Due Process Policy

Policy: GME DUE Process Policy
Original Approval: 6/27/24	Effective Date: 6/27/2	Revision Date: 6/27/2026

PURPOSE

The procedures set forth below are designed to provide University of Nevada Reno, School of Medicine (“UNR MED”) and its Trainees an orderly means of addressing performance and related issues of concern, and identifying the due process to be followed in connection with certain adverse or remedial actions taken, or proposed to be taken, against a Trainee. These Policies and Procedures apply exclusively to UNR MED -sponsored and ACGME approved programs, and they are the exclusive remedy by which Trainees may appeal reviewable academic actions.

POLICY & PROCEDURES

I. INTRODUCTION

Each ACGME-accredited and American Board of Medical Specialties (ABMS)ABMS accredited training program is referred to herein as a “Program.” The foremost responsibility of the GME training program is to provide an organized education program with guidance and supervision of residents and fellows (“Trainees”), facilitating the Trainees’ professional and personal development while ensuring safe and appropriate care for patients. Graduate medical education involves the development of clinical skills and professional competencies and the acquisition of detailed factual knowledge in a medical specialty. These professional standards of conduct include, but are not limited to, professionalism, honesty, punctuality, attendance, timeliness, duty hours and procedure record keeping, compliance with all applicable ethical standards and UNR MED policies and procedures, an ability to work cooperatively and collegially with staff and with other health care professionals, and appropriate and professional interactions with patients and their families.

A Trainee, as part of their GME training program, is assigned in a hospital, other clinical

setting, or research area. A Trainee’s appointment is academic in nature. The terms of the appointment are set forth in annual contracts signed by the Trainee. All such appointments, either initial or continuing, are contingent upon the Trainee maintaining good standing in the Program and meeting overall and year-specific educational expectations of the Program.

Dismissal from a Program will result in the Trainee’s automatic dismissal from any and all related appointments within the University of Nevada, Reno, School of Medicine.

The procedures set forth below are designed to provide the University of Nevada, Reno, School of Medicine (“UNR MED”) and its Trainees an orderly means of addressing performance and related issues of concern, and identifying the due process to be followed in connection with certain adverse or remedial actions taken, or proposed to be taken, against a Trainee. These Policies and Procedures apply exclusively to UNR MED - sponsored and ACGME approved programs, and they are the exclusive remedy by which Trainees may appeal reviewable academic actions. Deviation from these procedures that does not result in material prejudice to the Trainee will not be grounds for invalidating the action taken.

The UNR MED recognizes that the primary responsibility for remedial and adverse academic actions relating to Trainees resides within the UNR MED clinical departments and their respective Programs. Therefore, academic and performance standards and methods of GME training and evaluation are to be determined by each UNR MED Program. Trainees, Program Directors, and Program Faculty are encouraged to make efforts to resolve disagreements or disputes by discussing their concerns with one another. However, matters involving academic progress or meeting UNR MED standards may require actions as set forth in these Policies and Procedures. All actions set forth herein need not be progressive, and any action may be repeated as determined appropriate by the Program.

I. DEFINITIONS

Deficiency: The terms “Deficiency” or “Deficiencies” mean unacceptable performance or conduct, including failure to achieve or maintain good standing in the Program, or failure to achieve and/or maintain professional standards of conduct as required by the UNR MED.

Clinical Competency Committee: Clinical Competency Committee (“CCC”): A required body comprising three or more members of the active teaching faculty who is advisory to the program director and reviews the progress of all residents in the program.

Faculty: “Faculty” Any individuals who have received a formal assignment to teach resident/fellow physicians. At some sites, appointment to the medical staff of the hospital constitutes appointment to the faculty.

Medical Disciplinary Cause or Reason: “Medical disciplinary cause or reason” applies to a Trainee who holds a license from the Medical Board of Nevada and means that aspect of a licentiate’s competence or professional conduct that is reasonably likely to be detrimental to patient safety or to the delivery of patient care.

