UCSD Selection Policy

Effective July 1, 2005

UCSD POLICY ON THE ELIGIBILITY, SELECTION, NONDISCRIMINATION, PROMOTION, EVALUATION AND DISMISSAL OF HOUSESTAFF IN ACGME ACCREDITED GRADUATE MEDICAL EDUCATION TRAINING PROGRAMS

Eligibility Criteria

Applicants for appointment to the graduate medical education training programs sponsored by UCSD must meet the following criteria:

Graduate of a medical school located in the United States or Canada, accredited by the Liaison Committee on Medical Education (LCME); or
Graduate of a college of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA); or
Graduate of an international medical school located outside of the United States and Canada who meets the following qualifications:
- Holds a current, valid certificate issued by the Educational Commission for Foreign Medical Graduates; and
- Holds a full and unrestricted license in the State of California to practice medicine or has received written notification from the Medical Board of California of approval to commence training in an accredited program in this State; or
Graduate of a medical school located outside of the United States who has completed a Fifth Pathway program provided by an LCME-accredited medical school, and who provides evidence of compliance with the licensure laws of the State of California.

Selection Policy

Programs should select from among eligible applicants on the basis of their preparedness and ability to benefit from the program in which they are appointed. Aptitude, academic credentials, personal characteristics, and ability to communicate should be considered in the selection. Programs must not discriminate with regard to sex, race, age, religion, color, national origin, disability, or veteran status. In selecting from among qualified applicants, is it strongly suggested that programs participate in an organized matching program, where available, such as the National Resident Matching Program (NRMP). Eligibility shall be determined according to the ACGME requirements.

Programs with a pyramid system shall so notify candidates during the application process.

Nondiscrimination

Pursuant to University policy, no housestaff member in a UCSD program will be discriminated against because of race, color, religion, marital status, national origin, ancestry, sex, sexual orientation, physical or mental handicap, medical condition as defined in Section 12926 of California Government Code, status as a Vietnam-era veteran or special disabled veteran, or within the limits imposed by law or University regulations, because of age or citizenship.

Appointment/Promotion

House officers are initially appointed for a duration period of not more than one (1) year.

Appointments are based on the number of years of training, accepted by the board in the particular specialty or subspecialty. House officers must be graduates in medicine, osteopathic medicine or pharmacy or hold an equivalent degree, and must be licensed to practice medicine in the State of California by the end of their first 24 months of postdoctoral training, or as otherwise prescribed by law. Individual appointments are made on an annual basis.

House officer reappointment to subsequent years of training is not automatic. Promotion shall be subject to annual review and contingent upon mutual agreement, funding availability, and satisfactory performance. Reappointment to a subsequent year shall be for a one-year term.

Evaluation

The Training Program Director shall provide each house officer with a written summary evaluation at least twice per year or as otherwise required by the applicable ACGME Residency Review Committee.

The knowledge, skills, professional growth and progress of each house officer, including professional conduct, shall be evaluated by the Program Director in consultation with the teaching faculty in a semiannual, written review. The evaluation shall be provided to and discussed with the house officer in a timely manner. Appropriate criteria and procedures must be used.

House officers shall be advanced to positions of higher responsibility only on the basis of evidence of their satisfactory progressive scholarship and professional growth.

The program shall maintain a permanent record of evaluation for each house officer and have it accessible to the house officer and other authorized personnel.

House officers will participate in the annual confidential review of their teaching faculty and will participate, as well, in the annual evaluation of the program rotations and conferences.

The Program Director must provide a written final evaluation for each resident who completes the program. The evaluation must include a review of the house officer's performance during the final period of training and should verify that the trainee has demonstrated sufficient professional ability to practice completely and independently. The final evaluation shall be made part of the house officer's permanent record maintained by the Program Director.

Discipline, Dismissal, Due Process

The following policy statement is taken from the UCSD House Officer Policy and Procedure Document.

