BERSHIRE MEDICAL CENTER
INTERNSHIP/RESIDENCY PROGRAMS
PERSONNEL POLICIES
I. ADMINISTRATION
A. Purpose
The purpose of these Personnel Policies is to provide a common basis for the fair and equitable
treatment of Interns/Residents within BMC’s graduate medical education programs.
It is the policy of Berkshire Medical Center to provide Equal Employment Opportunities to all
qualified applicants and employees regardless of race, color, religion, sex, handicap, age,
national origin, veteran status or sexual orientation. We will also seek to affirmatively advance
the principles of Equal Employment Opportunity in all occupational categories.
Upon hire, Berkshire Health Systems will investigate all pertinent information in order to determine
the requisite qualifications for employment. Any falsification, misrepresentation or omission of facts
called for in this application may result in denial of employment or immediate dismissal.
All internship and residency offers are conditional on submission of satisfactory proof of legal eligibility to
work in the United States, and on satisfactory results of a background check, references, drug testing and
physical examination given by medical personnel at Berkshire Health Systems.
If employed by Berkshire Health Systems, interns and residents must agree to comply with all Berkshire
Health Systems rules and regulations as they may be changed from time to time.
B. Definitions
1. Department Chairperson: The head of a department who is responsible for the administration
of the department.
2. Hospital Service Director: A physician or dentist in charge of a patient care entity within any
hospital or clinic, who is usually designated as a hospital chief of service.
3. Berkshire Health Systems includes Berkshire Medical Center and any medical or health
delivery clinic, center or service established by Berkshire Health Systems or Berkshire Medical
Center.
4. Internship/Residency Program: An organized graduate medical education training effort
within a clinical department or service designed to prepare physicians for the practice of a
specialty, and to enhance dental skills and are accredited by the Accreditation Council on
Graduate Medical Education, the American Osteopathic Association or the Education Council of
the American Dental Association. Intramural programs are conducted primarily by one
institution; integrated programs involve more than one institution.
5. Internship/Residency Program Director: The Department Chairperson or a faculty member in
a Hospital Department who has specified supervisory and managerial responsibilities and
authorities for internship/residency program resources and activities.
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6. Interns/Residents: Physicians and dentists who are licensed to practice in Massachusetts, and
who are appointed to an accredited or recognized internship/residency/fellowship program.
7. Associate Dean/Designated Institutional Official: The individual chosen by BMC and an
affiliated medical school, when appropriate, who has administrative responsibility for all
medical education programs within the institution.
C. Applicability
These Internship/Residency Program Personnel Policies shall apply to those physicians and
dentists who have been appointed to a BMC graduate medical education position either in a
BMC intramural program or in an integrated program. For those serving in an integrated
program who are payrolled by BMC, the compensation policies and programs of BMC, as
described herein, shall apply, rather than those of the integrated institutions.
D. Governance
The Berkshire Medical Center Board of Trustees has all the authorities, responsibilities, rights,
privileges, powers, and duties of organization and government. The Chief Operating Officer
(COO) is the executive officer.
The Department Chairperson has ultimate responsibility for the internship/residency program
although there may also be a designated Internship/Residency Program Director. The chief of
the hospital service (the Hospital Service Director) to which the Intern/Resident is assigned on
rotation is responsible for the direct, on-site supervision of the Intern/Resident. BMC
Interns/Residents are subject to the rules, regulations, bylaws, accountabilities, and standards of
conduct as applicable to all professional employees, to all members of the medical staff, and to
all members of the medical profession; except as otherwise specified in these Personnel Policies.
In addition, Interns/Residents shall also abide by the policies, standards, rules, regulations,
requirements, and procedures of any hospital to which they are assigned regarding patient care
and professional conduct and as applicable to all other hospital professional staff members.
Where hospital policies and these Personnel Policies might conflict, the matter shall be referred
to the Department Chairperson and Hospital Service Director.
To facilitate their participation in hospital decision-making and policy-making processes,
Interns/Residents will be appointed to appropriate governing and advisory medical staff, faculty,
and hospital committees, on the recommendation of the Department Chairperson and/or the
appropriate Hospital Service Director.
E. Administration:
Each department is responsible for the implementation of these Personnel Policies and shall
maintain a departmental personnel file for each Intern/Resident. The departmental personnel
files shall be confidential, yet accessible to the Intern/Resident, as regulated by the
Massachusetts Fair Information Practices Act (MFIPA) and regulations promulgated there-under.
