Academic Action & Misconduct FAQs

The Sponsoring Institution must have a policy that requires each of its ACGME accredited programs to determine the criteria for promotion and/or renewal of a resident’s/fellow’s appointment.

IV.C.1.a) The Sponsoring Institution must ensure that its programs provide a resident/fellow with a written notice of intent when that resident’s/fellow’s agreement will not be renewed, when that resident/fellow will not be promoted to the next level of training, or when that resident/fellow will be dismissed.

Written notice of suspension is required but may be delivered in a timely manner following verbal notification.

IV.C.1.b) The Sponsoring Institution must have a policy that provides residents/fellows with due process relating to the following actions regardless of when the action is taken during the appointment period: suspension, non-renewal, non-promotion; or dismissal.

• Academic due process requires notifying a resident of a deficiency and giving the resident an opportunity to cure this deficiency in conjunction with a reasoned decision-making process. 
• Due process for misconduct requires notification, an opportunity to be heard, a reasoned decision-making process, but no required opportunity to cure.

IV.D. Grievances: The Sponsoring Institution must have a policy that outlines the procedures for submitting and processing resident/fellow grievances at the program and institutional level and that minimizes conflicts of interest.

• Each program sets their own criteria for promotion & renewal 
  • The Sponsoring Institution must have a policy that requires each of its ACGME accredited programs to determine the criteria for promotion and/or renewal of a resident’s/fellow’s appointment. 
• Written notice of intent is required for non-renewal, non-promotion, and dismissal 
  • IV.C.1.a) The Sponsoring Institution must ensure that its programs provide a resident/fellow with a written notice of intent when that resident’s/fellow’s agreement will not be renewed, when that resident/fellow will not be promoted to the next level of training, or when that resident/fellow will be dismissed.
• Written notice of suspension is required but may be delivered in a timely manner following verbal notification. 
• Due process is required for suspension, non-renewal, non-promotion, and dismissal
  • IV.C.1.b) The Sponsoring Institution must have a policy that provides residents/fellows with due process relating to the following actions regardless of when the action is taken during the appointment period: suspension, non-renewal, non-promotion; or dismissal. 
  • What is due process? 
    • Academic due process requires notifying a resident of a deficiency and giving the resident an opportunity to cure this deficiency in conjunction with a reasoned decision-making process. 
    • Due process for misconduct requires notification, an opportunity to be heard, a reasoned decision-making process, but no required opportunity to cure.
• UB GME must have grievance policy that minimizes conflicts of interest
  • IV.D. Grievances: The Sponsoring Institution must have a policy that outlines the procedures for submitting and processing resident/fellow grievances at the program and institutional level and that minimizes conflicts of interest. 

Under the anticipated new grievance policy, and in accordance with the ACGME requirements stated above, suspension, non-renewal, non-promotion, and dismissal will be grievable. Some examples include:

• If a rotation must be repeated, and this extends a resident’s contract, this is considered non-promotion, and therefore is grievable.
• If a repeated rotation does not extend a resident’s contract, the action is not grievable.
• A Letter for Improvement that does not extend training is not grievable.

The policy does not prescribe a timeframe, but Program Directors are encouraged to set one for each situation to ensure quick completion of tasks while considering current resident and Program Director schedules. 

Program Directors and Clinical Competency Committees should identify anyone at risk for non-promotion and send written notification as soon as the risk is identified. The ACGME formerly required non-promotion to be communicated to residents/fellows four months prior to the end of the current contract, but has now eliminated this timeframe from the Institutional Requirements. Please be aware that in cases of contract extension, visa renewals or a change in visa status frequently requires two or more months processing time. 

The institution is responsible for oversight of the actions of its residency and fellowship programs. Consultation ensures the actions are consistent with policy and enables the program to learn from past experiences of others in similar situations. Consultation for a first-time Letter for Improvement may consist of a phone conversation and a review of proposed written communication with residents/fellows. Consultation for more serious actions that extend training (i.e. a grievable matter) may also include a review of the resident/fellow file, evaluations, and CCC meeting minutes. GME staff may schedule meetings on-site to expedite the process. 

The DIO and GME staff will collaborate to ensure timely consultation. A typical consultation can be completed within a week. More complicated matters may require legal or other expert consultation, which can result in a longer review time. 

Please send an email to both Dr. Gregory Cherr and Dr. Susan Orrange.  Include a draft of your proposed communication to the resident/fellow. 

Yes. If reasonable efforts were made as described in the policy, the action is in effect.

Established: 2014
GMEC Approved Date: June 19, 2018