Be informed about policies that guide and protect McGaw Medical Center of Northwestern University, trainees, and program staff.
Addressing Housestaff Concerns and Grievances
The McGaw Medical Center of Northwestern University is committed to providing a supportive educational environment for its trainees. An important part of that commitment is to maintain an educational and professional culture that fosters learning for all housestaff members. McGaw residents and fellows and Northwestern University Feinberg School of Medicine (FSM) faculty members are governed by the Safe and Healthy Learning Environment Policy.
All faculty members, students, residents, and fellows must review this policy yearly and attest they understand and will abide by its contents.
Housestaff members who have any concerns regarding their educational and/or professional environment may raise their concerns either in writing or verbally in a variety of ways without fear of intimidation or retaliation. There is no time limit to reporting concerns. Routes to report concerns, feedback, or grievances include: Program Director, faculty mentor, Chief Resident, Departmental Chair, McGaw-GME Office, Designated Institutional Official (DIO), FSM Ombudsperson, Vice Dean for Education, McGaw Housestaff Association/Northwestern McGaw Underrepresented Residents & Fellows Forum (NMURFF). Concerns may also be raised via the online anonymous portal.
Once a concern is raised, the contact person will notify the Designated Institutional Official (DIO)/Dean for Graduate Medical Education. The DIO will arrange a meeting between the individual housestaff member (if known) or the reporter (Ombudsperson, McGaw Housestaff Association or NMURFF representative, Faculty member), the DIO, and other appropriate McGaw leadership to discuss the issues involved and to attempt to resolve those issues. If a resolution is successfully reached at this meeting, the DIO will issue a short written statement to the housestaff member, reporter, and/or others as needed, setting forth the agreed upon resolution. If a resolution is not successfully reached after a meeting with the DIO, the DIO may convene an ad-hoc subcommittee of the GMEC, implement a GMEC directed Internal Review, or take whatever other action s/he deems appropriate under the circumstances. If the investigation finds a concern regarding faculty, Departmental leadership, the learning environment, or other significant issue(s), the Dean of FSM will be notified. In the event that the DIO is the subject of the concerns, feels a conflict of interest, or is otherwise unable or unwilling to fulfill this role, the President of McGaw will select a faculty member of the GMEC to fulfill the role of the DIO with regard to the grievance. If the housestaff member has concerns regarding the process or its fairness, they should contact the confidential/discreet FSM Ombudsperson or the Vice Dean for Education. Faculty issues, including a perceived conflict of interest, may also be brought to the Vice Dean for Faculty Affairs, William Lowe, MD, for discussion and evaluation.
McGaw forbids retaliation against anyone for reporting a concern, registering a complaint, or reporting harassment pursuant to Northwestern University’s Non-Harassment and Non-Discrimination policy, assisting in making a harassment complaint, participating in an investigation, filing a charge of discrimination, or otherwise pursuing his/her rights under applicable municipal, county, state, and federal laws. Anyone experiencing or witnessing any conduct s/he believes to be retaliatory should immediately report it to any of the individuals named above, the confidential/discreet FSM Ombudsperson, or FSM leadership including the DIO/Associate Dean for GME or the Vice Dean of Education. Please note that both Northwestern University and all member hospitals have codes of conduct and non-retaliation policies that relate to the conduct of hospital employees in a teaching institution and the responsibility of a safe and healthy learning environment for trainees.
Connectivity with Other Policies
Issues relating to housestaff evaluation and actions taken to address performance deficiencies may be not covered by these Procedures for Addressing Housestaff Concerns and Grievances. Appeals of such actions are governed by the Evaluation and Addressing Performance Deficiencies section of the Housestaff Manual. Similarly, issues relating to sexual harassment and/or harassment or discrimination based upon sex, race, color, religion, ancestry or national origin, age, disability, marital status, parental status, sexual orientation, veteran status, citizenship status, or other protected group statuses are not covered by this section and should be addressed through the Non-Discrimination and Harassment policy of the Housestaff Manual.
Clinical Experience and Education (formerly Duty Hours)
Every McGaw training program, be it ACGME-accredited or a NAMF track must comply with the current clinical experience and education requirements specified by the Accreditation Council for Graduate Medical Education (ACGME). A request for exception to these requirements must first be approved by the GMEC and then by the program’s ACGME Residency Review Committee (RRC), if applicable.
The terms “clinical experience and education,” “clinical and educational work,” and “work hours” replace the terms “duty hours,” “duty periods,” and “duty” in the ACGME Common Program Requirements Section VI.
The Program Director from each training program must:
File a detailed clinical experience and education policy with the GMEC which covers all major assignments and specifies the means by which clinical and educational work and fatigue will be monitored;
Provide the GMEC with the program’s current policy annually and whenever changes to the program impact clinical experience and/or education;
Ensure that faculty and trainees in the program have received education in the effects of fatigue;
Ensure that residents and fellows respond to surveys regarding compliance with clinical experience and education from both the ACGME and McGaw;
Specify the method and frequency of the their review of the trainees’ clinical and educational work hours within the program’s clinical experience and education policy;
Ensure residents and fellows utilize New Innovations (NI) to record a daily log of their clinical and educational work. The frequency of entering hours may be at the discretion of the Program Director, but should not exceed 4 week intervals;
Ensure residents and fellows utilize NI to accurately record vacation and sick time. Although the frequency of logging may be at the discretion of the Program Director, vacation and sick entries in NI must be updated as changes occur; and
Utilize NI to identify areas of risk for violations of McGaw and ACGME policy and implement corrective actions;
Utilize NI to track trainees’ clinical experience and education. This process must include real-time reviews of all trainees across all rotations at least quarterly. Most programs will require more frequent monitoring. Program Directors must ensure the following when reviewing logs:
- Clinical and educational work is limited to 80 hours per week (averaged over a 4 week period), inclusive of all in-house clinical and educational activities, clinical work done from home, and moonlighting.
- Clinical work done from home must be counted toward the 80-hour weekly maximum. These hours should be logged in NI using the “Home call” duty type. Types of work from home that must be counted include using an electronic health record and taking calls. Reading done in preparation for the following day’s cases, studying, and research done from home do not count toward the 80 hours.
- Clinical work periods for all residents and fellows must not exceed 24 hours of continuous scheduled clinical assignments.
- In-house call can occur no more frequently than once every 3 nights (when averaged over a 4 week period).
- All trainees must have at least 14 hours free of clinical work after 24 hours of clinical assignments.
- Residents and fellows must be scheduled a minimum of one day in seven free of clinical work and education (when averaged over four weeks). At-home call cannot be assigned on these free days.
- In-house night float must occur within the context of both the 80-hour and one- day-off-in-seven requirements.
The GMEC shall:
- Approve and maintain a clinical experience and education policy from each training program via the Annual Program Review (APE) process;
- Review instances of non-compliance based on the NI data and request follow-up when warranted;
- Review the results of externally-conducted surveys of residents and fellows regarding clinical experience and education (including the ACGME resident survey) and request follow-up when appropriate; and
- Review a program’s compliance with the clinical experience and education policy at the time of Internal Review.
The GME office/DIO shall:
- Review the NI clinical experience and education logs quarterly;
- Request a formal response from the Program Director for isolated or extremely rare instances of non-compliance; and
- Bring to the GMEC any instances of non-compliance deemed to be more than extremely rare.
Program-Initiated Request for Clinical Work Hour Exceptions
McGaw will not consider requests for clinical work hour exceptions.
Conduct and Discipline of Housestaff Members
Conduct and Responsibilities
Housestaff members should strive for excellence in all aspects of patient care and teaching. This includes professional demeanor and conduct at all times, including but not limited to patient care and communication with family members, other health care team members, students, and staff. Please note that violations of the Conduct and Responsibilities policies of McGaw, other policies of McGaw, or the policy of any McGaw member hospital – or any other conduct or performance deemed to be inappropriate, unprofessional, or otherwise deficient – may result in disciplinary action, up to and including dismissal or termination, in accordance with the procedures set forth in the Evaluation and Addressing Performance Deficiencies section of this policy.
Housestaff members must be familiar with and adhere to all of their training program’s policies, including but not limited to the supervision policy regarding the manner in which they report to and are supervised by attending physicians or other supervisors in all clinical settings. Among other things, housestaff members must communicate effectively and promptly with their immediate supervisors or directly to attending physicians as outlined by the Program Director, attending physicians, or other supervisors.
