The following is an example of a Due Process Policy. Each program,
institution, and OPTI has their own.
POLICY Due Process
ACADEMIC DEFICIENCIES AND
Each Residency Program Director is
responsible for assessing and monitoring each resident’s academic and
professional progress including knowledge, skills and professional behavior as
well as adherence to departmental policies and procedures concerning resident
education and INSTITUTION graduate medical education policies. If a Program
Director determines that a resident should undergo a psychological assessment or
psychiatric evaluation, the cost for this will be split evenly between the
Department and GME. Failure to meet the established academic standards
will result in corrective action(s) up to and including dismissal from the
Each Residency Program Director
will provide written guidelines concerning resident accountability,
monitoring and disciplinary actions, all of which are subject to the
initial approval and annual review of the OMEC GME.
Directors shall report to and receive input from the OMEC on the progress
of the residents enrolled in the INSTITUTION AOA residency programs. This
will include plans for promotion, transfer, discipline or dismissal if any.
Policies regarding academic
deficiencies will be generally uniform throughout all residency programs and
will include the following categories of corrective actions:
2.1 Oral Reprimands
(OR) or Written Warnings
may occur for deficiencies for which some corrective action is necessary.
The resident will have the opportunity to correct
If the deficiency is
corrected, no further action will be taken. If the deficiency is not
corrected, the resident may be placed on "formal academic
remediation", suspended or dismissed from the program.
2.2 Formal Academic
Remediation (FAR) will be imposed for more serious and/or prolonged
deficiencies. The resident will have the opportunity to remediate the
deficiency within a defined period of time, as set forth in the "learning
contract" established by the Program Director. The resident will receive a
written document describing remediation measures to be corrected, the
specific time period in which improvement must be demonstrated, and the
possible consequences if no improvement is made. The resident will be
required to sign this document.
2.3 Suspension (S) may be
imposed. During suspension, the resident will be removed
from his/her clinical
rotations and will not receive credit for training during this time period.
Suspension will be for a specified period of time and specific corrective
measures will be required. Following successful completion of the terms of
the suspension, the resident will be placed on "formal academic
remediation" upon reinstatement into the residency program
as outlined in 2.2.
2.4 Dismissal (D) of a
resident may occur for academic reasons, disciplinary reasons, or if the
resident is deemed to be an immediate threat to patient safety. (See
Resident Dismissal Policy)
Prior to the imposition of any
action that may result in suspension or dismissal, the Residency Program
Director must submit the recommendation to GME.
A resident who does not report to
work for three (3) consecutively scheduled work days, without speaking
directly to his/her Program Director, will be dismissed from the residency
program and his/her Resident Agreement will be terminated. The resident
will have five (5) business
days from the date of
dismissal to contact GME and explain the reason(s) for the failure to
contact the Program Director. If GME
accepts the explanation, the resident will be
reinstated. If GME does not accept the explanation, the dismissal will be
A resident may be dismissed from
his/her residency program. The resident has
right to appeal the decision through the Resident Grievance Procedure.
Each Residency Program will have
regular evaluations of residents and with GME approval will define
specific criteria to recommend dismissal based upon these evaluations and/or
other material/s which document the reason for dismissal.
The Department will recommend
dismissal by notifying GME. GME will conduct a thorough review of the
resident's situation and share the results with the Program Director. In
the event GME concurs with the Program Director's recommendation the
resident will be notified via certified mail and of an outline or specific
time-frame for dismissal. The resident will be informed of the right to
appeal the decision.
dismissal include, but are not limited to, the following:
illness, which, in the judgment of the Program Director and faculty,
precludes the resident from participation in the graduate medical education
program and patient care activities.
3.2 Failure of the
resident to abide by INSTITUTION policies, GME policies, and/or any
applicable federal and state laws.
3.3 Failure of the
resident to maintain satisfactory levels of academic and clinical
performance as determined through periodic evaluations and a formal academic
remediation plan (i.e. learning contract).
3.4 Actions which
directly violate any of the terms of the Resident Agreement.
In the event of dismissal, the
resident has the right to appeal the decision through the appropriate
Procedure, academic or disciplinary.
In the event the resident's
dismissal is upheld after a formal grievance hearing, GME
will notify the
California Board of Medical Examiners, the ECFMG when necessary, and when
appropriate, the AOA, ACGME.
PROCESS FOR ACTION RESULTING FROM ACADEMIC DEFICIENCIES
The procedures as stated herein are
for the purpose of residency matters related to the competency of the resident
of an INSTITUTION sponsored residency program. The affected Resident shall be
entitled to a grievance hearing following: 1) a decision of dismissal from a
program, 2) failure to obtain credit for academic work completed as a result of
academic deficiencies, or 3) non-reappointment (i.e. non-renewal of the Resident
Upon receipt of written notice
from GME of a decision leading to an adverse action, a resident may request
a review of that decision by the appropriate GME committee. The
resident must make this request to GME within thirty (30) business
days of receiving that
The Resident must submit this
request, in writing to GME. Requests for a grievance hearing will not be
accepted from anyone other than the affected resident.
