Medical School Graduate Medical Education Personnel Policies (T00-024)

Medical School Graduate Medical Education Personnel Policies (T00-024)

Doc. T00-024
Passed by the Board of Trustees on February 2, 2000

I. Administration

A. Purpose

The purpose of this booklet is to provide residents and clinical fellows in the University of Massachusetts Medical School (UMMS) graduate medical education programs with information about personnel policies and procedures, which affect their daily professional activities and personal concerns.

The Medical School, as the sponsoring organization for Graduate Medical Education (GME,) has developed these Personnel Policies to ensure compliance with the institutional requirements of the Accreditation Council for Graduate medical education (ACGME). The University reserves the right to amend, modify, or revoke any of the provisions herein by action of the Board of Trustees. All policies contained and referenced herein are applicable to all residents and fellows employed by the Medical School and supersede University of Massachusetts Medical School Personnel Policies unless otherwise noted.

B. Definitions

  1. Department Chairperson: the head of a University of Massachusetts Medical School basic or clinical science department who is responsible for the administration of the department and who is appointed by the Dean.
  2. Service Director: a physician who is responsible for a patient care entity to which the resident or fellow is assigned. Patient care entity may be a hospital inpatient or outpatient service, ambulatory center or clinic, nursing home, or private medical practice.
  3. Residency/Fellowship Program: an organized graduate medical education training effort within a clinical department(s) or service(s) which is designed to prepare physicians for the practice of a medical specialty(ies) or subspecialty(ies), and, where applicable, to meet the requirements of the Accreditation Council for Graduate Medical Education (ACGME). Integrated and affiliated programs involve more than one institution while the program remains under the supervision of the University department chairperson(s). Combined or joint programs are shared between two clinical departments or divisions and remain under the supervision of the delegated program director or program directors and the respective department chairpersons.
  4. Residency/Fellowship Program Director: the department or division chair or designated faculty member who has the responsibility and authority for a specific residency/fellowship program’s administration, curriculum, resources, and activities as required by ACGME. Combined or joint residency programs may be under the responsibility and authority of a single program director or multiple program directors representing each participating specialty. The term “program director” (singular) as used in this document may also refer to “directors” (plural) when two or more program directors share responsibility for a combined or joint residency program.
  5. Residents: physicians and dentists appointed to an organized clinical residency or fellowship program; includes physicians commonly designated as interns and as clinical fellows. The term is used for physicians in both ACGME-accredited and non- ACGME-accredited programs. Residents have status both as students and as employees. This policy serves to clarify their relationship to UMMS, which is their sponsoring institution.
  6. Accreditation Council for Graduate Medical Education (ACGME): The national organization responsible for physician residency and fellowship program accreditation. The ACGME is made up of representatives from the American Board of Medical Specialties, the American Hospital Association, the American Medical Association, the Association of American Medical Colleges, and the Council of Medical Specialty Societies.
  7. Residency Review Committee (RRC): Committees of the ACGME designated for review and accreditation of specific medical specialties.
  8. Graduate Medical Education Committee (GMEC): A committee, made up of representatives from each of the residency programs, Medical School administration, UMass Memorial Health Care administration, affiliated institutions, residents and residency program coordinators. The GMEC is charged with the oversight of residency education at UMMS and other responsibilities as required by the ACGME. The ACGME is chaired by the Associate Dean for Graduate Medical Education. The Chief Medical Officer of UMass Memorial Medical Center serves as Vice Chair.

C. Applicability

These Graduate Medical Education Personnel Policies shall apply to all physicians and dentists who have been appointed to a UMMS graduate medical education program position. Residents who are not in UMMS residency programs, but who are on temporary rotation assignment to UMass Memorial Medical Center, are expected to follow the procedures herein which relate to residents’ conduct and performance while at UMMS.

D. Governance

The University of Massachusetts Board of Trustees has all the authority, responsibility, rights, privileges, powers, and duties of organization and government of the University of Massachusetts Medical School (UMMS). UMMS is comprised of three (3) schools: the School of Medicine (SOM), the Graduate School of Nursing (GSN), and the Graduate School of Bio-Medical Science (GSBS). There is a Dean of the School of Medicine who is its chief academic officer. The Dean may appoint a designee such as the Senior Associate Dean for Educational Affairs or the Associate Dean for Graduate Medical Education to manage matters related to residency training.

The UMMS department chair has ultimate responsibility for a residency program and may designate a residency program director. Joint or combined programs are the responsibility of participating department chairs. The service director is responsible for the direct, on-site supervision of the resident when on rotation.

