Corrective Action and Due Process Policy

Original Approval Date	GMEC Approval Date
6/29/2026	7/1/2026

I. Policy Statement

In accordance with Accreditation Council for Graduate Medical Education (ACGME) Institutional Requirements, UNR Med GME shall maintain a fair, consistent, and transparent process regarding corrective actions, and due process procedures for residents and fellows. This policy is intended to support both educational accountability and procedural fairness while maintaining patient safety, professionalism, and the integrity of graduate medical education programs. 

II. Purpose 

The purpose of this policy is to define corrective action processes for residents and fellows; distinguish educational remediation from disciplinary action; provide due process protections related to adverse actions; establish appeal procedures; ensure consistent institutional oversight of significant corrective actions; and support a fair and professional learning environment. 

III. Scope

This policy applies to all residents and fellows enrolled in ACGME-accredited and institutionally sponsored residency and fellowship programs sponsored by UNR Med. 

IV. Definitions 

• Academic Due Process: A structured and fair process that provides notice of concerns, an opportunity to improve or respond, and careful review before significant adverse action is taken.
• Corrective Action: Educational or disciplinary intervention intended to address deficiencies in performance, conduct, professionalism, patient care, or policy compliance.
• Adverse Action: Includes academic probation, suspension, non-promotion, non-renewal of appointment, or dismissal.
• Reportable Action: An action that may require disclosure in verification of training, credentialing, licensure, employment, or board certification documentation.
• Business Day:  Any day other than a Saturday, Sunday or legal holiday.
• Nonrenewal: Also known as non-reappointment. Not appointing a Resident/Fellow for a subsequent employment appointment after the completion of the current contract term. For purposes of calculating time periods specified in this policy, if a deadline falls on a Saturday, Sunday or legal holiday, the deadline will be extended to the next business day.    

V. Guiding Principles 

Residency and fellowship training are educational programs. Corrective processes should prioritize education and improvement whenever appropriate while maintaining patient safety, professionalism, fairness, and institutional accountability. 

VI. Levels of Corrective Action 

Corrective actions may be implemented progressively; however, depending on severity, programs may proceed directly to higher levels of action. 

VII. Educational Improvement Plan (EIP) 

An Educational Improvement Plan (EIP), also referred to as a PIP or ILP, is designed to identify performance deficiencies, provide structured support and improvement expectations, and establish measurable goals and timelines. An EIP is considered part of the normal educational process, is not disciplinary action, is not reportable, and is not subject to appeal procedures. 

VIII. Remediation 

Remediation may be initiated when prior interventions have not resulted in sufficient improvement or when concerns warrant formal documentation. Remediation is educational and corrective in nature. It is not considered disciplinary action or reportable, and is not subject to appeal procedures. 

IX. Academic Probation 

Academic probation is an adverse action and may occur when deficiencies persist despite prior intervention or when concerns place patient care, safety, educational, or professional standards at risk. Academic probation is reportable and subject to appeal 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, up to an including dismissal. 

X. Suspension 

Residents or fellows may be suspended from clinical or educational duties when necessary to comply with licensure requirements or workplace authorizations requirements, or to protect patient safety, workplace safety, or institutional integrity. Suspension may be with or without pay, depending on the circumstances at issue. 

XI. Non-Promotion, Non-Renewal, or Dismissal 

A Program Director, with institutional consultation, may recommend non-promotion, non-renewal, or dismissal due to issues such as persistent academic deficiencies, professionalism concerns, patient safety concerns, misconduct, or failure to maintain licensure or eligibility requirements. Non-renewal, suspension, or dismissal resulting from failure to maintain required licensure, credentialing, employment authorization, or eligibility requirements shall not be considered academic disciplinary actions and are therefore not subject to appeal under this policy. 

XII. Appeal Procedure 

Residents and fellows may appeal adverse actions including academic probation,  non-promotion, non-renewal, or dismissal. EIPs, remediation, milestone assessments, and routine evaluations are not subject to appeal. 

1. Written Notice 

When a Program Director determines grounds exist for: 

• Probation  
• Non-Promotion
• Non-Renewal of appointment
• Dismissal  

The resident/fellow shall receive written notice including: 

1. Action being taken
2. Basis for the action  
3. Supporting documentation
4. Effective date  
5. Reporting obligations, if applicable  
6. Appeal rights and deadlines  

The notice shall include signatures from: 

•  Program Director  
• Associate Dean of Graduate Medical Education/DIO

2. Submission of Appeal 

The only actions that may be appealed are those listed in subsection 1, above. The resident/fellow may appeal the action by submitting a written appeal to the Associate Dean for Graduate Medical Education/DIO or their designee within seven (7) business days of receipt of the notice.  Submission of a written appeal will be followed by a  hearing before an Appeal Panel as set forth below. The appeal must include: 

• Basis for disagreement and reason(s) for appeal
• Response to identified deficiencies and listed reasons for the action  
• Supporting documentation  
• Requested resolution  

Failure to timely submit a written appeal shall constitute acceptance of the action and renders the Program Director’s decision final and binding. 

