Policies / Remediation Policy and Grievance Procedure

Date Established: 01/10/2008

Revision History: 4/12/2018; 9/12/2024

Policy Reviewers: University of Washington School of Medicine Personnel Policy Unit, Washington Attorney General’s Office, GME Policy Subcommittee, UW Graduate Medical Education Committee (GMEC)

All University of Washington School of Medicine (UWSOM) graduate medical education (GME) training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) and sponsored by the UWSOM, programs accredited by the Commission on Dental Accreditation (CODA), and clinical training programs that are not accredited by the ACGME but are sponsored by the UWSOM. Residents and fellows in these programs are hereafter referred to as “residents”. Not included are non-ACGME fellows with faculty appointments, who are subject to relevant policies governing faculty, postdoctoral scholars or clinician researchers. See Appointment and Performance Management Guidance (Fellow Non-ACGME titles)

The University of Washington School of Medicine (UWSOM) is committed to providing high-quality graduate medical education (“GME”) through our residency and fellowship programs. Residents are first and foremost learners and are expected to pursue acquisition of all required competencies to allow them to practice safely and independently in their chosen specialties and subspecialties. In addition, residents must adhere to standards of professional conduct expected by UW Medicine. The policy and processes described herein are designed to ensure that actions that may adversely affect a resident’s status are taken only after appropriate, full and fair process, while also ensuring patient safety, quality of care, and the orderly conduct of training programs.

3. Policy

A. Principles and Requirements for Resident Remediation

1. Program directors must consult with the GME Office in any remediation matters.
2. A resident’s appointment, advancement, and completion of the program are neither assured nor guaranteed but are contingent on the resident’s satisfactory demonstration of continued professional growth in all required competency areas. ACGME accredited programs are required to evaluate residents on their Milestones and must have documented criteria for promotion and/or renewal of a resident’s appointment (ACGME Institutional Requirements (IR) 4.4).
3. The Program Director must ensure the program’s compliance with the Sponsoring Institution’s policies and procedures related to grievances and due process, including when action is taken to suspend or dismiss, or not to promote or renew the appointment of a resident (ACGME Common Program Requirements (CPR) 2.6.h.).
4. Due process refers to an individual’s right to be adequately notified of deficiencies in performance, and an opportunity to respond to these concerns and potentially remediate their behaviors.
   1. Regular, consistent feedback and evaluations (formal and informal; verbal and written) are the mechanisms by which residents are informed of any performance deficiencies.
5. The ACGME requires programs to conduct formal performance reviews of residents semi- annually. Evaluation of resident performance includes assessment based on the specialty-specific Milestones (CPR 5.1.c and CPR 5.1.e. See Resident and Fellow Evaluation Policy).
   1. Residents may submit written responses to their evaluations within thirty (30) calendar days. Written responses will be retained in the resident’s program file.
   2. The Program Director or their designee, with input from the Clinical Competency Committee (CCC) must: meet with and review with each resident their documented semi-annual evaluation of performance, including progress along the specialty-specific Milestones; assist residents in developing individualized learning plans to capitalize on their strengths and identify areas for growth; and develop plans for residents failing to progress, following institutional policies and procedures (CPR 5.1.c-5.1.e.). See Clinical Competency Committee Policy​.
   3. If a resident exhibits sub-standard performance, the program director may provide notice to, or request assistance from a faculty advisor, department chair, CCC, department or division faculty and/or others as appropriate.
   4. The CCC must advise the Program Director regarding each resident’s progress (CPR 5.3.b.3.). The program director has final responsibility for resident evaluation and promotion decisions.
6. Upon notification of an academic or professional performance issue, the program director will decide whether it can be addressed through the normal evaluation processes or whether formal intervention and remediation is required.
7. Unsatisfactory resident performance can result in remediation, a comprehensive list of which is outlined in this policy.
8. All remediation actions must be communicated to the resident in writing (IR 4.4.). The written notice must include the remediation status, the reasons for that status, the expectations that must be met to remediate the status, and the prescribed time frame to remediate.
9. The resident should be offered a meeting to discuss the remediation action; discussion/communication is strongly encouraged, including an opportunity for the trainee to ask questions about their performance and the program’s expectations. The trainee may also wish to invite a faculty advisor or mentor to join a remediation meeting, with program approval.
10. In any instance that an investigative interview is being conducted or discipline is being initiated for any resident who is represented by a union, the program director must notify the resident of their right to union representation. Programs should consult with the GME Office and UW Labor Relations Office if there are any questions about this obligation.