UMMS residents are subject to the rules, regulations, bylaws, accountabilities, and standards of conduct as applicable to all professional employees of the Commonwealth of Massachusetts, to all members of the medical staffs, and to all members of the medical profession; except as otherwise specified in these Personnel Policies. In addition, UMMS residents shall also abide by the policies, standards, rules, regulations, requirements, and procedures of the patient care entity to which they are assigned, and professional conduct as applicable to all other professional staff members. Where the entity’s policies and these UMMS Personnel Policies might conflict, the matter shall be referred to the department chair and the program director.

E. Implementation

Each UMMS department and residency/fellowship program is responsible for the implementation of these personnel policies, and shall maintain a program personnel file for each resident. Access to resident personnel files is limited to specified individuals to guarantee confidentiality as regulated by the Massachusetts Fair Information Practices Act (MFIPA) and University regulations promulgated thereunder. Information concerning the Resident as an applicant, such as National Resident Matching Program rank order and letters of recommendation, are filed in a confidential section of the resident's program and are governed by MFIPA. The UMMS Office of Graduate Medical Education (OGME) was established:

  1. To protect the educational integrity of all residency and clinical fellowship programs.
  2. To assist residency program directors and residents in administrative and personnel matters.
  3. To facilitate the implementation and coordination of systems for residency education such as core curricula, faculty development, performance and program evaluation, information resources, academic support and counseling services, and to ensure program and institutional compliance with ACGME, the Joint Commission, and other regulatory requirements.
  4. To develop fiscally sound GME budgets in cooperation with the Medical School, UMass Memorial Medical Center, and other affiliated health care institutions.
  5. To provide administrative support to the Graduate Medical Education Committee and its subcommittees.

F. Appointment (Eligibility and Selection)

Graduates of LCME- and AOA- approved U.S. and foreign medical schools are appointed to UMMS residency programs either through the National Resident Matching Program or, when allowed by the NRMP, by direct application. All applicants must use the Electronic Resident Application System (ERAS) when applying to participating programs. Graduates of medical schools outside of the United States who have completed a Fifth Pathway Program provided by an LCME-Accredited Medical School are also eligible. Graduates of foreign medical schools must have passed Steps 1 and 2CK and CS of the USMLE or COMLEX or equivalent Canadian Medical Licensing Examination and hold a valid ECFMG certificate. Graduates of accredited US medical schools MUST have passed Step 1 of the USMLE or COMLEX for appointment to a PGY1 position and Step 2CK and CS of the USMLE or COMLEX for appointment to a PGY2 position. Appointment eligibility is also subject to the Massachusetts Board of Registration in Medicine’s requirements for licensure. All applicants for PGY3 or higher level position MUST have passed Step 3 of USMLE or COMLEX or equivalent Canadian Medical Licensing Examination prior to their date of hire. An exception may be made for a resident transferring into a UMMS training program from a program that does not require passing UMSLE Step 3 prior to program completion. In such cases, the resident must take Step 3 within 6 months of transferring and must pass by the end of the academic year. This exception does not apply to applicant for fellowship positions. (UMMS Resident Selection and Appointment Criteria Attached). All applicants MUST meet the UMass Medical School Graduate Medical Education Technical Standards (including bloodborne pathogen policy) and any additional Residency/Fellowship Program-Specific Technical Standards. All residents and Fellows must sign the UMMS Graduate Medical Education Appointment Agreement and agree to abide by the provisions stated therein. Programs do not discriminate on the basis of gender, sexual orientation, race, age, religion, color, national origin, disability, or veteran status.

The Graduate Medical Education Appointment Agreement does not become effective until the applicant has been issued a Limited or Full Massachusetts Medical License by the Board of Registration in Medicine, has been approved by the UMass Memorial Medical Center Resident/Fellow Credentialing Subcommittee, and meets all other employment requirements of the University of Massachusetts including, but not limited to, (1) completion of payroll and benefits forms; (2) any necessary work authorization forms; (3) certification of compliance with physical examination and other health and safety requirements; and (4) completion of a malpractice insurance application and completion of mandatory orientation curriculum. Each appointment is limited to a maximum of one year (twelve months), which in most cases begins July 1st and ends June 30th.

G. Policies Review

The University reserves its right to modify, amend or change these policies at any time. New and revised policies will be made available to residents for review and comment. Policy revisions and amendments shall require consultation with the Department Chairpersons whose departments have a residency program (or residency program directors), and the chiefs of those services in affiliated hospitals, which are members of UMMS integrated residency programs. Any modifications, amendments, or changes to these policies require the approval of the Graduate Medical Education Committee, and the Chancellor/Dean of the Medical School, before submission to the Board of Trustees. The Board may take such action, as it deems appropriate on any proposed modifications, amendments, or changes.