Information concerning the Intern/Resident as an applicant, such as the Intern Registration
Program, National Resident Matching Program rank order and undergraduate evaluations, shall
not be filed in the Intern’s/Resident’s departmental personnel file, but shall be governed by
MFIPA. In addition, each hospital to which an Intern/Resident is assigned may require the
submission and filing of medical staff and administration documents and records.
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The Office of Medical Education (OME) was established in part: (1) To represent the interests
of the Intern/Resident and the internship/residency programs; (2) To assist internship/residency
programs and Interns/Residents in administrative matters; (3) To facilitate the coordination of
intramural and extramural efforts; and (4) To develop sound program planning and budgeting
processes. Accordingly, OME shall assist the departments in the administration of these
Personnel Policies.
After completion of the training program, residents are in no way discouraged from beginning
their practice within the catchment area served by Berkshire Medical Center, or within any area
served by Berkshire Health Systems. Additionally, in certain situations where a particular need
is evidenced, residents may be encouraged, or even recruited to begin practice in the area or at
the institution.
Berkshire Medical Center has no current plans to close or downsize any portion of its Graduate
Medical Education programs. In the unlikely event of such an occurrence in the future, we are
committed to assist any affected house officers in finding alternate sites to complete their
training.
F. Appointment
Graduates of approved U.S. and international medical, osteopathic and dental schools are
appointed to internship/residency programs through the National Resident Matching Program,
the Internship Registration Program, or when allowed, by direct application. Before a personnel
contract with the Intern/Resident can be processed, the applicant must submit a properly
completed, verified, and signed Massachusetts Limited Registration (license) application,
malpractice insurance application, completed payroll and benefits forms, and completed physical
examination forms. Each appointment is limited to one year (twelve months), may be less than
one year, and is not finalized until a Massachusetts Registration number is issued, and physical
health requirements are met.
G. Policies Review
These Personnel Policies shall be reviewed by the office of the Associate Dean/Designated
Institutional Official and an appropriate committee at least annually to determine the continued
relevance, value, and feasibility of each section and to develop, as necessary, recommendations
for deletions, additions, or modifications. These Personnel Policies may be amended at any time,
as necessary, upon recommendation of the COO, Chief of Staff, a Department Chairperson, a
Hospital Service Director, or an appropriate review committee. Proposed amendments shall be
made available to Interns/Residents for review and comment. As with the original Personnel
Policies, inclusion of amendments shall require consultation with the Department Chairpersons
(or Internship/Residency Program Directors) and the approval of the appropriate institutional
committees, including the Executive Faculty Committee acting as BMC’s GMEC.
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H. Sexual Harassment
Berkshire Medical Center is committed to providing a work environment that fosters mutual respect
among our staff. Sexual harassment and harassment in general, by or toward employees is prohibited and
will not be tolerated. This topic is developed in more detail at the time of initial orientation and is
described in written form in the BMC policy #106 entitled “Harassment”.
II. ACGME CORE COMPETENCIES
A. The residency programs must require that its residents obtain a competence in the six areas listed
below to the level expected of a new practitioner. Programs must define the specific knowledge, skills,
behaviors, and attitudes required and provide educational experiences as needed in order for their
residents to demonstrate the following:
1. Patient care that is compassionate, appropriate, and effective for the treatment of health problems and
the promotion of health.
2. Medical knowledge about established and evolving biomedical, clinical, and cognate (e.g.,
epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.
3. Practice-based learning and improvement that evolves investigation and evaluation of their own patient
care, appraisal and assimilation of scientific evidence, and improvements in patient care.
4. Interpersonal and communication skills that result in effective information exchange and collaboration
with patients, their families, and other health professionals.
5. Professionalism, as manifested through a commitment to carrying out professional responsibilities,
adherence to ethical principles, and sensitivity to a diverse patient population.
6. Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness
to the larger context and system of health care and the ability to effectively call on system resources to
provide care that is of optimal value.
