| UT Southwestern Medical Center
Policies and Procedures
For Supervision, Evaluation, Discipline, and Grievances
of Graduate Medical Education Trainees
I. Policy
It is the policy of UT Southwestern to supervise residents and fellows (collectively, “residents”) in a manner consistent with the educational goals of the applicable residency program and proper patient care, to assess the competence of residents in accordance with the applicable program requirements and standards of professionalism, and to encourage fair, efficient and equitable solutions for problems that arise out of the appointment of residents. In addition, the Accreditation Council of Graduate Medical Education (ACGME) requires the “establishment and implementation of fair institutional policies and procedures for academic or other disciplinary actions taken against residents” and the “establishment and implementation of fair institutional policies and procedures for adjudication of resident complaints and grievances related to actions which could result in dismissal, non-renewal of a resident’s contract or other actions that could significantly threaten a resident’s intended career development.”
II. Resident Supervision, Evaluation, and Discipline
A. Resident Supervision and Evaluation
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Residents will be supervised by attending physicians in a manner that is consistent with the ACGME program requirements for the applicable residency program. Supervision shall be structured to provide residents with progressively increasing responsibility commensurate with their level of education, ability and experience. The Program Director shall make determinations on advancement of residents to positions of higher responsibility.
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The Program Director shall provide explicit written descriptions of lines of responsibility for the care of patients, which shall be made clear to all members of the teaching teams. Residents shall be given a clear means of identifying supervising physicians, including faculty, who share responsibility for patient care on each rotation. There must be a prompt means of accessing input and assistance from these physicians.
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Each resident will be assigned a faculty supervisor for each rotation or clinical experience (inpatient or outpatient). The residents shall be provided regular opportunities to meet with the faculty supervisor. The faculty supervisor shall provide to the Program Director a written evaluation of each resident’s performance during the period that the resident was under his or her direct supervision. The evaluations will be in a format that is uniform within the applicable department or division. Residents will be provided an opportunity to review the evaluations. If the resident disagrees with the substance of the evaluation, or any part thereof, the resident may so indicate and provide written comments and/or an explanation to the Program Director indicating the basis for the disagreement.
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The Clinical Competence Committee of the department or division (the “Committee”) shall meet periodically to review the written evaluations for each resident. The Committee shall advise the Program Director regarding the competence of each resident’s performance and make recommendations regarding advancement of the residents.
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The Program Director or his or her designee shall counsel the residents individually on their performance at least twice annually during each year of training. The purpose of this counseling is to provide feedback to the residents on their clinical performance and suggest ways for the residents to improve their knowledge and skills. More frequent counseling may be held where the Program Director or the Committee determines that a problem exists that deserves more immediate attention.
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Residents may review records on their performance with permission from the department, but copies of the records may not be released. The evaluation process, and any action taken regarding a resident’s status in the program, including, but not limited to, probation, suspension, non-renewal and termination, is performed as “medical peer review” as that term is defined under Texas state law.
B. Corrective Action.
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Conduct Subject to Corrective Action. Residents may be subject to corrective action as a result of unsatisfactory academic performance and/or misconduct, including but not limited to issues involving knowledge, skills, scholarship, unethical conduct, illegal conduct, excessive tardiness and/or absenteeism, unprofessional conduct, job abandonment, or violation of applicable policies or procedures (collectively “job performance”).
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Counseling Prior to Corrective Action. Where the Program Director determines that an adverse evaluation or evaluations indicate(s) unsatisfactory job performance in the program, the resident may be requested to attend a conference with a program representative for purposes of discussion and counseling regarding the Program Director’s concerns prior to the imposition of any corrective action or disciplinary measures. The counseling conference serves as an opportunity to promote a mutual discussion regarding the specific issues or areas of concern, as well as to encourage mutual communications. The Program Director or the Committee shall designate a representative from the program to conduct the counseling conference with the resident. During the conference, the program representative shall inform the resident of the basis for the unsatisfactory performance assessment and may advise the resident regarding any corrective action that is being considered. The resident shall have an opportunity to respond to the issues raised and may offer any explanation and/or additional information regarding the facts and/or circumstances surrounding the resident’s job performance. The resident may elect to submit a written statement in response to the conference to the program representative. The program representative shall document the events of the counseling conference and any required action by the resident in a written summary, a copy of which shall be retained in the resident’s file. Counseling is not a prerequisite to the imposition of corrective action.
