EVALUATION OF HOUSESTAFF AND PROGRESSIVE MANAGEMENT OF SUBSTANDARD PERFORMANCE
PURPOSE
The purpose of this policy is to standardize the evaluation of housestaff and the management of substandard performance across all MCWAH Programs.
GOALS
1. The Program's educational goals and objectives for housestaff will be presented to housestaff in a clear format.
2. Housestaff will be evaluated against defined performance expectations in a similar manner across MCWAH Programs while being consistent with the ACGME criteria for the particular discipline.
3. Housestaff evaluations will be documented and communicated in a timely manner as applicable under accreditation requirements.
4. To the extent possible, substandard performance and behavior will be progressively managed.
5. Housestaff training files will be uniformly maintained.
EVALUATION PROCESS
1. Each Program must establish and clearly communicate the learning goals and objectives of the training program. These goals and objectives inform housestaff, faculty and others what is expected of the housestaff in terms of outcomes. They also form the basis for housestaff evaluation. For the purposes of this policy, goals are defined as broad, general statements whereas objectives are specific and measureable. To meet ACGME requirements, programs must ensure the following:
a. At the beginning of each year, housestaff and faculty must be given the overall education goals for the Program. This document can be distributed electronically or on paper. Programs must have a system in place to document that housestaff have reviewed and understand the overall goals.
b. At the beginning of each year, housestaff and faculty must be given goals and objectives for each rotation and assignment. These can be distributed electronically or on paper. Housestaff must review the goals and objectives at the start of each rotation/assignment. Programs must have a system in place to document that this review takes place. Rotation/assignment curricula must be written such that:
i. Goals and objectives are associated with one or more of the ACGME's six competencies.
ii. Goals and objectives are specific to PGY levels.
iii. Housestaff responsibilities for patient care are outlined.
iv. Housestaff supervision is outlined.
c. Programs must inform housestaff of any other Program requirements or expectations (e.g., required attendance at didactic sessions, participation in a quality improvement project, completion of on-line learning modules, timely completion of case logs).
2. Each Program must use a comprehensive assessment system. Assessments must measure achievement of the identified goals/objectives for the program, rotation or assignment. To meet ACGME requirements:
a. Evaluation instruments must be based on the ACGME’s six competencies.
b. Instruments must document housestaff performance as compared to expectations for his/her PGY level.
c. Faculty must evaluate housestaff at the completion of each rotation/assignment. Faculty must be educated on how to effectively use the evaluation tool(s).
d. Housestaff must be regularly evaluated by others such as self, peers, allied health care professionals, and patients.
e. The program must have mechanisms in place to ensure evaluations are completed in a timely manner, generally within 30 days following the end of the rotation.
f. Completed evaluations must be accessible to housestaff for review.
g. When available, housestaff evaluation should be guided by national standards-based criteria.
3. Correspondence regarding housestaff performance, such as letters and emails, that are evaluative documents and must be placed in the training file and must be accessible to the housestaff for review.
4. At least semiannually, the Program Director (or designee) must meet with each housestaff to discuss his/her performance and provide feedback. This meeting must be documented in writing and should reflect the substance of that conversation. A copy must be placed in the training file.
5. At least annually the Housestaff Evaluation Committee (HEC) will review and discuss the performance of the housestaff. (See MCWAH’s Program Evaluation Committee(s) policy.)
6. Upon completion of the program, the Program Director must provide a summative evaluation to the housestaff. This evaluation must become part of the housestaff’s training file and be accessible for review by him/her. The evaluation must:
a. Document housestaff performance during the final training period, and
b. Verify that the housestaff has demonstrated sufficient competence to enter practice without direct supervision.
PROGRESSIVE MANAGEMENT OF SUBSTANDARD PERFORMANCE AND UNPROFESSIONAL BEHAVIORS
Verbal Counseling
There are a number of reasons why housestaff may find himself or herself in the progressive management system. Examples of those reasons include:
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Failure to meet expected program performance standards;
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Violations of MCWAH policies including but not limited to: Discrimination & Harassment, Professional Behavior, etc.
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Unsafe Practices, egregious conduct or illegal activity.
If the housestaff is performing at a substandard level or demonstrates unprofessional behavior(s), the Program Director must meet with him/her to discuss the substandard performance or specific behaviors that are considered to be unprofessional. The Program Director will recommend measures that the housestaff can take to improve performance or behavior. The housestaff should be told that there is an expectation that s/he improve within a defined period of time. This encounter should be documented in the training file. Documentation should include a copy of the materials given to the housestaff member, a timeline for improvement, and a summary of the discussion including the dates of such discussions.
Formal Counseling
If the housestaff’s performance or unprofessional behavior does not improve within the expected time period, the following measures must be taken:
1. The Program Director must meet again with the housestaff to identify specific areas of deficiency and give the housestaff defined remediation measures and/or defined behaviors that are expected for him/her to perform successfully within a defined period of time.