3. Ad Hoc Appeal Panel 

a. Formation of Appeal Panel

Within ten (10) business days of receipt of the written appeal, the Associate Dean for GME shall appoint an Ad Hoc Appeal Panel. The Appeal Panel shall consist of at least three members but shall not exceed five members. Based on avil **Membership should generally include at least: 

• One Program Director or Associate Program Director
• One core faculty member  
• One senior resident/fellow (PGY-2 or higher)  

Panel members: 

• Shall not be from the same department/program as the resident who is appealing the action  
• Shall not have conflicts of interest  
• Shall not have any direct involvement in the underlying matter  

The Associate Dean for GME/DIO or their designee shall serve on the Appeal Panel as a non-voting administrative facilitator. The Chair of the Appeal Panel shall be appointed by the Associate Dean for GME/DIO or their designee. The Appeal Panel may request appointment of an attorney from UNR Med to provide legal counsel during the hearing and deliberations.  The attorney shall not vote in the Appeal Panel’s deliberation process.    

b. Representation 
The resident/fellow may attend the hearing and: 

• Be accompanied by an advisor or attorney at their own expense  

UNR Med GME may be represented by legal counsel. If either party intends to have legal counsel present at the hearing, written notice must be provided to the opposing party at least ten (10) business days before the hearing. Attorneys representing the resident/fellow must be licensed in the State of Nevada. Failure by the resident/fellow to attend the hearing may be treated as withdrawal of the appeal.

c. Timing of Hearing

A hearing before the Appeal Panel will be held within 45 business days of the date the Associate Dean of GME received the written appeal.  This period may be extended for good cause at the discretion of the Associate Dean of GME.  

d. Pre-Hearing Procedures

At least seven (7) business days before the hearing:

• Parties shall exchange witness lists
• Parties shall exchange all documents intended for use during the hearing  

Absent good cause, as determined by the Appeal Panel Chair, any witnesses not named, and documents not exchanged seven (7) business days before the hearing will be excluded from the hearing. The parties shall not be limited to the documents provided as part of the written notice of action or written appeal. Documents submitted should not be unduly repetitious and must be relevant to the appeal.  

e. Hearing Procedures

The hearing shall be closed and confidential.  Formal rules of evidence shall not apply. The Appeal Panel may:

•  Review documentation provided by each party
• Hear witness testimony presented by each party
• Ask questions of any witness
• Consider institutional standards and policies in their decision

The parties, individually or through their attorneys, shall each be provided a fair opportunity to:

• Present information to the Appeal Panel  
• Respond to allegations presented in the notice or appeal statement
• Question witnesses properly disclosed as required by this policy  

Witnesses may appear virtually when appropriate. If either party intends to have a witness appear virtually, the party will note the witness’s virtual appearance as part of their witness designation and exchange. Each party is responsible for managing the availability of their witnesses and appearance at the hearing. Only the witness testifying may be present at the hearing. Other potential witnesses will be excluded from the hearing until called to present their testimony.  The resident/fellow, Associate Dean of GME, and the Program Director shall attend as party representatives and shall not be excluded even if called as a witness during the hearing. Each party is responsible for preparing their documents in an organized fashion and providing copies at the hearing for each member of the Appeal Panel and the court reporter. The hearing shall generally be limited to six (6) hours unless extended for good cause. Requests for additional time must be made five (5) business days prior to the hearing and must be approved by the Appeal Panel Chair. Any additional time granted for the hearing may require a subsequent or different hearing date, which may affect the ability to complete the hearing within 45 business days. The parties shall each be afforded an equal time at the hearing for their respective  presentations, including presentation of documentation, witnesses, and opening and closing statements. The hearing shall be recorded by a court reporter at the expense of GME.

f. Order of Hearing

The resident/fellow shall present their position first, which may include an optional opening statement, presentation of documents and witnesses, cross-examination of witnesses, and an optional closing statement, subject to the six-hour limit for the entirety of the hearing. UNR Med GME shall follow the resident’s/fellow’s presentation and may present an optional opening statement, presentation of documents and witnesses, cross-examination of witnesses, and an optional closing statement, subject to the six-hour limit for the entirety of the hearing. It is intended that each party shall have three (3) hours in total for their presentation unless additional time is timely requested and approved by the Appeal Panel Chair.  

g. Appeal Panel Recommendation

After the conclusion of the hearing, the Appeal Panel shall deliberate privately in a closed setting. The Appeal Panel will prepare a written recommendation to the Dean with a copy to the Associate Dean for GME within seven (7) business days of the conclusion of the hearing. 

The recommendation shall include: 

•  Findings  
• Rationale  
• Recommended outcome  

Appeal Panel recommendations may include but not limited to: 

• No action against the resident
• Remediation, with a description  
• Repeat training, with a description  
• Suspension for a specified length of time  
• Non-promotion  
• Dismissal  
• Affirmation of non-Renewal  
• Rescinding non-Renewal 

Appeal Panel deliberations shall remain confidential and are not recorded. 

h. Final Decision

The Dean or designee shall issue the final institutional decision in writing within 10 (10) business days following receipt of the Appeal Panel’s recommendation. There is no further right of appeal or review. The resident/fellow, Associate Dean for GME, Program Director, and the Appeal Panel Chair shall receive a copy of the Dean’s final written decision.

The Associate Dean for GME/DIO shall coordinate any required reporting obligations to: 

• Nevada State Board of Medical Examiners  
• Nevada State Board of Osteopathic Medicine  
• Specialty boards  
• Other required entities  

i. Deviation from Procedure.  

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 Resident/Fellow or UNR Med, or any member of the Appeal Panel. 

XVI. Confidentiality 

Corrective action and appeal proceedings shall be handled confidentially to the extent permitted by law and institutional policy.

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.