There are a variety of administrative actions that may become part of the house officer's personnel record. These include, but are not limited to, periodic evaluations, commendations, letters of warning and/or censure, suspension of clinical privileges for medical record delinquency, or other reasons, and dismissal.
Letters of warning and/or censure are issued by the department chairperson or division head when a house officer's performance fails to meet the standards set by the Program Director. Receipt of such a letter requires that the house officer correct his/her delinquencies as presented within the letter within sixty days of receipt, or as otherwise noted. The Program Director will review the letter of delinquency and/or censure with the house officer and shall stipulate the specific reasons for such action and the recommended course of correction. The department chairperson or division head shall submit a copy of the letter to the Director, UCSD Medical Center, the Associate Dean for Graduate Medical Education and the Dean, School of Medicine. Failure to correct the deficiencies may lead to suspension or dismissal.
Suspension of clinical privileges for medical record delinquency shall follow the procedures set forth in the Bylaws, Rules and Regulations of the Medical Staff, and in the written policies of the University.
A house officer may be temporarily relieved of clinical duties for a period not to exceed 10 days, at any time, upon the written specific recommendation of a faculty member to the department chair or division head if, in the opinion of the department chair or division head, such action is considered required in the best interest of patient care. During the temporary release from clinical duties, the department chair or division head will review the resident's performance and determine whether a suspension from the residency program is warranted. At the conclusion of 10 days, unless the department chair or division head notifies the resident in writing that he/she is being suspended from the residency program, the temporary release from clinical duties shall expire.
Suspension for up to sixty days from the residency program shall occur when a house officer's performance fails to meet the standards set by the Program Director and/or patient well being is jeopardized. The department chair, or the department chair on the recommendation of the division head, shall (a) notify the house officer in writing of the reasons for the suspension and (b) duly advise the Director, UCSD Medical Center, the Associate Dean for Graduate Medical Education and the Dean, School of Medicine. The letter to the house officer shall also recommend a course of correction and state whether the house officer is being reassigned. In the event of such reassignment, the house officer will be notified as to where he/she has been assigned and as to whether the reassignment will meet specialty board requirements. In the event the reassignment does not meet such requirements, the house officer will be notified that the time spent on suspension must be made up. A reasonable effort shall be made to reassign the house officer to non patient care activities consistent with the educational objectives for the period involved. Where suspension is indicated for reasons that can usually be considered to be transient or correctable by remedial assistance, a continuing review of the situation will be made by the department chairperson or his/her designee(s). In such situations, the house officer will be reinstated to his/her program's regular activities as soon as he/she demonstrates sufficient improvement to the department chairperson.
A house officer may be subject to immediate dismissal during the term of appointment only by the Dean, School of Medicine, on the recommendation of the department chair and the Director, UCSD Medical Center, for any of the following reasons:
1. failure to rectify deficiencies of which he/she had been notified in one or more letters of warning, censure, or suspension;
2. where his/her performance presents a serious compromise to acceptable standards of patient care, or jeopardizes patient welfare;
3. for unethical conduct, and no accusation need be brought by the Medical Board of California or the Board of Osteopathic Examiners, and no determination by either body is necessary as a condition precedent to the dismissal;
4. for illegal conduct, provided, however, that unless the conduct giving rise to the criminal charge would fall within subparagraph a. or b. above, the house officer may not be immediately dismissed for conduct which has been alleged to be illegal until the house officer has either pled or been found guilty, pled nolo contendere or has been granted immunity from prosecution. The house officer will be notified of this decision in writing and the specific reasons therefor, and he/she will be informed of the right of appeal. A copy of the notification will be forwarded to the Associate Dean for Graduate Medical Education, UCSD Medical Center.
Dismissal will be based upon evaluation of the professional performance and fulfillment of the conditions of a house officer's appointment both to the training program and to the affiliated hospital or clinic to which he/she is assigned. Both the professional and the ethical behavior of the house officer shall be included in such evaluation.
In matters of discipline and/or denial of privilege or benefit of appointment, the house officer may appeal in accordance with the provisions of UCSD Policy and Procedure Manual Section 230-5, "Appeals for Academic Appointees Other Than members of the Academic Senate."
Description of UCSD Grievance Policy Under PPM Section 230-5
The following is a summary of PPM Section 230-5.
- Informal Review (Step I)
  Prior to filing formal grievance the house officer attempts to informally resolve circumstances with his/her supervisor.
  
  If the grievance is not resolved at Step I, it may be presented for formal review.
- Formal Review (Step II)
  Appeal to Step II must be submitted in writing to the V/C Academic Affairs within 30 calendar days of the notice of the action, (e.g. dismissal). Action at the Informal Review Step I level does not extend the thirty-day time limit.
  
  Within 15 days of receipt of the grievance the V/C for Academic Affairs shall forward the grievance to the department head for comment. If the department head is also the immediate supervisor involved in the informal review, the grievance shall be reviewed by the Dean, School of Medicine.
  
  Within 15 days of receipt of the formal grievance the department head/Dean will respond in writing to the house officer.
  
