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.