Discussion of a patient’s clinical condition, other than with the patient, should be conducted in appropriate settings and in a manner that safeguards patient privacy and confidentiality. Discussion in hallways, elevators, or any other place within earshot of any patients or visitors is unprofessional and may violate a patient's right to privacy. Housestaff members are responsible for knowing and complying with federal, state, and local laws and any applicable hospital policies governing patient privacy and confidentiality. Derogatory remarks about patients, patient families or visitors, or other professional personnel are unacceptable in any setting.
No housestaff member, in his or her actions or attitudes, may mistreat or misuse confidential or proprietary information; release confidential information including electronic passwords to unauthorized persons; leave patients under his or her care unattended; falsify institutional or personal records; steal, remove, or be in unauthorized possession of hospital, medical school, or other persons' property; or exhibit insubordination toward his or her clinical supervisor. The use of non-hospital or off-site electronic equipment, tablets, phones, servers, and/or computers for patient information, research, or clinical care is not allowed. Housestaff must comply with all Feinberg School of Medicine IT policies as well as those of base hospitals. Housestaff who fail to comply with IT policies will face disciplinary action as above.
Each McGaw member hospital maintains a policy on unacceptable conduct. Housestaff are responsible for reviewing the policy for every McGaw hospital to which they rotate and complying with applicable policies.
Housestaff members may prescribe or administer medications only to registered inpatients and outpatients who are under their supervised care in connection with a McGaw training program and for whom ongoing care permits knowledge of a patient’s medical history, physical examination, and results of appropriate diagnostic or screening tests. Providing “casual” prescriptions for oneself, friends, acquaintances, students, colleagues, staff, or others outside of the context of an established physician-patient relationship is prohibited. Housestaff members may not write such prescriptions nor may they self-prescribe medications. This policy applies to all housestaff, including those who have a permanent Illinois medical license. Housestaff are reminded that the liability insurance provided to them covers only their supervised practice within the training program to which they are appointed and excludes external moonlighting. Providing “casual” prescriptions represents medical practice outside of the scope of training and is therefore not allowed.
Should a housestaff member become ill while on duty and be unable to provide safe, high quality patient care, s/he should contact the appropriate supervisor in order to be relieved of duty. If medical attention is required, the individual should contact his/her personal physician or register at an acute care or emergency facility. An ill housestaff member should not return to duty until sufficiently recovered to carry out his/her duties. A housestaff member is expressly forbidden from the personal use of facilities, supplies, or medications at any training site in order to receive treatment that expedites a return to duty before s/he is sufficiently recovered (e.g., intravenous hydration). Similarly, a housestaff member may not assist with such treatment of other housestaff members, students, colleagues, or staff. The unauthorized use of hospital or clinic supplies or diverted patient medications is strictly prohibited and may constitute theft.
Housestaff members shall not use potentially addictive, abusive, or illicit drugs, including marijuana. Use of such drugs in any environment or in any amount is incompatible with safe clinical performance. Sick leave should be requested for the duration of time a housestaff member needs to use prescription medication(s) that impairs cognitive or motor function. Housestaff members shall not use alcohol when they may be called upon to provide, or while providing, direct patient care or advice to those providing direct care (for example, when on home call).
Housestaff members shall not provide patient care under circumstances of possible physical, mental, or emotional lack of fitness that could interfere with the quality of that care. It is the responsibility of the housestaff member, upon identifying a situation in which s/he or any other housestaff member is impaired to the potential detriment of patient care, to notify the supervising physician to arrange for alternative patient care coverage.
A housestaff member's demeanor should be professional at all times, and his or her neatness, cleanliness, and appearance should fall within accepted professional standards as determined by McGaw. Scrubs are only to be worn in clinical settings explicitly requiring their use and must be covered appropriately upon leaving the patient unit/operating room.
Housestaff members must comply with the clinical experience and education policy of the training program to which s/he is assigned. From time to time during training, housestaff members may receive surveys from a variety of sources regarding clinical experience and education. Each housestaff member is responsible for answering such surveys promptly and truthfully regarding his/her compliance with the relevant policy.
Housestaff members will receive a Northwestern University Network Identifier (NetID) and email address at orientation. The NetID and password identify the individual to the network and allow the housestaff member to access a variety of resources and services. The NetID is the housestaff member's electronic identity at McGaw. Each housestaff member is responsible for (1) maintaining his/her Northwestern University email address by changing the password whenever prompted to do so, and (2) checking his/her e-mail at this account on a regular basis. This will be the main mode of communication from the McGaw GME Office and from Program Directors. Forwarding of email to secure email servers such as nm.org, ric.org and luriechildrens.org is permissible. Forwarding email to nonsecure servers such as Gmail, AOL and Yahoo is not allowed.
Fitness for Duty
Housestaff must remain fit for duty at all times, which means that they must be able to perform their duties in a safe, appropriate, and effective manner. McGaw, through a clinical department Chair, Program Director, or Associate Dean for Graduate Medical Education/Designated Institutional Official (“DIO”)/Vice President for Academic Affairs may require that a housestaff member be removed from clinical care and undergo a fitness-for-duty evaluation at any time if apparent cause or reasonable suspicion exists to believe that a housestaff member is impaired or otherwise unfit.
A fitness-for-duty evaluation may include a comprehensive medical and psychological assessment and drug and alcohol screening. The examination results will be released to the Program Director and Vice President for Academic Affairs/DIO. Housestaff members shall comply with this policy and cooperate fully with its provisions. The housestaff member will remain on paid leave pending completion of the fitness-for-duty evaluation. The fitness-for-duty evaluation may be undertaken in conjunction or in parallel with other investigations or disciplinary actions. A fitness-for-duty evaluation will become part of the housestaff’s permanent file.
A housestaff member found to be impaired due to suspected alcohol or drug use will be removed from patient care responsibilities pending further evaluation in accordance with the provisions described under the Drug and Alcohol Abuse Section.
Drug and Alcohol Abuse
Drug and alcohol abuse is defined as the use of any potentially addictive, abusive, or illicit drug, including marijuana, or the use of alcohol to the extent of even minor impairment of cognitive or motor function.
A drug test result will be considered positive if drugs are detected in an amount above the detection limits established by the testing laboratory; a test will be considered negative if drugs are detected in an amount below these limits. Impairment of cognitive or motor functions is defined as a situation of unusual or aberrant behavior including but not limited to slurred speech, unsteady gait, abusive language, disheveled appearance, or diminution of fine motor coordination.
If a Program Director has apparent cause or reasonable suspicion to believe that a housestaff member may be under the influence of drugs or alcohol or otherwise impaired, the housestaff member may be removed immediately from his/her duties and immediately required to submit to a fitness for duty evaluation that may include testing for drugs or alcohol, a medical evaluation, a referral for a psychological or psychiatric evaluation, or any other evaluation or testing deemed necessary. Apparent cause or reasonable suspicion may be based upon the Program Director or a faculty member’s own observations or information obtained from other McGaw representatives, any McGaw member hospital, or any non-McGaw clinical site. Housestaff members must cooperate fully with the fitness for duty evaluation process.
A housestaff member who refuses to undergo a drug or alcohol test, or any other aspect of a fitness for duty evaluation, as outlined above or to sign a release authorizing disclosure of the results of the evaluation to McGaw, will be subject to disciplinary action, up to and including termination in accordance with the procedures set forth in the Evaluation and Addressing Performance Deficiencies section of this policy. In addition, a housestaff member who tests positive for drugs or alcohol may be terminated by McGaw in consultation with the Vice President for Academic Affairs/DIO in accordance with the procedures set forth in the Evaluation and Addressing Performance Deficiencies section of this policy. If permitted to remain in the program, the housestaff member may be required to enroll in a chemical dependence program selected by the Program Director or at the Program Director's discretion. The housestaff member may propose a program for review and approval by the Vice President for Academic Affairs/DIO. Prior to returning to clinical duties, McGaw may, in its sole discretion, require the housestaff member to submit to and pass a fitness for duty examination and/or sign a contract that specifies and requires expected behaviors.
