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Academic Improvement and Corrective Action (43.2)

Academic Improvement and Corrective Action (43.2) - Policies, Administrative, UWHC, Department Specific, Graduate Medical Education (GME)

43.2





Graduate Medical Education Departmental Policy
Policy Title: Academic Improvement and Corrective Action
Policy Number: 43.2
Effective Date: December 16, 2015
Version: New
I. PURPOSE
To establish procedures for all UW Health Graduate Medical Education (GME) training programs to
follow if a resident fails to meet academic expectations and/or engages in misconduct.

II. PERSONS AFFECTED
This policy applies to all residents and fellows in Graduate Medical Education (GME) programs
sponsored by the University of Wisconsin Hospitals and Clinics Authority (UW Health).

III. DEFINITIONS
A. The term “resident” refers to residents and fellows in ACGME accredited programs.
B. Program(s) will refer to ACGME-accredited program(s) sponsored by the University of Wisconsin
Hospitals and Clinics Authority (UW Health).
C. UW Health: For the purpose of this policy, the term “UW Health” shall mean University of
Wisconsin Hospitals and Clinics Authority, which is the sponsoring institution of the ACGME-
accredited training programs. “UW Health” is the trade name of University of Wisconsin Hospitals
and Clinics Authority and its affiliates.
D. Defined Training Period: The length of the training program as defined by the ACGME.

IV. POLICY
A. Academic Deficiency - the resident is not meeting an objective assessment of competence in one or
more of the ACGME Core Competencies (patient care and procedural skills, medical knowledge,
practice-based learning and improvement, interpersonal and communication skills, professionalism,
and systems-based practice) or is not meeting expected milestone levels. Examples of academic
deficiencies include but are not limited to:
1) Issues involving knowledge or skills;
2) Job performance or scholarship; and
3) Minor professionalism concerns.
B. Misconduct - the resident’s conduct or behavior violates workplace rules or policies, applicable law,
or widely accepted societal norms. Examples of misconduct include but are not limited to:
1) Unethical conduct, such as dishonesty or falsification of records;
2) Significant professionalism concerns;
3) Illegal conduct (regardless of criminal charges or criminal conviction);
4) Sexual misconduct or sexual harassment;
5) Workplace violence;
6) Tardiness, absenteeism, or job abandonment;



7) Boundary violations with patients;
8) Failure to meet conditions of employment; and
9) Violation of UW Health or other applicable policies or procedures.
C. Structured Feedback – giving a resident documented assessment of his/her competence in one or
more of the ACGME Core Competencies for the purpose of helping the trainee understand aspects of
his/her performance in order to reflect on, and where necessary, improve learning and practice.
D. Academic Improvement Plan (AIP) - a plan of academic remediation designed to improve a
resident’s proficiency in one or more ACGME Core Competencies. An AIP is not Corrective Action
or formal disciplinary action, but rather an educational tool to correct areas of unsatisfactory
academic performance by a resident. Therefore a resident may not appeal an AIP pursuant to the
Appeals of Resident Corrective Actions Policy. The issuance of an AIP does not trigger a report to
any outside agencies, but may be reported should an outside agency specifically inquire whether a
resident ever received remediation. An AIP may include one or more of the following measures:
1) Additional academic study and/or assessment;
2) Repetition of Rotation - due to identified areas of unsatisfactory performance, the resident must
repeat a rotation and perform at an acceptable level in order to advance to the next level of
training.
3) Extension of the Defined Training Period – due to identified areas of unsatisfactory performance,
the resident will not complete the program on time and the defined training period will be
extended to allow the resident an opportunity to perform at the level required.
E. Corrective Action - formal disciplinary action issued to a resident as the result of unsatisfactory
academic performance and/or misconduct. The program is not required to issue a resident an AIP as
a prerequisite to Corrective Action. Serious academic deficiencies and/or misconduct may warrant
Corrective Action up to and including dismissal, regardless of whether a resident ever received an
AIP. A Corrective Action may include one or more of the following measures:
1) Probation - formal notification to the resident that there are identified areas of unsatisfactory
performance that will require remediation and/or improvement or the resident will not be
permitted to continue in program.
2) Suspension – the resident is temporarily not permitted to perform any job duties due to
unsatisfactory performance.
3) Non-promotion to the next PGY level or successful program completion - due to identified areas
of unsatisfactory performance, the resident will not be promoted to the next level of training or
graduated from the program unless or until the resident’s performance improves to the level
required.
4) Non-renewal – the resident completes current contract and is then terminated from the program.
5) Dismissal – the resident is permanently separated from the program prior to the end of their
contract.
A Corrective Action may trigger a report to outside agencies (e.g., licensing or certification boards)
and is appealable pursuant to the General Grievances and Due Process for Corrective Actions Policy.
F. Appeals – Actions which result in probation, suspension, non-renewal, non-promotion or dismissal
must receive due process in accordance with the ACGME program and institutional level appeals
policies (IR IV.C.1.b).