Program Director: “Program Director” means the GME Program Director for the Trainee’s specialty or subspecialty, or designee as appropriate. The one physician designated with authority and accountability for the operation of the residency/fellowship program.

Reviewable: “Reviewable” means the Due Process will be provided to the trainee.

Trainee: “Trainee” includes all residents and fellows appointed by UNR MED to participate in an ACGME-accredited Program sponsored by the UNR MED.

II. ADMINISTRATIVE ACTIONS (NON-REVIEWABLE and NON-REPORTABLE)

The following actions are NOT disciplinary in nature and Trainees are not entitled to the due process rights set forth in Section VI below in connection with actions taken in accordance with this Section III. However, failure to correct administrative deficiencies may constitute academic deficiency and may be subject to academic actions in Section IV and V.

• Automatic Suspension from Program (ADMINISTRATIVE)
  • Reasons
  • for Automatic Suspension from Clinical Work. A Trainee will be immediately and automatically suspended from a Program for any of the following reasons:
    • Failure to complete and maintain medical records as required by the hospital in accordance with the hospital’s Medical Staff Bylaws and/or Rules and Regulations;
    • Failure to obtain and maintain active state licensure to practice medicine as required by the Medical or Osteopathic Medical Board of Nevada and as required for participation in the Program;
  • Reasons for Automatic Suspension from Training. A Trainee will be immediately and automatically suspended from a Program for any of the following reasons:
    • Failure to maintain proper visa status as required by state or federal law; or
    • Any unexcused absence from the Program for five (5) or more calendar days.
  • Status During Automatic Suspension from Clinical Work. In general, the Trainee will not receive academic credit during the period of automatic suspension; however, the Trainee’s stipend will continue to be paid while on automatic suspension status. If the automatic suspension is due to inactive licensure status, the trainee may be assigned vacation or non- clinical duties for academic credit at the discretion of the program and with approval of the DIO. The period of automatic suspension under this Section III will not exceed 14 (fourteen) calendar days from the date of the event identified in Section III.A.1. In general, the Trainee may be assigned non-clinical duties during this period at the discretion of the Program Director. Nothing herein precludes the Program from taking any other action with respect to a Trainee as provided in these Policies and Procedure, while the Trainee is on automatic suspension status.

  • Notice of Automatic Suspension from Clinical Work or Training. The Program Director will promptly notify the Trainee in writing of his/her automatic suspension and reasons therefore along with any supporting documentation. The date of the automatic suspension is the date of the occurrence in Section III.A.1, not the date of the written notice. The written notice will state the date on which the Trainee will be deemed to have resigned from the Program (as set forth in Section III.B below) if the basis for the automatic suspension (for categories III.A.1b,2a and 2b) is not fully resolved without qualification by the stated automatic-resignation date. Failure to complete medical records during the fourteen (14) day period may result in other forms of academic action taken against the Trainee.

• Automatic Termination from Program

  • A Trainee will be deemed to have resigned from his or her GME Program effective the fifteenth (15th) day following the event that caused an automatic suspension to be taken under Section III.A.1b,2a and 2b) herein, unless the basis for the automatic suspension has been fully resolved without qualification by that day. A Trainee will be deemed to have resigned from his or her GME Program effective the fifteenth (15) day following an unexcused absence as provided herein, unless the Trainee has submitted materials to the Program Director regarding the basis for the unexcused absence, and the Program Director has determined the absence to be excused and within the scope of other applicable UNR MED policy. The trainee may request an extension of the automatic suspension from clinical work with the Program Director if there are extenuating circumstances in maintaining licensure beyond the control of the trainee. Circumstances must be submitted in writing and approved by the Associate Dean for GME.