Medical leave for chemical dependence shall be documented in the housestaff member's permanent file. If this information is requested, it shall be part of the information released to support future applications for licensure, clinical privileges, or certification to the extent permitted by law.
Evaluation and Addressing Performance Deficiencies
The procedures set below are applicable to all housestaff members in all McGaw training programs. All references to housestaff members shall include both residents and fellows.
Supervising faculty will provide written evaluations and/or oral feedback regarding the performance of housestaff members. Nursing and technical personnel, administrators, fellow housestaff members, medical students, and patients may also provide written and/or oral feedback regarding a housestaff member’s performance. Such evaluations and/or feedback may be provided directly to housestaff members and/or to the Program Director or his/her designee. The Program Director or his/or designee will review any evaluations and/or feedback with the housestaff member at a time or times to be determined by the Program Director or his/her designee in accordance with any applicable accreditation requirements and may also share such evaluations and/or feedback with the Associate Dean for Graduate Medical Education/Designated Institutional Official (DIO) or other representatives of McGaw, McGaw’s member institutions, or sites at which housestaff members train. If the Program Director or DIO determines at any time in his/her judgment that a housestaff member’s performance is unsatisfactory, the Program Director or DIO will advise the housestaff member regarding the performance deficiencies and the expectations for improvement.
The Program Director shall maintain a training file for each housestaff member. Any written evaluations will be included in this file. Any disciplinary action, fitness for duty evaluation, investigation, leave, or chemical dependency will be documented in the training file. A housestaff member may review his/her training file by contacting the Program Director. McGaw will not release the training file directly to the trainee.
Basis for Evaluations
Each housestaff member will be evaluated according to his/her performance appropriate to his/her educational level in the following areas:
- Competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice
- Compliance with all terms and conditions set forth in the housestaff member's training contract and this Conduct and Discipline policy
- Compliance with other practices, rules, regulations, procedures, and policies of McGaw, and
- Compliance with practices, rules, regulations, procedures, and policies in place at any training location, including McGaw member hospitals and non-McGaw clinical sites.
Addressing Performance Deficiencies
The process used to address performance deficiencies is described below. The procedures set forth below are intended to treat the housestaff member fairly if performance deficiencies arise.
If the DIO, after consulting with the Program Director, determines that a housestaff member’s performance is unsatisfactory and therefore decides that probation, non-reappointment/non-renewal, non-promotion, suspension, dismissal, or termination is appropriate, the DIO or Program Director will notify the housestaff member of this decision in writing. The written decision of the DIO or Program Director will include a statement of the reasons for the adverse action. Upon request, the housestaff member shall have the opportunity to review his or her training file but may not copy it. In circumstances where the DIO determines, in consultation with the Program Director, that a housestaff member’s continued presence would pose an unacceptable threat to patient safety, the DIO or Program Director may place the housestaff member on summary administrative leave (with pay and benefits) pending an investigation or final decision in accordance with the procedures set forth in this section.
Letter of Warning
A letter of warning is appropriate if concerns arise or continue regarding the performance or conduct of a housestaff member that do not warrant probation or other type of disciplinary action. A warning will be given to the housestaff member explaining why the conduct or performance is unacceptable. Such a warning may include notification that continued lack of improvement may warrant probation or other more severe disciplinary action. A warning should be provided to the trainee in person and in writing. A letter of warning does not represent a disciplinary action, thus there is no appeal process available to challenge a letter of warning.
Probation is appropriate if a housestaff member’s performance falls below acceptable standards or other deficiencies exist. A decision to place a housestaff member on probation may be preceded by a warning, but a prior warning is not a prerequisite to placing a housestaff member on probation (or to imposing any other form of disciplinary action). The reasons for probation should be explained to the housestaff member in person and in writing. Expectations for improvement, the methods for evaluating improvement, the anticipated duration of probation, and possible future actions should be delineated in writing.
A probationary period should be long enough to permit a thorough evaluation of progress. Except in unusual circumstances, a period of at least two to four months will be appropriate, but the length of any period of probation shall be determined by McGaw in its sole discretion on a case-by-case basis. Alternatively, if a trainee’s lack of progress requires a period of probation late in the training year, there should be consideration of extending the current training year until a decision regarding adequacy of remediation can be made.
A template for a probationary letter is available in the GME office. Please contact the GME office at 312-503-7975.
Suspension is appropriate if a housestaff member’s performance deficiencies are deemed to be sufficiently serious as to warrant such action. Suspension is a period of time in which the housestaff member is not allowed to take part in any training activities or other activities associated with his/her program, except for any activities expressly approved by the DIO. Suspension may or may not be linked to an ongoing investigation or evaluation of the trainee’s performance. Any time spent on a period of suspension may not be counted toward completion of program requirements. A suspension may be with or without pay, depending upon the circumstances to be determined by the DIO.
Non-promotion is appropriate if a housestaff member is not making progress sufficient to warrant promotion to the next PGY level. In this case, the housestaff member may be required to repeat an entire year of training or only specific rotations. The housestaff member’s total length of training will be extended. Non-promotion may or may not follow a preceding warning or period of probation. Non-promotion may also be implemented independently by the Program Director or DIO, in consultation with the program’s Clinical Competency Committee (CCC) as a non-disciplinary educational action. In cases of non-promotion, the housestaff member may still appeal the decision as set forth below.
A housestaff member’s serious performance deficiencies and/or failure to remediate suboptimal academic and/or clinical performance may lead to a decision by the Program Director or the DIO not to reappoint the housestaff member at the end of the current training year (non-reappointment), to dismiss, or terminate the housestaff member immediately during an academic year. The action should be explained to the housestaff member in person and in writing. A template letter for a non-reappointment or dismissal/termination is available in the GME office. Please contact the GME office at 312-503-7975.
Early departure from a training program for any reason will be communicated by the Program Director with the Illinois Department of Financial and Professional Regulation (IDFPR) in keeping with state law and will include a description of any disciplinary action or investigation.
Appealing Adverse Action
As noted above, letters of warning are not adverse actions and are therefore not subject to appeal.
All appeals must be based upon one or more of the following: (a) an error of procedure that reasonably could have affected the outcome of the decision being appealed; (b) new information that reasonably could have affected the outcome of the decision being appealed and that was not reasonably available at the time the decision being appealed was made; or (c) the decision or adverse action being manifestly unreasonable and unsupported by the great weight of the information considered in reaching the decision or adverse action that is being appealed.
To appeal an adverse action that is subject to appeal, a housestaff member must submit a written request for appeal to the DIO within seven (7) calendar days of receiving written notification of the decision. Any request for appeal must include a statement of the precise action being appealed and of the grounds supporting the appeal. The housestaff member may also submit documentary evidence in support of his or her appeal. The DIO will appoint a member of the Graduate Medical Education Committee (GMEC) to convene an ad hoc appeals committee (“the Appeals Committee”) comprised of three (3) members of the GMEC who were not involved in the decision that is the subject of the appeal to review the housestaff member’s training file and any documentation submitted by the housestaff member in support of his or her appeal. Neither the DIO nor the Program Director will serve as a member of the appeals committee, but the appeals committee may wish to hear from the DIO and/or the Program Director in evaluating the housestaff member’s appeal. If requested by the housestaff member or by the appeals committee, the housestaff member will be given an opportunity to appear before the appeals committee. The housestaff member may bring a support person to the Appeals Committee meeting who is a member of the Northwestern Community (such as a trusted faculty mentor). The support person may not be a family member, a housestaff member, or an attorney. The support person may not address the committee directly. After deliberations, the Appeals Committee will arrive at a recommendation by majority vote and report its recommendation in writing to the President of McGaw, the DIO, and the Program Director whether to sustain, reverse, or modify the decision that is the subject of the appeal. The Appeals Committee may recommend imposition of a harsher sanction than the sanction initially imposed. The DIO or Program Director will notify the housestaff member of the recommendation of the Appeals Committee in writing within five (5) days of receiving the recommendation of the Appeals Committee.