Book Category
Board Policy: Personnel

II. Compensation and Benefits

II. Compensation and Benefits

A. Compensation

Each resident shall be paid at least bi-weekly in accordance with the annual stipend schedule and the terms of the Graduate Medical Education Appointment Agreement and the terms of the University of Massachusetts Medical School Personnel Action Form. PGY stipend levels are based on training level within the program and not necessarily on prior years of training or experience. Any general salary adjustments granted to professional or to classified Medical School employees during the fiscal year (July 1 through June 30) shall not alter the residency program stipend schedule in effect as of July 1 of that fiscal year.

B. Excused Days With Pay

Each full-time resident shall receive 15 days of paid vacation per year (the equivalent of three five-day work-weeks. Vacation days are awarded at the beginning of each appointment-year. Vacation days are pro-rated for those who are part-time or who are appointed for less than a full year. Vacation days are not reimbursable and cannot be carried over into any subsequent year of residency training. Any deviations and expectations from this general policy shall be at the discretion of the program director and the Associate Dean, GME. Vacation days unused during the resident’s terminal year (with prior approval of the program director and the ADGME may be reimbursed upon the resident's termination.

It is expected that during the year each resident will take all three weeks of vacation. Residents must receive prior approval for vacation days from the program director and, as appropriate, the clinical service director so as not to interfere with the resident’s duties and the provision of patient services. Residents shall receive 15 days of sick time per year. Sick leave days are pro-rated for those who are part-time or who are appointed for less than a full year. Sick days are awarded at the beginning of each appointment year and may be accrued to 120 days. Unused sick leave is not reimbursable. In addition, residents may join the UMMS Sick Leave Bank, which provides financial support for up to 90 days during an approved medical absence which would otherwise be unpaid due to the lack of accrued time off. Three days of personal time are awarded each July 1st to each resident for personal business. Personal time is pro-rated for those who are part-time or who are appointed for less than one year. Personal leave days not taken by the last Saturday in June are forfeited. Residents must receive prior approval from the program director and, as appropriate, the clinical service director before taking personal leave days.

Effort will be made to assign legal holiday schedules in an equitable manner among residents in the same residency program at the same PGY level. Residents do not receive holiday pay.

Residents may use personal leave or vacation days for religious beliefs, subject to approval of the program director and clinical service director.

C. Leave of Absence

Eligible residents may be granted a Family and Medical Leave (FMLA) of up to 12 weeks each calendar year for the birth or adoption of a child or a serious personal illness or serious illness of the resident’s child, stepchild, foster child, parent, spouse or domestic partner or other circumstances as specified by Federal law and UMMS Policy. Residents are eligible for an eight week leave per child (e.g. 16 weeks for twins) under the Massachusetts Maternity Leave Act. A FMLA or maternity leave is unpaid unless a Resident has accrued sick, personal, or vacation time. In accordance with UMMS policy, up to eight weeks of sick time pay may be used for maternity leave; up to three weeks of sick time pay may be used for paternity leave. A participating resident will continue to be covered under his/her health, dental and life insurance programs when accrued time off is used. When the FMLA leave is unpaid, the resident will be billed his/her share of the premiums directly at home. The UMMS Family and Medical Leave policy and UMMS Graduate Medical Education Leave of Absence policies are attached.

A resident may request an unpaid leave of absence of up to four weeks for reasons not covered under the FMLA. Each request will be considered by the program director on an individual basis and, in their sole and exclusive discretion, decisions will be based upon the nature of the request, staffing needs and the Resident's prior performance and attendance. Extension of a leave in excess of four weeks requires the approval of the Associate Dean of Graduate Medical Education or his/her designee.

Residents and fellows are also eligible for compensated leaves of absence under UMMS Policies for Bereavement Leave, Military Leave and Jury Duty. There is a Graduate Medical Education Policy for Absence due to Inclement Weather.

Leaves of absence must be reported to the Office of Graduate Medical Education. The provisions for leaves of absence which comply with institutional, federal and state policies may threaten compliance with rules imposed by the Board and/or Residency Review Committee for an individual’s program or specialty area. Some Boards and RRCs require strict adherence to both a total number of months in training and specific distribution of training effort. Residents must complete program requirements for the level when the leave was granted in order to be promoted to the next program level or in order to receive a Certificate of Completion of that level.

A program director may require a resident to compensate for excused days or a leave of absence which in total exceeded twenty days (the equivalent of four five-day work weeks) per training year (fifteen or less days for some programs as required by the ACGME) by extending his or her contract year by the number of excused or leave days in excess of twenty. This extension would be applicable only when the resident has not met residency training program requirements during the year and only when all other means for meeting the program requirements have been exhausted. The resident may, at the discretion of the program director, receive a stipend subject to available funding at the existing rate for the PG year being completed.

