documentation they feel is important to the subcommittee secretary prior to the first meeting. The subcommittee chairperson may request additional documentation, as they or the subcommittee feels necessary.
  4. The subcommittee will, at the designated time and place, hear the resident(s) concerned present the details of their complaint and their proposed solutions in full. Other concerned parties may also present their views on the issues to the subcommittees at that time. Having heard the resident(s) and other parties concerned, they will then be excused from the meeting.
  5. The subcommittee will then immediately deliberate behind closed doors, without interference or participation by anyone other than subcommittee members.
  6. The subcommittee will have the responsibility to make a final recommendation regarding resolution of the complaint. This will be expected at the time of the first meeting. In rare circumstances, at the chairperson’s discretion, the subcommittee may elect to obtain additional information and meet again in one week to finalize their recommendation(s) for resolution of the complaint.
  7. The final recommendation(s) of the Grievance Subcommittee will be distributed by the chairperson to the Graduate Medical Education Council, the resident(s) concerned, and the DIO within 3 work days.
  8. The subcommittee’s final recommendation(s) for resolution of the complaint are final and binding

Monitoring

The GMEC will monitor compliance with the institutional and program policies through the following venues:

  • Annual Program Evaluation
  • Special Review of the Program
  • ACGME Annual Resident Survey
  • Annual GME Resident evaluation of the program
  • ACGME Annual Faculty Survey
  • Annual GME Faculty evaluation of the program
  • Resident Council
  • Anonymous contact via hotline and/or online complaint form

Performance Improvement (formerly Corrective Action) Policy and Due Process

GMEC approved: March 2007
GMEC updated and approved: September 2011
GMEC updated and approved: March 2015

Purpose

The Wayne State University School of Medicine (WSUSOM) is committed to providing a high-quality graduate medical education (“GME”) through residency and fellowship programs. Residents and fellows (referred to in this policy collectively as “residents”) are first and foremost learners and are expected to pursue the acquisition of competencies that will qualify them for careers in their chosen specialties. In addition, residents must adhere to standards of professional conduct appropriate to their level of training. The policies and procedures described in this document are designed to ensure that actions which might adversely affect a resident’s status are fully reviewed and affirmed by neutral parties while at the same time ensuring patient safety, quality of care, and the orderly conduct of training programs.

Program appointment, advancement, and completion are not assured or guaranteed to the resident but are contingent upon the resident’s satisfactory demonstration of progressive advancement in scholarship and continued professional growth. Unsatisfactory resident evaluation can result in required remedial activities, temporary suspension from duties, non-promotion, non-renewal of appointment, or termination of appointment and residency education.

Due process refers to an individual’s right to be adequately notified of charges or proceedings against that individual and the opportunity to respond to these actions.

Policy

The WSU GME applies a consistent and equitable approach when a resident fails to meet the academic expectations of a program.

WSU GME recognizes resident unique and multiple roles in the system. It maintains a training environment where teaching, learning and improvement are supported. This policy outlines an improvement process based on timely and documented feedback to address performance and/or behavior issues.

Program Directors have the primary responsibility to monitor the resident’s progress in conjunction with the CCC and take appropriate academic and administrative disciplinary actions based on the resident’s performance in accordance with all ACGME core competencies.

This policy provides guidance in addressing resident performance and/or behavior issues, as well as facilitates decision-making. WSUSOM GME recognizes that some issues are more serious than others, and therefore require a more serious action. The steps in the process are not sequential. The action to be taken is determined by the program director based on the specific performance and/or behavior and associated risks.

Definitions
Performance Improvement Plan (PIP): A written document issued in connection with a Letter of Concern or Probation which:

  1. Identifies the specifics of the unacceptable performance and/or behavior
  2. Documents the resident’s response to concerns
  3. Defines specific remediation expectations/goals and evaluation metrics
  4. Specifies strategies for improvement
  5. Establishes a timeline for evaluation and feedback
  6. Delineates consequences of success and failure
  7. Is signed by both the program director and the resident and placed in the resident’s file.
    Signature by the resident indicates that the PIP has been reviewed with the resident; it does not indicate agreement by the resident. If the resident refuses to sign the PIP, the program director shall document such refusal.

Letter of Concern with Performance Improvement Plan: A Letter of Concern is documentation that describes serious issues of resident performance or behavior that requires remediation. Any written complaint by a patient, sentinel event, or professional liability law suit should at minimum trigger a Letter of Concern. The Letter of Concern may not be appealed. Letters of Concern are not disclosed in response to requests for information about the resident.