11. Table of Remediation Actions
This policy uses “Reportable” to mean must be shared with future employers or licensing bodies.

Remediation Status	Grievable	Reportable	Retain in resident file
Focus of Concern	No	No	Yes until remedied
Probation	No	Yes	Yes
Suspension	Yes	Yes	Yes
Non-promotion	Varies	Yes	Yes
Non-renewal	Yes	Yes	Yes
Removal from Patient Care Activities	No	Situational	Situational
Paid precautionary suspension pending investigation	No	Yes	Yes
Refusal to Certify Board Application	Yes	Yes	Yes
Dismissal for Cause	Yes	Yes	Yes
Training Site Actions	No	Yes	Yes
Separation from employment or unpaid status for failure to maintain immigration status	No	Yes	Yes
Actions by non-GME components of the University	No	Situational	Situational

B. Remediation Actions

This section describes actions that may be taken by a program in response to performance or behavior on the part of a resident that is determined to be academically or professionally deficient.

Residents and their program directors and faculty are encouraged to make efforts to resolve disagreements or disputes by discussing their concerns directly.

Each action is categorized as either grievable or non-grievable; this is noted in the table above. The grievance process is outlined below (IR 4.4.b.).

1. Focus of Concern (FOC)

1. FOC is the preliminary remediation step and is appropriate when the program identifies significant issue(s) of resident performance or behavior that require(s) remediation.
2. Failure to adequately remedy the deficiencies addressed in the FOC in the prescribed time, may lead to discipline including probation, suspension, non-renewal, non-promotion, or dismissal for cause.
3. A FOC may be reasonably extended beyond the original duration to allow a resident who is progressing in their competencies to meet expectations without moving to another remediation action.
4. Documentation of a FOC will not usually be considered part of the resident’s program file or reported to outside entities, as long as the recommended actions or remediation plan is completed within the prescribed time frame. If the FOC is remediated, the Program Director will remove documentation from the resident’s file.
   1. A FOC letter can be made part of the resident’s permanent file at the discretion of the program director. This may only be done in consultation with the GME Office.
5. The program will not report the FOC on privileging, credentialing, or board requirement inquiries, but may report the behavior that led to the FOC.

2. Probation

1. Probation is a serious remediation action that is taken in response to documented, substandard performance, behavioral issues, violations of educational standards or policy, and/or inability to remediate a FOC.
2. A resident on probation will typically continue clinical and educational activities, though they may be limited or modified.
3. The resident’s failure to successfully correct the substandard performance or behavioral issues leading to probation may result in progressive discipline including extension of probationary period, suspension, non-renewal, non-promotion, or dismissal for cause.
4. Documentation of probation will become part of the resident’s program file and will be disclosed to agencies or persons as appropriate when the individual seeks hospital privileges or licensure, or if the individual continues training in a different program.
5. The program director will notify the resident in writing when the probationary status has been successfully remediated. This letter will be retained in the resident’s program file.

3. Suspension from Clinical and/or Educational Activities

1. A program may suspend a resident from some or all education and clinical activities in response to the resident’s inability to provide safe patient care, or for failure to meet other obligations of the educational program, the clinical training site, and/or the Residency and Fellowship Position Appointment (RFPA). Suspension does not necessarily need to follow FOC.
2. Reasons for suspension may include, but are not limited to:
   1. Unprofessional Behavior:
      1. Violation of patient privacy rules, including but not limited to HIPAA regulations
      2. Unexcused absences beyond one day without reporting to the program director
      3. Conduct that is illegal, unethical, or in conflict with the University of Washington, School of Medicine or training regulations, site policies or compliance programs
      4. Conduct that is inconsistent with the UW Medicine Policy on Professional Conduct
      5. Performing resident duties while in an impaired physical or mental state. In this situation, the Physician Impairment Policy will also apply.
   2. Failure to comply with conditions of probation or other corrective action, or
   3. Academic and/or professional deficiencies warranting removal of the resident from patient care.
3. The length of the suspension should be appropriate to address the reason(s) for the suspension. A suspension may be indefinite in length if it requires action by the resident, e.g., obtaining proper credentials.
4. Suspension may be paid or unpaid depending on the circumstances and the judgment of the program director in consultation with the GME Office.