B. Scholarly Activities
1. The responsibility for establishing and maintaining an environment of inquiry and scholarship will rest
with the faculty, and an active research component will be included within each program, so that faculty
and residents participate actively in scholarly activity. Scholarship is defined as one of the following:
a. The scholarship of discovery, as evidenced by peer-reviewed funding or publication of original
research in peer-reviewed journals.
b. The scholarship of dissemination, as evidenced by review articles or chapters in textbooks.
c. The scholarship of application, as evidenced by the publication or presentation at local, regional, or
national professional and scientific society meetings, for example, case reports or clinical series.
d. Active participation in clinical discussions, rounds, journal club, and research conferences in a manner
that promotes a spirit of inquiry and scholarship; offering of guidance and technical support, e.g., research
design, statistical analysis, for residents involved in research; and provision of support for resident
participation as appropriate in scholarly activities.
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2. Adequate resources for scholarly activities for faculty and resident will be available, eg, sufficient
laboratory space, equipment, computer services for data analysis, and statistical consultation services.
3. There will be regular resident interaction with clearly identified faculty members.
a. who participate in research conferences that emphasize the presentation of original research;
b. who participate in research or scholarly activity that leads to publication or presentations at regional
and national scientific meetings;
c. who offer guidance and technical support such as research design and statistical analysis to residents
involved in research or scholarly activity.
III. RESIDENT DUTY HOURS AND THE WORK ENVIRONMENT
Providing residents with a sound academic and clinical education will be carefully planned and balanced
with concerns for patient safety and resident well-being. Each program must ensure that the learning
objectives of the program are not compromised by excessive reliance on residents to fulfill service
obligations. Didactic and clinical education must have priority in the allotment of residents' time and
energies. Duty hour assignments must recognize that faculty and residents collectively have responsibility
for the safety and welfare of patients.
1. Supervision of Residents
a. All patient care will be supervised by qualified faculty. The program directors will ensure, direct, and
document adequate supervision of residents at all times. Residents will be provided with rapid, reliable
systems for communicating with supervising faculty.
b. Faculty schedules will be structured to provide residents with continuous supervision and consultation.
c. Faculty and residents will be educated to recognize the signs of fatigue and adopt and apply policies to
prevent and counteract the potential negative effects.
2. Duty Hours
a. Duty hours are defined as all clinical and academic activities related to the residency program, ie,
patient care (both inpatient and outpatient), administrative duties related to patient care, the provision for
transfer of patient care, time spent in-house during call activities, and scheduled academic activities such
as conferences. Duty hours do not include reading and preparation time spent away from the duty site.
b. Duty hours will be limited to 80 hours per week, averaged over a four-week period, inclusive of all inhouse call activities. BMC’s Executive Faculty Council may grant exceptions for up to 10 % of the 80hour limit, to individual programs based on a sound educational rationale.
c. Residents will be provided with 1 day in 7 free from all educational and clinical responsibilities,
averaged over a 4-week period, inclusive of call. One day is defined as one continuous 24-hour period
free from all clinical, educational, and administrative activities.
d. Adequate time for rest and personal activities will be provided consisting of a 10 hour time period
provided between all daily duty periods and after in-house call.
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3. On-Call Activities
The objective of on-call activities is to provide residents with continuity of patient care experiences
throughout a 24-hour period. In-house call is defined as those duty hours beyond the normal work day
when residents are required to be immediately available in the assigned institution.
a. In-house call must occur no more frequently than every third night, averaged over a four-week period.
b. Continuous on-site duty, including in-house call, must not exceed 24 consecutive hours. Residents may
remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients,
conduct outpatient clinics, and maintain continuity of medical and surgical care as defined in Specialty
and Subspecialty Program Requirements.
c. No new patients, as defined in Specialty and Subspecialty Program Requirements, may be accepted
after 24 hours of continuous duty.
d. At-home call (pager call) is defined as call taken from outside the assigned institution.
1. The frequency of at-home call is not subject to the every third night limitation. However, at-home call
must not be so frequent as to preclude rest and reasonable personal time for each resident. Residents
taking at-home call will be provided with 1 day in 7 completely free from all educational and clinical
responsibilities, averaged over a 4-week period.
2. When residents are called into the hospital from home, the hours residents spend in-house are counted
toward the 80-hour limit.
3. The program director and the faculty will monitor the demands of at-home call in their programs and
make scheduling adjustments as necessary to mitigate excessive service demands and/or fatigue.