  If the grievance is not resolved at this step, it may be appealed for resolution at Step III (Administrative Consideration) or at Step IV (Hearing Consideration) but not both.
- The V/C Academic Affairs shall determine whether Step III or Step IV is the appropriate route as follows: Eligibility and Scope of Step IV include:
  - Corrective Action (Censure, Suspension, Demotion)
  - Dismissal
  - Reprisal
- Appeal to Step IV must be received by the V/C Academic Affairs within 10 calendar days of the date the Step II response was issued or due, whichever comes first. (This is the letter to the trainee from the department head/Dean, noted in second bullet, 3rd paragraph above.)
- The house officer shall elect to have the grievance heard by a University or non-University Hearing Officer or University Hearing Committee.
- Information to be submitted at the hearing shall be exchanged by parties 10 days in advance of the hearing date.
- Within 30 days of the close of the hearing, the Hearing Officer/Committee shall provide the Chancellor/house officer with written statement of findings and recommendation.
- The Hearing Officer/Committee is charged to make one of two determinations.
  - Has the house officer proven violation of applicable University rules/regulations and if so were the house officer's conditions of appointment adversely affected, or
  - That a specific administrative act was arbitrary and capricious and adversely affected the terms/conditions of the house officer's appointment.
- Decision by the Chancellor
  - Within 30 calendar days of receipt of the findings/recommendations of the Hearing Officer/Committee the Chancellor shall issue a final written decision.
  - The Chancellor shall provide the trainee with a copy of the findings and recommendations of the Hearing Officer/Committee and a statement of the reasons if the recommendation(s) is rejected or modified.

Graduate Medical Education Academic Due Process and Leave Guidelines

INTRODUCTION
1. Definitions
  
  Academic Deficiency: The terms "Academic Deficiency" or "Deficiencies" mean unacceptable conduct or performance in the professional and/or academic judgment of the Chair or Program Director, including failure to achieve, progress or maintain good standing in the Training Program, or achieve and/or maintain professional standards of conduct as stated below.
  
  Associate Dean: The term "Associate Dean" means the Associate Dean for Graduate Medical Education.
  
  Chair: The term "Chair" means the Chair of the Trainee's specialty or subspecialty department, or his/her designee.
  
  Clinical Competence Committee: The term "Clinical Competence Committee" means a committee of a School of Medicine department or division, and/or a committee specially selected by the Associate Dean for Graduate Medical Education in conjunction with the Chair, Graduate Medical Education Committee, that reviews the academic performance of Trainees.
  
  Days: The term "days" means calendar days.
  
  GME Training Program: The terms "graduate medical education training program" or "GME training program" refer to the second stage of medical education during which medical school graduates are prepared for independent practice in a medical specialty. The foremost responsibility of the GME training program is to provide an organized education program with guidance and supervision of the Trainee, facilitating the Trainee's professional and personal development while ensuring safe and appropriate care for patients. Graduate medical education involves the development of clinical skills and professional competencies and the acquisition of detailed factual knowledge in a medical specialty. These professional standards of conduct include, but are not limited to, professionalism, honesty, punctuality, attendance, timeliness, proper hygiene, compliance with all applicable ethical standards and UCSD policies and procedures (including but not limited to the UCSD Medical Center Medical Staff Code of Conduct Policy), an ability to work cooperatively and collegially with staff and other health care professionals, and appropriate and professional interactions with patients and their families.
  
  A Trainee, as part of his or her GME Training Program, may be in a hospital, other clinical setting, or research area. All such appointments, either initial or continuing, are dependent upon the Trainee maintaining good standing in a GME training program. Dismissal from a GME training program will result in the Trainee's automatic dismissal from any and all related appointments such as medical staff membership.
  
  Medical Disciplinary Cause or Reason: The term "medical disciplinary cause or reason" applies to a GME Trainee who holds a license from the State Medical Board of California and means that aspect of a licentiate's competence or professional conduct that is reasonably likely to be detrimental to patient safety or to the delivery of patient care in accordance with Business and Professions Code section 805.
  
  Program Director: The term "Program Director" means the Training Program Director for the Trainee's specialty or subspecialty, or designee.
  
  Trainee: The term "Trainee" includes all individuals appointed by UCSD's School of Medicine to the titles of Resident Physician I-IX (title codes 2709, 2723, 2708, 2724), Chief Resident Physician (title code 2725, 2738), Resident Physician/Subspecialist IV-IX (title code 2726), Other Post MD Trainee II-IX (title code 2732), where specified by UCSD guidelines, or any other GME title assigned by UCSD.
  