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Referral for Investigation. The Program Director, the Committee, or the Department Chairperson shall refer allegations of (i) sexual harassment or unlawful discrimination made against a resident for investigation by the Equal Opportunity Director of UT Southwestern in accordance with UT Southwestern’s Handbook of Operating Procedures, and (ii) substance abuse or other impairment of a resident for investigation and handling by the Committee on Physician Peer Review and Assistance at Parkland Memorial Hospital.
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Imposition of Corrective Action. “Corrective action” may include, but not be limited to, probation, suspension, non-renewal of contract, or dismissal from the program. In the event the Program Director determines at any time that corrective action is warranted with regard to a resident, the Program Director shall provide written notice to the resident which states: (i) the specific corrective action to be taken, (ii) the reasons for the corrective action, (iii) notice of the resident’s right to an appeal of the corrective action, (iv) the time period within which the resident must initiate the appeal, and (v) that failure to request a hearing constitutes waiver of all rights to appeal . In the event that the Program Director determines that the resident’s job performance presents a threat to patient safety or welfare, the resident may be immediately removed from the patient care environment pending a corrective action determination. In addition, the following supplemental requirements shall apply for each of the following corrective action measures:
a. Probation or Suspension. Probation is where the resident is formally notified that there are identified areas of unsatisfactory job performance, which will require remediation and/or improvement if the resident is to continue in the program. Suspension is where the resident is temporarily not permitted to perform his or her job duties due to unsatisfactory job performance, which will require remediation and/or improvement if the resident is to continue in the program. The notice to the resident of either probation or suspension shall set a commencement date and duration period for the probation or suspension status and shall set forth the specific remedial action or improvement that is required during this time period. The Program Director shall re-evaluate the resident at the end of the probation or suspension period and make a determination to (i) continue the probation or suspension period, (ii) remove the resident from probation or suspension status, or (iii) impose another corrective action measure. The Program Director’s decision shall be documented in the file and communicated in writing to the resident and the Committee chairperson.
b. Non-renewal of Contracts. In the event the Program Director, the Committee, and/or the Department Chairperson elects not to renew a resident’s contract for the next year, the Program Director shall provide the resident with written notice of this decision. Notice must be provided to the resident at least four (4) months prior to the expiration date of the current contract, unless the primary reason for the non-renewal occurs within the four (4) months prior to the expiration date, in which case the Program Director must provide the resident with as much written notice of the non-renewal prior to the expiration date as the circumstances will reasonably allow.
c. Dismissal. Notice of dismissal of a resident from the program shall set forth the effective date of the dismissal.
C. Appeal of Corrective Action. A resident shall have the right to appeal any measure of corrective action imposed. The procedures governing the process for resident appeals of corrective action determinations are set forth in the Appeal Procedures, a copy of which is attached hereto as Appendix A.
III. RESIDENT GRIEVANCES
A. General Grievances. If a resident has a complaint or grievance related to matters other than job performance, corrective action, discrimination or sexual harassment, the resident should first attempt to resolve it by consulting with the Chief Resident(s) or the Program Director. If the resident is unable to resolve it at that level, the resident should then present the grievance to the Department Chairperson. If the resident is unsatisfied with the Department Chairperson’s decision, recommendation or other handling of the complaint, the resident may present the grievance in written form to the Associate Dean of Medical Education (ME) who shall provide a written response to the resident within ten (10) business days of receipt of the written complaint. The decision of the Associate Dean of ME shall be final and binding.
B. Sexual Harassment and Discrimination. If a resident has a complaint or grievance related to discrimination or sexual harassment, the resident shall have the right to address said complaint in accordance with the policies and procedures set forth in UT Southwestern’s Handbook of Operating Procedures.
Appendix A
Appeal Procedures
1. FIRST APPEAL – CLINICAL COMPETENCE COMMITTEE.
a. Exercise of Right. A resident shall first have a right of appeal of a decision to impose corrective action to the department’s Clinical Competence Committee. The resident may exercise this right by notifying the chairperson of the committee, in writing, of the resident’s intent to appeal within twenty (20) days of the resident’s receipt of the notice of corrective action.
b. Appeal Conference. The chairperson shall arrange for an appeal conference to be held among the members of the Clinical Competence Committee and the resident. The appeal conference shall be held within ten (10) business days of the date the chairperson’s receipt of the resident’s notice of appeal. At the conference, the resident shall have an opportunity to make a statement, to present any written documentation relevant to the issues and to bring any new or additional information to the attention of the committee. The committee chairperson shall within ten (10) days after the date of the appeal conference notify the resident in writing of the decision of the Clinical Competence Committee and the resident’s right to appeal the decision.
