USF – College of Medicine

GRADUATE MEDICAL EDUCATION POLICY & PROCEDURE

 

Title:  Grievance (and Appeal) Process

No.: GME-218

Effective Date: 1/1/99

Revision Date:  07/30/2003; 6/05; 2/14/07

Distribution: All

Page:  1 of  4

 

 

Policy Statement

 

As part of the University’s policy of Grievance, the fundamental character of the academic enterprise should set the context of administrative decision making. Thus, the values of the academic environment -- values that encourage free expression, self direction, independence of thought and action, individual responsibility, collegiality, and the highest standards of ethical behavior -- should guide the determination of methods of investigation and documentation that will be utilized in the resolution of situations involving non-criminal malfeasance, misfeasance, or other misconduct of University employees in the performance of duties (See University Policy #0-017 – Non-Criminal Investigation Procedures). It should be noted that successful completion of the evaluation process should interface with the earliest phases of the progressive discipline process.

 

In addition, the University of South Florida recognizes the right of its employees and students to voice their concern on campus issues or personal issues of concern to them without fear of any negative, retaliatory, or reprisal action as a result of having lodged a grievance, appeal, or claim (See University Policy #0-013 – Reprisals).

 

Performance of the resident may result in disciplinary actions leading to the discontinuation of the individual in the Residency Program. A standardized five (5)-step progressive disciplinary process for all COM Housestaff consisting of two distinct levels and subsequent right of the resident to initiate the Grievance Procedure are outlined below.

 

Procedure

Following the receipt of reliable information that the resident’s clinical judgment or proficiency in clinical skills necessary to the practice of medicine is deficient or impaired the following steps shall be implemented until the deficiency is corrected or the resident is terminated from the program.    Upon or following review of the resident’s progress through the evaluation process outlined in Section IV.A.3 of the Resident Handbook

 

LEVEL I

 

Responsible Party

Action

Step 1 – Counseling     

Program Director

An unstructured counseling session between the resident and the program director, following the evaluation process as outlined in Section IV.A.3 of the Resident Handbook.

Step 2 – Written Warning

Program Director,

Associate Dean of GME Office

Program director issues a Written Warning with a copy to the Associate Dean of GME.

 

A resident’s appointment in the residency program may be conditioned, suspended or terminated in the following circumstances:

LEVEL II

 

Responsible Party

Action

Step 3 - Probation

Program Director

Residents may be placed on probation after steps one and two are exhausted or without preliminary warning if circumstances warrant an immediate probation decision.  Program Director notifies the GME Office of intent to place resident on probation. The Program Director meets with GME Office to:

 

Associate Dean of GME Office

 

 

 

 

 

 

 

 

 

 

 

Program Director

1.      Ascertain the validity of the action with regard to the issues.

2.      Clearly define the issues.

3.      Construct a statement of probation that outlines due process and right to appeal within 14 days of receipt.

 

General Counsel will review wording of the document(s).

Statement will specify:

a.       Reason(s) for action

b.       Duration of probation

c.       Specific requirements for reinstatement to full status

 

Upon successful completion of remediation plan/probation, Program Director will notify the resident and the GME Office and document the completion of probation in the resident’s file.

 

If probation is not completed successfully, resident may be continued on probation or may repeat a year, be non-renewed or be terminated.

 

Step 4 - Notice of Intent Not to Renew / Notice of Requirement to Repeat a Year / Notice of Continued Probation

Program Director

 

Program Director notifies the resident and the GME Office of intent not to renew; or notice of requirement to repeat a year or of continued probation and meets with General Counsel to review wording of the document(s) which will include:

 

 

Associate Dean of GME Office

 

 

 

General Counsel

1.      The grounds upon which the action is based;

2.      Advises the resident of his/her right to request a hearing with the Chair of the department;

 

 

3.      Informs the resident that he/she has 14 days after receipt to request a hearing;

4.      Informs the resident to whom a written request for hearing is to be directed; and

5.      States that failure to request a hearing constitutes waiver of all rights to an appeal.

 

 

Resident

May appeal the decision by filing a letter of dispute with the Chairman of the Department for repeat of a year, non-renewal of contract, suspension, termination, imposition of limits on responsibilities or imposition of disciplinary action, including but not limited to, continued probation.

 

 

Chairman

The Chairman of the respective department will attempt to address the appeal and resolve the dispute if possible.

 

 

Associate Dean of GME Office

If the Chairman is unable to resolve the dispute to the resident’s satisfaction, the resident may file the letter of dispute, within fourteen (14) days of receipt of the Chair’s decision, with the Associate Dean, Graduate Medical Education, who will review the situation and seek resolution. 

 

Resident

May appeal the decision of the Associate Dean by filing a letter of dispute within 14 days after receipt of the decision, with the Dean for consideration by a Performance Dispute Resolution Committee.

 

 

Associate Dean of GME Office

If unresolved, and the resident files an appeal, the Associate Dean of Graduate Medical Education shall refer the matter to the Dean for consideration by a Performance Dispute Resolution Committee.  At that time, the Chairman shall forward documents relating to the Department’s position to the Dean for subsequent consideration by the Professional Dispute Resolution Committee.

 

 

Dean

 

 

 

 

 

 

 

 

 

 

 

Dean

Shall designate a three- (3) person Professional Dispute Resolution Committee consisting of one USF College of Medicine Faculty member selected by the Department Chair, one Housestaff or USF College of Medicine Faculty Member selected by the resident, and a third Member selected by the first two members.  The third member cannot be a member of the involved Clinical Department or a Chairperson of any Department.

 

 

The Dean will provide all material relevant to the Dispute Resolution Committee, including a statement of the Department’s position and the resident’s letter of dispute.  The Dispute Resolution Committee will permit the resident to submit whatever material the resident believes to have bearing on the dispute for the Committee’s consideration.  The Committee will arrange to meet with the resident to afford him/her an opportunity to make an oral presentation.  The Committee will then review all material relevant to the dispute, interview appropriate individuals, and issue written findings and a recommendation to the Dean.  The Dean shall render the final agency decision for the College of Medicine and the University of South Florida.

 

Step 5-Termination / Revision of Decision

 

Program Director,

Associate Dean of GME Office,

General Counsel

 

Program Director meets with Associate Dean of GME Office to draft letters of termination/revision of decision after appeal. General Counsel will review wording of the document(s).

 

Timeline:                       Recognizing that it is in everyone’s best interest to resolve disputes expeditiously, it is difficult to meet or enforce strict time lines.  Every effort will be made to expedite each step in the appeal process, but emphasis will be placed on fairness rather than speed.

Hearing Conduct:

1.                  The resident will be given written notice of the time and place of the hearing before the Committee.

2.                  The resident may bring an attorney, or other advisor, who can assist the resident, however, the attorney/advisor will not be allowed to represent the resident or participate in the deliberation of the Committee.

3.                  Although evidence may be presented, the hearing is not a legal proceeding, does not follow the rules of law or of evidence, and is not subject to laws relating to the conduct of legal proceedings.

4.                  Since the Committee is advisory to the Dean and is not serving as the institutional official, the committee report is not subject to appeal, cross-examination, or negotiation.

 

APPROVED:

 

 

Associate Dean, Graduate Medical Education                                                  

 

 

Dean, College of Medicine                                                                               

 

c:p&p\grievance-appeal process  REVIEWED, REVISED, REISSUED 6/05; 2/07