  Vice Chancellor: The term "Vice Chancellor" means UCSD Vice Chancellor Health Sciences or his/her Designee.
2. Preamble
  
  The procedures set forth below are designed to provide the University of California San Diego ("UCSD"), UCSD resident physicians and other post-M.D. trainees (collectively referred to as "Trainees") an orderly means of resolving differences. These Guidelines apply to UCSD sponsored programs of Graduate Medical Education ("Training Programs"). These Guidelines shall be the exclusive remedy for appealing 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.
  
  Additional time for remediation, either within the Training Program appointment or beyond the expiration of the Trainee's current appointment may be required to meet the educational objectives and certification requirements of the department or specialty. The Trainee will be notified in writing of any requirements for additional time. Funding for additional time extending beyond the original period of appointment will be permitted only at the discretion of the Associate Dean and upon written confirmation by the Associate Dean and the Program Director or Chair. Academic credit will be given only for full participation in the regular program unless otherwise approved by the Program Director or Chair.
  
  At UCSD, the primary responsibility for remedial academic actions relating to Trainees and Training Programs resides within the departments and the individual training programs. Therefore, academic and performance standards and methods of training and evaluation are to be determined by each department and/or program at UCSD School of Medicine and UCSD Medical Center. There may be variances in these standards among the various departments and Training Programs.
  
  Trainees and their supervisors are encouraged to discuss their concerns with one another and, if there are any disagreements or disputes, Trainees and their supervisors should make efforts to resolve them. The action(s) taken should be those that in the professional and/or academic judgment of the Program Director or Chair best address the deficiencies and needs of the Trainee and/or the Training Program. These actions are at the discretion of UCSD and need not be progressive. UCSD may select those action(s) described below that it deems appropriate.
  
  A Trainee may request a correction or deletion of his/her academic file under this policy by submitting a written request to the Program Director. Within thirty (30) days of receipt of a written request to amend or delete a record, the Program Director will either make the amendment or deletion or inform the individual in writing that the request has been denied. If the Program Director refuses to amend or delete the record, the Trainee may enter into the record a statement setting forth the reasons for the Trainee's disagreement with the record. Removal of documentation of action(s) from the Trainee's file does not preclude the University from relying on the removed documentation should any subsequent academic action be taken or from communicating the information as required by law, upon receipt of a release from the Trainee, or to any appropriate third party such as a hospital, hospital medical staff, or professional licensing board when such communication is intended to aid in the evaluation of the qualifications, fitness, character, or insurability of the Trainee.

ACADEMIC ACTIONS - NON-DISMISSAL
1. Administrative Actions
  1. Non Appealable Suspension
    
    The Trainee may be suspended from the Training Program for any of the following reasons:
    1. failure to complete and maintain medical records as required by the medical center or site in accordance with the center's/site's medical staff bylaws and/or rules and regulations;
    2. failure to comply with state licensing requirements of the California State Medical Board;
    3. failure to obtain or maintain proper visa status;
    4. unexcused absence from Training Program for three or more days.
    The period of suspension should not exceed fourteen (14) days; however, other forms of academic action may follow the period of suspension.
    
    The Chair or Program Director will promptly notify the Trainee of his/her suspension. In addition, for subsections b, c, and d above, the Trainee will be provided the documentation upon which the suspension is based and a written notice of the intent to consider the Trainee to have automatically resigned at the end of the suspension period (see Part II.A.2. below). The Trainee may utilize the suspension period to rectify (a) or to respond to the notice of intent under (b), (c) or (d) which can include correcting the problem identified in (b) or (c). If the Trainee is suspended under (a) and does not complete the medical records as required within the 14 day suspension period, other academic action may be instituted.
    
    The Trainee will not receive any academic credit during the period of suspension. The Trainee's stipend will continue to be paid while on suspension status.
  2. Automatic Resignation
    
    Automatic resignation from the Training Program will not entitle the Trainee to the procedures contained in Part III.B. of these Guidelines. Reasons for automatic resignation include:
    1. Failure to Provide Visa or License Verification.
      
      Failure of the Trainee to provide verification of an appropriate and currently valid visa or verification of current compliance with state licensing requirements of the state Medical Board of California during the 14 day suspension period may result in the Trainee's automatic resignation from the Training Program.
    2. Absence Without Granted Leave.
      
      Trainees are expected to communicate directly with the Program Director in the event he or she is unable to participate in the Training Program for a period of time in excess of 48 hours. The Program Director may grant a leave in times of exceptional circumstances. If a Trainee is absent without leave for three (3) days or more, he or she may be considered to have resigned voluntarily from the program unless he or she submits a written explanation of any absence taken without granted leave. This explanation must be received by the Program Director within five (5) days of the first day of absence without leave.
      