GME, in coordination with the
Medical Executive Committee and Resident Advisory Committee (Housestaff
Committee for ACGME programs), will appoint a hearing committee of GME and
this committee will be convened to review the adverse decision. The hearing
committee will consist of four Program Directors, one Chief Resident, one
faculty member (not from the same department), one GME official but not the
GME official responsible for the over sight of that residency program and an
INSTITUTION official. The Resident may choose a
Program Director to be
on the committee and
either a faculty member or an INSTITUTION
official. If the Resident
making the appeal does not choose a Program Director or INSTITUTION
official within ten (10) business days,
GME will appoint these individual(s). No member
shall be selected who is materially involved in the consideration of the
The hearing committee will meet
within ten (10) business days of being named by GME. GME shall select a
Chairman of the hearing committee. GME shall set the date, place, and time
of the hearing and so notify all parties concerned by letter. The
Resident will be
notified, by certified mail, of the date, time and location of the meeting.
The hearing procedures will be closed. The
hearing committee will
review the Resident’s record of performance and any relevant documents.
The hearing committee may
request and consider any additional information as the members deem
The Resident may present any relevant
information or testimony from any colleague or faculty member.
The Resident is NOT
entitled to legal representation during the hearing committee hearing.
During the hearing, the committee
will consider the following questions: 1) Was the Resident’s performance
judged using the same criteria and instruments as those used for other
Residents in the program? 2) Was the Resident notified
of the specific deficiencies to be corrected? 3) Was the Resident instructed
to correct the deficiencies? 4) Was the Resident placed on "formal academic
remediation?" (If the Resident was
placed on "formal
academic remediation," the Program Director must provide the reasons for
that action.) and 5) Was the Resident’s performance re-evaluated according
to the terms of
the remedial plan (e.g. “learning contract”)?
will be in writing and give the hearing committee’s recommendation and the
reasons for it. The GME committee will vote on whether to accept the report.
If the report is not accepted, the relevant DME/DIO will within ten (10)
days, convene a special meeting of the GMEC for a de novo appeal
hearing, which will be conducted in the same manner as in number 3 above in
this section. The Program Director whose decision is being appealed may not
participate in the GME committee’s deliberations or votes. If the report is
accepted, in will be referred to the CEO of the hospital for final action.
will notify the Resident of the final disposition.
DISCIPLINARY PROBLEMS AND
CORRECTIVE ACTION (With Respect to State and Federal Laws)
INSTITUTION has a disciplinary system
which, depending upon the circumstances, gives the resident the opportunity to
improve his/her performance or conduct after violating state or federal law.
Residents are expected to abide
by all applicable state and federal laws.
A resident, who is suspected of
violating state or federal laws, will have corrective action initiated by
his or her supervising faculty, Program Director, and GME. Length of
service and previous disciplinary and work performance records may also be
considered. It is not possible to list all acts and omissions which may
result in disciplinary action. Violation of these rules will result in
disciplinary action ranging from written reprimands to dismissal depending
upon the severity of the situation.
Any resident assisting other
residents or employees to breach any standards, before, during or after the
fact, can expect to receive the same corrective action as the offender.
Each written corrective action
report should contain the specifics of the misconduct discussed with the
resident and signed by the resident, the Program Director and GME. The
report should also outline what corrective action is required of the
Resident. The signature of the resident is mandatory and acknowledges that
the resident has received a copy of the report. If a resident refuses to
sign the corrective action report, the resident will be suspended from the
residency program. The completed corrective action report is forwarded to
A resident who is dismissed will
receive a final paycheck from INSTITUTION for hours worked to the day of
Residents who engage in
scientific research at INSTITUTION are responsible for maintaining the
integrity of all research projects in accordance with the policies, rules
and guidelines as outlined in the INSTITUTION Resident Handbook.
Furthermore, residents who may produce tangible products from these research
endeavors or assets ("Intellectual Property") must comply with
the Intellectual Property Policy contained in the Resident Handbook.
Residents who are dismissed have
a right to submit a request for a formal hearing committee meeting within
ten (10) working days. (See:
procedure/due process for action resulting from academic deficiencies 3, 4,
If a Resident is arrested or
formally charged with any infarction of the law, other than a minor traffic
violation and/or misdemeanor, the offending Resident shall report such
violation or charges to his/her Program Director, and GME within 48 hours of
the offense. The Resident will immediately be placed on an "administrative
leave of absence" by GME. If the Resident fails to notify his/her Program
Director, or GME within 48 hours of the offense, the Resident will be
suspended from the residency program. GME, in consultation with the
Residency Program Director and the INSTITUTION Legal Office, will determine
the conditions for reinstatement. GME will notify the resident, in writing,
of the terms of the leave of absence, or suspension, and the reinstatement
PROCESS FOR TERMINATION DUE TO MISCONDUCT (“Disciplinary Cause”)
The procedures as stated in this
document are for the purpose of resolving matters related to the misconduct
(i.e. violation of State or Federal laws) of a resident of INSTITUTION. The
affected resident shall be entitled to representation including legal counsel
during these procedures. All directed and associated costs of legal or other
representation, shall be the sole responsibility of the resident. INSTITUTION
shall reserve the right to be represented by an appointed member of the
INSTITUTION staff and/or legal counsel during these procedures.