    • Administrative Leave and Investigatory Leave

    Administrative Leave and Investigatory Leave are both administrative in nature and are not intended to replace any leave that a Trainee may otherwise be entitled to under state or federal law or University Policy including but not limited to vacation leave, sick leave, family, medical and other leaves related to life events. Investigatory leave may be used to permit the University to review or investigateallegations of trainee wrongdoing which warrants removing the trainee from the work site. Administrative leave is used for situations that require the trainee to be removed from the work site for reasons not investigatory in nature.

III. ACADEMIC ACTIONS - EDUCATIONAL IMPROVEMENT (NON-REVIEWABLE and NON- REPORTABLE)

The following actions are non-disciplinary and therefore non-reviewable in nature. Trainees are NOT afforded the due process rights set forth in Section VI herein for actions taken against them under this Section IV. The actions below are not progressive and each can be taken at any time, and can be repeated as determined appropriate, by the Program Director. These tools are educational and DO NOT constitute disciplinary action and therefore are not reported in response to third party inquiries except as required for medical licensure. The specific Academic Action being utilized must be clearly labelled in the written communication delivered to the trainee.

• Educational Letter of Counseling.

An Educational Letter of Counseling may be issued by the Program Director to a Trainee to address an identified deficiency or concern that needs to be remedied or improved. Letters of counseling should describe the nature of the deficiency or concern and specific suggestions for remedial actions or changes required on the part of the Trainee and should be reviewed with the Trainee. Failure by the Trainee to remedy the deficiency or concern to the satisfaction of the Program Director, or a repetition of the deficiency or concern, may lead to additional actions, including but not limited to disciplinary actions under Section V herein. Educational Letters of Counseling should be used for minor, isolated problems.

• Educational Notice of Concern.

THE GME OFFICE MUST BE NOTIFIED WHEN AN EDUCATIONAL NOTICE OF CONCERN WILL BE ISSUED.

An Educational Notice of Concern may be issued by the Program Director to a Trainee to address an academic deficiency that needs to be immediately remedied or improved.

Notices of Concern must be in writing and should describe the nature of the deficiency and any necessary remedial actions required on the part of the Trainee. The Program Director will review the content of the Notice of Concern with the Trainee. Failure by the Trainee to immediately improve and to maintain improvement, or a repetition of the conduct identified in the Educational Notice of Concern, may lead to additional actions, including but not limited to disciplinary actions under Section V herein. Educational Notices of Concern should NOT be used for minor, isolated problems that can be communicated and addressed less formally.

IV. ACADEMIC ACTIONS-DISCIPLINARY ACTIONS (REVIEWABLE and REPORTABLE)

The following actions constitute disciplinary action and Trainees are entitled to the due process rights set forth in Section VI of these Policies and Procedures. The specific Academic Action being utilized must be clearly labelled in the written communication delivered to the trainee.

THE GME OFFICE MUST BE CONSULTED BEFORE ANY OF THESE ACADEMIC ACTIONS IS TAKEN.

• Probation.

A Program Director may place a Trainee on probation when the Trainee is in jeopardy of not successfully completing the requirements of the Program, or the Trainee is not satisfactorily meeting Program standards. The Trainee will be notified of the probation in a letter from Program Director (Associate Dean of GME Co-signature required) that will identify the basis for the probation; any required remedial activity necessary to remove the probation status; the expected time frame within which the required remedial activity must occur and information on how the Trainee may appeal the notice of probation in accordance with Section VI of these Policies and Procedures. Failure to correct the identified deficiency(s) within the specified period and to the satisfaction of the Program Director may lead to an extension of the probationary period or other academic actions. Probation should be used instead of a Notice of Concern when the underlying deficiency threatens a Trainee’s ability to complete the Program in a satisfactory manner or time frame, and remedial action requires Faculty oversight. The probationary period should be not less than thirty (30) days and its duration should be appropriate for the identified deficiency.

• Academic Suspension.