V. PROCEDURES
A. Providing Structured Feedback
1) When a program determines a resident has an academic deficiency, the program may elect to
first provide structured feedback to the resident concerning the deficiency. Depending on the
level of deficiency, the feedback may be in the form of a letter of advisement or warning.
2) Structured feedback should include discussion with the resident of the specific (or global)
deficiencies and strategies for improvement.
3) Structured feedback, including documentation of verbal feedback, must be documented in the
resident’s file.
4) If the program determines that structured feedback has not produced the necessary improvement
within a specified amount of time, or the deficiency is significant enough to warrant more formal
action, the program may elect to issue an AIP or Corrective Action.
B. Issuing an Academic Improvement Plan (AIP)
1) An AIP must be in the form of a letter from the program director to the resident and should
follow the AIP Template available from the UW Health GME Office. An AIP must include:
a. formal notice to the resident of the specific academic deficiencies;
b. the remedial action or improvement that is required;
c. a plan of remediation to correct the deficiencies;
d. a defined period of time the resident has to correct cited deficiencies (e.g., 60 days) with
a start and end date; and
e. information regarding the Employee Assistance Program.
2) The AIP must be reviewed and approved by the Director of Graduate Medical Education before
it is delivered to the resident.
3) The AIP must be signed by the program director, delivered to the resident in person, and co-
signed by the resident. If the resident refuses to sign, the program director should note this on the
document.
4) A copy of the signed AIP must be placed in the resident’s file and forwarded to the UW Health
GME Office.
5) At the end of the AIP period, the program director must provide the resident with written notice
as to whether the resident has or has not satisfactorily corrected the deficiency. A copy of this
written notice must be placed in the resident’s file and forwarded to the UW Health GME Office.
6) If the program director determines that the resident has failed to satisfactorily correct the
deficiency or produce the necessary improvement(s) outlined in the resident’s AIP by the end of
the AIP period, the resident may be issued an updated or new AIP or Corrective Action.
7) If the program director determines that there is insufficient evidence of progressive improvement
after a reasonable time to evaluate during the AIP period, the program director may move to
corrective action which may include termination.
8) An AIP is academic in nature and is not appealable pursuant to the Appeals of Resident
Corrective Actions Policy.
C. Issuing Corrective Action
1) When a program director has determined that Corrective Action is warranted, the program
director should first consult the UW Health GME Office. A Corrective Action cannot be issued
to a resident until it has been reviewed and approved by the Director of Graduate Medical
Education.



2) A Corrective Action must be in the form of a letter from the program director to the resident and
must include:
a. the specific Corrective Action measure(s) to be taken;
b. a description of the academic deficiencies and/or incidents of misconduct that are the
basis for the Corrective Action;
c. the specific remedial action or improvement that is required (unless the Corrective
Action is dismissal);
d. a defined period of time the resident has to correct cited deficiencies (e.g., 60 days) with
a start and end date (if applicable);
e. information regarding the Employee Assistance Program; and
f. notice of the right to appeal, the deadline to initiate an appeal, and that failure to timely
appeal constitutes the resident’s waiver of all appeal rights.
3) The Corrective Action should be signed by the program director, delivered to the resident in
person, and co-signed by the resident. If the resident refuses to sign, the program director should
note this on the document.
4) A copy of the signed Corrective Action must be placed in the resident’s file and forwarded to the
UW Health GME Office.
5) If the Corrective Action was suspension, probation, or dismissal and the resident timely submits
an appeal, the program director may remove the resident from participation in the program
(administrative leave) pending final resolution of the appeal.

VI. RESPONSIBILTIES
A. Clinical Competency Committee or Clinical Education Committee - advise the program director
about resident performance and progress and make recommendations to the program director
regarding promotion, remediation, and dismissal decisions.
B. Director of Graduate Medical Education – review and approve all AIPs and Corrective Actions
before they are issued to the resident; provide guidance to the program director regarding this
procedure and the proper handling of academic improvement and corrective action issues involving
residents.
C. Program Director - make decisions regarding resident performance; ensure structured feedback, AIPs
and Corrective Actions are given in accordance with this procedure and in consultation with the
Director of Graduate Medical Education.
VII. COORDINATION
Sr. Management Sponsor: Susan L. Goelzer, M.D., M.S., Designated Institutional Official
Author: Director, Graduate Medical Education and Medical Staff Administration
Approval Committee: Graduate Medical Education Committee
SIGNED BY
Susan L. Goelzer, M.D., M.S.
Professor of Anesthesiology, Internal Medicine and Population Health Sciences
Senior Medical Director for GME/Designated Institutional Official
Associate Dean for Graduate Medical Education

Revision Details:
Previous Revision Date: New
Next Revision Due: 12/16/2018 (3 years after effective date)