D. Benefits

All residents are eligible to participate in the group medical, dental and life insurance programs offered to Medical School professional employees. The Medical School provides long term disability insurance which may be at low or no cost to the resident. Residents are eligible for Workers Compensation Coverage for work-related illness or injury. In addition, there are opportunities to participate in long term disability insurance and tax sheltered retirement plans on a self-pay basis and in dependent care reimbursement accounts. Residents participate in the Commonwealth of Massachusetts Retirement System, in lieu of deductions for Social Security. Tuition aid is available to residents, spouses, domestic partners and dependent children in accordance with University Policies. The descriptions of these benefits are set forth in Exhibit A. In addition, at the New Resident Orientation and annual re-enrollments, residents receive additional information about their fringe benefit package. Other benefits, which may be modified from time to time, may include limited license fees, white coats/scrubs, meals when on call, and education allowance.

E.  Professional Liability Insurance

Each resident, upon proper application, shall be covered by a professional liability (malpractice) policy provided by UMMS. Residents shall be informed of the type (occurrence or claims made with tail coverage) and limits of the insurance and of any restrictions thereof). UMMS shall provide risk management, risk assessment and claims management services to Residents/Fellows with respect to any professional liability claims that may arise from activities within the resident’s scope of employment. Each resident agrees to fulfill his/her obligations for reporting and follow-up as required by the risk management plan or plans in place at each hospital site including but not limited to occurrence, adverse outcome or sentinel event reporting as well as quality improvement activities and other processes that may come within the Massachusetts peer review privilege. Each resident shall conform to hospital policies and procedures that cover these processes understanding that peer review work product is confidential and not subject to discovery. Each resident shall also fulfill their obligation to cooperate with hospital licensing, accrediting and other regulatory agencies when appropriate. UMMS Program Directors shall be available for consultation when necessary.

F. Outside Employment

Residency training is a full time endeavor and the program director must ensure that outside employment (commonly known as moonlighting) does not interfere with the ability of the resident to achieve the goals and objectives of the educational program. Before a resident may accept any outside employment, the resident must obtain the written approval of the program director on a form provided by the OGME. A separate written approval is needed for each outside employment site, for each separate position within the same employment site, and for all changes thereof.

In reviewing a request for approval to engage in outside employment, the program director and the resident should consider: (1) the resident's capacity to fulfill primary responsibilities while accepting outside responsibilities; (2) the nature and content of the outside employment activities in terms of service and educational value; (3) the health care needs of the community being served; (4) any additional limitation or controls set by the program's accreditation requirements, and (5) implications for professional liability coverage. The program director may also consider any potential conflict of interest of the employment location and responsibilities. The program director will monitor the impact of moonlighting activities on academic performance, and adverse effects may lead to withdrawal of permission. Permission must be renewed annually.

In no instance may a resident engage in outside employment when such employment may require the resident's physical presence or personal attention during regularly assigned duties as a UMMS resident. All moonlighting hours must comply with the duty hours regulations as specified by the ACGME in their Common Program Requirements. In no instance may a resident be required to engage in moonlighting.

A full Massachusetts Medical License and Federal and State DEA registrations are required for all outside employment.

The UMMS offers malpractice insurance coverage for resident engaged in outside employment only under strict conditions, as described in the UMMS Extended Employment Guidelines. Residents whose outside employment does not comply with these guidelines are responsible for their own malpractice insurance.

III. Work Environment

III. Work Environment

A. Duty Hours

The structuring of duty hours and on-call schedules shall focus on the needs of patients, continuity of care and the educational needs of the residents as determined by the department chairperson and the ACGME General and Special Duty Hours Requirements that apply to each program. Residents who voluntarily agree to duties which are not considered a normal part of their duties within their residency/fellowship program may receive additional compensation with the prior approval of the program director, and the Associate Dean for Graduate Medical Education. The Hospital will provide adequate on-call space and availability of food for residents assigned to overnight in-hospital call and to residents who are called in from home.

B. Substance Abuse and Physician Impairment

Drug and Alcohol Abuse in the Workplace

All members of the University of Massachusetts Community shall comply with the Federal Drug-Free Workplace Act and laws of the Commonwealth of Massachusetts, the regulations of the Alcoholic Beverages Control Commission and local ordinances and regulations relative to the illegal use, sale, dispensing, possession or manufacture of illegal drugs, controlled substances or alcohol at all buildings, grounds and property owned, used or leased by the University and the affiliated training sites. At no time shall a resident report to work under the influence of alcohol or illegal drugs. If it is determined that a violation of UMMS’s Policy or State or Federal law relative to controlled substances or alcoholic beverages has occurred, a resident will be subject to disciplinary action up to and including termination of employment and referral for prosecution.