The Program Director may suspend the Trainee from part or all of the Trainee’s usual and regular assignments in the GME training program, including clinical and/or didactic duties, when the removal of the Trainee from the clinical service is required for the best interests of the Trainee and/or the GME training program. The suspension will be confirmed in writing (“Notice of Suspension”) from the Program Director (Associate Dean of GME Co-signature required). The Notice of Suspension will identify the reason(s) for the suspension, its expected duration, and information on how the Trainee may appeal the Notice of Suspension in accordance with Section VI of these Policies and Procedures. Suspension generally should not exceed thirty (30) calendar days. Suspension may be coupled with or followed by other academic actions. The Trainee’s stipend will continue to be paid while the Trainee is on suspension status.

• Adverse Annual Evaluation.

A Trainee may receive an adverse annual evaluation due to overall unsatisfactory or marginal performance (“Adverse Annual Evaluation”) at the recommendation of the Program’s Clinical Competency Committee. Trainees will be notified in writing by the Program Director of any Adverse Annual Evaluation. In cases where specialty board reporting is required, the resident will be notified at the same time that the adverse evaluation is sent to the resident’s specialty board. Any Notice of Adverse Annual Performance must include the basis for the non-renewal, and information on how the Trainee may appeal the decision in accordance with Section VI of these Policies and Procedures.

• Requirement That Trainee Must Repeat an Academic Year.

A Trainee may be required to repeat an academic year due to unsatisfactory progress, as assessed by the Program’s Clinical Competency Committee, at the sole discretion of the Program Director. Notice of a Requirement to Repeat Academic Year must be provided to the Trainee in writing by the Program Director and should identify the grounds for the need to repeat a year, and the right to appeal the decision in accordance with Section VI of these Policies and Procedures.

• Non-Renewal of Appointment.

The Trainee’s appointment to a Program is for a one (1) year duration, which is renewed annually when there are no educational or clinical concerns. Due to the increasing level of responsibilities and increasing complexity of clinical care over the course of the Trainee’s training, satisfactory completion of prior academic year(s) or rotation(s) does not ensure satisfactory proficiency in subsequent years or rotations. A Trainee may have their appointment not renewed at any time when there is a demonstrated failure to meet programmatic standards.

The Program Director must provide each Trainee with a written evaluation at least twice per year. The first evaluation should occur by the end of the seventh month of the appointment term. If prior to the end of eight months (no later than February 28th of the academic year), the Program Director concludes that the Trainee’s appointment should not be renewed for the following year, the Program Director will notify the Trainee in writing (Associate Dean of GME signature required) that their appointment will not be renewed for the following academic year (“Notice of Non-Renewal”). The Trainee will be permitted to conclude the remainder of the academic year unless further academic action is taken.

Any Notice of Non-Renewal must include the information set forth in Section VI.B of these Policies and Procedures.

• Denial of University Certificate of Completion.

If the Program Director, in consultation with the CCC, decides not to award the Trainee a University Certificate of successful completion of the Program, the Program Director will notify the Trainee in writing of the decision (Chair Co-Signature required) to deny the certificate. Any Notice of Denial of Certificate must include the information set forth in Section VI.B of these Policies and Procedures.

• Dismissal from the Program.

Based on the Program Director’s discretion, a Trainee may be dismissed from a GME Program for Academic Deficiencies for reasons including but not limited to the following:

• • A failure to achieve or maintain programmatic standards in the Program;
  • A serious or repeated act or omission compromising acceptable standards of patient care, including actions that constitute a medical disciplinary cause or reason;
  • Unprofessional or unethical behavior that is considered unacceptable by the Program; and/or
  • A material omission or falsification of a Program application, medical record, or other University document.

The Trainee must receive a written Notice of Dismissal from the Program Director (Chair Co-signature required) and include the information set forth in Section VI.B of these Policies and Procedures

V. DUE PROCESS PROCEDURES

• A. Appeal to the Clinical Competency Committee.

A Trainee may submit an appeal to the Clinical Competence Committee for actions taken against the Trainee in accordance with Sections V.A, V.B, V.C or V.D as set forth below; provided, however, if the action taken was based on a medical disciplinary cause or reason it may be reportable to the Nevada State Medical Board.