      The Program Director and Chair will review the explanation and any supporting documentation submitted by the Trainee regarding the absence without leave and notify the Trainee of their decision within Five (5) days. Failure to adequately explain or document the unexcused absence to the satisfaction of the Program Director and Chair will result in the Trainee's automatic resignation from the Training Program.
  3. Leaves
    
    Investigatory leave and conditional leave of absence are not intended to replace any leaves that a Trainee may otherwise be entitled to under state or federal law or University policy.
    1. Investigatory Leave
      
      A Chair or Program Director may place a Trainee on investigatory leave in order to review or investigate allegations of deficiencies or circumstances where the Trainee may pose a threat to the health or safety of the public, patients or staff or in situations where the Trainee's own health or safety may be compromised. The leave will be confirmed in writing, stating the reason(s) for and the expected duration of the leave. The alleged deficiency should be of a nature that warrants removing the Trainee from the Training Program. The Chair or Program Director should, as soon as practicable under the circumstances, conclude the investigation and either return the Trainee to the program or initiate action under these Guidelines. The Trainee will be paid for the period of investigatory leave.
    2. Conditional Leave
      
      A conditional leave of absence from the Training Program may be provided only under exceptional circumstances, at the Chair's discretion and upon the Trainee's request. At the end of the conditional leave, the Chair will determine whether to re-admit the Trainee conditionally, unconditionally, on probation, or to seek the Trainee's dismissal pursuant to the procedures contained in these Guidelines. The Trainee will not be paid a stipend for the period of the conditional leave.
2. Non-Reviewable Academic Actions
  
  The following actions are non-reviewable and may or may not be used sequentially or in tandem with one another:
  - Counseling Letter
  - Notice of Concern
  - Probation.
  1. Counseling Letter
    
    A counseling letter may be issued by the Program Director or Chair to a Trainee to address an academic or professional deficiency that needs to be remedied or improved. The purpose of a counseling letter is to describe a single instance of problematic behavior and to recommend actions to rectify the behavior. The Program Director will review the counseling letter with the Trainee. Failure to achieve immediate and/or sustained improvement, or a repetition of the conduct may lead to other disciplinary actions. These actions are determined by the professional and academic judgment of the Program Director and/or the Chair and need not be sequential. For the purposes of this policy and for responses to any inquiries, a counseling letter does not constitute a disciplinary action.
  2. Notice of Concern
    
    A notice of concern may be issued by the Program Director or Chair to a Trainee who is not performing satisfactorily. Notices of concern should be in writing and should describe the nature of the deficiency(ies) and any remedial actions required on the part of the Trainee. A Letter of Concern is typically used when a pattern of problems emerges. The Program Director or Chair will review the notice with the Trainee. Failure to achieve immediate and/or sustained improvement, failure to meet any requirement(s) set forth in the letter, or repetition of the conduct may lead to additional actions. This action need not follow a counseling letter nor proceed other academic actions described later in these guidelines. A notice of concern does not constitute disciplinary action for purposes of these guidelines or for responses to inquiries.
  3. Probation
    
    Trainees who are in jeopardy of not successfully completing the requirements of the Training Program or who are not performing satisfactorily may be placed on probation by the Chair or Program Director. Probation will be communicated to the Trainee in writing and should include: a description of the reasons for the probation, any required remedial activity, and the expected time frame for the required remedial activity. Failure to correct the deficiency(ies) within the specified period of time may lead to an extension of the probationary period or to other actions.
3. Academic Actions Appealable to the Clinical Competence Committee
  
  Trainees may appeal the following actions to the Clinical Competence Committee:
  - Suspension
  - Adverse Annual Evaluation
  - Non-renewal of appointment before four months prior to the end of the Trainee's current appointment
  - Repetition of an academic year
  - Denial of a UCSD Certificate of Completion of Training.
  1. Suspension
    
    The Chair may suspend the Trainee from part or all of the Trainee's usual and regular assignments in the Training Program, including clinical and/or didactic duties, when the removal of the Trainee from the clinical service is required for the best interests of the Trainee, patients, staff and/or the Training Program. The suspension will be confirmed in writing, stating the reason(s) for the suspension and its expected duration. Suspension generally should not exceed sixty (60) days. Suspension may be coupled with or followed by other academic actions and will continue unless and until overturned by the Clinical Competency Committee after an appeal. The Trainee's stipend will continue to be paid while the Trainee is on suspension.
  2. Adverse Annual Evaluation
    
    Trainees will only be entitled to a review by the Clinical Competence Committee for annual evaluations that are adverse (overall unsatisfactory or marginal) ("Adverse Annual Evaluation"). Trainees will be notified by the Program Director of any Adverse Annual Evaluation.
  3. Non-Renewal Of Appointment Before Four Months Prior to End of Appointment
    
    The Trainee's appointment is for a one-year duration, which is normally renewed annually. Due to the increasing level of responsibilities and increasing complexity of clinical care over the course of the Trainee's training, satisfactory completion of prior academic year(s) or rotation(s) does not ensure satisfactory proficiency in subsequent years or rotations. A Trainee may have his/her appointment not renewed at any time there is a demonstrated failure to meet programmatic standards.
    
