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GME Grievance & Due Process

South Georgia Health System Policies And Procedures

Title: GME Grievance & Due Process

Facilities: System Policy

Number: 8.003

  • [X] SGMC
  • [ ] SGMC Berrien Campus
  • [ ] SGMC Lanier Campus
  • [ ] SGMC Lakeland Villa

Function:

  • [ ] 1.000 Administrative/Operations
  • [ ] 2.000 Clinical Services
  • [ ] 3.000 Compliance
  • [ ] 4.000 Environment of Care
  • [ ] 5.000 HIPAA
  • [ ] 6.000 Finance
  • [ ] 7.000 Human Resources
  • [X] 9.00 GME

Purpose

The purpose of this policy is to provide a mechanism for resolving disagreements, disputes and complaints, which may arise between postgraduate residents and their Program Director or other faculty member.

Application

This Policy is applicable to the following SGHS Facilities: SGMC

Definitions

Grievance: any unresolved disagreement, dispute or complaint a resident or fellow has with the academic policies or procedures of the Residency Training Program or any unresolved dispute or complaint with his or her Program Director or other faculty member. These include, but are not limited to, issues of suspension, probation, retention at current level training, and refusal to issue a certificate of completion of training.

ACGME: Accreditation Council for Graduate Medical Education
SGMC: South Georgia Medical Center
DIO: Designated Institutional Official
GMEC: Graduate Medical Education Committee

Policy

Residents may appeal disagreements, disputes, or conflicts with the decisions and recommendations of their program regarding academic related issues using the procedure outlined in this section. This grievance procedure does not cover issues arising out of (1) termination of a resident during an annual contract period; (2) alleged discrimination; (3) sexual harassment; (4) salary or benefits issues. These grievances are covered by separate policies and/or the resident contract/agreement and the policies of South Georgia Medical Center.

Procedure

The resident should first attempt to resolve the concern informally by consulting with faculty mentor and/or appropriate faculty, Associate Program Director or Program Director. If the resident is unable to resolve the concern informally, he or she may submit the concern in writing, see below resolution levels, which should be followed step wise.

  1. Level 1 Resolution Should grievance be directly with Program Director, proceed to level 2. A good faith effort will be made by an aggrieved resident and the Program Director to resolve a grievance, which will begin with the aggrieved resident notifying the Program Director, in writing, of the grievance within ten (10) working days of the date of receipt of the dispute or complaint. This notification should include all pertinent information and evidence which supports the grievance. Within ten (10) working days after notice of the grievance is received by the Program Director, the resident/ and the Program Director will set a mutually convenient time to discuss the complaint and attempt to reach a solution. Step 1 of the grievance procedure will be deemed complete when the Program Director informs the aggrieved resident/ in writing of his/her final decision. This should occur within ten (10) working days after the meeting between the resident and Program Director. A copy of the Program Director's final decision will be sent to the Designated Institutional Official for GME (DIO).

  2. Level 2 Resolution If the Program Director's final written decision is not acceptable to the aggrieved resident, the resident may choose to proceed to a Level 2 resolution, which will begin with the aggrieved resident notifying the Designated Institutional Officer for GME (DIO) of the grievance in writing. Such notification must occur within ten (10) working days of the receipt of the Program Director's final decision. Failure to submit the grievance to the DIO in the ten (10) working day time frame will result in the resident waiving his or her right to proceed further with this procedure. In this situation, the decision at Level 1 will be final. The resident's notification should include all pertinent information, including a copy of the Program Director's final written decision, and evidence which supports the grievance. Within ten (10) working days of receipt of the grievance, the resident/fellow and the DIO will set a mutually convenient time to discuss the complaint and attempt to reach a solution. Level 2 of this grievance procedure will be deemed complete when the DIO informs the aggrieved resident/ in writing of the final decision. This should occur within ten (10) working days of the meeting with the resident/fellow. Copies of this decision will be kept on file with the Program Director.