Rights of Parties
Should a disciplinary matter be
presented at a hearing, the parties thereto shall have a right to: call and
examine witnesses, introduce exhibits, cross examine witnesses on any matter
relevant to the issues, and/or rebut any evidence presented. The affected
resident upon whose request that hearing is held may be called as a witness and
fully examined by the committee.
Should a hearing be requested, said
hearing committee shall be appointed by GME in coordination with the Medical
Executive Committee and Residency Advisory Committee. The hearing will
be conducted according to the above “Grievance
procedure/due process for action resulting from academic deficiencies number 3,
4, and 6”
in an informal manner by GME as long as proper decorum is preserved.
All findings and actions of the
committee shall be recorded with sufficient accuracy to permit an informed,
valid judgment to be made by any group who, at a later date, may be called upon
to review the record and render a recommendation or decision on the issues. The
hearing committee shall elect at its discretion the most appropriate method to
be used for creating the record but not limited to: electronic recording,
detailed transcription, or minutes of the proceedings.
The majority of the hearing committee
shall be a quorum and must be present throughout the hearing and deliberations.
If a hearing committee member is absent from any substantial part of the
proceedings, that member shall not be permitted to participate in the
deliberations and/or decisions of the committee.
A request for postponement or delay
of a hearing may be granted by the hearing committee upon the showing of good
cause and only if in the committees’ judgment the request is timely.
Recess or Continuation
The hearing committee may recess the
hearing and reconvene the same without additional notice in order to accommodate
the participants or for the purpose of obtaining new or additional evidence or
consultation. Upon conclusion of the presentation of oral and written evidence
by the parties to the hearing, the hearing shall be deemed closed. The hearing
committee shall there upon give their timely deliberation to the issues outside
the presence of the parties. Upon conclusion of its deliberations and a decision
on the issues, the hearing shall be declared concluded.
SUMMARY SUSPENSION AND DISMISSAL
The Medical Director, the Chairman of
the appropriate clinical department, the Hospital Chief Executive Officer, or
the Chairman of the Board of Supervisors, each and individually, shall have the
authority to request that a program director or his designee, and GME consider
summary suspension of all or any portion of the clinical privileges of a
resident when in their sole discretion patient safety and well being may be in
jeopardy. Summary suspension shall be effective immediately upon imposition
and dismissal procedures may be commenced within five (5) days of suspension.
A resident may be relieved of
clinical duties at any time on the recommendation of any faculty member to the
Program Director, when in the opinion of the Program Director such action is
deemed as in the best interest of patient care. The resident will be fully
advised of the reasons for such action and the action will be immediately
communicated to GME. Upon request of the resident, the reason for such action
shall immediately be stated in writing. All efforts shall be made to reassign
the resident to non-patient care activities consistent with his or her
educational objectives for the period involved. If such action is indicated for
reasons that can normally be considered to be transient or correctable by
remedial assistance, a continuing review of the situation will be the
responsibility of the Program Director and GME who will return the resident to
full activities as soon as possible. If such action is indicated for reasons not
considered to be transient or remedial, the resident will be dismissed.
AUTOMATIC SUSPENSION OF
Action by the State Medical Board
revoking or suspending a resident's license or placing him/her upon probation
shall automatically suspend all of his/her hospital privileges and may result
in dismissal from the residency program.
When a question arises concerning
the dismissal of a resident, the Program Director shall first discuss the
matter with the resident in a personal and informal conference. The
resolution of the matter may invoke appropriate remedial action or
the dismissal of the resident. The Program Director will write a letter to
GME recommending a course of action (i.e. remediation or dismissal).
If GME concludes that there is
sufficient evidence to justify dismissal from the residency program, GME
will notify, in writing, the Program Director, and the resident. This
notification shall state:
a. grounds for dismissal
based on evidence of failure to meet the conditions of the resident's
appointment to the training program. The resident's total professional
behavior shall be considered.
b. grounds for dismissal
with sufficient information, particularly of the underlying facts, to fully
inform the Resident of the reason for the dismissal.
If the Program Director
recommends remediation, GME will establish a hearing committee consisting of
three individuals: a Program Director, a Chief Resident and an INSTITUTION
faculty member or official. GME will preside over the committee.
a. The purpose of the
committee will be to review the information regarding the Resident's actions
leading to the suspension of his/her license as well as determine the
appropriate remedial plan.
b. The remedial plan will be reviewed
by the Program Director and signed by him/her and the resident.
c. The resident's salary and fringe
benefits shall be continued during these proceedings until a final decision is
made by GME.
provision for termination for cause shall not apply to the decision to not
reappoint a resident resulting from his/her failure to attain educational
objectives of his/her training program.