4. Non-Promotion

1. In a non-promotion action, the program has determined that a resident has not performed to a sufficient level to justify progressing to the next year of their training program.
2. When a program decides not to promote a resident, the program may either require the resident to repeat the year at the same R-level, or the program may require the resident to make up specific rotation(s) or assignment(s) for a portion of the year, due to performance concerns.
3. Any additional training must be performed prior to graduation from the program. In such cases, the training extension will include prorated salary and benefits at the current R-level until the resident completes all required assignments.
4. A resident will be notified of non-promotion as soon as possible in keeping with any board requirements. If no board requirements govern timing, notification of non-promotion should occur at least four months prior to the then-current termination date of the resident’s existing appointment.
5. If the program delays promotion to the next level of training but issues a new agreement at the R-level for which the resident would have otherwise been eligible, the program is delaying promotion rather than non-promoting. This decision is not subject to grievance.

5. Non-Renewal of Appointment

1. Non-renewal is the program’s decision not to reappoint a resident to any subsequent years of training beyond the current.
2. The program must notify the resident of non-renewal as soon as possible, and consistent with any applicable board requirements. If no board requirements govern timing, notification of non-renewal should occur as soon as possible prior to the then-current termination date of the resident’s existing appointment.
3. The program at its sole discretion may revisit a non-renewal decision and may rescind the non-renewal decision and offer re-appointment. The non-renewal may be rescinded up to forty-five (45) calendar days prior to the end of the resident’s existing appointment. The program’s decision to rescind a non-renewal must be discussed with the GME Office.

6. Removal from Patient Care

1. A resident may be removed from patient care activities for any of the following reasons:
   1. Failure to maintain an active medical or dental license for the state where the resident is training
   2. Failure to obtain or maintain credentials required for the clinical practice, including an individual Drug Enforcement Administration registration
   3. Failure to complete required orientation and/or annual training requirements
   4. Failure to comply with the Moonlighting and Outside Work Policy
   5. Failure to maintain compliance with UW Medicine immunization requirements
2. The duration of removal will extend until the deficiency is resolved.
3. Residents may be assigned to non-clinical duties or other status at the discretion of the program director. If assignment to another activity is not practical, the duration of removal from patient care may be unpaid.

7. Paid Precautionary Suspension Pending Investigation

1. In cases of egregious conduct, imminent danger to patients, self or others, or when immediate leave of the resident from direct patient care is reasonable in light of the surrounding facts and circumstances, a resident may be removed from patient care and/or other educational activities and placed on paid precautionary suspension pending investigation. Examples of a relevant investigation include a Washington Medical Commission inquiry, UW Medicine Drug Diversion Prevention Program, and/or University of Washington Civil Rights / Title IX Investigation.
2. A precautionary suspension is determined by the program, in consultation with the GME Office, for a temporary duration pending completion of the investigation.
3. The precautionary suspension will last as long as needed for the investigation to be completed and the program and GME Office to determine appropriate actions based on the results of the investigation.
4. Actions based on the results of a completed investigation may include any remediation action described herein. A resident will be notified of the outcome in writing at the conclusion of the investigation. If the outcome is a remediation action that can be grieved, the resident may seek review using the procedure described in this policy.

8. Refusal to Certify Board Application

1. A program may allow a resident to complete training but may refuse to approve the resident’s application for board certification. In such a case, the program will notify the resident of this decision as soon as possible. Refusal to certify board application may be appropriate if a resident has not met program, specialty or subspecialty board, and / or ACGME requirements; it should follow remediation action including at minimum an FOC.

9. Dismissal for Cause

1. A resident may be dismissed for cause if they fail to meet standards of performance expected at their appointed level of training, fail to fulfill the conditions of appointment to the program, and/or fail to meet the requirements of the hospital or clinic to which they are assigned. Dismissal for cause is also appropriate if a resident fails to meet program expectations in a remediation plan; it should follow remediation action including at minimum an FOC.
2. The resident’s overall academic performance and professional behavior must be considered in decisions to dismiss for cause.

10. Training Site Actions

1. In situations when a training site, such as a hospital or clinic, withdraws permission for a resident to train at that site, typically due to resident violation of a hospital or clinic policy and/or concerns about the resident’s ability to provide safe patient care, the resident may be reassigned to another site or to administrative activities, and/or be subject to disciplinary action depending on the circumstances that led to the withdrawal.
2. A training site’s withdrawal of permission to train may also result in a legal requirement that the University notify an appropriate licensing body of such action. The resident will be notified if the University notifies a licensing body.

