1. Trainee Supervision and Evaluation
   1. Trainees will be supervised by attending physicians in a manner that is consistent with the ACGME program requirements for the applicable residency program. Supervision shall be structured to provide trainees with progressively increasing responsibility commensurate with their level of education, ability and experience. The Program Director shall make determinations on advancement of trainees to positions of higher responsibility.
   2. The Program Director shall provide explicit written descriptions of lines of responsibility for the care of patients, which shall be made clear to all members of the teaching teams. Each patient admitted to a trainee has his/her own private physician. This is the person with whom the trainee will communicate regarding patient care. There must be a prompt means of accessing input and assistance from these physicians.
   3. Each trainee will be assigned a faculty supervisor for each rotation or clinical experience (inpatient or outpatient). The trainees shall be provided regular opportunities to meet with the faculty supervisor. The faculty supervisor shall provide to the Program Director a written evaluation of each trainee's performance during the period that the trainee was under his or her direct supervision. The evaluations will be in a format that is uniform within the applicable department or division. Trainees will be provided an opportunity to review the evaluations. If the trainee disagrees with the substance of the evaluation, or any part thereof, the trainee may so indicate and provide written comments and/or an explanation to the Program Director indicating the basis for the disagreement.
   4. The Committee to Evaluate Clinical Competence of the department or division (the "Committee") shall meet periodically to review the written evaluations for each trainee. The Committee shall advise the Program Director regarding the competence of each trainee's performance and make recommendations regarding advancement of the trainees.
   5. The Program Director or his or her designee shall counsel the trainees individually on their performance at least twice annually during each year of training. The purpose of this counseling is to provide feedback to the trainees on their clinical performance and suggest ways for the trainees to improve their knowledge and skills. More frequent counseling may be held where the Program Director or the Committee determines that a problem exists that deserves more immediate attention.
   6. Trainees may review records on their performance with permission from the department, but copies of the records may not be released. The evaluation process, and any action taken regarding a trainee's status in the program, including, but not limited to, probation, suspension, non-renewal and termination, is performed as "medical peer review" as that term is defined under Texas state law.
2. Corrective Action.
   1. Conduct Subject to Corrective Action. Trainees may be subject to corrective action as a result of unsatisfactory academic performance and/or misconduct, including but not limited to issues involving knowledge, skills, scholarship, unethical conduct, illegal conduct, excessive tardiness and/or absenteeism, unprofessional conduct, job abandonment, or violation of applicable policies or procedures (collectively "job performance").
   2. Counseling Prior to Corrective Action. Where the Program Director determines that an adverse evaluation or evaluations indicate(s) unsatisfactory job performance in the program, the trainee may be requested to attend a conference with a program representative for purposes of discussion and counseling regarding the Program Director's concerns prior to the imposition of any corrective action or disciplinary measures. The counseling conference serves as an opportunity to promote a mutual discussion regarding the specific issues or areas of concern, as well as to encourage mutual communications. The Program Director or the Committee shall designate a representative from the program to conduct the counseling conference with the trainee. During the conference, the program representative shall inform the trainee of the basis for the unsatisfactory performance assessment and may advise the trainee regarding any corrective action that is being considered. The trainee shall have an opportunity to respond to the issues raised and may offer any explanation and/or additional information regarding the facts and/or circumstances surrounding the trainee's job performance. The trainee may elect to submit a written statement in response to the conference to the program representative. The program representative shall document the events of the counseling conference and any required action by the trainee in a written summary, a copy of which shall be retained in the trainee's file. Counseling is not a prerequisite to the imposition of corrective action.
   3. Referral for Investigation. The Program Director, the Committee, or the Department Chairperson shall refer allegations of (i) sexual harassment or unlawful discrimination made against a trainee for investigation by the Human Resources Department of THD in accordance with THR Policies and Procedures, and (ii) substance abuse or other impairment of a trainee for investigation and handling by the Impaired Physician’s Advisory Committee of Texas Health Presbyterian Hospital Dallas.
   4. Imposition of Corrective Action. "Corrective action" may include, but not be limited to probation, suspension, non-renewal of contract, or dismissal from the program. In the event the Program Director determines at any time that corrective action is warranted with regard to a trainee, the Program Director shall provide written notice to the trainee which states: (i) the specific corrective action to be taken, (ii) the reasons for the corrective action, (iii) notice of the trainee's right to an appeal of the corrective action, (iv) that failure to request a hearing constitutes waiver of all rights to appeal . In the event that the Program Director determines that the trainee's job performance presents a threat to patient safety or welfare, the trainee may be immediately removed from the patient care environment pending a corrective action determination. In addition, the following supplemental requirements shall apply for each of the following corrective action measures:
      1. Probation or Suspension. Probation is where the trainee is formally notified that there are identified areas of unsatisfactory job performance, which will require remediation and/or improvement if the trainee is to continue in the program. Suspension is where the trainee is temporarily not permitted to perform his or her duties due to unsatisfactory performance, which will require remediation and/or improvement if the trainee is to continue in the program. The notice to the trainee of either probation or suspension shall set a commencement date and duration period for the probation or suspension status and shall set forth the specific remedial action or improvement that is required during this time period.