It is the responsibility of all individuals to maintain a working environment free from drug and alcohol abuse. The UMass Memorial Medical Center Clinician Health and Well-Being Committee is available to evaluate, refer, and otherwise assist practitioners impaired or potentially impaired by reason of alcohol, drugs, physical disability, mental illness or other health condition. Residency program directors, chief residents, and other employees are encouraged to refer colleagues with suspected Impairment to the Clinician Health and Well­Being Committee. The House Officer Counseling Program is also available as a referral resource.

The Clinician Health and Well-Being Committee serves as a liaison to the Massachusetts Medical Society's Physician Health Service (PHS). The PHS can accept referrals, evaluate, make recommendations for treatment, and monitor physicians with problems of chemical dependence or mental health issues.

A resident or fellow who is suspected of or found to have abused illegal drugs, controlled substances or alcohol, and who refuses participation in a monitoring program or who violates a monitoring contract with the PHS, will be reported to the Massachusetts Board of Registration in Medicine. A resident, or fellow, failing to abide by the treatment program guidelines established in a contract with PHS may be terminated.

All reporting and monitoring is considered confidential.

All licensed physicians In the Commonwealth of Massachusetts are required to report fellow physicians who are guilty of practicing medicine while the ability to practice Is Impaired by alcohol, drugs, physical disability or mental instability (M.G.L.c.112 5f) to the Massachusetts Board of Registration in Medicine.

C. Psychiatric Impairment

The Office of Graduate medical education provides access to highly confidential counseling services to residents. Outside referrals may also be made. Information from resident encounters is not shared with the residency program or OGME without the explicit permission of the resident. A residency program director may, however, require resident assessment or participation in counseling as a requirement to remain in the residency program if there is sufficient evidence of impairment or behavioral difficulties, which make it difficult to carry out responsibilities within the residency program and/or which might adversely impact patient care and safety. This requirement may be subject to appeal as described in Section IV.E.

D. Sexual Harassment

Sexual harassment is a violation of Federal and State law. It is the policy of the University of Massachusetts Medical School to provide an educational, employment and business environment free of sexual harassment in the form of unwelcome physical advances, requests for sexual favors and verbal and written communications of a sexual nature. UMMS’ Diversity and Equal Opportunity Office (DEOO) has primary responsibility for investigating and resolving sexual harassment complaints. The Office conducts investigations of all complaints and implements remedies to ensure compliance with University sexual harassment policies and Federal and State laws. Any member of the Medical School community found to have violated the University’s sexual harassment policy will be subject to a range of disciplinary action up to and including possible termination.

Complaints will be investigated in a timely and confidential manner, whether they occur at UMass Memorial Medical Center or at other affiliated training sites. Appropriate representatives from UMMS and the affiliated site will jointly investigate complaints involving faculty, staff, or personnel at affiliated training sites. Every effort will be made to respect the privacy of those involved and retaliation in any form for having made a complaint, or for participating in the investigation of a complaint is prohibited. A copy of the sexual harassment complaint procedure may be obtained from the Diversity and Equal Opportunity Office, the Office of Graduate Medical Education or the Clinical Department Administrator.

E. Residency Closure or Reduction

Residents will be notified promptly of an approved plan to implement a reduction in the size of or closure of their residency or fellowship program. To the extent possible, any such reduction or closure will be phased in to permit residents/fellows to complete their education. Assistance will be provided to residents wishing to transfer to another ACGME-accredited program in which they can continue their education.

IV. Performance

IV. Performance

A. Standards

All residents must possess appropriate communication, behavioral and social skills which enable them to function effectively as members of the health care team, as delineated in the Technical Standards and Professionalism documents. These include: (1) ability to relate effectively and sensitively with patients; (2) the ability to communicate promptly, effectively and efficiently in oral and written English with all members of the health care team; (3) the ability to develop professional relationships with patients; (4) maintaining patient confidentiality; and (5) the ability to work in a collegial and appropriate manner with members of the health care team. Failure to meet these minimum standards may be grounds for corrective action and possible dismissal. Residents are expected to promptly and adequately address and modify any inappropriate behaviors that may be brought to their attention.

In addition to the above, each program director shall provide written residency program standards which shall include program educational goals and objectives. The standards shall also specify the levels of knowledge and technical skills against which each resident will be evaluated. Such standards should recognize the requirements for residency program accreditation plus the requirements for specialty board certification. A copy of the approved standards shall be provided to each resident, along with a description of UMMS and individual residency program evaluation procedures. These will also be available in the OGME.

B. Evaluation

It is the responsibility of faculty to provide ongoing feedback to each resident concerning his/her performance. A resident must be informed as soon as possible when performance is below the level of performance set by the program’s written standards or other applicable standards such as professional ethics or hospital policies. Remedial work or additional educational responsibilities may be assigned or additional supervision may be provided.