5. Oversight
a. Each program will have written policies and procedures consistent with the Institutional and Program
Requirements for resident duty hours and the working environment. These policies must be distributed to
the residents and the faculty. Monitoring of duty hours is required with frequency sufficient to ensure an
appropriate balance between education and service.
b. Back-up support systems will be provided when patient care responsibilities are unusually difficult or
prolonged, or if unexpected circumstances create resident fatigue sufficient to jeopardize patient care.
IV. COMPENSATION
A. Stipends
Each Intern/Resident shall be paid an annual stipend in accordance with the terms of the
Internship/Residency Program Agreement and of the Professional Staff Appointment or Reappointment
Contract, and in accordance with the stipend schedule in effect as of July 1 of each year for which the
Intern/Resident is appointed. The internship/residency program stipend schedule shall be reviewed each
year by the administration to consider possible adjustments to be effective on July 1.
B. Excused Days With Pay
Each full-time Intern/Resident shall be entitled to vacation days at the rate of 20 days per year (the
equivalent of four five-day work weeks). These vacation days shall be credited to each Intern/Resident on
the first day of the Intern’s/Resident’s appointment or reappointments and vacation days credited to each
Intern/Resident shall not be carried over into any subsequent year of internship/residency training except
in unusual circumstances and are not usually reimbursable. However, vacation days unused during the
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Intern’s/Resident’s terminal year shall be reimbursed upon the Intern’s/Resident’s termination on a prorated basis.
It is expected that during the year each Intern/Resident will in fact take all 20 credited vacation days.
Interns/Residents must receive prior approval from the Department Chairperson or designee and, as
appropriate, the Hospital Service Director before taking vacation days.
Vacation shall be scheduled so that the needs of the hospital and clinic services to which the
Intern/Resident is assigned are considered.
Interns/Residents shall earn sick leave at the rate of 1.25 days per month, or 15 days per year, which is
awarded on the first day of the Intern’s/Resident’s appointment and which shall be accrued with no limit.
Sick leave is for use only when personally ill, and unused sick days are not reimbursable.
It is expected that no Intern/Resident will be on call or on duty on religious holidays on a disproportionate
basis compared to all other Interns/Residents in the same internship/residency program, at the same PG
level, at the same hospital.
D. Leave of Absence
Interns/Residents may be granted a leave of absence without pay by the Department Chairperson or
designee, at the Chairperson’s discretion, based on reasons such as prolonged illness, temporary
disability, or extreme family or personal need. Maternity and paternity leave benefits shall be granted in
accordance with federal and Massachusetts General Laws and BMC policies. In the even that any Leave
of Absence will require additional educational time commitment to satisfy a given residency curriculum
requirement, the extension will be decided by the appropriate Chairperson.
E. Moonlighting
Outside employment, commonly known as “moonlighting” is allowed by fully licensed house officers.
Medical malpractice insurance covers moonlighting in conjunction with residency training and rotations
at affiliated and integrated institutions but strongly suggests no outside activities that would place a house
officer at greater risk than formal training itself entails.
Anyone holding LIMITED REGISTRATION from the Commonwealth of Massachusetts holds “authority
to practice only at Berkshire Medical Center and Affiliates.” For those holding full licensure, each
Residency Review Committee stipulates its own regulation outside activities and therefore, each
individual request for “moonlighting should receive the written consent of the appropriate Program
Director who has the obligation to counsel and advise whether the activity may be detrimental to the
individual’s educational experience or to the program as a whole. The decision should include: 1) the
ability of the individual to fulfill primary responsibilities while accepting other responsibilities; 2) the
educational and service value and the nature and content of moonlighting activity; 3) the health care needs
of the community being served; 4) any limitations or control set by accreditation requirements; 5)
implications for professional liability coverage.
a. The program director will comply with BMC's written policies and procedures regarding
moonlighting, in compliance with the Institutional Requirements III. D.1.k.
b. Moonlighting that occurs within the residency program and/or BMC or the primary clinical site(s), ie,
internal moonlighting, will be counted toward the 80-hour weekly limit on duty hours. In no instance
may outside employment require physical presence or personal attention during regularly scheduled
assigned duty hours at BMC.