2. SECOND APPEAL –APPEAL COMMITTEE.
a. Exercise of Right. A resident shall have a right of appeal of the decision of the Clinical Competence Committee and a right to a hearing before an ad hoc appeal committee to be appointed by the Program Director. The resident may exercise this right by delivering a written notice of his or her decision to appeal to the Program Director within twenty (20) days after the date of receipt of the decision of the Clinical Competence Committee. The notice of appeal shall state whether or not the resident will have legal counsel in attendance at the hearing and, if so, the name, address and telephone number of legal counsel in writing. Failure of the resident to provide written notice of appeal within said twenty (20) days shall be deemed acceptance of the corrective action and waiver of appeal.
b. Appointment of Appeal Committee; Notice of Hearing.
ii. The Appeal Committee shall provide the resident with at least fifteen (15) days written notice of the date, time and place for the appeal hearing and the names of the members of the Appeal Committee. The notice will include a written statement of the deficiencies of the resident and a summary statement of the evidence supporting such deficiencies. The notice shall be delivered in person or by regular or certified mail to the resident at the last known address on file for the resident.
iii. The resident may challenge the fairness and impartiality of any member(s) of the Appeal Committee by stating in writing to the Associate Dean of ME the factual basis for the challenge. This challenge must be received by the Associate Dean of ME no less than ten (10) days prior to the hearing date. The Associate Dean of ME shall communicate the challenge to the member and it shall be up to the member challenged to determine whether he or she can serve with fairness and impartiality. If a challenged member determines that he or she cannot be fair and impartial in the consideration of the appeal, a replacement shall be appointed in the same manner as the original member was appointed.
c. Witnesses and Documents.
i. Each party shall provide to the Associate Dean of ME a complete list of all witnesses, a brief summary of the testimony to be given by each, and a copy of each document, record and exhibit to be introduced at the hearing.
ii. The Associate Dean of ME shall set deadlines for submission of the above information and shall provide copies to the other party prior to the hearing.
d. Hearing.
i. The Appeal Committee chairperson shall preside at the hearing, ensure order of presentation and make determinations on the relevancy of testimony and documentary evidence. The Appeal Committee may ask questions of the parties and their witnesses. The chairperson may request consultation with legal counsel during the hearing.
iii. UT Southwestern shall designate an institutional representative to present evidence on behalf of UT Southwestern. UT Southwestern shall have the burden of proving the allegations by a preponderance of credible evidence that good cause exists for the corrective action. The resident shall have the opportunity, but shall not be required, to address the committee and present evidence. Both parties shall have the right to introduce witnesses and documentary evidence. The parties shall have the opportunity to cross-examine witnesses.
iv. If the resident elects to have counsel present during the hearing, the hearing will be recorded by a court reporter furnished by UT Southwestern. Both parties will be allowed to purchase a copy of the transcript from the court reporter. If the resident does not have counsel present, the hearing will be recorded by audio equipment, which shall be furnished by UT Southwestern. UT Southwestern shall make a copy of the audiotape available to the resident upon request.
e. Appeal Committee Decision.
ii. If the resident disputes the findings and recommendations of the Appeal Committee, the resident may within ten (10) days of receipt of the written findings and recommendations submit a written request for review of the matter to the Department Chairperson. The resident’s submission should include only the record of the hearing proceedings, documentary evidence submitted at the hearing, and a written argument setting forth the reasons why the decision was in error. The Department Chairman may, in his or her discretion, elect to have a meeting with the resident and an institutional representative to discuss his or her review of the record. The Department Chairperson shall mail a written decision to the resident within twenty (20) days of receipt of the resident’s request and said decision shall be final and binding.
f. Due Process Challenges. If the resident believes at any stage of the appeal that procedural due
process has not been followed, he or she should notify the Associate Dean of ME of the substance
of the alleged deficiency. If the Associate Dean of ME finds a material deficiency in the procedural
due process afforded the resident he or she shall institute appropriate remedial action.
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