THE GME OFFICE AND THE OFFICE OF LEGAL AFFAIRS SHOULD BE CONSULTED WITH ANY QUESTION OF WHETHER AN ADVERSE ACTION IS REPORTABLE TO THE MEDICAL BOARD OF NEVADA

• Within ten (10) business days of receipt of the Notice, the Trainee may submit to the CCC a written statement detailing the reasons they believe the action is unfounded and should be withdrawn or revised. For purposes of this Section VI.A, a Notice of: Probation, Suspension, Adverse Annual Evaluation, or Requirement to Repeat Academic Year, are referred to collectively herein as a “Notice.”
• Failure by the Trainee to timely submit a written statement in accordance with this Section A constitutes an acceptance by the Trainee of the action taken.
• The CCC will review any such written statement within ten (10) business days of its receipt, absent unusual circumstances that warrant additional time.
• The Trainee should be permitted to meet with the CCC upon request by the Trainee or at the request of the CCC to discuss the action and the Trainee’s position regarding that action. Such meeting should occur within ten (10) business days of the CCC’s receipt of the Trainee’s written statement to the CCC.
• The CCC will provide a written decision to the Trainee within ten (10) business days of its receipt of the Trainee’s written statement if no meeting occurs; or within ten (10) business days of a meeting that occurs in accordance with Section VI.A.3 herein.
• The CCC’s decision shall be considered final.

• Appeal to the Associate Dean for GME

A Trainee may appeal actions taken against the Trainee in accordance with Sections V.E, V.F and V.G in the manner set forth herein. Failure of a Trainee to timely follow the procedures herein will be deemed an acceptance by the Trainee of the academic action.

• NoticetoTrainee.

When the Program Director determines that grounds exist to issue a Notice of: Non-Renewal, Denial of Certificate, or Dismissal, the Program Director will provide the Trainee with a written notice of the action that must include a statement of the reason(s) for the action; a copy of the materials upon which the intended action is based; and a statement that the Trainee has a right to appeal the decision in writing to the Associate Dean for Graduate Medical Education within ten (10) working days of receipt of the notice. The Notice should include a statement informing the Trainee of any reporting requirements to the Medical Board.

• Trainee Appeal to the UNR MED Associate Dean for Graduate Medical Education(GME).
  • Filing of Complaint. If the Trainee wishes to appeal the decision of the Program Director the Trainee (“Complainant”) must file a written complaint with the Associate Dean for GME no later than ten (10) business days of receipt of the Program Directors written decision. The written complaint should explain in detail why the Complainant disagrees with decision of the Program Director and should address each reason for the dismissal set forth in the Notice of Non-Renewal, Notice of Denial of Certificate, or Notice of Dismissal, as applicable.
  • Appointment of Ad Hoc Committee. Within ten (10) working days of receipt of the complaint, or as soon thereafter as is practical, the Associate Dean for GME will appoint an Ad Hoc Formal Review Committee to hear the complaint (the “Hearing”). The Committee will consist of four to five members, at least one of which shall be an, associate program director, a member of the core faculty, one senior trainee (PGYII or higher), and one member of the Graduate Medical Education None of the Panel members shall be from the same department as the resident requesting the hearing to avoid conflicts of interest. The Associate Dean for Graduate Medical Education shall serve on the Panel as a non-voting member.
  • The Associate Dean for GME will designate one of the Committee members to be the Committee Chair. Until the appointment of a Committee Chair, the Associate Dean for GME will resolve all issues related to these
  • RepresentationforCommittee. The Committee may, at its discretion, request that an attorney from UNRMED be appointed to provide legal counsel to the This attorney shall not vote in the Committee’s deliberation process.
  • Representation for Complainant or UNR MED . The Complainant may be assisted or represented by another person at the Complainant’s sole UNR MED may also be represented. The complainant’s department at UNR MED may also to represented by counsel. If the Complainant or UNR MED is represented by an attorney, notice will be provided to the other party of such representation within fifteen (15) business days prior to the hearing. The attorney must be licenses in the state of Nevada to represent the complainant at the hearing. The Complainant must appear at the hearing in person even if represented by counsel or another person. Failure of the Complainant to appear at the hearing will be deemed a voluntary dismissal of the complaint.
  • Dateof The Hearing will be held within forty-five (45) calendar days of receipt of the complaint by the Associate Dean.