Immediate Suspension from Clinical Responsibilities: A resident will automatically be removed from patient care activities for any of the reasons listed below following notification in writing.

  1. Lack of an Educational Limited or Permanent license in the State of Michigan
  2. Failure to obtain or maintain credentials required for the clinical practice
  3. Failure to complete required orientation and/or annual training requirements
  4. Failure to comply with the WSUSOM GME Moonlighting Policy
  5. Failure to comply with the WSUGME USMLE and Comlex Examination Policy
  6. Removal from payroll due to failure to maintain proper immigration status for legal employment as a resident at Wayne State University

Immediate Suspension from Clinical Responsibilities is not appealable and is not disclosed in response to requests for information about the resident.

Probation with Performance Improvement Plan: Probation is a period when a resident is required to correct continued documented substandard performance or behavioral issues, violations of educational standards or policy, or inability to remediate a letter of concern. Probation becomes a permanent designation in the resident’s file, may be appealed in accordance with the appeals process included in this policy, and is disclosed in response to requests for information about the resident.

Renewal Without Promotion: A residency program may determine a resident has not performed to a level that would allow the resident to progress to the next year of their training program. The program may in that case ask the resident to repeat the year at the same Program year level.

Non-Renewal of Appointment: Non-Renewal means the training program has decided not to offer a contract to the resident for the next academic year or training period for failing to maintain academic and/or other professional standards required to progress in or complete the program. Non-renewal of Appointment becomes a permanent designation in the resident’s file, may be appealed in accordance with the appeals process included in this policy, and is disclosed in responseto requests for information about the resident. Non-renewal of Appointment due to failure to pass the USMLE or Comlex examinations is not appealable (see USMLE and Comlex Examination Policy).

Dismissal: Dismissal involves immediate and permanent removal of the resident from the educational program for failing to maintain academic and/or other professional standards required to progress in or complete the program as determined by the Program Director in conference with the program’s CCC, department chair and the DIO. Dismissal is typically preceded by sufficient notice to the resident that there are significant deficiencies in the knowledge, performance, or behaviors and potentially by previous disciplinary actions. However, there is no requirement that there be any preceding disciplinary action prior to a resident being terminated. Dismissal can occur at any point other than the end of the academic year or end of the stated contract period, at which time it is defined as Non-Renewal of Appointment. Dismissal becomes a permanent designation in the resident’s file, may be appealed in accordance with the appeals process included in this policy, and is disclosed in response to requests for information about the resident.

Procedures

Letter of Concern with PIP
A letter of concern is documentation that describes serious issues of resident performance or behavior that requires remediation. Any written complaint by a patient, sentinel event, or professional liability law suit should at minimum trigger a letter of concern.

The Program Director on recommendation from the CCC will:

  1. Meet with the resident and provide him/her with a Letter of Concern PIP
  2. Provide the resident with a copy of the Performance Improvement Policy
  3. Ensure that the resident understands that failure to adequately address the letter of concern as evidenced by repeated behaviors may lead to progressive discipline including probation, suspension, non-renewal of appointment, or dismissal.
  4. The program director may extend or change the terms of the Letter of Concern PIP and/or may issue more than one Letter of Concern PIP.
  5. Letters of concern can be made part of the file at the discretion of the program director if complete remediation is not achieved.
  6. A resident may request the letter of concern be removed from the individual’s program file. The program director will confirm with the resident that this removal has taken place or provide an explanation why it has not occurred.

Immediate Suspension from Clinical Responsibilities:
A resident will automatically be removed from patient care activities for any of the reasons listed below following notification in writing.

  1. Lack of an Educational Limited or Permanent license in the State of Michigan
  2. Failure to obtain or maintain credentials required for the clinical practice
  3. Failure to complete required orientation and/or annual training requirements
  4. Failure to comply with the WSUSOM GME Moonlighting Policy
  5. Failure to comply with the WSUGME USMLE and Comlex Examination Policy

The period of removal will extend until the deficiency described is resolved to the satisfaction of the program. Residents may be assigned to non-clinical duties, vacation, or other status at the discretion of the program director. If assignment to another activity is not practical, the removal from patient care may be in an unpaid status.

Residents who become ineligible for employment at Wayne State University due to changes in their immigration status will be removed from the active payroll and may not work in any capacity, including voluntary, at the Wayne State University or WSUSOM. They will be placed on inactive, unpaid status until their work eligibility status is resolved.