      The Program Director shall re-evaluate the trainee at the end of the probation or suspension period and make a determination to (i) continue the probation or suspension period, (ii) remove the trainee from probation or suspension status, or (iii) impose another corrective action measure. The Program Director's decision shall be documented in the file and communicated in writing to the trainee and the Committee chairperson.

      2. Non-renewal of Contracts. In the event the Program Director, the Committee, and/or the Department Chairperson elects not to renew a trainee's contract for the next year, the Program Director shall provide the trainee with written notice of this decision. Notice must be provided to the trainee at least four (4) months prior to the expiration date of the current contract, unless the primary reason for the non-renewal occurs within the four (4) months prior to the expiration date, in which case the Program Director must provide the trainee with as much written notice of the non-renewal prior to the expiration date as the circumstances will reasonably allow.
      3. Dismissal. Notice of dismissal of a trainee from the program shall set forth the effective date of the dismissal.
3. Appeal of Corrective Action. A trainee shall have the right to appeal, any measure of corrective action imposed. The procedures governing the process for trainee appeals of corrective action determinations are set forth in the Appeal Procedures, a copy of which is attached hereto as Appendix A.

II. TRAINEE GRIEVANCES

1. General Grievances. If a trainee has a complaint or grievance related to matters other than performance, corrective action, discrimination or sexual harassment, the trainee should first attempt to resolve it by consulting with the Chief Resident(s) or the Program Director. If the trainee is unable to resolve it at that level, the trainee should then present the grievance to the Graduate Medical Education (GME) Coordinator. The decision of the GME Coordinator shall be final and binding.
2. Sexual Harassment and Discrimination. If a trainee has a complaint or grievance related to discrimination or sexual harassment, the trainee shall have the right to address said complaint in accordance with the policies and procedures set forth in the GME and THR Policies and Procedures.
   
   

Appeal Procedures
 
FIRST APPEAL – COMMITTEE TO EVALUATE CLINICAL COMPETENCE.

1. Exercise of Right. A trainee shall first have a right of appeal of a decision to impose corrective action to the department's Committee to Evaluate Clinical Competence. The trainee may exercise this right by notifying the chairperson of the committee, in writing, of the trainee's intent to appeal within twenty (20) days of the trainee's receipt of the notice of corrective action.
2. Appeal Conference. The chairperson shall arrange for an appeal conference to be held among the members of the Committee to Evaluate Clinical Competence and the trainee. The appeal conference shall be held within ten (10) business days of the date the chairperson's receipt of the trainee's notice of appeal. At the conference, the trainee shall have an opportunity to make a statement, to present any written documentation relevant to the issues and to bring any new or additional information to the attention of the committee. The committee chairperson shall within ten (10) days after the date of the appeal conference notify the trainee in writing of the decision of Committee to Evaluate Clinical Competence and the trainee's right to appeal the decision.