Time Limitation. Time Limitation: The Due Process hearing shall be limited to six hours unless additional time is specifically requested by the resident and their representative or the representative of the School of Medicine. Requests for additional time must be made 5 days prior to the hearing and must be approved by the Committee Chair. Any additional time granted for the hearing may require a subsequent or different hearing date. Notwithstanding the limitation on time the resident shall be afforded and equal time person for the presentation of

• • documentation and witness and the hearing as the department.
  • Exchangeof At least seven (7) business days prior to the all documents to be introduced as evidence at the Hearing and names of all witnesses shall be exchanged. Any witnesses not named and documents not exchanged seven business days before the hearing will be excluded from the Hearing.
  • The Hearing will provide an opportunity for each party to present evidence and cross examine witnesses. The Hearing will be recorded by a court reporter at the expense of Graduate Medical Education. The Hearing will be closed and confidential. All materials, reports and other evidence introduced and recorded during the course of a closed proceeding may not be disclosed until the final resolution of the complaint under these procedures except as may be required by applicable law. Only the witness testifying may be present; other potential witnesses will be excluded temporarily. Subject to availability witnesses may appear virtually during the hearing.
  • Deviation from these procedures will not invalidate a decision or proceeding unless it is determined by the Dean, in the Dean's sole discretion, that the course of the proceedings would have been substantially different had the deviation not occurred. A deviation may be brought to the attention of the Dean by the Compliant, the Department, the Associate Dean for Graduate Medical Education or any member of the committee.
  • Technical departures from or errors in following the procedures established in the [NSHE] Code or in any applicable stated prohibition, policy, procedure, rule, regulation or bylaw of a System institution under which disciplinary procedures are being invoked shall not be grounds to withhold disciplinary action unless, in the opinion of the Dean, the technical departures or errors were such as to have prevented a fair and just determination of the charges.
  • Recommendation

The Committee Chair will provide recommendations to the Dean, with a copy to the Associate Dean for Graduate Medical Education. This recommendation(s) should occur, absent unusual circumstances, within ten days (10) business days of the Hearing’s conclusion.

The recommendations will set forth the committee's findings and decision and the reason(s) for reaching such decision. The committee's deliberations will not be recorded. Recommendations may include but are not limited to the following

• • • No action against the resident;
    • A verbal or written reprimand;
    • A period of monitoring, after which the Panel, or its successors, will reconvene to review the case and make its final recommendation;
    • The repeat of certain training or education;
    • Remediation;
    • Suspension from the residency program for a specified length of time;
    • The continuance or discontinuance of an emergency suspension by the Dean (if in place);
    • Demotion;
    • Non-promotion;
    • Dismissal from the residency program;
    • Affirmation of a Notice of Non-renewal;
    • Rescinding of a Notice of Non-renewal.

The Dean’s ultimate decision will be final and will be in writing and sent to the Program Director, the Complainant, and the Committee Chair within 5 business days of the Committee Chairs recommendation.

The Associate Dean for Graduate Medical Education will be required to notify the Nevada Board of Medical Examiners or the Nevada Board of Osteopathic Examiners, as applicable, when the Dean has rendered a final decision.

REFERENCES

ACGME Institutional Requirements

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.

ACGME Common Program Requirements

II.A.4.h) ensure compliance with grievance and due process procedures as set forth in the Institutional Requirements and implemented by the sponsoring institution.