Resident Grievance Procedure for Appeal of a Corrective Action

POLICY #: 8240.23


To provide due process to residents in the Graduate Medical Education program by establishing uniform procedures for the appeal of a Corrective Action issued pursuant to the Resident Academic Improvement and Corrective Action policy (No. 8240.32).


If a resident wants to appeal a Corrective Action issued by a Program Director:

1. The resident must give written notice of intent to appeal to the Program Director within 14 days of receiving the Corrective Action. The notice of intent to appeal provided by the resident must include a summary statement of the grounds upon which the appeal will be based, but it is not required that the notice of appeal set forth all details or supporting facts that the resident intends to present in the appeal.

2. Within 14 days of the resident’s delivery of a notice of intent to appeal, the Program Director will provide the resident with copies of any documents in the possession of the Program that are relevant to the Corrective Action that was imposed. Documents may be redacted by the Program Director if necessary to preserve the privacy of patients or coworkers, so long as doing so does not significantly interfere with the resident’s right to know the specific issues that resulted in the Corrective Action and the facts upon which the Program Director based the issues. Documents may not be redacted solely to prevent the resident from knowing the identity of those who have relevant facts. If the existing documents are not sufficient to fairly apprise the resident of the issues against him or her, and the facts supporting those issues, the Program Director will create a document speaking to those issues to ensure the resident is fully apprised. If it is not otherwise apparent from the documents being provided to the resident, the Program Director will also disclose to the resident the identity of any fact witnesses who have been interviewed and a summary of the interview.

3. Within 30 days of the resident’s delivery of a notice of intent to appeal to the Program Director, the Clinical Competency Committee (CCC) or the Educational Advisory Committee (EAC) will hold a hearing on the resident’s appeal. This 30-day deadline can be extended by agreement of the parties, or due to the unavailability of crucial persons, or as needed to provide the resident a full and fair opportunity to prepare for the hearing. At the hearing, the resident will be provided with a full opportunity to present a defense, including presentation of documents and presentation of witnesses.If any additional evidence, beyond what has been provided to the resident in advance of the hearing, is presented to the CCC or EAC, the resident shall be provided with copies contemporaneously and, if evidence is presented in the form of witness accounts, the resident shall be present while the witnesses speak to the CCC or EAC and shall have the right to ask questions of the witnesses. The hearing shall be of a length that provides the resident a fair opportunity to present his or her defense and the resident’s ability to present supporting witness testimony shall not be limited in a manner that deprives the resident of a fair opportunity to present relevant evidence. Attorneys or other advocates/representatives will not be permitted at appeal hearings, except in the case of an appeal of dismissal from the Program, in which event each party may have one person present at the hearing to act as a representative/advocate.

4. After the hearing has concluded, the resident and the Program Director will be excused and the CCC or EAC will deliberate regarding its decision. The decision of the CCC or EAC will be by majority vote. The CCC or EAC will prepare a document setting forth its decision and the basis for the decision in reasonable detail, with reference to key specific facts and issues. The CCC or EAC may decide to reject the appeal in its entirety, in which case the Corrective Action stands. The CCC or EAC may decide to accept the appeal and invalidate the Corrective Action entirely. The CCC or EAC may decide to partially reject and partially accept the appeal, in which case the EAC will modify the Corrective Action accordingly and the modified corrective action will replace the original Corrective Action.

5. The CCC or EAC will deliver a letter outlining its decision to the resident and the Program Director within 14 days of the appeal hearing. Should either the resident or Program Director disagree with the decision of the CCC or EAC, either may request in writing within 10 days that a specially convened Decision Appeal Panel review the CCC or EAC decision. This request should be delivered to the Vice President of Medical Affairs.

6. The Decision Appeal Panel will consist of

A) the Vice President of Medical Affairs (as Chair),

B) one of the Cottage Health medical staff officers (who cannot be a member of the Department of the Program involved),

C) the Designated Institutional Officer (DIO) (unless the DIO is Program Director or faculty of the Department of the Program involved) and

D) a final year resident, from one of the other two programs, chosen by the Vice President of Medical Affairs and acceptable to both the involved resident and involved Program Director.

A representative of the Employee Relations Department will participate in the meeting(s) and serve as an Advisor to the Decision Appeal Panel.

7. The Decision Panel will be convened within fourteen (14) days of receipt by the Vice President of Medical Affairs of a letter requesting its review. The Decision Appeal Panel will consider input from at least the involved resident, the involved Program Director, and the Chair of the involved CCC or EAC. The Decision Appeal Panel may also consider at its discretion input from any individuals suggested by any of these three parties. The Decision Appeal Panel will normally not receive any new evidence or facts that were not presented at the appeal hearing, except in exceptional circumstances in which the Decision Appeal Panel finds there was a good reason why this evidence or fact was not presented at the earlier stage. If the Decision Appeal Committee accepts new evidence (including new interviews of witnesses), the new evidence will be shared with the party adversely affected and that party shall have the right to present new evidence as necessary in rebuttal. If the new evidence is especially significant, the Decision Appeal Panel may request that the CCC or EAC convene a new appeal hearing to receive and consider the new evidence.

8. The Decision Appeal Panel will render a decision that is final and is consistent with any of the options previously described as available to the CCC or EAC. The decision of the Decision Appeal Panel will be in writing and will set forth its reasons. The decision of the Decision Appeal Panel is final and not eligible for appeal.


RECOMMENDED BY: Diana Lovan, Health & Safety Director DATE: 12/14
APPROVED BY: E Wroblewski, MD DATE: 9/17, 11/18, 1/21
DATE REVISED: 3/01, 5/07, 10/08 , 7/14, 9/17, 11/18
DATE REVIEWED: 12/93, 3/97, 3/99, 9/02, 4/03, 10/08, 1/12, 12/14, 1/21