EVALUATION, CORRECTIVE ACTION, AND DISCIPLINARY POLICY FOR RESIDENTS

IV. Performance Deficiencies

Upon receipt of satisfactory evaluations and compliance with all other terms of the House Staff Policies and Procedures, each resident should expect to continue to the next level of training to program completion. If, however, a resident's performance is unsatisfactory, the Director shall notify the resident of that conclusion, both verbally and in writing, as soon as it is determined and initiate appropriate corrective and/or disciplinary action, as provided in Section IV.B., Written Warning with Remediation. In the ordinary course, corrective and/or disciplinary action should be imposed progressively, beginning with a written warning with plan for remediation and proceeding to probation and dismissal from the program if performance does not improve. In extraordinary cases, summary suspension may be appropriate. Prior to initiating any corrective and/or disciplinary action, the Director must consult with the Assistant Dean for Graduate Medical Education and the Administrative Director of NYU House Staff Affairs. In addition, the Director must inform all relevant Hospital Medical Directors of any corrective and/or disciplinary action initiated against the resident under this Section IV.

A. Summary Suspension. A resident may be summarily suspended from participation in the residency training program by the Director, the Department Chair, a Hospital Medical Director, or the Dean of the School of Medicine or his/her designee a) if the resident's actions or his/her continued participation in the program may constitute a threat to the welfare or safety of patients, employees, or other staff members or to the integrity of the program; or b) if his/her license or permit is suspended or revoked.

When a resident is summarily suspended from the program, the following procedures shall be followed:

1. The Director, in conjunction with the NYU Office of House Staff Affairs, shall provide the resident with written confirmation of his/her suspension. The notice shall specify the deficiencies that gave rise to the suspension, the term of the suspension, and any conditions that might be imposed for resuming participation in the residency program after the period of suspension. Copies of this notice shall be maintained in the Director's and the NYU Office of House Staff Affairs' files. Copies also shall be forwarded to all relevant Hospital Medical Directors. Credit for residency training shall not be given to a resident during a period of suspension.

2. The resident shall be advised in writing of the right to appeal the suspension as provided in Section V, Appeals.

3. At the end of the suspension period, the Director, in conjunction with the NYU Office of House Staff Affairs, shall notify the resident in writing as to what further action, if any, is to be taken. Copies of this notice shall be maintained in the Director's and the NYU Office of House Staff Affairs' files. Copies also shall be forwarded to all relevant Hospital Medical Directors. One of the following may occur:

a. Termination of suspension, with a statement provided to the resident stating that such suspension occurred and there is no present need for additional disciplinary action;

b. Termination of summary suspension and placement of the resident on probation as specified under Subsection C, Probation, of this section; or

c. Termination of the resident's participation in the residency program, in accordance with Section IV.A., Summary Suspension, and Section IV.D.2., Dismissal.

4. A decision to suspend requires reporting to the appropriate State agency, as discussed in Section VI, Reporting.

B. Written Warning with Remediation.

1. In the event that a resident's performance is unsatisfactory and summary suspension is not appropriate, the Director, after consultation with the NYU Office of House Staff Affairs, shall issue a written warning to the resident, which must include a detailed plan for remediation. Copies of the written warning with remediation and all subsequent administrative documentation relating to this disciplinary action shall be maintained in the Director's and the NYU Office of House Staff Affairs' files. Copies also shall be forwarded to all relevant Hospital Medical Directors. The written warning may include documentary evidence, such as letters of complaint, attendance logs, reports from the licensure board, and other relevant documents and materials. The plan for remediation must include directives for additional supervision and specific instructions with clear educational goals and performance expectations.

In determining the appropriate plan of remediation, the Director shall decide which action to take based on numerous factors, such as the nature and severity of the deficiency giving rise to the need for discipline, the potential impact on patient health or safety, the impact of the resident's conduct on the program or the facility, the likelihood that the deficiency can or shall be successfully remediated, and the degree of notice and opportunity to cure that the resident has previously received.

2. At the end of the remediation period, the following may occur:

a. Termination of remediation, with a statement provided to the resident stating that the conditions of remediation were satisfactorily resolved and there is no present need for further corrective action. Copies of such statement shall be maintained in the Director's and the NYU Office of House Staff Affairs' files and forwarded to all relevant Hospital Medical Directors;

b. Continuation of remediation, provided the resident has performed satisfactorily on a significant portion of his/her plan of remediation and the Director agrees to the assignment of an additional term of remediation. Continued remediation shall be approved for a specified period of time, with a redefinition of the problems and procedures to be followed in order to satisfy this additional term of remediation in accordance with this Section IV,B.1.; or

c. Imposition of a term of probation as specified under Subsection C, Probation, of this section.

