Disciplinary Action Policy

I. Purpose of policy

The purpose of this policy and process is to establish disciplinary procedures for all Graduate Medical Education (GME) training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) to follow if a Resident’s training in such a program fails to meet academic expectations and/or engages in misconduct.

II. Policy scope

This policy applies to all ACGME-accredited residency and fellowship programs at Dartmouth-Hitchcock (D-H).

III. Definitions

Resident: Any physician in an accredited graduate medical education program, including residents and fellows.

Designated Institutional Official: the individual in a sponsoring institution who has the authority and responsibility for all of the ACGME-accredited GME programs.

Academic Deficiency: The Resident is not meeting one or more of the ACGME Core Competencies, as revised from time to time, which may include: patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice. Examples of academic deficiencies, include, but are not limited to: a. Issues involving knowledge, skills, job performance or scholarship; b. Failure to achieve acceptable exam scores within the time limits identified by the training program; c. Unprofessional conduct; d. Professional incompetence including conduct that could prove detrimental to Dartmouth-Hitchcock’s patients, employees, staff, volunteers, visitors or operations.

Misconduct: Conduct by a Resident that violates workplace rules or policies, applicable law, or widely accepted societal norms. Examples of misconduct include, but are not limited to: a. Unethical conduct, such as falsification of records; b. Illegal conduct (regardless of filing of criminal charges or criminal conviction); c. Sexual misconduct or sexual harassment; d. Workplace violence; e. Unauthorized use or disclosure of patient information; f. Violation of D-H or other applicable policies or procedures, including without limitation the Code of Ethical Conduct; g. Scientific misconduct.

Disciplinary Action: Any of the following actions taken in response to a Resident’s Misconduct or Academic Deficiency: dismissal from a program; non-promotion to the next PGY level; non-renewal of a Resident’s agreement; suspension; and probation.

IV. Policy statement

Non-disciplinary measures for academic improvement are set forth in the GME Academic Improvement Policy. In circumstances under which non-disciplinary measures are unsuccessful, formal disciplinary action may be undertaken pursuant to this policy and process.