Each resident shall receive from the program director a formal, written evaluation at least every six months, which shall include a review of knowledge, skill, growth and development, professional attitude, and demeanor. The evaluations shall be filed in the resident's departmental personnel files and shall be discussed with the resident as required by the AGME. A resident may dispute a written evaluation report by submitting a written response, which shall be filed with the evaluation report.

Each resident must complete all required written or electronic evaluations as scheduled including confidential written evaluations of the faculty and educational experiences at least yearly or as requested by each department. Each resident must submit an annual anonymous program evaluation to the Office of Graduate Medical Education.

C. Reappointment and Certification

For reappointment to the next higher PG level within a UMMS program, each resident must satisfactorily complete all reappointment requirements as established by the Medical School and the program, and must complete a residency program reappointment agreement. This includes passage of Step 2 CK and CS of the USMLE or COMLEX or equivalent Canadian Medical Licensing Examination for appointment to the PGY2 level. This also includes maintenance of a valid Massachusetts Full or Limited Medical Practice License. Passage of Step 3 of the USMLE or COMLEX or equivalent Canadian Medical Licensing Examination is required prior to promotion to the PGY3 year.

Candidates for completion-of-program certificates must satisfactorily complete predetermined programmatic, educational, administrative, HIPAA, and patient care requirements including medical records.

The program director shall notify a resident and the OGME, in writing, if s/he will not be advanced to the next higher PGY level or if s/he will not receive a certificate of completion (that is, will not be certified for specialty board eligibility). Notice of non-reappointment will generally be given six months prior to the expected date of completion or advancement. The program director and the resident may mutually agree, and confirm in writing, to postpone a notification concerning advancement or certification until four months prior to the expected date of completion or advancement. Notwithstanding the above time frames, notice of non-reappointment may be given to the resident at any time prior to the expected date of completion or advancement if circumstances warrant. Residents have the right to appeal the program director’s notification of non-reappointment through the grievance process described for Disciplinary action of the appeal process,, set forth in Section V “B” below.

In order to guarantee continued participation in the residency/fellowship program, each resident must sign and return a GME Reappointment Agreement no later than 90 days prior to the effective date of the reappointment unless otherwise agreed upon by the resident and program director.

D. Termination

The program director may terminate the resident’s employment during the term of the contract pursuant to the evaluative process described herein. A resident may terminate his/her employment upon three months notice or such shorter period, as the program director shall approve. All medical records and all evaluation and other required forms must be completed and equipment returned before termination. Upon termination a resident will be paid the portion of salary earned prior to termination. Also health and dental benefits may be continued under COBRA by paying the full premiums plus the administrative fee allowed by the law. The Certificate of Completion for Board eligibility will be issued and request for withdrawal or transfer of state retirement contributions will be processed upon satisfactory completion of all requirements as determined by the program director. A resident will have the right to appeal the decision to terminate his/her employment pursuant to the appeals process set forth in Section V “C” below.

V. Corrective Action, Grievance, and Appeals Procedures

V. Corrective Action, Grievance, and Appeals Procedures

A. Corrective Actions and Disciplinary Actions

Any complaint against a resident should be directed to the program director. On the basis of such a complaint, or on his/her own initiative, the program director after whatever investigation and consultation s/he deems appropriate, shall determine whether the residents’ behavior warrants a course of action including a verbal warning, or other possible corrective action. Evidence of behavior meriting corrective action may include, but is not limited to: failure to meet standards of performance or rules established by the particular training program; frequent unexcused absenteeism from clinical or didactic responsibilities, unprofessional behavior toward colleagues, patients, patients’ family, or staff; drug or alcohol abuse; criminal activity; violation of UMMS rules, regulations, bylaws, or personnel policies applicable to residents, conduct which negatively affects the University of Massachusetts Medical School or any of the academic affiliates, or any of the activities constituting unprofessional conduct under the Medical Practice Act of the Commonwealth of Massachusetts.

Residents may be placed on administrative leave (relieved of their clinical and educational responsibilities) pending resolution of any complaint or grievance if, in the best judgment of the program director and department chair, such leave is in the best interest of UMMS.

Early and timely feedback and interventions should occur to prevent issues as soon as possible and to provide the resident the opportunity to remedy same. Documentation of such feedback provided to the resident and included in his/her file. Corrective actions may be requested by the chief of any service to which the resident is assigned in order to correct any unacceptable performance or behavior.