Probation with PIP
Probation is a serious academic action that is taken in response to continued documented substandard performance or behavioral issues, violations of educational standards or policy, or inability to remediate a letter of concern.

The Program Director after conferring with the CCC and DIO will:

  1. Notify residents in writing of their probationary status and provide him/her with a Probation PIP which will include:
    the reasons for the probationary status, the expectations
    that must be satisfied to remediate the probationary status, and the time limit for satisfactory remediation. The probationary and remedial period together should not be less than 30 days in length and may last as long as 12 months if appropriate (such as in the case of academic probation for yearly board exams, etc.). For ethical misconduct or substance abuse, a resident may be placed on probation indefinitely through the remainder of the training program.
  2. Provide the resident with a copy of the Performance Improvement Policy
  3. Ensure that the resident understands that probation is a permanent designation in the individual’s file, is disclosed in response to requests for information about the resident and may be appealed in accordance with the appeals process included in this policy.
  4. Ensure that the resident understands that if the unacceptable performance and/or behavior is not corrected in the specified time, or if, while on probation there is another occurrence of unacceptable performance and/or behavior, the next step may be non-renewal of appointment or dismissal.
  5. Meet with the resident regularly during the probationary period to formally review the resident’s progress. (Meetings may be held more frequently if deemed necessary.)
  6. During and at the end of the probationary period along with the CCC will review the resident’s progress and determine whether satisfactory improvement has been made based on information obtained from various sources and results relating to terms of remediation outlined in the Probation PIP, which may be solicited from faculty, staff and peers of the resident. If improvement has been unsatisfactory during the probation period, the resident may be (1) continued on probation for a specific period of time not to exceed an additional six months or (2) dismissed. Any resident who is placed on probation for a third time for any reason may be continued on probation indefinitely, through the remainder of the training program, or dismissed without further notice.
    1. There are limited circumstances where the period of probation may be indefinite and could be imposed for the remainder of the program. These circumstancesinclude, but are not limited to, substance abuse and ethical misconduct. Examples of ethical misconduct include, but are not limited to, sexual harassment, patient abandonment, abuse of prescribing privileges and unlawful discrimination. Certain programs may have stricter standards regarding substance abuse which supersede this policy.
    2. Any substance abuse or ethical misconduct will result in mandatory referral of the resident to the Michigan Health Professionals Recovery Program (HPRP) (see Resident Impairment Policy). As a condition of probation, the resident must allow exchange of information between HPRP and the Program Director and DIO. The Resident shall sign a release of information from the HPRP as a condition of probation.
    3. If a resident, who has been placed on probation for substance abuse or ethical misconduct, demonstrates a recurrence of unsatisfactory performance due to substance abuse during training, he/she may be dismissed without any additional remedial period.
    4. If the resident’s behavior is considered potentially dangerous to patients, himself, herself or other individuals, immediate suspension of clinical responsibilities may be imposed at the discretion of the Program Director and Department Chair without a probationary period.
  7. Ensure that while on probation, all moonlighting privileges and out-of-town electives for the resident will be suspended.
  8. Place a copy of the Probation PIP in the resident’s file and send a copy to the GME office.

Renewal Without Promotion
A residency program’s CCC may determine a resident has not performed to a level that would allow the resident to progress to the next year of their training program. In this case the program may ask the resident to repeat the year at the same program year level.

The Program Director after conferring with the CCC and DIO will:

  1. Notify the resident in writing by March 1st, or at least four months prior to the normal termination date of the resident’s existing appointment if the date of appointment is any date other than June 30th. The notification will be by letter to the resident and will contain a Non-Promotion PIP which will include a summary of the resident’s performance that necessitates the non-promotion action and that defines a timeline for promotion.
  2. Provide the resident with a copy of the Performance Improvement Policy
  3. Ensure that the resident understands that Renewal without Promotion is a permanent designation in the individual’s file, is disclosed in response to requests for information about the resident and may be appealed in accordance with the appeals process included in this policy.
  4. Place a copy of the Renewal Without Promotion PIP in the resident’s file and send a copy to the GME office.

In some cases, residents will be required to make up partial-year rotations or assignments due to performance problems or absence following medical or personal leave. If the program delays the resident’s commencement of the next level of training but issues a new agreement at the program year level for which the resident would have otherwise been eligible, then the resident may not seek appeal. Likewise, when a resident at the end of their training must make up less than a full year of rotations due to repeating rotations or because of medical or personal leave, those extensions to the resident’s current agreement or new agreements will not be subject to appeal. In such cases, the agreement extension will include stipends and benefits at the current level for the resident until they have completed all required assignments.

