Due Process

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The following is an example of a Due Process Policy. Each program, institution, and OPTI has their own.

POLICY Due Process

ACADEMIC DEFICIENCIES AND CORRECTIVE ACTIONS

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 program.

 

  1. 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.
  2. Program 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.
  3. 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 the deficiency.  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)
  4. Prior to the imposition of any action that may result in suspension or dismissal, the Residency Program Director must submit the recommendation to GME.
  5. 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 upheld.

 

RESIDENT DISMISSAL

A resident may be dismissed from his/her residency program.  The resident has the right to appeal the decision through the Resident Grievance Procedure.

 

  1. 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.
  2. 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.
  3. Reasons for dismissal include, but are not limited to, the following:

    3.1 Incapacitating 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.

 

  1. In the event of dismissal, the resident has the right to appeal the decision through the appropriate Resident Grievance Procedure, academic or disciplinary.
  2. 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.

 

GRIEVANCE PROCEDURE/DUE 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 Agreement).

 

  1. 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 notice.
  2. 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.
  3. 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 adverse recommendations.
  4. 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 necessary.  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.
  5. 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 not 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”)?
  6. The report 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. GME 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.

 

  1. Residents are expected to abide by all applicable state and federal laws.
  2. 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.
  3. 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.
  4. 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 GME.
  5. A resident who is dismissed will receive a final paycheck from INSTITUTION for hours worked to the day of dismissal.
  6. 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.
  7. Residents who are dismissed have a right to submit a request for a formal hearing committee meeting within ten (10) working days. (See: Grievance procedure/due process for action resulting from academic deficiencies 3, 4, and 6).
  8. 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

 

GRIEVANCE PROCEDURE/DUE 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.


Hearing

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.


Record

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.


Quorum

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.


Postponements

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.


 Dismissal Procedure

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 LICENSE

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.

 

  1. 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).
  2. 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.
  3. 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.

The above 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.