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F. Health Insurance (MEDFLEX)
Medflex, Berkshire Medical center’s flexible benefit program includes Health Insurance Options, Dental
Insurance Options, Basic Life Insurance, Supplemental Life Insurance, Long and/or Short Term Disability
Insurance, Health Care and Dependent Care Spending Accounts on a pre-tax basis, and spouse and child
term life insurance on an after-tax basis. The Flexible benefit program includes dollars provided by BMC
to be applied toward the purchase of benefits on a pre-tax basis, or a lesser sum to be taken as taxable cash
if your spouse provides health insurance for you from another source. The dollars, if utilized for health
insurance, include 90% of the cost of individual coverage or 75% of family coverage based on the
Network Blue New England plan. Benefit dollars are provided to partially cover dental insurance
premiums, and to fully cover the cost of long-term disability (50% option) insurance. Each
Intern/Resident must enroll in the Medflex program at time of initial entry into the internship/residency
program at BMC and again each year during the Medical Centers’ open enrollment period.
Basic Life Insurance - Term life insurance is provided, paid in full by BMC for 1 times the annual
stipend, effective upon date of hire.
G. Personal Liability Insurance
Each Intern/Resident, upon proper application, may be covered by a personal liability (malpractice) policy
purchased by BMC. Interns/Residents at the PGY-1 level are covered by an institutional policy and all
other Interns Residents are covered by an individual policy. Interns/Residents shall be informed of the
type and limits of the insurance and of any restrictions thereof.
III. EVALUATION
A. Standards
Each Department Chairperson shall provide written internship/residency program standards which shall
specify program goals and objectives. The standards shall also specify the levels of knowledge and
technical skills against which each Intern/Resident will be evaluated. Such standards should recognize the
requirements for internship/residency programs accreditation plus the requirements for specialty board
certification.
The standards shall be approved and be filed with the office of the Associate Dean/Designated
Institutional Official. A copy of the approved standards shall be provided to each Intern/Resident, along
with a description of BMC and individual internship/residency program evaluation procedures. The
standards shall be reviewed and updated, as necessary, at least bi-annually.
B. Evaluation
Outcome Assessment
a. Programs will use resident performance and outcome assessment in evaluation of educational
effectiveness.
1. the effectiveness of inpatient and ambulatory teaching
b. Programs will have in place processes for using resident and performance assessment results together
with other program evaluation results to improve the entire residency program.
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Each Intern/Resident shall receive from the Department Chairperson or designee a formal, written
evaluation at least every six months which shall include a review of knowledge, skill, personal growth
and development, and attitude. The evaluations shall be filed in the Intern’s/Resident’s departmental
personnel files and shall be discussed with the Intern/Resident. Further, each internship/residency
program is encouraged to conduct and to record more frequent evaluations. An Intern/Resident may
dispute a written evaluation report by submitting a written response, which shall be filed with the
evaluation report.
C. Corrective/Disciplinary Action
It is the responsibility of the Department Chairperson or designee to take informal or formal
corrective/disciplinary actions when an Intern’s/Resident’s performance is below the level of performance
set by the program’s written standards or other applicable standards, such as professional ethics or
hospital policies.
BMC first encourages internship/residency programs to provide internal policies and procedures for
responding informally to minor and initial incidents of poor performance or misconduct, and to notify
Interns/Residents of these policies. Formal corrective or disciplinary actions may be requested by the
chief of any service to which the Intern/Resident is assigned.
One of two stages of formal corrective/disciplinary procedures shall be considered when internal,
informal procedures are unsuccessful. The specific stage to be implemented shall be determined by such
factors as severity and frequency of offense, documented history of prior informal or formal
corrective/disciplinary actions, and the Intern’s/Resident’s overall performance and conduct. Stage One
may be applied repeatedly without necessarily going to Stage Two, and Stage Two may be applied
without first applying Stage One.
In Stage One, Written Warning, the Department Chairperson of designee shall notify the Intern/Resident
in writing of the Intern’s/Resident’s specific unacceptable conduct or performance, of the required method
and timetable for correction, and of the possible consequences of noncompliance with the required
correction. The written notification shall also inform the Intern/Resident of the Intern’s/Resident’s right
to appeal.