11. Separation from Employment or Unpaid Status for Failure to Maintain Proper Immigration Status for Legal Employment

1. Residents who become ineligible for employment with the University of Washington due to changes in their immigration status will be separated from employment or placed in unpaid status and may not work in any capacity, including voluntary, for the University of Washington or within UW Medicine. They will be placed on inactive, unpaid status (or whatever status is deemed appropriate) until their work eligibility status is resolved.

12. Actions by entities other than GME

1. If a resident violates a University of Washington, UW Medicine, and/or University of Washington School of Medicine policy, and is consequently disciplined by one of these entities under policies and procedures outside the scope or authority of the GME Office, the resident may not grieve discipline through the procedure defined in this policy.
2. The resident may, however, exercise due process procedures available from the entity taking action.
3. Subsequent remediation actions taken by the resident’s program in response to actions by non-GME components may be grieved as described in this policy.

C. Remediation Grievance Process

The process described here is the exclusive mean of grievance for remediation actions described in this policy.

This grievance procedure allows secondary review of a programs’ remediation action(s). The grievance procedure is not an adversarial or legal proceeding but is the exercise of academic and professional judgment by GME community members regarding whether the resident has the necessary ability to meet the academic and professional standards of the UWSOM GME program and to perform adequately as a physician.

1. Request for Review

1. In a situation where a program decides that a resident will be subject to a remediation action that is designated grievable by this policy (see table above), the resident may choose to grieve the program’s decision after meeting and discussion with the program director.
2. If the resident chooses to grieve the remediation decision, they must notify the program director or the GME Office. Once notified of the resident’s decision to grieve, the program director or the GME Office will notify the Chair of the Graduate Medical Education Committee (GMEC), who will provide written notice to the resident that contains:
   1. A copy of the remediation documentation;
   2. Notice that a grievance must be formally initiated by the resident in writing to the GMEC Chair within fourteen (14) calendar days from receipt of the remediation documentation; and
   3. A copy of this policy, and other relevant policies.
3. The GMEC Chair must receive a remediation grievance request in writing within fourteen (14) calendar days from receipt of the remediation documentation. If no request for review is received within this timeframe, the remediation becomes final, and no grievance is permitted.
4. Within five (5) business days of receipt of the resident’s written request for remediation grievance, the GMEC Chair will provide the program director/designee a copy of the resident’s written request for remediation grievance. The GMEC Chair will also acknowledge in writing to the resident the timely receipt of the grievance request.

2. Composition of Grievance Review Committee (GRC)

1. The GMEC Chair will convene an ad-hoc panel, hereafter referred to as the Grievance Review Committee (GRC), consisting of four members of the GMEC as follows:
   1. Two GMEC members who are UWSOM faculty and who are not members of the same department as the resident requesting review;
   2. A resident or fellow member of the GMEC who is not in the same department as the resident requesting review; and
   3. The GMEC Chair will designate a member of GMEC to serve as a non-voting GRC Chair. The GRC Chair will be responsible for overseeing the GRC and ensuring compliance with this policy.
2. If the GMEC Chair is unable to identify two faculty members and a resident or fellow member of the GMEC to participate in the GRC, the GMEC Chair shall appoint other UWSOM faculty or residents as needed to fill the panel, with the restriction that one GRC member will be a current UWSOM resident or fellow and none will be members of the same department as the resident requesting review.
3. The GMEC Chair may designate alternates for GRC members to ensure a full committee is available on the day of the hearing. The alternates will not participate in the hearing unless the original designated members are unable to attend.

3. Grievance Review Committee Charge and Responsibilities

1. The GRC is charged with reviewing the program’s remediation decision and issuing a Recommended Outcome. The GRC’s sole determination is whether the program’s remediation decision was arbitrary or capricious. The burden of proof is on the resident to demonstrate that the program’s decision was arbitrary or capricious.
2. Arbitrary or capricious action is defined as willful and unreasoning action, without consideration and in disregard of facts or circumstances. Where there is room for two opinions, an 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.
3. Only the GRC members who are present at the hearing may participate in the GRC deliberations. Submission of a Recommended Outcome by the GRC requires a quorum of those present at the hearing and simple majority vote. If the GRC is unable to achieve a simple majority, the Recommended Outcome(s) of the GRC should reflect the views of each of the members.