After receiving the recommendation of the Appeals Committee, the President of McGaw will make the final determination regarding the appeal. The President shall consider the information in the housestaff member’s training file and any other documentation presented to or considered by the Appeals Committee, as well as the Appeals Committee’s recommendation and any other information that the President deems relevant. The Appeals Committee’s recommendation is not binding on the President. The President may, in his/her discretion, interview the housestaff member, the DIO, the Program Director, the Chair of the Appeals Committee, and the Vice President for Academic Affairs, as well as any faculty members responsible for the supervision of the housestaff member or any other individuals with knowledge regarding the housestaff member’s performance.
The President may accept, reject, or modify the decision that is the subject of the appeal. This includes increasing the sanction imposed if the President determines, in his/her professional and academic judgment, that such an action is warranted, regardless of whether the Appeals Committee recommends doing so. The President will notify the housestaff member and the Program Director of his/her decision in writing. This decision will be final.
McGaw will make every effort to convey a decision not to reappoint or promote a housestaff member at least four months prior to the end of his/her current training year, but any failure on the part of McGaw to do so will not be grounds for challenging or overturning the decision not to reappoint a housestaff member.
All actions regarding performance deficiencies shall be documented in the housestaff member's permanent file. If this information is requested, it shall be part of the information released to licensing bodies or in connection with future applications for licensure, clinical privileges, certification, training, or employment to the extent required or permitted by law.
Addressing Performance Deficiencies After Separation from McGaw
This policy applies to cases in which McGaw becomes aware of information after a housestaff member has completed, resigns, or otherwise leaves his or her training program that would have resulted in the housestaff member not being permitted to complete the training program or the housestaff member being subjected to investigation, warning, probation, non-reappointment, suspension, dismissal, or termination pursuant to McGaw’s Evaluation and Addressing Performance Deficiencies policy.
McGaw and its training programs reserve the right to take action to address performance deficiencies that become known to McGaw after a housestaff member completes, resigns from, or otherwise leaves his or her training program. Such performance deficiencies could include, but are not limited to, conduct that is inconsistent with McGaw policies, procedures or standards; conduct that is inconsistent with any policy, procedure, or standard of any McGaw member hospital or other training site; and conduct that McGaw determines in its judgment to be unprofessional. Possible actions include, but are not limited to, revocation of the former housestaff member’s training certificate; retroactive dismissal or termination; or reports of findings to external agencies, such as the Accreditation Council for Graduate Medical Education, state or other medical licensing boards, specialty certification boards, hospital appointment committees, hospitals or other potential employers, and licensing or credentialing verification services or bodies.
Prior to any action being taken by McGaw, the former housestaff member will be provided with notice of the suspected or alleged performance deficiencies and the action that McGaw proposes to take to address such deficiencies and will also be given an opportunity to respond to the information presented by McGaw. In addition, the former housestaff member will have the right to appeal any adverse decision as outlined in the Addressing Performance Deficiencies section of this policy.
Housestaff, Faculty, and Program Evaluation
The purpose of this policy is to establish uniform expectations and procedures regarding housestaff, faculty, and program evaluations for all McGaw training programs.
McGaw training program: Includes all accredited by the Accreditation Council for Graduate Medical Education (ACGME) and Non-Accredited McGaw Fellowship (NAMF) programs.
Housestaff: Interns, residents, and fellows in any McGaw training program.
New Innovations (NI): Web-based Residency Management System (RMS) required to be utilized by all McGaw training programs to distribute and collect all evaluation data.
Evaluation and feedback are critical to the development of the housestaff and to continuous improvement in the educational process. Evaluations are to be used in making decisions about promotion, program completion, remediation, and any disciplinary action.
Each housestaff member will be evaluated according to his/her performance appropriate to his/her educational level, in the following areas:
- ACGME core competencies in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice
- Compliance with all terms and conditions set forth in the housestaff member's training contract and McGaw policies
- Compliance with other practices, rules, regulations, procedures, and policies of McGaw, and
- Compliance with practices, rules, regulations, procedures, and policies in place at any training location, including McGaw member hospitals and non-McGaw clinical sites.
McGaw’s Graduate Medical Education Committee (GMEC) has mandated the use of New Innovations to be the electronic evaluation system utilized by all McGaw training programs for distribution and collection of formative evaluations of housestaff, faculty evaluations, and program evaluations.
Anonymity of Evaluations
Faculty members must complete and sign all evaluations regarding the performance of trainees in a timely fashion.
All evaluations completed by interns, residents, and fellows must be confidential from program leadership and faculty.
Formative Evaluations of Housestaff
The faculty must evaluate housestaff performance in a timely manner during each rotation or similar educational assignment and document this evaluation at completion of the assignment.
The program must:
- Provide objective assessments of competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice
- Use multiple evaluators (e.g., faculty, peers, patients, self, and other professional staff) and multiple assessment tools (e.g. global evaluations, 360 evaluation, self-evaluation, etc.)
- Document progressive resident performance improvement appropriate to educational level
- Provide residents/fellows with documented semi-annual evaluation of performance with feedback, and
- Document semi-annual face-to-face meeting with the Program Director.
The Program Director must provide a written summative evaluation for each resident/fellow upon completion of the program. This evaluation is to ensure that residents/fellows are able to practice core professional activities without supervision upon completion of program. The evaluation must become part of the resident/fellow’s permanent record maintained by the institution.
The Program Director must:
- Document the resident/fellow performance during the final period of education
- Document a summative final evaluation including the approved ACGME verbiage
- Verify that the resident/fellow has “demonstrated sufficient competence to enter practice without direct supervision” and include this statement in the summative evaluation, and
- Include dates and signatures on the evaluation by both the Program Director and resident/fellow.
The Program Director shall maintain a training file for each resident/fellow. The evaluations of resident/fellow performance should be included in this file and be accessible for review by the resident/fellow and other authorized personnel, including the Designated Institutional Official and Director of Accreditation for McGaw, in accordance with this policy.
Evaluation of Faculty
The evaluation must:
- Include an annual evaluation by the program of faculty performance as it relates to the educational program and the faculty’s clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism, and scholarly activities, and
- Include at least an annual written confidential evaluation by the residents/fellows.
Program Evaluations and Improvement
The program, through its Program Evaluation Committee (PEC) must document formal, systematic evaluation of the curriculum at least annually and is responsible for rendering a written annual program evaluation (APE) using the standard institutional APE template. The program must monitor and track each of the following areas:
- Resident/fellow performance
- Faculty development
- Graduate performance, including performance of program graduates on the certification exam
- Program quality, and
- Progress on the previous year’s action plan(s).
Housestaff and faculty must evaluate the program confidentially and in writing at least annually.
The program must use the results of resident/fellows’ and faculty members’ assessments of the program together with other program evaluation results to improve the program.
The PEC must prepare a written plan of action to document initiatives to improve performance in one or more areas listed above, as well as delineate how they will be measured and monitored.
The action plan should:
- Be reviewed and approved by the teaching faculty, and
- Include the meeting’s minutes which must state the date of the meeting and a list of those in attendance (making certain to identify residents/fellows and faculty).
A passing score on both the USMLE Step 1 and Step 2 (Clinical Knowledge) exams - or, Canadian or osteopathic equivalent - is a prerequisite for starting training in any McGaw residency program. All new residents will be asked to submit official score reports to the GME Office prior to starting training.
The above requirement also applies to international medical school graduates.
All residents are strongly encouraged to take the USMLE Step 3 exam as soon as they are eligible.
All fellows must pass Step 3 (or equivalent) before starting a fellowship unless they are on a J-1 training visa and located outside of the United States of America, thus physically unable to sit for the examination. All new fellows will be asked to submit an official score report to the GME Office prior to starting training.
These policies and procedures apply to all housestaff members (residents and fellows) in McGaw training programs. Please note that a web link to hospital-specific policies and procedures on topics such as identification badges, medical record training, pagers, etc. is provided in this Manual. Housestaff members are responsible for complying with any applicable hospital policies and procedures and should review them from time to time, as they may be subject to change.
- Northwestern Memorial Hospital/Northwestern Memorial HealthCare
- Shirley Ryan Ability Lab
- Ann & Robert H. Lurie Children's Hospital of Chicago
- Jesse Brown VA Medical Center
- MacNeal Hospital
McGaw housestaff must adhere to the IT policies of Northwestern University Feinberg School of Medicine, with special attention to the following.
