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Grievance Policy

Introduction:

Mount Carmel Health System established this grievance procedure to provide a forum for the fair resolution of grievances regarding a resident’s clinical and educational performance, conduct, or eligibility to continue in one of Mount Carmel's Graduate Medical Education Residency Training Programs.

Right to File Grievance:

A resident has the right to grieve the following actions by the program director:

  • probation;
  • suspension;
  • termination;
  • non-renewal of a Graduate Medical Education agreement; or
  • non-promotion to the next PGY level.

Requesting A Grievance:

  1. All requests for grievance must be in writing and must be submitted, by the resident, to the Designated Institutional Official (DIO) within fifteen (15) calendar days of the resident’s receipt of the written notice of one or more of the actions described above in Section II. A written request for a grievance submitted by a third party on behalf of a resident will not be accepted.
  2. The written request for grievance must include the following information:
    • a description of the action giving rise to the grievance;
    • the date of the action; and
    • a request that the action be overturned.
  3. A resident who fails to request a grievance in writing within the time and in the manner specified above in Sections III.A. and III.B. shall have waived any right to a grievance and the action which could have been grieved shall be considered final.

Grievance Hearing

The following procedure will apply for all grievance hearings:

  1. Upon receipt of the written request for hearing, the DIO shall appoint a Hearing Committee of three (3) physicians to conduct the hearing. Members of the Hearing Committee shall not be selected from the same residency program as the resident requesting the hearing. At least one member of the Hearing Committee shall be a program director. The DIO shall appoint one member of the Hearing Committee to serve as the Hearing Committee Chairperson. In addition, the GME Accreditation Specialist shall serve on the Hearing Committee in an advisory capacity. The GME Accreditation Specialist shall not have a role in deciding the outcome of the grievance.
  2. The hearing shall be held within thirty (30) calendar days of the DIO's receipt of the written request for a hearing. The DIO shall notify the resident and the Program, in writing, of the date, time, location of the hearing, and names of the Hearing Committee and Hearing Committee Chairperson as soon as practicable.
  3. The resident and the Program shall notify the Hearing Committee Chairperson, in writing, by 5:00 p.m. two (2) business days prior to the date and time of the hearing, of any and all individuals whom he/she intends to present as witnesses at the hearing. The resident shall be limited to three (3) witnesses, not including him/her. The Program shall be limited to three (3) witnesses, not including the program director. Witnesses not disclosed within the time and manner specified above will not be permitted to testify at the hearing.
  4. The resident and the Program may submit a position statement summarizing why the action giving rise to the grievance should overturned or upheld. The position statement must be limited to five (5) pages in length and must be submitted to the Hearing Committee Chairperson by 5:00 p.m. five (5) business days prior to the date and time of the hearing. Position statements not submitted within the time and manner specified above will not be considered by the Hearing Committee.
  5. At the hearing, the resident and Program may present any and all information which is relevant to a resolution of the grievance including, testimony of witnesses, written documents and/or other tangible things.
  6. The Hearing Committee Chairperson shall decide all questions of procedure. The Program will present its case first and the resident will present his/her case second. The Program and the resident will each be given sixty (60) minutes to present their cases and, if requested, an additional fifteen (15) minutes for rebuttal after the other party has presented its case. Unless the Hearing Committee Chairperson deems it necessary, the hearing will not exceed two and one half (2.5) hours.
  7. The rules of evidence do not apply and all information provided shall be considered for relevance and reliability by the Hearing Committee. Neither the Program nor the resident may question each other or cross examine the other party’s witnesses. The Hearing Committee may ask questions of any individual participating in the hearing.
  8. The Hearing Committee may request additional information and/or clarification from the parties and others as it deems appropriate.
  9. The Hearing Committee shall issue a written report which includes the Hearing Committee decision regarding the grievance at issue and recommendations, if necessary, to the DIO within fourteen (14) calendar days of the conclusion of the hearing.
  10. Within two (2) calendar days of receipt of the Hearing Committee's report, the DIO shall advise the resident and the Program of the Hearing Committee's decision, in writing, and provide them with a copy of the written report. A copy of the Hearing Committee's decision and report shall be retained in the resident’s file.

The following shall also apply to grievance hearings.

  1. The resident may be assisted by any member of the Mount Carmel Health System community in preparing his/her side of the grievance.
  2. The resident may have a support person present at the grievance hearing; however, the resident is solely responsible for presenting his/her case and the support person will not be permitted to participate in the hearing.
  3. The procedures are intended to be informal and collegial and to resolve disputes within the framework of the Mount Carmel Health System academic setting. No attorney, including family members, may be present at or participate in any grievance hearing. If the Hearing Committee determines that either party has brought an attorney into the hearing, that individual shall be asked to leave the hearing.
  4. The grievance hearing is not a legal or judicial proceeding and no attempt shall be made to conduct the hearing in accordance with any procedural, statutory, or other rules of procedure, or evidence other than as described within this procedure.
  5. There shall be no written transcript or audio or video recording of any grievance hearing by either party; however, individuals participating in the hearing may take notes if they choose.
  6. The DIO and the GME Accreditation Specialist may answer questions regarding process and procedure. Neither the DIO nor the GME Accreditation Specialist may assist the Program or the resident in preparing or presenting his/her grievance.

Appeall to the DIO

  1. If the resident is dissatisfieddisagrees with the decision of the Hearing Committee, he/she may appeal the decision in writing to the DIO within seven (7) calendar days of receipt of the written decision and report.
  2. The written request for appeal to the DIO must include the following information:
    1. a description of the action from which the grievance is taken;
    2. the date of the action; and
    3. a copy of the written decision issued by the Hearing Committee.
  3. A resident who fails to request an appeal in writing within the time and in the manner specified above in Sections VI.A. and VI.B. shall have waived any right to an appeal and the decision of the Hearing Committee shall be considered final.
  4. The DIO shall provide a copy of the appeal to the Program and the Hearing Committee members.
  5. In conducting the appeal, the DIO shall review the following:
    1. The resident’s written request for appeal;
    2. The materials submitted by the resident and the Program to the Hearing Committee; and
    3. The written decision and report of the Hearing Committee.

    No additional hearing will be conducted at this stage.
  6. The issues considered by the DIO shall be limited to:
    1. Whether there was a material failure to comply with this Grievance Policy so as to deny the resident a fair hearing; and
    2. Whether the decision of the Hearing Committee was supported by credible information.

    The DIO shall not conduct a new review of the action giving rise to the grievance.
  7. The DIO shall issue a final written decision within fourteen (14) calendar days of receipt of the written request for appeal. A copy of the DIO's decision shall be sent to the resident, the Program, and the Hearing Committee members. A copy of the DIO's written decision shall be retained in the resident's file.
  8. The DIO's written decision is the final decision in the matter under appeal.

Dates

  1. In the event a deadline set forth above falls on a weekend or a MCHS Holiday, the due date shall be the next business day.
  2. Exceptions to any of the time frames set forth in this Grievance Policy may be made in the event of extenuating circumstances and/or by mutual agreement of the parties.

Applicability

This Grievance Policy governs all disputes regarding the professional performance, conduct and eligibility to continue in a Graduate Medical Education Program at MCHS. Any provisions of any Program rules of conduct which may conflict with or be at variance with these procedures are superseded by this procedure.

Resolution of Other Matters

  1. For matters related to resident work environment or issues related to the Program or faculty, please refer to the MCHS Human Resources policy Harassment Policy (policy #410).
  2. If at any point a resident raises issues of discrimination, harassment and/or hostile work environment, those issues will be referred to MCHS Human Resources for investigation and will not be addressed in the grievance proceedings.

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