Non-Renewal of Appointment
Non-Renewal means the training program has decided not to offer a contract to the resident for the next academic year or training period for failing to maintain academic and/or other professional standards required to progress in or complete the program.

The Program Director after conferring with the CCC and DIO will:

  1. Notify the resident of non-reappointment by March 1st, or at least four months prior to the normal termination date of the resident’s existing appointment if the date of appointment is any date other than June 30th. The notification will be by letter to the resident and will contain the reasons for the non-reappointment.
  2. Provide the resident with a copy of the Performance Improvement Policy
  3. Ensure that the resident understands that Non-Renewal of Appointment is disclosed in response to requests for information about the resident and may be appealed in accordance with the appeals process included in this policy.
  4. Place a copy of the notification of Non-Renewal of Appointment in the resident’s file and send a copy to the GME office.

The program at its sole discretion may revisit any non-reappointment decision at a later date and may rescind the non-reappointment notice and offer re-appointment at that time. In no instance may the program rescind a non-reappointment notice later than forty-five (45) calendar days prior to the end of the resident’s existing appointment. The department’s decision to rescind or not rescind a non-reappointment notice is not subject to appeal at any time.

Dismissal
Dismissal involves immediate and permanent removal of the resident from the educational program for failing to maintain academic and/or other professional standards required to progress in or complete the program.

The Program Director after conferring with the CCC and DIO will:

  1. Determine that the resident should be dismissed. Dismissal can occur at any point other than the end of the academic year or end of the stated contract period, at which time it is defined as Non-Renewal of Appointment.
  2. Notify the resident of dismissal; the notification will be by letter to the resident and will contain the reasons for the dismissal.
  3. Provide the resident with a copy of the Performance Improvement Policy
  4. Ensure that the resident understands that dismissal may be appealed in accordance with the appeals process included in this policy.
  5. Place a copy of the notification of dismissal in the resident’s file.

Due Process

Due process refers to an individual’s right to be adequately notified of charges or proceedings against that individual and the opportunity to respond to these actions.

If a resident believes s/he has been wrongfully dismissed from the program, not renewed or renewed without promotion the appeal procedure described below can be invoked. The process is intended to protect the rights of the resident and the training program and to ensure fair treatment for both parties.

The decision to dismiss a resident from the program, not renew or renew without promotion is an academic responsibility and is the decision of the Wayne State University School of Medicine Graduate Medical Education programs.

In all cases of dismissal from the program, nonrenewal or renewal without promotion, it is expected that the appropriate probationary and remedial periods will have occurred as prescribed in this policy. However, there may be instances where immediate suspension without probation or other remediation will occur.

All “written notification” associated with the formal appeal process shall be by certified mail.

Due Process Procedure

Notification of intent to appeal:

  1. Any resident who is dismissed from the program, or whose Agreement of Appointment is not renewed or renewed without promotion shall be informed of the decision in person and/or by certified mail.
  2. The resident who receives said notice may appeal the dismissal, non-renewal or renewal without promotion.
  3. Any appeal by the resident must be received by the DIO within ten (10) calendar days of the resident’s receipt of the certified notice, or personal notice, whichever occurs first.
  4. However, in the event the resident refuses to accept the notice or otherwise does not receive the certified notice, the GMEC will presume that the certified notice is received within three (3) business days following dispatch from the program. In that case, the resident will have ten business days, plus three business days for a total of thirteen (13) days from the date of dispatch to file an appeal. For example, the program mails the notification on March 2nd, the resident would have until March 19th to file the appeal.
  5. A dated return receipt from the United States Postal Service shall be conclusive proof of an “attempt to deliver the notice.”

Assembly of review committee:

  1. Upon receipt of an appeal, the Chair of the GMEC/DIO (or designee) will convene an ad hoc committee to review the resident’s case.
  2. The committee shall seek advice from WSU counsel who shall be present for the hearing to advise the committee.
  3. The review committee may also seek advice from outside experts in the field of theresident’s specialty if deemed necessary.
  4. The review committee will include the Chair of the GMEC/DIO (or designee), one full-time faculty member from a different training program and one resident representative from GMEC who is in a different clinical training program. The Chair of the GMEC/DIO will chair the review committee. The resident may object to a member of the review committee for cause. The Chair of the GMEC/DIO has sole discretion to replace a member if deemed warranted.