McGaw realizes that trainees may be involved in intellectual property (IP) development while appointed through McGaw. However, it is important to remember that any product, invention, copyright, patent, or other intellectual property created as a result of work done as a McGaw Medical Center trainee must be reviewed by the McGaw IP Committee to determine the role of McGaw and need for assignment of property to McGaw. Please also note that such work (including performing research under faculty supervision) is also subject to Northwestern University and/or base hospital intellectual property policies, which may require you to assign such intellectual property to Northwestern University or the base hospital and execute related documentation to effect the same. Additional support that must be reported include base hospital/Northwestern University resources such as computers/space or funding that are used in the creation of the IP. To determine what additional steps need to be done, trainees should promptly report the development of any IP during the course of training to the DIO in writing.
Each housestaff member must have a valid Illinois medical license. No housestaff member shall begin training until a valid license is issued nor will credit be given for time spent in activities performed prior to obtaining a license. It is the responsibility of each housestaff member to obtain or renew his or her permanent or temporary license.
Temporary licenses are issued for three years, but if the housestaff member has not changed programs (and upon the approval of the Medical Examining Board), can be renewed for the length of the training program.
Permanent licenses can be issued only after two full years of training and successful completion of the USMLE examinations. Some housestaff members anticipate a future position in a state other than Illinois following training and thus do not wish to pursue a permanent Illinois license.
Housestaff members who choose to complete training on a temporary license should nonetheless plan to complete the USMLE examinations as soon as they are eligible to do so. Failure to complete these examinations in a timely manner may result in a delay in obtaining a permanent license once training is complete.
Moonlighting/Extra Call for Pay
The term "moonlighting" refers to employment outside of the activities of the training program for the purpose of providing medical services regardless of whether it is performed at one of the McGaw affiliated hospitals or at another non-affiliated institution. The official policy of McGaw and its member hospitals is that moonlighting must not interfere with the housestaff member’s ability to achieve the goals and objectives of his or her training program. Furthermore, moonlighting constitutes the unlicensed practice of medicine unless the trainee has been issued a permanent medical license by the state in which the moonlighting occurs.
McGaw and its affiliated hospitals are not responsible for any professional activities in which housestaff members participate outside the scope of the training program to which they are appointed. Neither professional liability nor workers' compensation insurance provided by McGaw affiliated hospitals covers these activities.
The desire to perform moonlighting activities must be reported to the housestaff member's Program Director and may occur only with written permission. The written permission will be maintained in the housestaff member's training file. The Program Director will monitor the housestaff member's performance to ensure that the moonlighting activities are not excessive and do not impair the housestaff member's ability to carry out assigned McGaw responsibilities. If the Program Director denies or withdraws permission to moonlight, any failure to comply with the Program Director’s decision shall be considered insubordination and may lead to the housestaff member being placed on probation, suspended, dismissed, or terminated as outlined in the Evaluation and Addressing Performance Deficiencies section of the McGaw Conduct and Discipline policy.
Some training programs may offer pay for taking additional call. When such an opportunity is offered by a program, participation by housestaff members is voluntary and shall not be required. When a housestaff member is taking additional call for pay within his/her training program, the same supervision policy applies as when the housestaff member is taking regular training call. The time spent taking such additional call must be included in calculating total work hours.
The Program Director from each training program must:
- Have a Moonlighting policy specifically stating whether housestaff are allowed to moonlight during training
- Include individual written permission in housestaff member’s training file
- Ensure that all housestaff log moonlighting hours in New Innovations (NI), as these must be counted towards the 80-hour Maximum Weekly Hour Limit. The frequency of entering hours may be at the discretion of the Program Director, but should not exceed four week intervals, and
- Utilize NI for the institutional purpose of tracking moonlighting to include at least quarterly real-time reviews of all trainees across all rotations. Most programs will require more frequent monitoring.
Housestaff who choose to moonlight must:
- Have a valid permanent license
- Not be a visa holder
- Obtain own professional liability and workers’ compensation insurance
- Regularly log work hours accurately in New Innovations (NI), and
- Obtain Program Director’s written permission.
The GMEC shall:
- Approve and maintain a moonlighting policy from each training program via the Annual Program Evaluation (APE) process, and
- Review instances of non-compliance based on the NI data and request follow-up when warranted.
The GME office/DIO shall:
- Review the NI work hours quarterly (including moonlighting)
- Request a formal response from the program Director for isolated or extremely rare instances of non-compliance, and
- Bring to the GMEC any instances of non-compliance deemed to be more than extremely rare.
Raise Concerns and Provide Confidential Feedback without Retaliation or Intimidation
McGaw is committed to providing a supportive educational environment. An important part of that commitment is to maintain an educational and professional culture that fosters learning for all housestaff members. McGaw residents and fellows and Northwestern University Feinberg School of Medicine faculty members are governed by the Safe and Healthy Learning Environment Policy found here:
All faculty members, students, residents, and fellows must review this policy yearly and attest they understand and will abide by its contents.
Housestaff members who have any concerns regarding their educational and/or professional environment may raise their concerns either in writing or verbally in a variety of ways without fear of intimidation or retaliation. There is no time limit to reporting concerns. Methods to report include:
a) Bringing concerns to their Program Director or other Departmental Advisor.
b) If a housestaff member does not feel comfortable raising an issue with his/her Program Director, s/he may contact the ACGME Designated Institutional Official (DIO), Joshua Goldstein, MD. Alternatively, a housestaff member may bring his/her concern to the attention of Nancy Parlapiano, McGaw Executive Director of Graduate Medical Education. Either of these individuals can be reached in person at the GME office on the first floor of the McGaw Pavilion, by email, or by phone at 312-503-7975.
c) McGaw also provides an online portal for submitting anonymous feedback.
d) Housestaff may directly contact the confidential/discreet FSM Ombudsperson, Lisa Rone, MD who will review any situation and provide guidance.
e) Housestaff may contact their peer representatives through the McGaw Housestaff Association. Association leadership contact information is available on their dedicated page of the McGaw website. Association leadership participate in the Graduate Medical Education Committee (GMEC) and report each month on issues affecting the learning environment.
f) As detailed in the Feinberg Safe and Healthy Learning Policy, housestaff may also contact the Vice Dean for Education/President of McGaw, Diane Wayne, MD (312-503-9443) to raise issues or concerns.
McGaw forbids retaliation against anyone for reporting a concern, registering a complaint, or reporting harassment pursuant to Northwestern University’s Non-Harassment and Non-Discrimination policy, assisting in making a harassment complaint, participating in an investigation, filing a charge of discrimination, or otherwise pursuing his/her rights under applicable municipal, county, state, and federal laws. Anyone experiencing or witnessing any conduct s/he believes to be retaliatory should immediately report it to any of the individuals named above, the confidential/discreet FSM Ombudsperson, or FSM leadership including the DIO/Associate Dean for GME or the Vice Dean of Education. Please note that both Northwestern University and all member hospitals have code of conduct and non-retaliation policies that relate to the conduct of hospital employees in a teaching institution and the responsibility of a safe and healthy learning environment for trainees.
More information can be found under Addressing Housestaff Concerns and Grievances.
Safe and Healthy Learning Environment
The McGaw Medical Center of Northwestern University, in association with Northwestern University Feinberg School of Medicine (FSM), is committed to the principle that educational relationships should be one of mutual respect between teacher and learner. Because McGaw oversees the training of individuals who are entrusted with the lives and well-being of others, we have unique responsibilities to assure that residents and fellows learn as members of a community of scholars in an environment that is conducive to learning. McGaw residents and fellows are subject to and covered under the Safe and Healthy Learning Environment policies. Staff at member hospitals are likewise bound by the safe and healthy learning policy expectations through our affiliates’ code of conduct policies
Both McGaw and Feinberg want to encourage residents and fellows to bring attention to any breach or perceived breach of the Safe and Healthy Learning Environment and wish to be open about the process the University has in place should such a claim be made. This process flow document offers a snapshot of our reporting, escalation, and resolution procedures related to a perceived mistreatment claim and is an option as outlined above for McGaw trainees. The School also offers an ombudsperson for student, resident and fellow support. The ombudsperson will strive to maintain the complaint or feedback as confidentially as possible. There may be situations including those with safety concerns where some loss of confidentiality will be incurred. These situations will be communicated with the complainant by the ombudsperson. Details regarding the FSM safe and healthy learning environment policy/process are below. Note that these represent one of many option for McGaw trainees.