In Stage Two, Written Order, the Department Chairperson or designee shall prescribe in writing to the
Intern/Resident a specific action, including but not limited to additional work assignments, limitation of
responsibilities, temporary suspension, non-reappointment, or dismissal from the internship/residency
program. The Chairperson’s letter shall include, as a minimum, the reasons for the order, the effective
date, the possible consequences of noncompliance, and the Intern’s/Resident’s right to appeal. Standard
practice is to provide a minimum of six months’ notice of non-reappointment unless there is a reasonable
basis for a less-than-six-month notice.
D. Advancement and Certification
For appointment to the next higher PG level within a program, each Intern/Resident must complete a new
internship/residency program letter of agreement followed by a formal contract, license application (if
applicable), and malpractice insurance application. Candidates for advancement and completion-ofprogram certificate must satisfactorily complete predetermined programmatic, administrative, patient
care, and educational requirements to include evidence of progressive scholarship and professional
growth of the trainee.
The Department Chairperson or designee shall notify Interns/Residents, in writing, if they will not be
advanced to the next higher PG level or if they will not receive a certificate of completion at least six
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months prior to the expected date of completion or advancement. Except as provided below,
Interns/Residents have the right to appeal the Chairperson’s notification through the first two steps in the
appeals process. In addition, the Department Chairperson and an Intern/Resident may agree, and confirm
in writing, to postpone a notification concerning advancement or certification until four months prior to
the expected date of completion or advancement. If the Chairperson’s notification is given either less
than six months or, if there has been an agreement to postpone notification as above, less than four
months prior to the expected date, then the Intern/Resident has the right to appeal through all four steps in
the appeals process.
A Department Chairperson may require an Intern/Resident to compensate for excused days or a leave of
absence which in total exceeded twenty days (the equivalent of four five-day work weeks) per training
year (fifteen or less days for some programs as required by training year (fifteen or less days for some
programs as required by the ACGME) by extending his or her current PG level year by the number of
excused or leave days in excess of twenty. This extension would be applicable only when
internship/residency training program requirements have not been met by the Intern/Resident during the
year and only when all other means for meeting the program requirements have been exhausted. The
Intern/Resident may, at the discretion of the Chairperson, receive a stipend subject to available funding at
the existing rate for the PG year being completed. The Intern/Resident has the right to appeal the required
extension through Step One and Step Two only of the appeals process.
E. Appeals (See Chart Page 14)
Without necessarily implementing a formal appeals process, the Intern/Resident has the right to respond
in writing to a Stage One or Stage Two action. The Intern’s/Resident’s response shall be filed with the
Department Chairperson’s relevant correspondence to the Intern/Resident.
Step One: To initiate a formal appeal to a Stage One or Stage Two action, the Intern/Resident shall
request the Department Chairperson or designee to modify or withdraw the written warning or the written
order. The request shall be submitted in writing within five working days of the Intern’s/Resident’s
receipt of the corrective/disciplinary action written notice. A conference between the Intern/Resident and
the Department Chairperson shall be held in consideration of the Intern’s/Resident’s request. The
Department Chairperson shall respond in writing to the Intern’s/Resident’s request for modification or
withdrawal within five working days of receipt of the Intern’s/Resident’s request. Working days are
defined as weekdays, excluding Saturdays, Sundays, and holidays.
Step Two: If the Department Chairperson sustains the Stage One or Stage Two action, the
Intern/Resident has the right to request a review by a departmental committee. The Intern’s/Resident’s
request shall be submitted in writing to the office of the Associate Dean/Designated Institutional Official
within five working days of the Intern’s/Resident’s receipt of the Department Chairperson’s response to
the Step One conference. The departmental review committee shall convene and shall deliver a written
decision within ten working days of receipt of the Intern’s/Resident’s request. The review committee may
be an existing departmental or internship/residency program committee or may be formed on an ad hoc
basis. In either case, the committee membership must be acceptable to both the Intern/Resident and the
Department Chairperson. The decision of the committee to sustain, modify, or withdraw the Department
Chairperson’s corrective/disciplinary action is binding upon the Chairperson. Relative to Stage One
action, the Intern/Resident has no rights to further appeal if the committee sustains the action of the
Department Chairperson.
Step Three: Relative to Stage Two action, the Intern/Resident has the right to appeal further to the
Academic Dean, by submitting in writing a request for appeal within five working days of the
Intern’s/Resident’s receipt of the written decision by the departmental review committee. A conference
with the Associate Dean/Designated Institutional Official or designee, the Department Chairperson, and
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the Intern/Resident shall be held; and the Associate Dean/Designated Institutional Official or designee
shall deliver a written decision within five working days of the Associate Dean/Designated Institutional
Official’s receipt of the Intern’s/Resident’s request.