Responsibility of the review committee:

The committee is charged with responsibility to review the decision of the program by hosting a formal hearing and issue a recommended outcome as a result of that hearing. The question before the committee is whether the program’s decision was arbitrary or capricious. The burden of proof is on the resident to show that the program’s decision was arbitrary or capricious. (Arbitrary and capricious action is willful and unreasoning action, without consideration and in disregard of facts or circumstances. Where there is room for two opinions, action is not arbitrary or capricious when exercised honestly and upon due consideration even though it may be believed an erroneous conclusion has been reached.) Only those members of the committee that are present at the hearing may participate in the deliberations of the committee. The submission of a recommended outcome by the committee shall require a quorum of those present at the hearing and simple majority vote. If the committee is unable to achieve a simple majority vote, the recommended outcome(s) of the committee should reflect the views of each of the eligible committee members.

Hearing:

The review committee will assess the merits of the decision at issue and hear evidence and arguments by the resident and the Program Director, and Department Chair. Since the hearing is an academic proceeding, the rules of evidence shall not apply.

The Program Director and Department Chair are obligated to present to the review committee the reasons for and substantiating evidence in support of the decision at issue. The resident and Program Director may present documents or letters of support and call the testimony of witnesses. The resident may question witnesses who testify on behalf of the Program Director, or Department Chair. Witnesses called by the resident may be questioned by the Program Director, or department chair.

The resident may be represented by an attorney in an advisory capacity, but the attorney may not function as a spokesperson for the resident during this grievance process.

Final Determination:
The review committee will not overturn or modify the academic decision at issue unless, by majority vote, it concludes that the resident has established by a preponderance of the evidence that the decision at issue was arbitrary or capricious.

  1. The review committee will make its determination within thirty (30) calendar days from the close of the hearing.
  2. The review committee will notify the resident, Department Chair, Program Director and GMEC (in writing) of its decision.
  3. The decision of the committee is final.
  4. Should the resident be reinstated, the review committee may impose an additional period of probation as a condition of continuation.

Monitoring

  • All notifications of probation, dismissal, non-renewal and renewal without promotion decisions will be reviewed by the GMEC to ensure compliance with this policy.

Summary

Action Documentation Location Appeal Disclosed
Letter of Concern with PIP Letter of Concern with PIP File (may be removed in certain circumstances No No
Immediate Suspension from Clinical Responsibilities Memo File – will be removed when reason for suspension is resolved No No
Probation with PIP Probation letter with PIP Permanent File* Yes Yes
Renewal Without Promotion Memo Permanent File* Yes Yes
Non- Renewal of Appointment Memo Permanent File* Yes Yes
Dismissal Written notice of dismissal from the program and termination of Agreement of Appointment Permanent File* Yes Yes

* If an action is overturned through the appeal process documentation will be removed from the Permanent File

USMLE and COMLEX Examinations Policy

GMEC approved: March 2015

Purpose

To ensure that Residents enrolled in training programs meet eligibility requirements to obtain medical licensure in Michigan beyond the level of the Educational Limited License.

Policy

All Residents in GMEC approved programs are required to sit for the USMLE Step 3 examination or COMLEX Level 3 examination by June 30th of their first year of training (PGY 1). Failure to sit for theexaminations before June 30th will result in the resident being suspended from clinical duties (see Performance Improvement and Due Process policy) until documentation of sitting for the exam has been submitted to the program. If they fail to sit for the exam by November 1st of their PGY-2 year they may be terminated from the training program.

Residents who fail the examinations on their first attempt will enter an educational enhancement plan as determined by their residency program and will need to pass the examination by March 1st of their PGY 2 year. Failure to pass the examination will result in non-renewal of appointment to the residency program.

All Fellows and PGY-2 Residents entering GMEC approved programs must have successfully completed the USMLE Step 3 examination or COMLEX Level 3 examination, as evidenced by obtaining a passing grade for that examination prior to starting a fellowship or categorical program.

Exceptions to this policy may only be granted upon approval by the GMEC.

Academic actions including non-renewal or termination as a consequence of failure to meet requirements in this policy are not reviewable under the terms of the Performance Improvement and Due Process Policy.

Monitoring

  • Review by the program’s CCC
  • Promotion/Reappointment forms to GME office
  • Onboarding Checklist on the resident management system.

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