Maintaining a safe and healthy learning environment requires that the faculty, administration, residents, fellows, healthcare professionals, staff, and students treat each other with the respect due to colleagues. All teachers should realize that students, residents, and fellows depend on them for evaluations and references, which can advance or impede their career development. Teachers must take care to judiciously exercise this power and to maintain fairness of treatment, avoiding exploitation or the perception of mistreatment and exploitation. The quality and worth of a Feinberg School of Medicine education rest not only in the excellence of the content and the skills that are taught, but also in the example provided to students, residents and fellows of humane physicians and scientists who respect their professional colleagues at all career levels, their patients, and one another.
II. RESPONSIBILITIES OF TEACHERS AND LEARNERS
The teacher-learner relationship confers rights and responsibilities up-on both parties. Behaving in a way that embodies the ideal teacher-learner relationship fosters mutual respect, minimizes the likelihood of learner mistreatment, and optimizes the educational experience.
Responsibilities of Teachers
- Treat learners fairly, respectfully, and without bias related to their race, color, religion, national origin, sex, sexual orientation, gender identity or expression, parental or marital status, age, disability, citizenship, or veteran status.
- Distinguish between the Socratic Method, where insightful questions are a stimulus to learning and discovery, and overly aggressive questioning, where detailed queries are repeatedly presented with the endpoint of belittlement or humiliation of the learner.
- Give learners timely, constructive, and accurate feedback and opportunities for remediation.
- Provide written evaluations on time.
- Be prepared and on-time for all activities.
- Provide learners with current material and information and appropriate educational activities.
Responsibilities of Learners
Be courteous and respectful of others, regardless of their race, color, religion, national origin, sex, sexual orientation, gender identity or expression, parental or marital status, age, disability, citizenship, or veteran status.
- A student, resident, or fellow should act in accordance with the handbook associated with their educational program.
- Be prepared and on time for all activities.
- Be aware of the medical condition and current therapy of patients.
- Put patients' welfare ahead of educational needs.
- Know limitations and ask for help when needed.
- Maintain patient confidentiality.
- View feedback as an opportunity to improve knowledge and performance skills.
Inappropriate behaviors are those that are not respectful or professional in a teacher-learner relationship. Examples of inappropriate behaviors which compromise the integrity of the educational process include, but are not limited to:
- Unwanted physical contact (such as touching, hitting, slapping, kicking, pushing) or the threat of the same;
- Sexual harassment (see the Northwestern University Policy on Sexual Harassment);
- Discrimination based on race, color, religion, national origin, sex, sexual orientation, gender identity or expression, parental or marital status, age, disability, citizenship, or veteran status (see the Northwestern University Policy on Discrimination and Harassment);
- Requiring learners to perform personal chores (e.g., running errands or babysitting);
- Verbal harassment, including humiliation or belittlement in public or privately (see the Northwestern University Policy on Civility);
- Use of grading and other forms of assessment in a punitive or self-serving manner;
- Romantic or sexual relationships between a teacher and student, resident or fellow (see the Northwestern University Policy on Consensual Romantic or Sexual Relationships Between Faculty, Staff, and Students).
The list above identifies a few specific situations. See Mistreatment Examples for further examples. Other behaviors may qualify as mistreatment and, if the student, resident or fellow is unsure, s/he should consult with the appropriate faculty or university officials as detailed in Section V.
The university and medical school prohibit the taking of any retaliatory action for reporting or inquiring about alleged improper or wrongful activity. For further details, see the Northwestern University Policy on Non-Retaliation. There are additional polices of the base hospital that similarly prohibit retaliation from staff or faculty.
While we believe that professional behavior is generally practiced and respected by the members of our diverse community of scholars throughout Feinberg, we recognize there may be occasions when real or perceived incidents of unprofessional behavior directed toward learners occur. In these circumstances, Feinberg is committed to establishing the facts through a fair process, which respects, to the extent possible, the privacy of the involved parties.
A complaint should be reported in a timely fashion, typically within 30 days of the end of an academic quarter or the clinical rotation in which the alleged incident occurred (although claims of discrimination can be reported at any time). Depending upon the nature of the complaint, different avenues of reporting are available. Our approach and process for addressing complaints are outlined below, illustrated in Appendix A, and described in more detail in Section VII.
To provide students, residents and fellows with an impartial initial point of contact, a faculty ombudsperson is available for students, residents, and fellows to contact firstname.lastname@example.org. There may be situations including those with safety concerns where some loss of confidentiality will be incurred. These situations will be communicated with the complainant by the ombudsperson. Alternative contacts are outlined above in the McGaw process for the raising of concerns and include the Dean for GME, the Vice Dean for Medical Education, and the housestaff association leadership. These individuals can either help address the concern directly or help with referral to an appropriate office or individual who is best suited to address the problem.
If after discussion of the incident, the student, resident, or fellow and faculty point of contact agree that particular events could constitute mistreatment, the incident can be addressed as described below. If the incident involves sexual harassment, sexual violence, or assault, the student, resident, or fellow will be referred to the University Sexual Harassment Prevention Office for further discussion and investigation. If the incident involves other types of discrimination or discriminatory harassment, the student, resident, or fellow will be referred to the University Office of Equal Employment Opportunity and Access for further discussion and investigation.
If the incident does not fall into either of these categories, a first choice, where appropriate, is to seek informal resolution. This may be achieved through direct communication between the student, resident, or fellow and/or faculty point of contact and the respondent (individual being reported by the student) or, potentially, other avenues of communication. If an informal approach is either not appropriate or unsuccessful, then the student, resident, or fellow should make a formal complaint with the Dean for GME or Vice Dean for Education.
If the incident does not involve sexual harassment or other types of discrimination or discriminatory harassment and the student, resident, or fellow and faculty point of contact disagree that the incident was mistreatment, the student, resident, or fellow may pursue the matter directly with McGaw.
Students, residents, and fellows may always directly contact an office empowered to address specific policies. In cases of possible sexual harassment or sexual assault or violence, the University Sexual Harassment Prevention Office may be contacted directly at email@example.com or 847-491-3745. Additional information related to a student, resident, or fellow’s rights and options if they have experienced sexual assault or violence is available on the Title IX resource page. For concerns related to discrimination and harassment, the Office of Equal Opportunity and Access may be contacted at firstname.lastname@example.org or 847-491-7458.
VI. CONFLICTS AND DOCUMENTATION
- If the Dean for GME of McGaw is part of the complaint or in any other way has a conflict of interest or the appearance of a conflict of interest, s/he is obligated to remove him or herself from the case during the investigation and the Dean of the School of Medicine shall appoint someone else to assume responsibility for the complaint.
- The School of Medicine may act under these procedures, irrespective of possible civil or criminal claims arising out of the same or other events. The Dean for GME, with the concurrence of the Dean of the School of Medicine, after consulting with the Office of the General Counsel, shall determine whether the University shall, in fact, proceed against a respondent who also faces related charges in a civil or criminal complaint. If the University defers proceedings, it may subsequently proceed, irrespective of the time provisions set forth in these procedures.
- The Dean for GME shall have the authority to take any actions on behalf of the School of Medicine that s/he deems necessary to protect the complainant and/or the respondent, or to address other needs or deliberations related to the situation, pending the investigation and resolution of the complaint.
As described in section V above, students, residents, and fellows with concerns related to mistreatment can use the faculty ombudsperson that is designated specifically for this purpose, college mentors, or a trusted faculty member as an initial point of contact. Together with this individual, the student, resident, or fellow can decide whether to seek an informal resolution to the problem and/or whether to move forward with a formal complaint.
If the complaint alleges discrimination or sexual harassment, the complaint must be referred to the University Office of Equal Employment Opportunity and Access or the Sexual Harassment Prevention Office, respectively. Complaints brought to the Sexual Harassment Prevention Office or the University Office of Equal Employment Opportunity and Access will be handled using the processes and procedures of these offices, per University protocol and policy. Otherwise, if the student, resident, or fellow decides to proceed with a formal complaint of mistreatment, it will be addressed according to the process described below.
