GME Policies

I. INTRODUCTION

The foremost responsibility of the graduate medical education (GME) training program (“Program”) is to provide an organized education program with guidance and supervision of residents, fellows, and other trainees as outlined below (“Trainees”), facilitating Trainees’ professional and personal development while ensuring safe and appropriate care for patients. GME training involves the development of clinical skills, professional competencies and standards, and the acquisition of detailed factual knowledge in a specialty. Professional standards of conduct include, but are not limited to, honesty; punctuality; attendance; timeliness; proper hygiene; appropriate record keeping; compliance with all applicable ethical standards and UCSF policies and procedures; an ability to work cooperatively and collegially with colleagues, staff, and other health care professionals; and appropriate and professional interactions with patients and their families. A Trainee, as part of a Program, is assigned to a hospital, other clinical setting, or research area. A Trainee’s appointment is academic in nature. The terms of the appointment are set forth in annual contracts signed by the Trainee, Program Director, and Department Chair. All such appointments, either initial or continuing, are dependent upon the Trainee maintaining good standing in the Program and meeting overall and year-specific educational expectations of the Program. The procedures set forth below are designed to provide the UCSF School of Medicine and its Trainees an orderly means of addressing performance and related issues of concern and identifying the due process to be followed. These Policies and Procedures apply exclusively to UCSF GME-sponsored MD/DO programs, and they are the exclusive remedy by which MD/DOTrainees may appeal reviewable academic actions. Deviation from these procedures that does not result in material prejudice to the Trainee will not be grounds for invalidating the action taken. Non-MD/Non-DO Trainees should refer to their program-specific academic due process policies.The primary responsibility for remedial and adverse academic actions relating to Trainees resides within the UCSF School of Medicine clinical departments and their respective Programs. Therefore, academic and performance standards and methods of GME training and evaluation are to be determined by each Program. There may be variances regarding these standards among the various Programs. Trainees, Program Directors, and Program faculty are encouraged to make efforts to resolve disagreements or disputes by discussing their concerns with one another. However, matters involving academic progress or meeting Program standards may require actions as set forth in these Policies and Procedures. All actions set forth herein need not be progressive, and any action may be repeated as determined appropriate by the Program. This UCSF School of Medicine policy provides Trainees with due process relating to the following actions regardless of when the action is taken during the Trainee’s appointment 32 period: probation, suspension, involuntary extension of training, denial of certificate of completion, non-renewal of contract, or dismissal.

II. DEFINITIONS

Academic Deficiency: The terms “Academic Deficiency” and “Deficiencies” mean unacceptable conduct or performance, in the professional and/or academic judgment of the Program Director or their designee, including failure to achieve, progress or maintain good standing in the Program, or achieve and/or maintain professional standards of conduct as stated below.

Chair: The term “Chair” means the Chair of the Trainee’s specialty or subspecialty department, or designee, except in Section V.A.1. below, where it refers to the Chair of the appeals committee.

Clinical Competency Committee: The term “Clinical Competency Committee” means a regularly constituted committee of the Program or department that reviews the academic performance of Trainees.

Day(s): The terms “day” and “days” means business day and business days based on UCSF’s administrative calendar unless otherwise specified.

Dean: The term “Dean” means Dean of the School of Medicine or designee.

Program Director: The term “Program Director” means the GME Training Program Director for the Trainee’s specialty/subspecialty or designee. A designee is only appropriate if the program director is temporarily unable to serve in the director role and has designated a substitute Program Director during absence.

Trainee: The term “Trainee” refers to any individual appointed by the University’s School of Medicine Office of Graduate Medical Education to the titles of Resident Physician (title codes 2709 and 2723), Chief Resident Physician (title code 2738), ACGME Fellow Physician (title code 2736), Non-ACGME Fellow Physician (title code 2733), or any other GME title assigned to MD/DOs by UCSF.

Unprofessional Conduct: The term “unprofessional conduct” means conduct that is reasonably likely to be detrimental to patient safety and delivery of patient care, or is disruptive to the operations of the Medical Center or UCSF Affiliated Clinical Sites (sites in which UCSF trainees rotate).

Vice Dean: The term “Vice Dean” refers to the Vice Dean for Education in the School of Medicine or designee.

Associate Dean for GME: The term “Associate Dean for GME” refers to the Associate Dean for Graduate Medical Education or designee.

III. Conditions for Reappointment and Promotion to a Subsequent PGY Level

Reappointment and promotion of trainees are not automatic and must be decided upon annually based on satisfactory trainee performance. Each ACGME program must determine the criteria for promotion and/or renewal of a resident’s/fellow’s appointment. All reappointment and promotion decisions must align with ACGME requirements, individual program criteria, and institutional GME policies to ensure trainees are progressing toward independent practice. Reappointments allow trainees to be appointed to the next academic year. Reappointments for the subsequent academic year do not necessarily indicate promotion. Promotion requires satisfactory progress via cumulative evaluations, professional growth, and scholarly evaluation by faculty through the program’s Clinical Competency Committee (CCC). The CCC, in collaboration with the Program Director determines if the Trainee has met established criteria for promotion throughout the program. This includes documented and demonstrated proficiency in the ACGME competencies of: Patient Care, Medical Knowledge, Practice Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, and Systems Based Practice; as well as any program-specific milestones. In cases where reappointment or promotion is not recommended, programs must provide the trainee with a written notice of intent when the trainee’s agreement will not be renewed, when the trainee will not be promoted to the next level of training, or when the trainee will be dismissed as detailed in the policy below.

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