Due Process and Resident Complaint
This policy will apply to all residents/fellows who participate in an SIU Graduate Medical Education (GME) training program. Due Process, as described within, applies to Actions that are taken as a result of academic deficiencies and/or misconduct. (See Academic Deficiency Policy and Professional Conduct and Misconduct Policy) Complaint refers to the review of resident/fellow complaints or issues related to the work environment or the program or faculty.
Academic Matters: A review of the program’s decision to take an Action for academic matters may be requested by the resident/fellow. A written request for review must be submitted to the DIO/Chair of GMEC within fourteen (14) days of learning of the Action. Upon a request for review, the DIO/Chair of GMEC will first determine whether the matter is reviewable under this policy and if so, shall appoint a Review Committee. The Review Committee will be composed of two (2) full time faculty members and one (1) resident from a department or departments different than the requesting resident/fellow. The committee will make a determination whether the resident/fellow received appropriate notice of deficiency and an opportunity to correct it, and whether the decision to take the Action was thoughtfully and deliberatively made. The Review Committee will make a recommendation in this regard to the Dean of the School of Medicine and the CEO/COO of the resident’s/fellow’s employing hospital, who will jointly render a decision. This decision will be immediately effective, binding, final, and not subject to further appeal.
Prior to the Review Committee meeting, the Office of Graduate Medical Education (OGME) will be responsible for providing a copy of the resident’s/fellow’s file to the committee members. The resident/fellow and/or program director are at liberty to submit any additional relevant documentation to OGME for distribution to the committee members. Patient and peer identifiers shall be removed from any documents. The committee will review the resident’s/fellow’s request for review, the resident’s/fellow’s file and any additional documentation provided (Materials).
The review meeting will be scheduled in a timely manner. If the resident/fellow fails to attend without good cause, he/she will have been considered to have withdrawn the request for review. If the program director fails to attend without good cause, the meeting will proceed.
The meeting will be attended by the three (3) committee members, the resident/fellow, program director and a representative of OGME. As this is an academic process, no attorneys or legal advisors shall be in attendance. The resident/fellow may have a faculty advisor or other support person present if he/she chooses. This support person will not be permitted to actively participate unless requested by the chairperson of the Review Committee. The chairperson of the Review Committee will preside over the meeting, make introductions, and verify that all committee members have reviewed the Materials in advance.
The resident/fellow will be given an opportunity to describe why he/she believes the Action was unwarranted and the basis for the request for review. The program director will then have an opportunity to respond to or clarify issues raised in the resident’s/fellow’s request for review. The committee members will then have an opportunity to ask final questions of the resident/fellow and program director.
The committee may interview others as they see appropriate to aid in the decision making process. If the committee identifies such individuals in advance, they will be invited to attend the meeting. Alternatively, the committee may identify individuals they need to interview after the meeting and before their deliberations. On conclusion of the committee meeting and after the committee members have had a chance to interview any other individuals they identify, the committee will deliberate without the program director and resident/fellow but with the attendance of an OGME representative.
The committee will make a written report with their recommendations, along with a discussion of the rationale for the committee’s decision. The OGME will be responsible for forwarding the written report along with a copy of the Materials to the Dean and the CEO/COO of the employing hospital. The Dean and CEO/COO will review the committee’s written report and Materials and jointly render a decision either upholding, overturning, or modifying the Action
Misconduct Matters: A review of the decision to take an Action for misconduct matters may be requested by the resident/fellow. The review process will be the same as that for academic matters (outlined above) with the following exception: The Review Committee will make a determination whether the resident/fellow received appropriate notice, had an opportunity to be heard regarding the matter at hand, and whether the decision to take the Action was thoughtfully and deliberatively made.
The procedures as outlined above shall not preempt the Medical Staff By-laws or personnel codes of the hospitals and shall not preempt or limit any right of the hospitals under the Agreement With Physician (resident contract) to immediately suspend a resident/fellow.
Complaint Matters: This refers to some cause of distress (such as an unsatisfactory working condition) that is felt by the resident/fellow to present a reason for complaint, but does not involve an Action that is eligible for due process. Complaints must be dealt with in as confidential a manner as possible, and without fear of retaliation. A complaint or incident should be reported to the resident/fellow’s Chief Resident or attending physician. If the Chief Resident or attending is unable to help the trainee effectively resolve the issue, the resident/fellow should take the problem to the Program Director for resolution. If satisfactory resolution is still not achieved after the Program Director has become involved, the resident/fellow may provide a written complaint report to the DIO/Chair of GMEC.
The DIO/Chair of GMEC will review the written complaint report and meet with the resident/fellow to ensure that steps as outlined above for Complaint Matters were followed. He/she may then convene other individuals deemed necessary to perform a reasonable inquiry and problem-solving process, including but not limited to the complainant’s Program Director, hospital administrators, other residents/fellows or faculty, and/or human resources personnel. The DIO/Chair of GMEC and other appropriate participants will investigate all the issues associated with the complaint and will provide a final and binding decision to the resident/fellow, unless precluded by confidentiality (i.e. if a complaint culminates in a personnel action against a resident/fellow, faculty or staff member).
Last Approval Date: June 16, 2017
Effective Date: June 16, 2017