The process for addressing formal complaints of mistreatment is as follows:
- Inquiry into a violation of the standards of conduct committed by any individual, whether or not affiliated with the University, should be initiated by written complaint and filed with the Vice Dean for Education as soon as possible, typically within 30 days of the end of an academic quarter or the clinical rotation in which the alleged incident occurred. A delay in filing may be grounds for rejection of a complaint.
- The complaint must be detailed, specific, and accompanied by appropriate Documentation, if available.
- After receipt of a properly documented complaint, which has been made in good faith, the Vice Dean shall inform the respondent of the nature of the charges. The Vice Dean will also remind the respondent about the non-retaliation policy of the University described above in Section IV.
- To initiate an investigation, the Vice Dean shall appoint an investigation committee of not less than three individuals, all of whom shall be faculty members of the School of Medicine but not members of the same department as, or collaborators with, the complainant or respondent. The investigation shall be initiated within two weeks of forming the committee, and the complainant and respondent will be notified that the investigation has been initiated. The Vice Dean shall also make every effort to protect the identities of both complainant and respondent with respect to the larger community.
- The investigation committee shall undertake a thorough examination of the charges. Whenever possible, interviews shall be conducted with the complainant and respondent. Interviews may also be conducted with others having information regarding the allegations, if the committee deems it necessary. Summaries of these interviews shall be prepared, provided to the interviewed party for comment or revision, and included as part of the file. When appearing before the committee, the respondent and the complainant may each be accompanied by a non-attorney adviser. The student, resident, or fellow's adviser shall be a School of Medicine faculty member and the respondent's adviser must be a Northwestern University employee. The committee shall not conduct formal hearings. Except in unusual cases, the respondent and the complainant shall not appear before the committee at the same time.
- Following the completion of its investigation, the committee shall submit a report of its findings to the Vice Dean for Education (who will share it with the Dean), with copies to the complainant and respondent. This report shall describe the policies and procedures under which the investigation was conducted, how and from whom information was obtained, the findings, the basis of the findings, and texts or summaries of the interviews conducted by the committee. This report shall ordinarily be submitted to the Vice Dean for Education within 60 days of the appointment of the formal investigation committee. The complainant and respondent shall be permitted to make a written reply to the Vice Dean within 15 calendar days of receipt of the report. Such replies shall be incorporated as appendices to the report of the investigation committee. The entire investigation process shall typically be completed within 90 calendar days of its initiation, unless circumstances warrant a delay. In such cases, the reasons for a delay shall be documented.
- If the investigation committee finds the charges to be unfounded, the matter shall be dropped and the concerned parties shall be informed.
- If the investigation committee finds the charges against a respondent to be substantiated, the Dean will notify the following offices:
- For a non-faculty employee of the Feinberg School of Medicine or one of its affiliated clinical entities (including but not limited to nursing, housestaff, and fellows), the Dean shall inform the Office of Human Resources of the appropriate institution (e.g., Northwestern University, Northwestern Memorial Hospital, Northwestern Medical Faculty Foundation, etc.) or, for a resident or fellow of the McGaw Medical Center of Northwestern University, the Associate Dean for Graduate Medical Education.
- If charges against a faculty member are substantiated, the Dean will proceed to take whatever actions are appropriate to the seriousness of the offense, in consultation with the Provost and in accordance with University procedures, and which consider the previous record of the respondent. For major offenses by any faculty members, the Dean of the School of Medicine shall determine with the Provost whether there is substantial reason to believe that just cause exists for imposition of a major sanction, e.g., termination of appointment or suspension. Such action will be executed in accordance with the policies and procedures in the Faculty Handbook. For less serious offenses the Dean of the School of Medicine may impose minor sanctions, as described in the Faculty Handbook. These may include, but are not limited to, removal from a particular project, a letter of reprimand, special monitoring of future work, or probation.
Safe and Healthy Learning
The McGaw Medical Center of Northwestern University, in association with Northwestern University Feinberg School of Medicine, is committed to the principle that educational relationships should be one of mutual respect between teacher and learner. Because McGaw oversees the training of individuals who are entrusted with the lives and well-being of others, we have unique responsibilities to assure that residents and fellows learn as members of a community of scholars in an environment that is conducive to learning. Both McGaw and Feinberg want to encourage residents and fellows to bring attention to any breach or perceived breach of the Safe and Healthy Learning Environment and wish to be open about the process in place should such a claim be made.
All members of the Northwestern Medicine community are committed to treating others with dignity and respect. From time to time issues may arise that are not in keeping with this commitment. When these issues arise residents and fellows may access the Feinberg School of Medicine Ombudsperson who has been appointed to serve as an impartial, neutral, and confidential facilitator for students, residents, and fellows. The Ombudsperson is chosen because s/he is a neutral, third-party physician who is not otherwise involved with the academic promotion or evaluation of Feinberg students or McGaw residents and fellows. The Ombudsperson is committed to ensuring that students, residents, and fellows are treated fairly and equitably and is available to serve as a nonjudgmental and objective sounding board for students, residents, and fellows and to help resolve complaints of student, resident, or fellow mistreatment. These incidents may occur in the classroom, clinical venue, or other school-sponsored events and may involve other students, residents, fellows, faculty, or staff. The Ombudsmen will work with students, residents, and fellows to describe available options to address the issue and, if desired, help resolve conflicts. Student, resident, and fellow interactions with the ombudsperson are handled as discreetly as possible.
Housestaff should be aware of several safety precautions one should employ while living and commuting in Chicago. Although our neighborhood has many safety precautions, no community is immune to criminal activity. It is very important that each of us heighten our safety awareness when travelling around campus and throughout the city.
We encourage the following in Streeterville/NMH:
- Use Security Escort services 312-479-5051 after sunset when travelling around areas on campus.
- If walking alone at night, feeling uneasy, or noticing suspicious behavior, stop and return to the hospital and call for an escort.
- During evening hours please be aware of your surroundings and walk in well-lit areas.
- We encourage walking in groups of 2 or more at night.
- Be mindful of valuables; expensive purses, wallets, phones, and other visible electronics.
- Do not walk around wearing headphones or other electronic devices.
- Report any safety issues to Northwestern University Police Department (NUPD) 312-926-3117 and, if applicable, file a police report with the City of Chicago. Extensive crime prevention and safety tips are available on the NUPD website.
Suggested safety precautions for the Jesse Brown VA:
- Do not walk outside of the VA or take public transportation home after sunset.
- After 11 p.m., if there is no shuttle, ask the VA police for an escort to the cab/Uber waiting area outside. The training program’s department will reimburse with submission of the receipt.
- E-mail any and all JBVA concerns to CHS_TRAINEE@VA.GOV.
Suggested safety precautions for the Anne & Robert H. Lurie Children's Hospital of Chicago:
- Report any safety issue and/or request a walking escort by contacting the Security Office at 312-227-4222.
Suggested safety precautions for John H. Stroger, Jr. Hospital of Cook County:
- Report any safety issue and/or request a walking escort after dark by contacting the Security Office at 312-864-8097.
All McGaw housestaff members are strictly prohibited from self-prescribing and/or prescribing for friends or family members. Housestaff members may prescribe or administer medications only to registered inpatients and outpatients who are under housestaff physicians’ supervised care in connection with a McGaw training program and for whom ongoing care permits knowledge of a patient’s medical history, physical examination, and results of appropriate diagnostic or screening tests. Providing “casual” prescriptions for friends, acquaintances, students, colleagues, staff, or others outside of the context of an established physician-patient relationship is prohibited. Housestaff members may not write such prescriptions nor may they self-prescribe medications. This policy applies to all housestaff, including those who have a permanent Illinois medical license.
Liability insurance provided to housestaff solely covers their supervised practice within the training program to which they are appointed. Providing “casual” prescriptions represents medical practice outside of the scope of training.
Violations to this policy may result in disciplinary action including being removed from McGaw’s pharmacy benefit plan.
All residents, subspecialty residents, and fellows will be paid the published stipend rate appropriate to postgraduate year level for the clinical training program to which they are appointed.
- The provision of safe, effective, and high quality patient care at all times;
- The presence of a clear and uniform structure for resident supervision within all training programs that is consistent with national standards of supervision and graduated responsibility as defined by the Accreditation Council for Graduate Medical Education(ACGME);
- Educational needs of all residents are attained in a structured environment that provide appropriate supervision and graded responsibility appropriate to the residents’ level of education;
- Competence and experience;
- All training environments promote the development of health care providers who are competent to deliver patient care independently upon completion of their training.