    The Program Director should provide each Trainee with a written evaluation at least twice per year. The first evaluation should occur no later than sixth months following the beginning of the appointment term. If the Program Director with the approval of the Chair concludes that the Trainee's appointment should not be renewed for the following year, the Program Director will notify the Trainee of such. The Trainee will be permitted to conclude the remainder of the current academic year unless further academic action is taken.
    
    A Trainee who is notified of the non-renewal of his/her appointment for the following year before the four months prior to the end of his/her current appointment, will be entitled only to the procedures contained in this Part II.D. of these Guidelines. (A Trainee who is notified of the non-renewal of his/her appointment for the following year after this time will be entitled to the procedures contained in Part III.B. of these Guidelines. See Part III.B.2.)
  4. Requirement That Trainee Must Repeat An Academic Year
    
    A Trainee may be required to repeat an academic year in lieu of dismissal from the Training Program due to unsatisfactory progress or other deficiencies at the discretion of the Program Director and Department Chair provided there are sufficient funds. Funds for the additional year must be identified with written confirmation by the Program Director or Chair to the Associate Dean.
  5. Denial of University Certificate of Completion
    
    If the Program Director, in consultation with the Chair, decides not to award the Trainee a University Certificate, the Program Director will notify the Trainee as soon as reasonably practicable of this intent.
4. Clinical Competence Committee Appeal Procedures
  
  The Trainee will be notified as soon as reasonably possible that s/he has been suspended, received an Adverse Annual Evaluation, that his/her appointment will not be renewed (notice given more than four months before the end of his/her appointment), that s/he will be required to repeat the current academic year, or that s/he will not be granted a UCSD Certificate of Completion of Training. The Trainee will also be provided the name of and manner by which to contact the appropriate Clinical Competence Committee Chair to appeal the Training Program's decision.
  
  In order to appeal, the Trainee must within ten (10) days from the date of the notification provide the Clinical Competence Committee Chair with a written statement detailing the reasons s/he believes s/he should not have been suspended, should not have received an Adverse Annual Evaluation, should have had his/her appointment renewed (for the Trainee notified of non-renewal before four months prior to the end of his/her appointment), not be required to repeat the academic year, or should not be granted a UCSD Certificate of Completion of Training. The Clinical Competence Committee will review the Trainee's statement within ten (10) days of its receipt. The Clinical Competence Committee, in its discretion, may permit or request the personal attendance of the Trainee. While the Trainee has no right to representation by an attorney at the Clinical Competence Committee meeting, another person of his/her choice may accompany the Trainee.
  
  The Clinical Competence Committee will orally notify the Trainee of its decision within three (3) days of its meeting, and provide the Trainee a written decision within ten (10) days of the oral notification. The decision of the Clinical Competence Committee will be final. Failure by the Trainee to timely request a review before the Clinical Competence Committee will be deemed an acceptance by the Trainee of the academic action.
ACADEMIC ACTIONS - NON-RENEWAL OF APPOINTMENT WITHIN FOUR MONTHS OF END OF CURRENT APPOINTMENT AND DISMISSAL
1. Grounds for Action
  
  The following actions, if appealed, are reviewable by the Vice Chancellor:
  - Dismissal from the Training Program including non-renewal of appointment at any time for a medical disciplinary cause or reason;
  - Non-renewal of appointment within four months of the end of the current appointment.
  1. Dismissal From Training Program
    
    Based on the Program Director's discretion as approved by the Chair, a Trainee may be dismissed from the Training Program for academic deficiencies, including any of the following reasons:
    1. Failure to achieve or maintain programmatic standards in the Training Program;
    2. Serious or repeated act or omission compromising acceptable standards of patient care, including an act which constitutes a medical disciplinary cause or reason;
    3. Unprofessional, unethical or other behavior that is otherwise considered unacceptable by the Training Program;
    4. Material omission or falsification of Training Program application, medical record, or other University document, including billing records.
  2. Non-Renewal of Appointment Within Four Months of End of Current Appointment
    
    See Section II, C.3. of these guidelines for discussion of non-renewal of appointment.
2. Dismissal Procedures
  
  The procedures contained in this Part III.B of these Guidelines apply only to those actions reviewable by the Vice Chancellor listed in Part III.A. of these Guidelines. Failure to appeal within thirty (30) days will be deemed a waiver of any appeal rights and acceptance by the Trainee of the academic action.
  