C. Probation. Following a summary suspension or the unsuccessful completion of a plan of remediation, the Director or his/her designee shall place the resident on probation, provided the resident's continuation in the program does not constitute a serious threat to the welfare or safety of patients, employees, or other staff members or to the integrity of the program, as follows:

1. The Director or his/her designee shall meet with the resident and present a written notice, drafted in conjunction with the NYU Office of House Staff Affairs, stating a) the term of probation (ordinarily not to exceed 6 months); b) the reasons for probation (i.e., the resident's specific actions or deficiencies that led to the recommendation for probation); and c) the conditions of probation (i.e., what the resident shall be expected to do differently and the specific measures the department will take to provide the resident the opportunity to achieve these goals). Copies of the written notice and all subsequent administrative documentation relating to this disciplinary action shall be maintained in the Director's and the NYU Office of House Staff Affairs' files. Copies also shall be forwarded to all relevant Hospital Medical Directors. The written notice shall advise the resident of the right to appeal the decision of probation as provided in Section V, Appeals.

2. At the end of the probationary period, the following may occur:

a. Termination of probation, with a statement provided to the resident stating that the conditions of probation were satisfactorily resolved and there is no present need for further probation. Copies of such statement shall be maintained in the Director's and the NYU Office of House Staff Affairs' files and forwarded to all relevant Hospital Medical Directors;

b. Continuation of probation for an additional specified period of time with a written redefinition of the problems and procedures to be followed in order to satisfy this additional term of probation in accordance with this Section IV, C.1.; or

c. Termination of the resident's participation in the residency program in accordance with Section IV.D.2., Dismissal.

3. A decision to place a resident on probation may require reporting to the appropriate State agency, as discussed in Section VI, Reporting.

D. Consequences of Failure to Remediate.

1. Denial of Academic Credit. If a resident fails to make up work missed during a summary suspension; does not satisfactorily complete remedial work during a probationary period; misses a significant component of the academic program during leave from the program; or has otherwise failed to make sufficient academic progress, the Director may require the resident to repeat all or part of the academic year's work.

2. Dismissal.

a. The Director shall recommend the resident's dismissal from the program to the Department Chair or Dean or his/her designee, if the resident has:

i. Misrepresented credentials upon which s/he had been accepted into the program;

ii. Engaged in conduct that threatens the welfare or safety of patients, employees, or other staff members or the integrity of the residency training program, or if his/her license or limited permit is revoked or suspended;

iii. Failed to meet standards for academic, clinical, or professional conduct/performance, as set forth in Section II.E., Basis for Evaluations, after having received written warning with opportunity to remediate.

b. The process of dismissal shall be initiated by recommendation of the Director after consultation with the NYU Office of House Staff Affairs and notification to all relevant Hospital Medical Directors. The Department Chair shall make the final decision to dismiss in consultation with the Director and/or the Dean or his/her designee and shall record the recommendation and the reasons therefor in writing.

c. The resident shall receive a copy of the recommendation for dismissal and the reasons therefor. S/he also shall receive notice of his/her right to appeal, as provided in Section V, Appeals. Copies of the recommendation for dismissal and all subsequent administrative documentation relating to this disciplinary action shall be maintained in the Director's and the NYU Office of House Staff Affairs' files. Copies also shall be forwarded to all relevant Hospital Medical Directors.

d. If the resident does not request a hearing, the recommendation for dismissal shall be final and effective as of the date of receipt by the resident, and the decision to dismiss shall not be subject to further review, in accordance with Section V, Appeals.

e. If a resident is dismissed before the completion of his/her academic year, the Director shall determine the number of months' credit to be given the resident for that academic year.

f. A decision to dismiss requires reporting to the appropriate State agency, as discussed in Section VI, Reporting.

E. Notification. Any action taken by the Director under this Section IV must be in conjunction with the Assistant Dean for Graduate Medical Education and the Administrative Director of NYU House Staff Affairs and with notice to all relevant Hospital Medical Directors. It shall be the responsibility of the Assistant Dean for Graduate Medical Education to advise the Graduate Medical Education Committee of all such actions.