1. Administrative Leave Pending Investigation
   • The Program Director and the Designated Institutional Official (DIO) (or their designees) determine that immediate action is required prior to completion of a review or investigation of possible Misconduct or Academic Deficiency, in order to protect the health and safety of patients, staff or other persons, or the interests of D-H, the Resident may be placed on immediate administrative leave, with or without pay as appropriate depending on the circumstances. In this event, the Office of General Counsel and Employee Relations should be alerted. This action is not disciplinary in nature and therefore cannot be appealed pursuant to the Appeal of Disciplinary Action Policy. This type of leave is intended to be a short term measure to allow for a review of the underlying concern and determination as to whether Disciplinary Action is warranted;
2. Disciplinary Action
   • Disciplinary Action is issued to a Resident as the result of Academic Deficiency or Misconduct.
   • A program is not required to issue a Resident any form of non-disciplinary, remedial action as a prerequisite to recommending or taking Disciplinary Action. Serious Academic Deficiencies and/or Misconduct may warrant Disciplinary Action, up to and including dismissal, regardless of whether a Resident ever received or was subject to any prior form of remedial action.
   • Types of Disciplinary Actions:
     • Dismissal: A permanent separation of the Resident from the program.
     • Non-Promotion to the Next PGY Level: A lack of promotion of the Resident to the next level of training unless or until Resident’s performance improves to the required level.
     • Non-Renewal: Non-renewal of a Resident Agreement for the next academic year.
     • Probation: A temporary modification of a Resident's participation in or responsibilities within the training program; these modifications are designed to facilitate the Resident’s accomplishment of program requirements. Generally, a Resident will continue to fulfill training program requirements while on probation, subject to the specific terms of the probation. The Program Director shall have the authority to place the Resident on probation (and shall identify the resident’s status as “on probation”) pursuant to this policy and have wide discretion based on his/her professional judgment to determine the terms of probation. Probation may include, but is not limited to, special requirements or alterations in scheduling a Resident's responsibilities, a reduction or limitation in clinical responsibilities, or enhanced supervision of a Resident’s activities.
     • Suspension: A period of time in which the resident is not allowed to take part in all or some of the activities of the program. Time spent on suspension may not be counted towards the completion of program requirements. During the suspension the Resident will be placed on administrative leave with, or without, or with pro-rated pay as appropriate depending on the circumstances.
     • Recommending Disciplinary Action:
       • When a Program Director has determined that disciplinary action is warranted, the Program Director must consult with his/her Clinical Competence Committee, Department Chair, and the DIO, of his/her intended actions. In making a determination of what disciplinary action to recommend, the Program Director should consider the totality of circumstances as then known, including but not limited to, the severity of the Resident’s behavior, potential for patient harm, prior attempts at behavior modification and the results of these attempts, and the Program Director’s experience and judgment on Resident knowledge, skill, and professionalism progression.
       • The Program Director will prepare a written notice of recommendation for Disciplinary Action utilizing the Graduate Medical Education (GME) Office’s standard notice template. The written notice of recommendation will be reviewed by the DIO and Office of General Counsel prior to being provided to the Resident. This notice must include:
         • A recommendation of the specific Disciplinary Action to be taken
         • A description of the Academic Deficiency(ies) and/or incident(s) of Misconduct that are the basis for the Disciplinary Action
         • The specific remedial action or improvement that is required, unless the Corrective Action is dismissal or non-renewal
         • A defined period of time with a start and end date for improvement (if applicable)
         • Notice of the right to appeal, along with a copy of the Appeal of Disciplinary Action Policy.
       • The Disciplinary Action notice of recommendation should be signed by the Program Director and delivered by the Program Director to the Resident in person, if possible. The Resident should be requested to co-sign the notice to acknowledge receipt. If hand delivery is not possible, the notice of recommendation will be delivered to the Resident’s residence by certified mail/return receipt requested or by national overnight courier service.
       • A copy of the signed Disciplinary Action notice of recommendation must be placed in the Resident’s file and forwarded to the GME Office and Employee Relations.
     • Pending Final Decision
       • The Program Director may remove the Resident from participation in the program pending expiration of the time frame to request appeal and final resolution of the appeal. In making a determination as to whether to remove the Resident from the program pending final resolution, the Program Director should take into account whether the Resident’s continued participation could endanger the health or wellbeing of patients, staff, or others. The Program Director should also consider the nature of the underlying concern giving rise to the Disciplinary Action (i.e., an allegation of serious misconduct tends to weigh in favor of removal from participation pending resolution). The Resident shall continue to be paid his or her stipend until there is a final decision on the Disciplinary Action and the appeal if invoked by the Resident) is final.
       • Residents may appeal a Disciplinary Action pursuant to the Appeal of Disciplinary Action Policy. No report of Disciplinary Action to any outside entity, including but not limited to any certifying body, professional association, or other training program, may be made until the appeal process has concluded or any appeal rights have expired (unless any such disclosure is authorized in writing by the Resident or disclosed pursuant to compulsory legal process, in which case the Office of General Counsel should be consulted prior to such disclosure). The foregoing shall not prevent the Program or GME Office from notifying necessary persons or entities that the Resident is on leave for purposes of ensuring appropriate patient coverage.
     • Finalization of Disciplinary Action:
       • The recommended Disciplinary Action will become final at such time as: the time frame for requesting an appeal expires and the Resident has not submitted a request for an appeal; the Resident withdraws an appeal; or the appeal process concludes and the hearing panel upholds or modifies the recommended Disciplinary Action, pursuant to the Appeal of Disciplinary Action Policy.
3. Other Administrative Actions
   • Administrative actions as set forth below are non-disciplinary in nature. Residents do not have the right to request review of administrative actions pursuant to the Appeal of Disciplinary Action Policy.
     • Automatic Resignation: The Resident may be considered to have automatically resigned under the following circumstances:
       • Failure to provide Visa or License Verification: Failure of the Resident to provide verification of eligibility to work legally in the United States or verification of current compliance with state licensing requirements of the New Hampshire Board of Medicine and/or DEA registration may result in the Resident’s automatic resignation from the GME training program.
       • Unapproved Absence: Residents must communicate directly with the Program Director in the event he or she is unable to participate in the training program for any period of time in excess of twenty-four (24) hours. Based on the Resident’s communication, the Program Director may grant a leave in times of exceptional circumstances and/or pursuant to D-H policy.
       • If a Resident is absent without leave for forty-eight (48) hours or more, he or she may be considered to have resigned voluntarily from the program unless he or she submits an acceptable written explanation of any absence taken without leave. This written explanation must be received by the Program Director within ten (10) days of the first day of absence without leave. The Program Director or his or her designee will review the explanation and any materials submitted by the Resident regarding the absence without leave in question. The Program Director or designee will notify the Resident in writing of his or her decision within ten (10) days of submission of the Resident’s written explanation. Failure of the Resident to submit a written explanation or failure to explain adequately or to document the unexcused absence to the satisfaction of the Program Director or his/her designee may result in the Resident’s automatic resignation from the GME training program.
   • The Program Director will consult with the DIO prior to deeming the Resident to have automatically resigned based on the circumstances set forth in this section. The Program Director will provide written notice to the Resident of the Resident’s automatic resignation.
   • The notice of deemed resignation should be delivered by the Program Director to the Resident in person, if possible. If hand delivery is not possible, the notice should be delivered to the Resident’s residence by certified mail/return receipt requested or by national overnight courier service.
   • Automatic resignation does not entitle the Resident to the appeal procedures set forth in the Appeal of Disciplinary Action policy.
   • Failure of the Resident to Pass the United States Medical Licensing Examination (“USMLE”) Step 3 or Comprehensive Osteopathic Medical Licensing Examination (“COMLEX”) Level 3 in accordance with the requirements and timeframe set forth in the Dartmouth-Hitchcock GME USMLE/COMLEX Policy, as may be amended by Dartmouth-Hitchcock from time to time. In this event, automatic resignation will be effective as of the conclusion of the academic year in which the timeframe for passing the licensing examination as set forth above expired.
4. Reporting to the New Hampshire Board of Medicine
   • Under New Hampshire law, certain actions involving physician discipline or adverse action must be reported to the Board of Medicine. In addition, behavior incompatible with the role of a physician including illegal, immoral or unethical behavior must also be reported to the Board of Medicine. Required reports shall be made by D-H following the conclusion of the appeal process, if invoked by the Resident, or following conclusion of the time period for the Resident to request an appeal (pursuant to the Appeal of Disciplinary Action Policy). The DIO is designated as the D-H representative who will make required reports in connection with GME matters to the New Hampshire Board of medicine. The DIO is encouraged to consult with the Office of General Counsel for guidance in making required reports.

D-H Policy ID: 11324