4. Procedure

a. Timing

1. The GRC Chair will set a date for the hearing a minimum of thirty (30) calendar days after the program director/designee receives notice of the resident’s intent to grieve.
2. The program may request an extension, which cannot exceed an additional thirty (30) calendar days. The decision to grant an extension will be made by the GRC Chair.

b. Materials

1. The program director/designee shall provide the following information to the GRC, a minimum of five (5) business days before the meeting:
   1. A statement of the matters asserted by the program;
   2. A list of witnesses who may be presented at the GRC hearing by the program director/designee; and
   3. Any documents to be presented at the GRC hearing by the program director/designee.
2. The resident may submit a written statement to the GRC Chair instead of or in addition to making a presentation at the GRC hearing. The resident’s complete written materials must be submitted a minimum of five (5) business days before the meeting.
3. The GRC Chair will submit the resident’s statement to the full committee. The GRC will make its decision based on materials furnished by program director/designee, the program director’s/designee’s written and/or verbal statement, and the resident’s written and/or verbal statement.
4. Each party’s submitted written materials will be shared with the GRC members and the other party.
5. Legal discovery is not available, including but not limited to pre-meeting witness interviews, requests for records, interrogatories, or depositions.

c. Attendees

1. The resident may be accompanied by one (1) advisor or legal counsel at the resident’s own expense. The program director/designee and GRC may request legal counsel from the Attorney General’s Office, University of Washington Division. However, advisor/legal counsel for either party will not be allowed to speak at the GRC hearing nor to actively participate in the proceedings unless permission is granted by the GRC Chair.

d. Hearing Format

1. The resident and program director/designee are entitled to hear all presentations and examine all documents presented at the GRC hearing. The resident and program director/designee may present documents and witnesses in support of their respective positions and may ask questions of any other witnesses.
2. The GRC Chair shall give parties full opportunity to submit and respond to statements.
3. All components of the grievance process will be closed to public observation.
4. All testimony of parties and witnesses shall be made under oath or affirmation.
5. No communications are permitted by the resident, program director/designee or their respective representatives to GRC members regarding any issue in the proceeding other than those communications that are necessary to maintain an orderly meeting process. All other communications regarding the review are to be directed to the GRC Chair.
6. Neither the resident nor program director/designee have the right to be present during the GRC deliberations.
7. All GRC proceedings will be conducted with reasonable dispatch and be completed as soon as possible, consistent with fairness to all parties involved. The GRC Chair shall have the discretion to continue the hearing if requested by either party, or as otherwise appropriate.

e. Summary of Proceedings

1. An adequate summary of the proceedings will be kept. Such a summary shall include all documents that were considered by the GRC and may include a recording of the presentations and any other documents related to the meeting.

5. Case Ruling by Dean

1. The GRC shall submit its Recommended Outcome and a copy of the record to the Dean of the UWSOM or UW School of Dentistry, the GMEC Chair, the program director/designee, and the resident within ten (10) calendar days of the conclusion of the hearing. The Recommended Outcome shall reflect the GRC’s finding(s) regarding whether the program’s remediation decision was arbitrary or capricious. Such finding(s) shall be based exclusively on the record in the review meeting and matters officially noticed in that proceeding.
2. Within thirty (30) calendar days of receipt of the GRC’s Recommended Outcomes, the Dean will forward a written final decision to the resident. The Dean’s final decision shall include a statement of findings and conclusions.
3. Within ten (10) calendar days of the resident’s receipt of the Dean’s final decision, the resident may file a written Request for Reconsideration with the Dean stating the specific grounds upon which relief is requested. Petitions submitted later than ten (10) calendar days from receipt of the final decision will not be considered.
   1. Any Request for Reconsideration will be deemed to be denied unless the Dean notifies the resident of a different outcome within twenty (20) calendar days of receipt.
   2. A denied Request for Reconsideration does not delay the effective date of a dismissal for cause.

6. Remedy

1. The resident’s salary and benefits shall be continued during the period necessary to assure due process, provided that salary and benefits shall cease at the expiration of the resident’s appointment or the effective date of dismissal by the Dean, whichever shall occur first.
2. Rulings by the Dean that are made in favor of the resident may not include remedies beyond reinstatement and recovery of any stipend and benefits lost as a result of the disciplinary action.