Academic Action and Misconduct Due Process Policy

1. This Policy permits residents/fellows to grieve/request a review (Review) of the following Actions taken at any time during the residents’/fellows’ training:

2. All parties to a Review are expected to demonstrate appropriate, responsible and professional conduct during the Review proceedings.

3. Review proceedings are academic proceedings. Attorneys may advise a party to a Review but may not be present during any meetings or hearings conducted under this Policy.

4. Review proceedings may not be recorded.

5. The Designated Institutional Official (DIO) for GME, or their designee, has discretionary authority to extend any timeframe outlined in this Policy.

6. Written statements issued under this Policy will be maintained in the resident’s/fellow’s GME file.

Upon written notification of an Action, residents/fellows may request a Review of the Action in accordance with the process outlined below.

Requesting a Physician Review:

General Requirement. A resident/fellow may request a physician review (Physician Review) of an Action by emailing the DIO and the Program Director no later than fourteen (14) calendar days after the Program Director provides the resident/fellow with written notification of the Action.  

Content Requirement.  The request for a Physician Review must reference the challenged Action and summarize the resident’s/fellow’s reason(s) for requesting the Physician Review. The resident/fellow may not submit any information that would violate federal or state patient privacy protection laws. 

Appointment of Physician Reviewer.  The DIO or designee will appoint a Program Director or faculty member from a UB residency or fellowship training program who has not previously supervised the resident/fellow to serve as the Physician Reviewer. The DIO or designee will make this appointment within fourteen (14) calendar days of receiving the resident’s/fellow’s request for a Physician Review. 

Physician Review Process:

Role of the Physician Reviewer.  The Physician Reviewer is charged with determining whether there was a reasonable basis for the Action taken by the Program Director.

In making this determination, the Physician Reviewer will:

• Examine the resident’s/fellow’s request for a Physician Review
• Meet individually with the resident/fellow
• Meet individually with the resident’s/fellow’s Program Director
• Determine, in their sole discretion, whether to conduct a joint meeting with the resident/fellow and program Director
• Request documentation, as necessary, from the resident/fellow and/or the Program Director; and
• Consult with others, as appropriate, to obtain any additional information that would aid the Physician Reviewer in rendering a determination.

Determination.  After conducting meetings, reviewing any requested documentation and consulting with others, the Physician Reviewer will prepare a written statement of their findings and the basis for such findings. This written statement will be presented to the DIO for review and approval no later than fourteen (14) calendar days after the Physician Reviewer’s appointment. Within three (3) business days of receipt of the final written statement, the DIO or designee will provide copies of the final written statement to the resident/fellow and the Program Director.

Requesting a Panel Review:

General Requirement.  If either party disagrees with the findings of the Physician Reviewer, the party may request a panel review (Panel Review) by emailing the DIO and the Program Director no later than ten (10) calendar days after distribution of the Physician Reviewer’s written statement to the parties by the DIO or designee. The requesting party must copy the other party on this email. 

Content Requirement.  A request for a Panel Review must include a concise statement of the facts upon which the Review is being sought. The requesting party may not submit any information that would violate federal or state patient privacy protection laws. 

Timeline.  A request for a Panel Review must be received by the Senior  

Waiver of Review. If neither party timely requests a Panel Review, the determination of the Physician Reviewer constitutes a final and binding decision.

Appointment of Panel.  The DIO or designee will appoint a panel (Panel) consisting of three (3) members: a Program Director from another UB residency or fellowship training program, a faculty member who has not previously supervised the resident/fellow, and a resident/fellow who has not previously worked with either party. Either the Program Director or the faculty member will be appointed by the DIO or designee to chair the Panel. The DIO or designee will appoint the Panel and select a chair within fourteen (14) calendar days of receiving the request for a Panel Review. 

Panel Review Process:

Role of the Panel.  The Panel is charged with determining whether there was a reasonable basis for the Action taken by the Program Director.

In making its determination, the Panel will:

• Examine the request for a Panel Review
• Review the Physician Reviewer’s written statement
• Meet jointly with the resident/fellow and Program Director to hear statements and pose questions
• Meet individually with the resident/fellow and/or Program Director to pose additional questions or seek clarification, if necessary
• Request documentation, as necessary, from the resident/fellow and/or the Program Director
• Consult with others, as appropriate, to obtain any additional information that would aid the Panel in rendering a determination; and
• Meet privately to render at determiniation
  

Supportive Attendees: Each party may bring one person (Supportive Attendee) with them to any meeting with the Panel. Supportive Attendees are prohibited from speaking on behalf of, or advocating for, a party, unless requested by the Panel. Supportive Attendees may not be attorneys. 

Determination.  After conducting meetings and reviewing any requested documentation, the chair of the Panel will prepare a written statement of the Panel’s findings and the basis for such findings. This written statement will be presented to the DIO or designee for review and approval no later than twenty-one (21) calendar days after the Panel’s appointment. Within three (3) business days of receipt of the final written statement from the chair of the Panel, the DIO or designee will provide copies of the final written statement to the resident/fellow and the Program Director.

Panel decisions are determined by a majority of members of the Panel.

The determination of the Panel constitutes a final and binding decision. 

ACGME Institutional Requirements Effective 7/1/2022:

• 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. (Core) (IV.D.1.b))
• 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. (Core) (IV.E.)

Established:  2014
Reviewed by GMEC: 10/14; 1/17; 5/17; 6/18; 6/22