“Corrective action” includes all types of complaints and related remedial activity up to but specifically not including suspension, non-promotion or termination. Corrective actions are intended to inform the resident of any deficiencies in performance or behavior and/or of an educational or instructional nature, and the expected remedial response, so the resident may conform to expectations. The resident is responsible for addressing and fulfilling all performance requirements within a certain stated timeframe.

If the program director elects, in his/her sole and exclusive discretion, to issue a Notice of Corrective Action to a resident, it must be in writing, state the alleged deficiency and what the resident must do to remedy/correct same and by what date. There must be clear and objective means of determining if the resident’s corrective action has been successful.

During the course of their residency, residents may receive more than one Notice of Corrective Action. Depending on the nature, severity and frequency of the complained-of­ conduct and/or the potential threat to patient care and safety, the program director may choose to skip a “Notice of Corrective Action", and instead go directly to the issuance of a "Notice of Disciplinary Action." However, any time there Is the possibility of the resident receiving a suspension, termination, non-reappointment, and/or non-promotion; it must Involve a "Notice of Disciplinary Action."

If, as a result of the "Notice of Corrective Action”, the resident fails to properly, fully, or timely cure the alleged deficiency, the matter may proceed to a "Notice of Disciplinary Action."

“Disciplinary action" includes but is not limited to any, conduct, act, or omission that, following notice and an opportunity to be heard, may result in a suspension, termination, non­ reappointment, and/or non-promotion. Disciplinary action may be reportable to the Board of Registration in Medicine. Further, in the event that a resident elects to resign while under or when subject to Disciplinary Action, the resignation may nevertheless be reportable to the Board of Registration in Medicine.
The specific action to be implemented shall consider such factors as severity and frequency of offense, threat to patient care and safety, documented history of prior informal or formal corrective action and the resident's overall performance and conduct.

B. Grievances

Residents who feel they have been treated unfairly under the interpretation or application of a policy, rule or procedure and/or through a Notice of Corrective Action, or a Notice of Disciplinary Action may file a grievance. The grievance process shall be conducted without the presence of legal counsel.

A request for resolution of a grievance resulting from either (a) alleged unfair treatment based on the interpretation or application of a policy, rule or procedure, or (b) from a Notice of Corrective Action shall be submitted in writing by the resident to the Program director within seven (7) working days following the date when (a) the resident became aware (or should have become aware) of the alleged unfair treatment based on the interpretation or application of a policy, rule or procedure, or (b) the resident was served with the Notice of Corrective Action, or (c) when the resident’s attempted corrective action was deemed Insufficient. The involved department chair and Program Director shall convene a meeting with the resident, may interview other "interested" parties, and may gather and obtain any information that might assist their decision making. The Department Chair and Program Director shall issue their ruling on the resident’s grievance within ten (10) days after receiving same. If the resident is dissatisfied with this ruling, he/she may appeal same to the Associate Dean for GME by written notice served within five (5) days of the Department Chair - Program Director's decision. The Associate Dean for GME will consider all evidence, interview any needed persons (Including the resident), and must issue his/her final ruling within the following ten (10) days, which decision shall be the resident's final recourse with respect to this matter.

A request for resolution of a grievance resulting from a "Notice of Disciplinary Action shall be submitted in writing by the resident to the Program director within seven (7) working days following the date when the resident was first served with the Notice of Disciplinary Action.

The involved Department Chair shall convene a departmental grievance committee. Such committee shall be comprised of three members of the department faculty. The resident may select one member. The committee shall meet with the resident (without legal counsel), and may review any records, or interview any persons whom they consider helpful for resolution of the grievance. The chair or committee shall advise the resident In writing of the proposed resolution of the grievance within ten (10) working days after receiving the notification of the grievance.

If the committee (by a majority vote) does not resolve the grievance to the satisfaction of the resident, the resident may appeal in writing within five (5) working days to the Dean of the School of Medicine. The Dean or his/her designee shall appoint a senior faculty or administrative person to convene and chair a five-member UMMS Appeal Review Committee. The resident shall select two members of the committee and the department chair shall select two members; the appointed committee chairperson shall vote only in the case of a tie. One member of the Faculty Review Committee may come from another UMMS clinical department (the resident may make this selection). The UMMS Appeal Review Committee shall be provided with all documents comprising the appeal in the case. The resident may provide the Review Committee with any additional information or evidence which the resident believes would be of assistance to the committee. The Review Committee, in its sole discretion, may or may not meet with the resident (without counsel). The Review Committee may determine whether it requires any additional information or evidence from any other persons and may determine whether this information may be provided orally, or in writing. The Review Committee may adopt, modify, or reject the decision of suspension, non-promotion, non-reappointment or termination. The Review Committee shall deliver a final binding decision in writing within twenty (20) working days of the receipt of the notice of appeal from Dean. When a resident has been removed from clinical service due to concerns of patient safety or to protect the interests of UMMS the resident will be placed on paid administrative leave, pending completion of the appeal process.