Step Four: The Intern/Resident has the right to appeal the decision of the Associate Dean/Designated
Institutional Official or designee by submitting a request in writing for a hearing within five working days
of the Intern’s/Resident’s receipt of the decision by the Associate Dean/Designated Institutional Official
or designee. The Associate Dean/Designated Institutional Official shall hold a conference with the
Department Chairperson and the Intern/Resident, and request a senior faculty or administrative person to
convene and chair a five-member Medical Center Hearing Board. The Intern/Resident shall select two
members of the Board and
Department Chairperson shall select two members; the appointed Board chairperson shall vote only in the
case of a tie. The Associate Dean/Designated Institutional Official or the Hearing Board shall deliver a
final binding decision in writing within ten working days of the Associate Dean/Designated Institutional
Official’s receipt of the Intern’s/Resident’s request.
F. Grievances
Reasonable efforts shall be made within each department and internship/residency program to resolve
grievances on an informal basis.
Interns/Residents have the right to submit a written request for the resolution of a grievance on matters of
alleged violation or rights or procedures or benefits granted by these Personnel Policies and by any other
applicable federal or state law, Hospital policy, or professional society statement; on matters of conduct of
a supervising physician which the Intern/Resident believes to be unfair; or on matters of working
conditions.
A request for formal resolution of a grievance shall be submitted in writing by the Intern/Resident to the
Department Chairperson within ten working days following the date when the Intern/Resident first had
knowledge of the incident that gave rise to the grievance. In accordance with Step One and Step Four of
the appeals process, the Department Chairperson shall first confer with the Intern/Resident and shall
respond to the Intern/Resident within five working days of receipt of the Intern’s/Resident’s request for a
grievance resolution. If the Department Chairperson fails to resolve the grievance to the satisfaction of
the Intern/Resident, Step Four of the appeals process shall apply.
G. Procedures
In the appeals and grievance processes, the Intern/Resident has the right to attend and to submit to
conferences, committee meetings, and hearings whatever oral or written information and arguments the
Intern/Resident believes are relevant, and to request faculty and other Interns/Residents to provide
additional information. Any Hearing Officer may limit the amount of persons providing information, the
length of any hearing, and other procedural matters.
The imposition of any aggrieved disciplinary action may be suspended during the appeals process except
when the Department Chairperson, in consultation with the Associate Dean/Designated Institutional
Official or designee, believes that some restrictions of the Intern’s/Resident’s responsibilities are required
in the interest of patient care.
In extremely unusual appeals process circumstances, the Intern/Resident, Department Chairperson, and
Associate Dean/Designated Institutional Official or designee may agree to bypass Step Two and Step
Three of the appeals process. In all instances, the times provided (in terms of working days) should be
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considered the maximum allowable times and all appeals and grievance requests should be processed as
expeditiously as possible. Conversely, the involved parties may consent to an extension of the maximum
allowable times.
If the Intern’s/Resident’s appeal is successful, then the Intern’s/Resident’s file shall be expunged of all
documents relative to the matter which was appealed.
_____________________________________________________________________
INTERNSHIP/RESIDENCY PROGRAM
PERSONNEL POLICIES
Appeals Process
_____________________________________________________________________
Written Warning or
Written Order
Received by Intern/Resident
___________________________________________________________________
Step One
Intern/Resident Appeals to Chairperson (5 days)
Chairperson Responds (5 days)
10 working days/2 calendar weeks
____________________________________________________________________
Step Two
Intern/Resident Requests Committee Review (5 days)
Committee Responds (10 days)
25 working days/5 calendar weeks
___________________________________________________________________
Step Three
Intern/Resident Appeals to Associate Dean/Designated Institutional Official (5 Days)
Associate Dean/Designated Institutional Official Responds (5 days)
35 working days/7 calendar weeks
___________________________________________________________________
Step Four
Intern/Resident Further Appeals to Associate Dean/Designated Institutional Official (5 days)
Hearing of Board Responds (10 days)
50 working days/10 calendar weeks
___________________________________________________________________
*Process days are cumulative from beginning of process to end.
Rev 2/13/07
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