  3. Level 3 Resolution If the resident disagrees with the DIO's final decision, he or she may pursue a Level 3 resolution of the grievance. The aggrieved resident must initiate this process by presenting their grievance, in writing, along with copies of the final written decisions from the Program Director and DIO, and any other pertinent information, to the office of the Graduate Medical Education within five (5) working days of receipt of the DIO's final written decision. Failure to submit the grievance in the five (5) working daytime frame will result in the resident/fellow waiving his or her right to proceed further with this procedure. In this situation, the decision at Level 2 will be final. Within ten (10) working days of the written grievance, the DIO will notify the Graduate Medical Education Committee (GMEC) and will contact the aggrieved resident to set a mutually convenient time for a hearing. The GMEC will become the Grievance Committee. The GMEC as the Grievance Committee will review and carefully consider all material presented by the resident and his or her Program Director or the grieveable party at the scheduled meeting, following the protocol outlined in Section D (see below). The Grievance Committee will provide the aggrieved resident with a written decision within ten (10) working days of the meeting and a copy will be placed on file in the Office of Graduate Medical Education, and with the Program Director. The decision of the GMEC will be final.

B. The GMEC as the Grievance Committee Protocol

  1. Attendance: All committee members should be present throughout the hearing unless prior approved by the DIO. The aggrieved resident must personally appear at the Grievance hearing. Should a committee member (to include but not limited to faculty, APD, PD and/or DIO) be the subject of grievance compliant, they should be recused from serving on committee in the specific grievance.

  2. Committee Structure: During the proceedings, the GMEC will serve as the Grievance Committee. A member of the GMEC will be elected by the GMEC to serve as chairman of the Grievance Committee. The DIO will not be in consideration for the Chair position of the Grievance Committee.

  3. Conduct of Hearing: The Grievance Committee Chair will preside over the hearing, determine procedure, assure there is reasonable opportunity to present information relevant to the hearing and it should be presented or excluded. The aggrieved resident may present any relevant information or testimony from any colleague or faculty member. This is not a legal proceeding so the resident will meet with the grievance committee without the presence of legal representation. The Grievance Committee Chair is authorized to exclude or remove any person who is determined to be disruptive.

  4. Recesses and Adjournment: The Grievance Committee Chair may recess and reconvene the hearing by invoking the right for executive session. Upon conclusion of the presentation of oral and written information, the hearing record is closed. The Grievance Committee Chair will prepare a written decision to be reviewed and signed by all of the Committee members. The aggrieved resident will be notified of the final decision within ten (10) working days of the grievance hearing.

  5. Meeting Record: A secretary/transcriptionist will be present for the purpose of recording the meeting minutes. Minutes and the final written decision of the Grievance Committee will be placed on file in the Office of GMEC and in the resident or fellow's academic file at the residency program.

C. Confidentiality

All participants in the grievance are expected to maintain confidentiality of the grievance process by not discussing the matter under review with any third party except as may require for the purposes of the grievance procedures.

Important Considerations:

State of Georgia Requirements

Pursuant to Article 2, Chapter 34, Title 43 of the Official Code of Georgia Annotated, a licensed physician who qualifies as a Program Director is required to report to the Board the following within 15 days of the event:

  1. Resident with a Temporary Training permit who withdraws or is terminated from a postgraduate training program and reasons for such termination or withdrawal.
  2. Occurrence of any event identified as grounds for disciplinary action, violations, or practice restriction taken against a Temporary Training permit holder or any disciplinary action regarding quality of care and/or ability to practice with reasonable skill and safety.
  3. Any permit holder who has an unauthorized absence from the Program for any length of time in excess of two weeks and reason.
  4. At the completion of the Program year, Program Directors must report to the Board whether a permit holder has failed to advance in the Program for performance or behavioral reasons.
  5. Complete rules may be viewed at: http://rules.sos.ga.gov/gac/360-2

Responsibility

GMEC & DIO

Policy History

Original Adoption Date: July 2019
GMEC Review/Revision History: May 2022, November 2023

Last update: June 26, 2025