GME Policy and Procedure
XX.  Corrective Action
Introduction
Causes for Corrective Action
Corrective Actions
Appeals
  
20.1 Introduction
Whenever the professional activities, conduct, or demeanor of a resident interfere with the discharge of assigned duties or those of other University or affiliated institution employees, or jeopardize the well-being of patients, the University, through its administration, reserves the right to correct the situation through corrective action as it sees fit.
The Procedural Rights process detailed in the residency agreement is available to all residents who wish to appeal certain corrective actions which significantly threaten the resident's career development.   The following is an overview of the process;  the agreement document will rule in case of discrepancy with the overview provided here.  The decision to reduce clinical privileges is not considered a corrective action and, as such, not subject to the provisions contained herein.

  
20.2 Causes for Corrective Action
The following list provides examples of resident actions that can be grounds for discipline.  It is not intended to be inclusive of all reasons for a corrective action.  The Program Director's action will depend on the severity of the infraction, prior warnings, and efforts on the part of the resident to correct his or her behavior. In all cases the basis for the decision will be in the Program Director's best judgment.
1.
Behavior that threatens the well-being of patients, medical staff, employees, or the general public.
2.
Other substantial or repetitive conduct which is considered by the resident's supervisor to be professionally or ethically unacceptable or which is disruptive to the normal and orderly functioning of the institution to which the resident is assigned.
3.
Failure to conform to the letter and spirit of the Resident Agreement, or to policies and procedures of The University of Illinois, The College of Medicine, or the resident's program.
4.
Failure to comply with federal, state and local laws whether or not related to the medical profession.  
5.
Failure to provide patient care of satisfactory quality expected for the resident's training level.
6.
Fraud by commission or omission in application for the residency position, or in completing other official University documents.
7.
Suspension, revocation, or any other inactivation, voluntary or not, of a resident's license by the State of Illinois for any reason.
8.
Continued or lengthy absence from duty assignments without reasonable excuse.
9.
Failure to perform the normal and customary services of a resident as defined in the ACGME "General Requirements."
10.
Sexual harassment or abuse of patients, other residents, or hospital staff.

  
20.3 Corrective Actions
A. Residents may be subject to the following actions taken by the Program Director or by the Dean, College of Medicine, or his designee.  Corrective action may but need not be progressive, in that it follows the order of actions listed below.  However, if the resident's behavior, in the judgment of the resident's supervisor or University administration, warrants removing the resident from normal duties, suspension or dismissal may be imposed without prior warning.
B. Written Warning
A Program Director may issue a letter of warning to a resident.  The letter will detail the situation, the remedy required of the resident, and the consequences of not correcting the problem.  A copy of the letter will be placed in the resident's department file.
C. Probation
Definition:  Probation is a corrective action in which the Program Director notifies a Resident in writing of specific deficiencies that must be corrected in a stated period of time or the Resident will not be allowed to continue in the Program or will be continued on probationary status.  The Resident receives credit for training time and salary and benefits remain in force during probation.

Procedure: Prior to placing the resident on probation, the Program Director schedules a meeting with the resident to discuss the reasons for probation, the actions required by the resident, and the dates of probation.  The Program Director will provide the resident with a letter detailing the above points, either at the meeting or within a reasonable time following the meeting.  Copies of this letter will be placed in the resident's department file and the GME Office file.
At the end of the probationary period, the Program Director meets again with the Resident.  Depending on the resident's performance, he/she may be:
1.
Removed from probation,
2.
Given an additional period of probation, or
3.
Entered into the termination process.
The Resident shall have the right to appeal the probation in the manner set forth in Exhibit B.


D, Suspension
1. Definition:  Corrective action that removes the Resident from any Program duties.
2. Process:
a. Summary Suspension
The Department Head, his/her designee, or such other individual in a similar capacity may at any time summarily suspend with pay a Resident if he/she believes such suspension is in the interest of patient or staff welfare.  Within ten (10) days of the date of imposition of such summary suspension, unless extended by agreement of the Resident, the Department Head/Program Director must either reinstate the Resident or provide the Resident with a written notification of his/her general suspension and/or termination and the reasons therefore.  The Resident shall not have the right to appeal a summary suspension, but may appeal the general suspension or termination in the manner set forth in Exhibit B.
b. General Suspension
The Department Head, his/her designee, or any such other individual in a similar capacity may suspend with pay a Resident if he/she believes that the Resident has failed to comply with the Resident's Duties set forth in this Agreement.  The Resident shall be provided with written notification detailing the reasons for the suspension, its length, and the remedy necessary to remove the suspension.  The notice may also indicate under what circumstances the resident may be terminated if the situation is not corrected.  The Resident may be suspended until such time as the infraction has been corrected.  Failure to correct the infraction adequately, in a timely manner, or in the period specified by the University may lead to further corrective action.  Suspension will be removed when the initiating reason has been corrected to the satisfaction of the Department Head, his/her designee or the Program Director.  The Resident shall have the right to appeal that general suspension in the manner set forth in Exhibit B.
c. The Resident does not receive credit for training time while on suspension of any kind.
E. Involuntary Dismissal/Termination
Definition:  Termination/Dismissal means the cessation from participation in a residency training program even though the Resident holds a current Resident Agreement.
Procedure:  
a. By the University:     If this Agreement is terminated by the University before the end of its term for any reason other than due to the resident's name appearing on any government exclusions/sanctions list, the University shall follow the process for notification and appeal of said termination set forth in Exhibit B of the Resident Agreement.  For Residents whose Resident Agreement has been terminated due to his/her name appearing on  any government exclusions/sanctions list, the process set forth in GME Policy Number XXXVIII shall apply.
b. By the Resident:    If the Resident wishes to terminate this Agreement before the end of its Term, he/she must provide thirty (30) days’ advance written notice to the Office for Graduate Medical Education and the Program Director.
c. By Mutual Agreement:    If both parties agree to terminate this Agreement before the end of its term, that agreement to terminate must be reduced to writing and signed by both parties.

  
20.4 Appeals
A. The following corrective actions may only be appealed by using the process set forth in Exhibit B of the Resident Agreement:
1.
Termination, as defined herein and in the Resident Agreement
2.
General Suspension, as defined herein and in the Resident Agreement
3.
Non-renewal/Non-reappointment
4.
Probation


        
Policy and Procedure     XX. Corrective Action
Approved: February 8, 1993
Joint Committee on Graduate Medical Education
Revised: GMEC:
February 28, 1997
April 25, 1997
May 12, 2000
April 2004
December 2006
May 2007
October 2009
January 1, 2010