2. Program Director. These meetings should be documented to include dates of such meetings and the substance of the discussions. Copies should be provided to the Program Director.
3. Potential internal and external factors should be considered as possible causes for the substandard performance or unprofessional behavior. If personal issues or emotional stress are identified as a contributing factor, the housestaff member should be reminded that MCWAH has a mental health program to help housestaff and his/her family. A substandard evaluation in and of itself can be a significant stressor.
4. Deficiencies and remediation measures must be documented in writing and given to the housestaff with a copy to the training file.
5. A copy must also be sent to MCWAH’s Designated Institutional Official (DIO) & Executive Director for review. It shall be filed in the MCWAH housestaff file.
Probation for Substandard Academic Performance or Unprofessional Behavior
If the housestaff’s performance or unprofessional behavior has not sufficiently improved with counseling within the defined time period, or is too serious to be addressed by counseling alone, the Program Director may determine if probation is appropriate. If so:
1. The housestaff’s performance or unprofessional behavior must be presented to the department’s HEC for its recommendations regarding probation. (See the MCWAH Program Evaluation Committee(s) policy.)
2. MCWAH's DIO & Executive Director must be notified by the Program Director anytime housestaff will be placed on probation or when a probation period is being extended.
3. Housestaff may be placed on probation for up to a three month period.
4. The Program Director or Associate Program Director must meet with the housestaff member to identify specific areas of deficiency, inform him/her of the probation and give him/her written remediation measures and/or defined behaviors that are expected.
5. The Program Director or Associate Program Director may require a Fitness for Duty Evaluation if s/he feels the housestaff member is unsafe to practice or is a safety threat to patients, others or themselves. (See MCWAH’s Fitness for Duty Evaluation policy.)
6. A mentor from the Department must be assigned. The mentor must meet with the housestaff at least monthly and regularly communicate the housestaff’s progress to the Program Director. These meetings should be documented to note the dates of the meetings and substance of the discussions. This documentation should be provided to the Program Director in a timely manner.
7. At the end of the probationary period the Program Director or Associate Program Director will evaluate the housestaff’s performance or behavior based on the faculty’s written performance evaluations, the housestaff’s self-evaluation(s), co-workers’ evaluations, the mentor’s evaluation and recommendation(s) of the HEC.
8. If the housestaff member has successfully completed the remediation measures and his or her performance or behavior has sufficiently improved to the expected level, the probation shall be ended.
9. If the housestaff is on probation at the end of the academic year, s/he will continue to be on probation and will not be promoted to the next level of training until the housestaff is no longer on probation. An exception to this may only be made by the Executive Director and DIO of MCWAH. Housestaff who are not promoted because they are on probation may file a complaint or grievance regarding the non-promotion due to probation as described in MCWAH’s Complaints and Grievances by Housestaff Regarding the Educational or Professional Environment policy. The housestaff may not request an appeal of the decision not to promote under this circumstance.
10. If the housestaff has not successfully completed the remediation measures and performance is not at the expected level, the Program Director, with input from the HEC may:
a. Extend the probation period for up to an additional three months;
b. Make a decision not to promote to the next level of training;
c. Make a decision not to renew the training agreement; or
d. Make a decision to terminate the housestaff.
11. Deficiencies, probationary status, remediation measures and the end of probation must be documented in writing and given to the housestaff with a copy to the training file.
12. A copy of all documentation regarding probation must also be sent to MCWAH’s DIO & Executive Director for review. It shall be filed in the MCWAH housestaff file.
13. Housestaff shall be informed of his/her right to file a complaint or grievance regarding a probationary decision as described below in this policy and in MCWAH’s Complaints and Grievances by Housestaff Regarding the Educational or Professional Environment policy.
14. Subsequent substandard performance or unprofessional behavior by housestaff formerly on probation, but who had returned to good standing, may result in non-promotion, non-renewal or termination without an additional probation period.
Non-Promotion
If a housestaff’s performance or behavior is not at the expected level, a Program Director may decide not to promote him/her to the next level of training.
1. The Program Director or Associate Program Director must consult with the department’s HEC regarding concerns about the housestaff’s performance and the consideration of non-promotion to the next level of training. The Program Director and HEC must concur with the decision not to promote to the next level of training and an educational plan must be developed to guide the housestaff in achieving a promotion to the next level.
2. The Department Chair and the MCWAH DIO & Executive Director must be consulted and informed of this decision and the educational plan.
3. Housestaff must be informed in writing why the decision was made not to promote him/her to the next level of training and the educational plan for him/her to achieve a promotion to the next level. This written notice must be given to the housestaff no later than four months prior to the end of the current year of training.
4. If the decision not to promote is made less than four months before the end of the housestaff’s training year, the Program Director will provide the trainee with as much prior written notice as the circumstances reasonably allow.