  The Ad Hoc Formal Review Committee, see below, will handle all procedural matters during the actual hearing. At all other times, before and after the actual hearing, including up to the Vice Chancellor's final decision, the Associate Dean will make all such decisions.
  1. Level One - Informal Review
    
    When the Program Director, with the approval of the Chair, determines that grounds exist to dismiss a Trainee or to not renew his/her appointment (notice given within four months of the end of the appointment date), the Program Director will provide the Trainee with written notice of the intent to dismiss or non-reappointment. This notice will include a statement of the reason(s) for the intended dismissal or non reappointment, a copy of the materials upon which the intended dismissal or non-renewal is based, and a statement that the Trainee has a right to respond in writing to the Chair within ten (10) calendar days of receipt of the notice. If the Trainee does not respond, the intended action shall become final eleven (11) calendar days after receipt of the notice or as otherwise noted by the Program Director. If the Trainee submits a written response within the ten-day period, the Chair will review it. After reviewing the Trainee's written response (if any), the Chair will decide whether non reappointment or dismissal is appropriate. Within ten (10) days thereafter, the Chair will notify the Trainee of the Chair's decision by letter, which shall also be copied to the Program Director and Associate Dean. If the decision is to uphold the intended non-renewal or dismissal, the letter should include the reasons for upholding the proposed action, provide the effective date of the non reappointment or dismissal if the Complainant does not appeal the Chair's decision, and include a copy of these guidelines. Attempts at informal resolution do not extend the time limits for filing a formal appeal unless the Trainee and the Program Director so agree, or upon the approval of the Associate Dean. The Trainee will continue to receive regular stipends until the effective date of the dismissal or appointment end date.
  2. Level Two - Formal Review
    
    If the Trainee wishes to appeal the Chair's decision to dismiss or not reappoint, the Trainee ("Complainant") must file a written complaint with the Associate Dean no later than thirty (30) days after the Trainee receives the Chair's decision. The written complaint should concisely explain why the Complainant believes the Chair's decision was arbitrary and capricious and should address the specific reasons for the dismissal, or non-reappointment set forth in the Program Director's notice of intent to dismiss or to not reappointment.
    
    The Complainant may be assisted or represented by another person at his or her own expense. UCSD may also be represented. If the Complainant is represented by an attorney, he/she shall notify the other party fifteen (15) days prior to the pre-hearing conference or thirty (30) days prior to the hearing, whichever occurs first. The University will not be represented by an attorney if the Complainant is not so represented. The Complainant must appear in person at the hearing, even when represented. The failure of the Trainee to appear in person for the full duration of the hearing will be deemed a voluntary dismissal of his/her complaint.
    
    Within ten (10) days of receipt of the appeal, or as soon thereafter as is practicable, the Associate Dean will appoint an Ad Hoc Formal Review Committee to hear the complaint. The Committee will consist of either three or five members, at least one of which shall be a member of the full-time faculty, one senior trainee (PGYIII or higher), and one faculty member of the Graduate Medical Education Committee. The Associate Dean will designate one of the Committee members to be the Committee Chair. If possible, one of the Committee members should be from the same department as the Complainant; however, individuals who were substantially involved in any earlier review of the issues raised in the complaint, or who were substantially involved in any incident underlying the complaint generally should not sit as a member of the Committee. The Committee may, at its discretion, request that an attorney from the Office of the General Counsel be appointed to provide independent legal counsel to the Committee. This attorney shall not vote in the Committee's deliberation process. Until the appointment of a Committee Chair, the Associate Dean will resolve all issues related to these procedures.
    
    The Hearing will ordinarily be held within forty-five (45) days of receipt of the appeal by the Associate Dean. Unless otherwise agreed by the Parties and the Chair, the Complainant and his/her advocate, if any, will meet at least fifteen (15) days prior to the Hearing at a pre-hearing conference with the Committee Chair, the University representative and the University advocate (if any) to agree upon the specific issues to be decided by the Committee. If the parties are unable to reach an agreement on the issues to be decided, the Committee Chair will determine the issues to be reviewed. Issues that were not raised in the notice of intent to dismiss or to not reappoint, the Trainee's written and timely response thereto, or the notice of the Chair's decision, may not be raised in the Hearing absent a showing of good cause. At this conference, the parties may raise other procedural and substantive issues for decision by the Chair.
    
