Resident Academic Improvement and Corrective Action

DEPT: MEDICAL EDUCATION
POLICY #: 8240.32

GOAL

To establish uniform procedures for all Santa Barbara Cottage Hospital Graduate Medical Education training programs to follow if a resident fails to meet academic expectations and/or engages in Misconduct.

DEFINITIONS

1. Unsatisfactory Academic Performance - the resident’s performance is not evaluated by relevant faculty as satisfactory in one or more of the ACGME Core Competencies (patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice).

a) Examples of unsatisfactory academic performance include but are not limited to:

i) Issues involving knowledge, skills, job performance or scholarship;

ii) Failure to timely achieve acceptable exam scores (USMLE, in-training exam, etc.);

iii) Tardiness or absenteeism; and

iv) Unprofessional conduct.

2. Misconduct – the resident’s conduct or behavior violates workplace rules or policies, applicable law, or widely accepted societal norms.

a) Examples of Misconduct include but are not limited to:

i) Unethical conduct, such as dishonesty or falsification of records;

ii) Illegal conduct (regardless of criminal charges or criminal conviction);

iii) Sexual Misconduct, sexual harassment or any other harassment based on a legally protected characteristic (e.g. race, age, sex, sexual orientation, religion, national origin, etc.);

iv) Workplace violence or physically threatening statements or behavior;

v) Job abandonment;

vi) Violation of Santa Barbara Cottage Hospital policies or procedures; and,

vii) Unprofessional conduct.

3. Coaching and Development Plan (CDP) – a plan of remediation designed to improve a resident’s proficiency in one or more ACGME Core Competencies. A CDP is not Corrective Action or disciplinary action, but rather an educational tool to provide the resident with guidance regarding how to correct areas of Unsatisfactory Academic Performance. Since a CDP is not a Corrective Action or disciplinary in nature, a resident may not appeal a CDP pursuant to the Resident Physician Grievance Procedure. The issuance of a CDP does not trigger a report to any outside agencies, but may be reported should an outside agency specifically inquire whether a resident ever received a CDP or in other exceptional circumstances in which disclosure or reporting is deemed appropriate by the Program.

4. Corrective Action – formal disciplinary action issued to a resident as the result of Unsatisfactory Academic Performance and/or Misconduct. The Program is not required to issue a resident a CDP as a prerequisite to Corrective Action or to follow any particular order or “steps” prior to issuing Corrective Action Unsatisfactory Academic Performance and/or Misconduct may warrant Corrective Action up to and including dismissal, regardless of whether a resident ever received a CDP or a prior Corrective Action. A Corrective Action may include one or more of the following measures:

a) Probation – formal warning to the resident that there are identified areas of Unsatisfactory Academic Performance or Misconduct that will require remediation and/or improvement, and in the absence of remediation and/or improvement, the resident will not be permitted to continue in the program.

b) Repetition of Rotation – due to identified areas of Unsatisfactory Academic Performance, the resident must repeat a rotation and perform at an acceptable level in order to advance to the next level of training.

c) Non-promotion to the next Post Graduate Year level – due to identified areas of Unsatisfactory Academic Performance, the resident will not be promoted to the next level of training unless or until the resident’s performance improves to the level required.

d) Extension of the Defined Training Period – due to identified areas of Unsatisfactory Academic Performance, the resident will not complete the program on time and the defined training period will be extended to allow the resident an opportunity to perform at the level required.

e) Suspension – the resident is temporarily not permitted to perform any job duties due to Unsatisfactory Academic Performance or Misconduct. Suspension will be imposed when there is a significant risk to the safety of patients or co-workers may be compromised in the absence of the resident’s suspension. Suspension is a temporary measure. Suspension may be accompanied by other Corrective Action and may be provided to allow the resident time to achieve objectives identified by the Program as necessary prerequisites to a return to duty.

f) Dismissal – the resident is permanently separated from the program.

g) A Corrective Action may trigger a report to outside agencies (e.g. licensing or accreditation boards) and is appealable pursuant to the Resident Grievance Procedure for Appeal of a Corrective Action.