5. Housestaff shall be informed of his/her right to file a complaint or grievance regarding a decision of non-promotion to the next level training as described in MCWAH’s Complaints and Grievances by Housestaff Regarding the Educational or Professional Environment policy.
6. The decision not to promote to the next level of training must be documented in writing and given to the housestaff with a copy to the training file.
7. A copy of all documentation regarding the decision not to promote must also be sent to MCWAH’s DIO & Executive Director for review. It shall be filed in the MCWAH housestaff file.
Non-Renewal or Termination
Decisions not to renew the training agreement or to terminate housestaff should be made by the Program Director in conjunction with the department’s HEC, the Chair of the Department and MCWAH’s DIO & Executive Director.
1. The Program Director or Associate Program Director must meet with the housestaff as soon as possible to inform him/her of the decision not to renew the training agreement or to terminate him/her from the program.
2. Housestaff should be notified of non-renewal decisions at least 4 months prior to the end of the current agreement.
3. If the decision not to renew is made less than four months before the end of the housestaff’s training year, the Program Director will provide him/her with as much prior written notice as the circumstances reasonably allow.
4. The reasons why the housestaff’s training agreement will not be renewed or why the housestaff is being terminated must be documented in writing and given to him/her with a copy to the training file.
5. Housestaff shall be informed of his/her right to appeal non-renewal and termination decisions as described in the Graduate Medical Education Training Agreement and the Appeal of Academic Adverse Decisions policy.
6. A copy of the documentation regarding the decision of non-renewal or termination must also be sent to MCWAH’s DIO & Executive Director for review. It shall be filed in the MCWAH housestaff file.
7. Upon termination, any rights to the use of equipment including, but not limited to, pagers, ID badges, keys, PDAs, parking cards, laptops, email privileges, is revoked. All equipment must be returned. Additionally, all access to hospital and MCW computers and electronic records is terminated.
UNSAFE PRACTICE OR EGREGIOUS CONDUCT
Unsafe practice, egregious conduct, or illegal activity should be promptly addressed to maintain patient and staff safety.
1. If the Program Director determines that a housestaff’s continued presence poses or may potentially pose an unacceptable threat to patient or staff safety or his/her conduct is egregious, the Program Director should remove the housestaff from patient care and place him/her on administrative leave (see below) pending an investigation and evaluation.
2. Based on the circumstances, the Program Director may require the housestaff to undergo testing for drug and alcohol use or a Fitness for Duty Evaluation. Failure to submit to testing or a Fitness for Duty Evaluation may be grounds for termination. (See MCWAH’s Fitness for Duty Evaluation policy.)
3. Following an investigation, if the Program Director, Chair and MCWAH’s DIO & Executive Director concur that the housestaff is unsafe, or his/her conduct was egregious and too serious for probation or other disciplinary measures, s/he will be terminated following the steps in the above section.
ADMINISTRATIVE LEAVE
An administrative leave of absence is employed under unusual circumstances during which the housestaff is relieved of all work-related responsibilities so that the Program Director and MCWAH may conduct an investigation of the circumstances involved in the reported unsafe practice or egregious conduct. During the leave, the housestaff shall continue to receive pay and benefits. Housestaff may be required make up the time not on service due to an administrative leave.
1. When the housestaff is placed on an administrative leave, the Program Director shall advise him her that:
a. S/he will continue to receive his/her pay and benefits while on administrative leave, and
b. S/he must leave the premises and may not access patient records or work in any capacity until directed to do so or the leave has been rescinded.
2. MCWAH shall notify the Medical College of Wisconsin (MCW) and the affiliated hospitals’ security and information services that the housestaff is on administrative leave until further notice. If the leave is rescinded the same entities will subsequently be notified that the housestaff member is returning.
3. At the conclusion of the investigation either the Program Director or MCWAH’s DIO & Executive Director shall contact the housestaff to inform him/her whether:
a. The leave is ended and that s/he may return to work,
b. The leave is continued pending further evaluation, or
c. S/he is being terminated.
TRAINING FILE RECORD KEEPING AND ACCESS
Each Program must maintain a training file, either electronically and/or in paper form, that houses all documentation related to the evaluation of housestaff performance.
1. Training files shall include evaluations, correspondence regarding housestaff performance, test scores, attendance at lectures and conferences, and correspondence sent to the Program Director or HEC regarding housestaff performance.
2. Housestaff must have access to all documents related to his or her evaluation and performance including documents submitted as being confidential. Housestaff should contacting the Program Director or Program Coordinator to arranging a time to view the record. The record must be viewed in the presence of the Program Director or Program Coordinator.
3. Housestaff may request a copy of his/her training file by submitting a written request to the Program which will be filed in the training record. Copies of training files should be provided within 10 working days. (See MCWAH’s Records and Record Retention policy.)
This revised policy was approved by the MCWAH Graduate Medical Education Council on July 18, 2011. The original policy was approved on July 16, 2007.