Supervision and Accountability:
Resident and fellow education is progressively graduated in both experience and responsibility with primary attention to the benefit, and safety of the patient. Development of mature clinical judgment requires that each resident be involved in the decision-making process. The conditional independence of the resident should be determined by each program and individualized to be commensurate with the clinical circumstances and ability of the resident. In such an environment, each physician participating in the clinical training environment will have specific and defined roles and responsibilities:
Attending Physicians are ultimately responsible for:
- The assessment, diagnosis, treatment, and evaluation of all patients undergoing care;
- Ensuring their role is identified and consist with site hospital policy and ACGME P.R. VI.A.2.(a-f);
- Providing the appropriate level of supervision (direct, indirect, and / or oversight) based upon the nature of a patient’s condition, complexity of care, and level of competence of the residents being supervised;
- Being available for direct communication with the trainee as needed;
- Oversight and delineation of duties and graded responsibilities for care provided by all members of any service team caring for a patient.
The Program Director is responsible for:
- Defining formal program specific policies that establish roles, need for communication, and responsibilities appropriate for each level of training or clinical milestone in accordance with national standards of supervision and graded responsibility as defined by the Accreditation Council for Graduate Medical Education;
- Communication and collaboration with residents, faculty, clinical and operational leadership to ensure these policies are understood by all parties;
- Monitoring adherence to these policies.
- Are supervised by an attending physician at all times during clinical rotations (direct or indirect);
- Are responsible for knowing who their supervising attending is and how to reach that person at all times;
- Are responsible for being aware of their limitations, roles, and responsibilities within the course of patient clinical care;
- Are provided responsibility and supervision in a manner consistent with national standards of graded responsibility and conditional independence as defined by the Accreditation Council for Graduate Medical Education;
- Are expected to know the level of supervision required for their level of training or clinical training goal, and not practice outside of that scope of service;
- Are expected to communicate effectively with attending physicians and other members of the health care team;
- Are required to inform patients of their respective role in each patient’s care as required by ACGME C.P.R. VI.A.2.a).(1).(b).
Direction of clinical care and supervision of the residents must be documented by the attending physician in the medical record in accordance with the Bylaws and/or Rules and Regulations of the participating site.
The GMEC will review the program specific policy on supervision at the time of the annual program evaluation as well as during the Internal Review.
Resident/Fellow File Requirements
Each trainee’s file/binder should contain the following:
- Photo of Resident/Fellow
- Curriculum Vitae (CV)
- Letter of Agreement (LOA)
- New Hire Paperwork
- Research/Scholarly Activity
- Procedure Logs
- Work Hours
- Rotation Schedules
- Letters of Standing
- Exam Scores
Resident/Fellow File Guidelines
The GME office strongly requests all programs to have their resident/fellow files organized as listed above as this uniform organization will make certain processes more efficient globally.
Each trainee’s file or binder must be clearly labeled with his/her name and training years in the program (e.g. John Smith - 2015-2016).
Programs should feel free to add, omit, or edit file sections listed above if not applicable.
Details of Individual Tabs
- Photo: Can be a black and white, color, or photocopy.
- Application: May be either ERAS, McGaw, or from another service as used by program.
- Curriculum Vitae (CV): May be from ERAS or document provided by trainee.
- Letter of Agreement (LOA): Copy of the fully-executed annual Letter of Agreement between McGaw and the trainee.
- Certificate(s): For fellows include a copy of their Certificate of Completion from Residency.
- New hire paperwork: A copy of all new hire paperwork submitted to the GME office, including transfer letters from other departments or institutions.
- Licensure/Certification: Copies of all current required licenses and certifications required to practice (e.g. state medical license, NPI, BLS, ACLS, Medicare enrollment, as well as CDS and DEA, if applicable). Must be kept current throughout training.
- Evaluations: This section should include a sub-tab for each training year. Within each training year a sub-tab should be utilized for each evaluation type (e.g. rotation, 360, semi-annual, et al.).
- Rotation Evaluations
- 360-degree Evaluations (inclusive of peer, self, nurse, and patient evaluations)
- Semi-annual Evaluations (in the mid-year evaluation include status on clinical experience and education, procedures, research/QI project, etc.)
- End of year Evaluations (summative for all graduates)
- Final Summative Evaluations – (includes an overall evaluation of the resident/fellow over the entirety of their training, which is completed by the program director (letter must state the resident/fellow is competent to practice without direct supervision)
- Research/Scholarly Activity: All publications, presentations, and quality improvement and safety projects.
- Procedure Logs: At least quarterly summaries of procedures completed.
- Work hours: At least quarterly work hour summaries printed from NI.
- Rotation Schedules: Rotation schedules by week, month, or year.
- Letters of standing: Any letters written on behalf of the resident/fellow including letters of recommendation written while in training. Letters of Recommendation as submitted prior to their appointment with McGaw should be filed within the Application section.
- Exam Scores: Core curriculum completion summaries, all USMLE/COMLEX scores, and must include board scores after graduation if received by the program.
- Anonymous evaluations completed by residents/fellows on faculty and on the program should be kept together in a separate binder or file.
- Upon graduation, the first page in the binder or file should be the final summative evaluation. If the trainee separates from the program due to disciplinary action, the first page in the binder or file should be the final letter stating the termination/resignation.
- Please include forwarding address of new home and/or work address, if available.
Trainee File Retention
Along with the ACGME, we recommend holding the full file for at least seven years from the resident/fellow’s completion of training or separation. Should you want to streamline the file after seven years, hold on to the following:
• All milestone, semi-annual, and final review documentation.
• Original application and supporting documentation.
• Copies of completed verification requests.
• Copy of certificate of completion.
• Copy of final procedure log (if applicable).
• Copies of rotation schedules.
• Any disciplinary records (if applicable).
• Any documents the PD deems viable for future reference.
If space is an issue, we encourage programs to scan these documents and upload them to each respective graduated trainee’s profile in New Innovations under their Files & Notes tab.
12 months of satisfactory performance as determined by the Program Director are eligible to receive a certificate for that training.
Duplicate certificates will be issued on proof of loss or theft. There is a fee for duplicate certificates.
Transitions of Care
A responsibility of the Institution that sponsors Graduate Medical Education is to ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety [Common Program Requirement VI.E.3.]. The ACGME has charged the institution and the programs with designing clinical assignments to minimize the number of transitions in patient care [CPR VI.E.3.(a-b)], ensuring that residents are competent in communicating with team members in the hand-over process [CPR VI.E.3.c)], ensuring the availability of schedules that inform all members of the health care team of attending physicians and residents currently responsible for each patient’s care [CPR VI.E.3.d)], and ensuring continuity of patient care in the event that a resident may be unable to perform their patient care responsibilities due to excessive fatigue or illness, or family emergency [CPR VI.E.3.e)].
Transitions of Care - The transfer of information, authority and responsibility during transitions in care across the continuum for the purpose of ensuring the continuity and safety of the patient’s care. Hand- off communication is a real time, active process of passing patient-specific information from one caregiver to another, generally conducted face-to-face, or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient’s care. Hand-offs should occur at a fixed time and place each day and use a standard verbal or written template.
- Each training program will be responsible for developing a formal policy for hand-offs and transitions of care. This policy must be distributed to all trainees and
- When possible, residents and faculty will identify a quiet area to give report that is conducive to transferring information with few
- Off going provider will have at hand any required supporting documentation or tools used to convey information and immediate access to the patient’s
- All communication and transfers of information will be provided in a manner consistent with protecting patient confidentiality and
- Providers will afford each other the opportunity to ask or answer questions and read or repeat back information as needed. If the contact is not made directly (face-to-face or by telephone), the caregiver must provide documentation of name and contact information (extension, pager, or email address) to provide opportunity for follow up calls or
- The patient will be informed of any transfer of care or responsibility, when possible.
Sample Hand-off Communication Tools:
- I PASS THE BATON
- 5 P’s
The GMEC will review each department’s approach to hand-offs at the time of Internal Review as well as annually when the department submits its annual report.