    At least ten (10) days prior to the Hearing or at another date agreed to by the Parties and the Chair, all documents to be introduced as evidence at the hearing and names of all witnesses shall be exchanged. With the exception of rebuttal witnesses and documents used in rebuttal, any witnesses not named and documents not exchanged seven (7) days before the hearing may, at the Committee Chair's discretion, be excluded from the Hearing.
    
    The Hearing will provide an opportunity for each party to present evidence and cross-examine witnesses. The Committee Chair has broad discretion regarding the admissibility and weight of evidence and is not bound by federal or state rules of evidence. If requested by either party, the Committee will take judicial notice of (i.e., recognize as a fact the existence of) any University policies. The Committee Chair will rule on all questions of procedure and evidence. The hearing will be recorded on audio tape by the University unless both parties agree to share the cost of a court reporter, or one party elects to pay the entire cost for the reporter in order to have a transcript for its own use, in which case the other side may purchase a copy of the transcript for half the cost of the court reporter and transcription plus any copy costs. The Complainant may listen to any audio tape and may purchase a copy of the audio tape. The Associate Dean, or designee, will be the custodian of the audio tape and any stenographic record, and will retain the recording for five (5) years from the time the Vice Chancellor's decision becomes final.
    
    Unless both the Complainant and the University agree to an open hearing, the hearing will be closed. All materials, reports and other evidence introduced and recorded during the course of a closed proceeding may not be disclosed until the final resolution of the appeal under these procedures except as may be required by applicable law. At the request of either party or the Committee Chair, only the witness testifying may be present and other potential witnesses will be excluded. However, the Complainant, his/her advocate and the University's representative and its advocate will at all times have the right to attend the hearing.
    
    The University has the responsibility to establish that the dismissal or non-renewal was neither arbitrary nor capricious. The University will initially come forward with evidence in support of the Chair's decision. Thereafter, the Complainant will present his/her evidence. The parties shall have the opportunity to present rebuttal evidence. The Committee Chair has the right to limit rebuttal evidence in his/her discretion.
    
    At the discretion of the Committee, briefs may be submitted. The Committee Chair will determine the appropriate briefing schedule, if any. If briefs are not requested, each party shall have the opportunity to present a closing statement. In any event, the Complainant may submit a written statement at the close of the hearing. Following the close of the Hearing, including receipt of any briefs, the Committee will present its written recommendation(s) to the Complainant, the Chair, Program Director, and Associate Dean. This recommendation(s) should occur, absent unusual circumstances, within fifteen (15) days of the Hearing's conclusion, or if briefs are submitted, within fifteen (15) days of the date the briefs are submitted.
    
    The Committee will evaluate the evidence presented and prepare a recommended decision that shall contain written findings of fact and conclusions. The decision of the Chair will be upheld if the Committee finds that the University has met its burden and established by a preponderance of the evidence that the Chair's decision was not arbitrary and capricious. The recommended decision shall become final after fifteen (15) days unless an appeal is filed pursuant to III.C.
3. Decision By Vice Chancellor
  
  Within fifteen (15) days of receipt of the Committee's recommendation(s), either party may submit a final written response to the Committee's recommendation(s) to the Vice Chancellor. Any such response submitted to the Vice Chancellor must be limited to:
  1. evidence to support the Committee's recommendation; or
  2. Whether there is new evidence that could not reasonably have been introduced at the hearing and would be likely to change the result.
  After receipt of the Committee's recommendation, the parties' written response (if any), and the record, the Vice Chancellor within sixty (60) days, or as soon as practically reasonable thereafter, will take any action deemed appropriate, including upholding the Committee's Recommended Decision, rejecting the Committee's recommendation or remanding the matter back to the Committee with instruction for further review and recommendation. The Vice Chancellor's ultimate decision will be final and will be in writing and sent to the Program Director, the Chair, the Complainant, the Associate Dean and the Ad Hoc Formal Review Hearing Committee Chair.
4. Remedy
  
  If the Complainant appeals and the Chair's decision is not upheld, the remedy will not exceed restoring the Complainant's stipend payment, benefits, or any rights lost as a result of the action, less any mitigating income earned from other sources. The Trainee will also receive his/her stipend for any time that they remain in the Training Program unless further action is taken.

Revised by the GMEC to Incorporate 7/1/05 Academic Due Process Guidelines: September 8, 2005

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