C. Appeals Procedures for Corrective Actions

A resident has the right to appeal a Level Two Written Order of Corrective Action. During the appeal process, the resident may submit whatever oral or written information and arguments the resident believes are relevant, and to request faculty and other residents to provide additional information. The chair of the designated Appeal Review Committee (as described in Step Two below) may limit the type, the amount of information submitted, the number of persons providing information, the length of any meeting, and other procedural matters which in the committee’s judgment are not necessary or helpful to the committee’s determination of the issues. The appeals procedures shall be conducted without the presence of legal counsel. A written report will be prepared listing the documents that were reviewed, and summarize the evidence and issues.

The imposition of any corrective action may be suspended during the appeals process except in those circumstances when the department chair or program director believes that restrictions of the resident’s responsibilities are required to protect patient care or the interests of UMMS.

The time frames established herein should be considered the generally allowable times and all appeals and grievance requests should be scheduled and concluded expeditiously. However, the involved parties may consent to an extension of allowable times.

If the resident’s appeal is successful, the resident’s file shall be expunged of all documents relative to the matter that was appealed.

Step One

To initiate a formal appeal of a Level Two Written Order of Corrective Action, including a decision of suspension, non-reappointment, non-advancement or dismissal, the Resident shall request the Department Chairperson or his/her designee to modify or withdraw the written order.

The Step One appeal request shall be submitted in writing within five (5) working days of the resident’s receipt of the written order from the program director. A conference between the resident, the program director and the department chair or designee shall be held in consideration of the resident’s request. After the conference, the chair shall respond in writing within ten (10) working days to the resident’s request for modification or withdrawal.

The Resident has the right to appeal the decision of the chair to the Chancellor/Dean, by submitting in writing a request for appeal within five (5) working days of the receipt of the written decision by the department chair.

Step Two

For appeal of a Level Two Written Order for Corrective Action except orders regarding non-reappointment or termination, the Chancellor/Dean or designee shall hold a conference with the department chair, the program director and the resident. The Chancellor/ Dean or designee shall be provided with all documents comprising the appeal in the case. The resident may provide the Chancellor/Dean or designee any additional information or evidence which the resident believes would be of assistance in evaluation of the case. The Chancellor/Dean or designee may request any additional information from the department chair, the program director, the resident, or any other person, which the Chancellor/Dean or designee believes would aid his/her determination of the appeal. The Chancellor/Dean or designee may adopt, modify, or reject the corrective order that is under appeal. The Chancellor/Dean or designee shall issue his/her determination in writing within twenty (20) working days of the receipt of the resident’s appeal, and this determination shall be final.

For appeal of a decision to non-reappoint or to terminate, the Chancellor/Dean or designee shall appoint a senior faculty or administrative person to convene and chair a five-member UMMS Appeal Review Committee. The resident shall select two members of the committee and the department chair shall select two members; the appointed committee chairperson shall vote only in the case of a tie. One member of the Faculty Review Committee may come from another UMMS clinical department. The UMMS Faculty Review Committee shall be provided with all documents comprising the appeal in the case. The resident may provide the Review Committee with any additional information or evidence which the resident believes would be of assistance to the committee. The Review Committee may determine whether it requires any additional information or evidence from any other persons and may determine whether this information may be provided orally, or in writing. The Review Committee may adopt, modify, or reject the decision of non-reappointment or termination. The Review Committee shall deliver a final binding decision in writing within twenty (20) working days of the receipt of the notice of appeal from Chancellor/Dean.

Affirmative Action

Affirmative Action

University of Massachusetts Medical School
55 Lake Avenue North
Worcester, MA 01655

The University of Massachusetts Medical School is firmly committed to its policy of Equal Opportunity through Affirmative Action, and takes active measures against discrimination in all areas.

Additional Human Resources Policies Applicable to Residents and Fellows:

  • Bereavement Leave
  • Jury Duty Court Leave
  • Military Leave
  • Sick Leave Bank
  • Employee Recognition
  • Tuition Programs
  • Reference and Criminal Records Checks
  • Access and Solicitation
  • Conflict of Interest
  • Confidentiality
  • Domestic Partnership
  • Employee Assistance Program
  • Employee Records
  • Political Activity
  • Staff Requests Concerning Participation in Patient Care
  • Work-Related Illness or Injury
  • Personal Appearance
  • Preventing Hostility and Violence in the Workplace
  • Deductions and Withholding
  • Distribution of Paychecks
  • Pay Advances
  • Payroll Procedures
  • Salary Repayments
  • Tax Treaty
  • Vacation Pay Advances
  • Transfer to/from State/Municipal Service