POLICY

1. Issuing a Coaching and Development Plan (CDP)

a. A CDP must be in the form of a letter from the Program Director to the resident and should follow the CDP Template. A CDP must include:

i. Formal notice to the resident of the specific Unsatisfactory Academic Performance or Misconduct;

ii. The remedial action or improvement that is required;

iii. A plan of remediation to cure the deficiencies;

iv. A defined period of time (e.g. 60 days) with a start and end date.

b. The CDP must be signed by the Program Director (or appropriate designee), delivered to the resident in person, and co-signed by the resident. The resident’s signature is not required for a CDP to be finalized but it is required that the resident be given the opportunity to sign. If the resident declines to sign the CDP, the Program Director will write “refused to sign” on the resident’s signature line and the CDP will be considered final.

c. At the end of the CDP period, the Program Director must provide the resident with written notice as to whether the resident has or has not satisfactorily cured the deficiency. A copy of this written notice must be placed in the resident’s file. If the Program Director decides the resident has satisfactorily produced the necessary improvement, he or she may elect to expunge the CDP from the resident file at the end of the resident’s training at Santa Barbara Cottage Hospital.

d. If the Program Director determines that the CDP is not producing the necessary improvement or the resident has failed to satisfactorily address the Unsatisfactory Academic Performance or Misconduct by the end of the CDP period, the resident may be issued an updated or new CDP or Corrective Action.

e. A CDP is academic in nature and is not appealable pursuant to the Resident Grievance Procedure for Appeal of Corrective Action.

2. Issuing Corrective Action

a. When a Program Director has determined that Corrective Action is warranted, the Program Director must first consult the Designated Institutional Officer (DIO). A Corrective Action cannot be issued to a resident until it has been reviewed and approved by the DIO (or designee) and the Vice President of Medical Affairs (or designee).

b. A Corrective Action must be in the form of a letter from the Program Director to the resident and must include:

i. The specific Corrective Action measure(s) to be taken;

ii. A description of the Unsatisfactory Academic Performance and/or Misconduct that is the basis for the Corrective Action;

iii. The specific remedial action or improvement that is required (unless the Corrective Action is dismissal);

iv. A defined period of time (e.g. 60 days) with a start and end date (if applicable);

v. Notice of the right to appeal, the deadline to initiate an appeal (14 days from issuance of Corrective Action), and that failure to timely appeal constitutes the resident’s waiver of all appeal rights.

c. The Corrective Action should be signed by the Program Director, delivered to the resident in person, and co-signed by the resident.

d. A copy of the signed Corrective Action must be placed in the resident’s file and forwarded to the DIO. The resident’s signature is not required for a Corrective Action to be finalized but it is required that the resident be given the opportunity to sign. If the resident declines to sign the Corrective Action, the Program Director will write “refused to sign” on the resident’s signature line and the Corrective Action will be considered final.

e. If the Corrective Action was suspension or dismissal and the resident submits a timely appeal, the Program Director may suspend the resident from participation in the program pending final resolution of the appeal.

RESPONSIBILITIES

Clinical Competency Committee or Education Advisory Committee – advise the Program Director about resident performance and progress and make recommendations to the Program Director regarding promotion, remediation, and dismissal decisions.

Designated Institutional Official (DIO) – review and approve all Corrective Actions before they are issued to the resident; provide guidance to the Program Director regarding this procedure; ensure the proper handling of Unsatisfactory Academic Performance, Misconduct and Corrective Action issues involving residents.

Program Director – make decisions regarding resident performance; ensure CDPs and Corrective Actions are given in accordance with this procedure and in consultation with the DIO and the Vice President for Medical Affairs (VPMA).

Program Coordinator – facilitate the issuance of Corrective Actions in accordance with this policy and maintain appropriate documentation.

Vice President for Medical Affairs – review and approve all Corrective Actions before they are issued to the resident; provide guidance to the DIO, the GME Office and the Program Director regarding this procedure and the proper handling of Unsatisfactory Academic Performance, Misconduct and Corrective Action issues involving residents.

COTTAGE HEALTH POLICY

Original Policy Effective Date: 11/2018
Last Review Date: 1/2024
Last Revision Date: 1/2024
Owner Title: Designated Institutional Official (DIO)
Owner Approval Date: 1/2024
Committee Approval: Graduate Medical Education (GMEC)
Committee Approval Dates: 1/2024
VP Approval: CMO/VPMA
VP Approval Date: 1/2024
Previous Review Dates: 1/2021