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GME Promotion, Dismissal & Evaluation

South Georgia Health System Policies And Procedures

Title: GME Promotion, Dismissal & Evaluation

Facilities: System Policy
Number: 8.002

  • [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] 8.000 GME

Purpose

Each residency program is responsible for implementing policies and procedures for addressing resident evaluation, promotion, and dismissal based on the South Georgia Medical Center institutional policies. Program policies and procedures must be consistent with GME Grievance guidelines and ACGME requirements.

Application

This Policy is applicable to the following SGHS Facilities: SGMC

Definitions

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

Policy

Each residency program shall develop written criteria for advancement in level of training. Criteria will generally include successful completion of rotations as determined by faculty through written evaluations, documented competency in performing certain procedures, demonstrated ability to assume increasing responsibility for patient care, and developmentally appropriate progress toward achieving the 6 competencies.

Faculty must evaluate resident performance in timely manner during each educational assignment and document this evaluation at the completion of the assignment.

Procedure

  1. The program must:

    • Provide objective assessments of each of the 6 competency domains
    • Use multiple evaluators
    • Document progressive resident performance improvement appropriate to educational level
    • Provide each resident with documented semiannual evaluation of performance with feedback

  2. Evaluations of resident performance must be accessible for review by the resident.

  3. Some residents will encounter difficulty during their training. These difficulties generally fall into three specific areas: academic, disciplinary, and/or impairment.

    • Academic difficulties generally involve resident performance issues that are specific to the resident's development as a physician and may involve cognitive and psychomotor performance, as well as professional attitudes and behaviors. Residency programs identify academic problems through their evaluation systems. Residents with academic difficulties generally should be managed through an education plan designed to address the identified deficiencies. Continuation in a program is contingent on a resident successfully addressing such deficiencies and meeting academic standards for that program within a specified timeline. Failure to meet academic standards may result in disciplinary action or may result in a decision not to renew a resident's appointment. Residents who are placed on a performance improvement plan or under any active disciplinary action plan are not eligible to sit on any committees.

    • Disciplinary/Professionalism problems generally involve violations of laws, policies, or contractual agreements. Certain professional behaviors, because of their potential for adverse effects on patients and other health care workers, may also give rise to disciplinary actions.

    • Impairments generally refer to medical, psychological, or substance abuse issues that may interfere with performance of a resident's duties and responsibilities. Suspected or known impairments which may be interfering with a resident's performance must be addressed with the assistance of the DIO.

    • Promotion: each program must determine criteria and have written guidelines for promotion and renewal of appointment. The CCC assesses resident/fellow progress and provides recommendations to the program director at the end of each academic year (or end of contract year for off cycle residents) regarding promotion, graduation, or corrective actions (i.e., letter of concern, probation, decision not to promote, non-renewal of contract, or dismissal). The program director has final decision-making authority regarding promotion, graduation, and corrective actions. Except for combined program positions, no trainee may remain at the same level of training for more than 24 months. Trainees in combined programs may not remain at the same level of training for more than 12 months. v. USMLE and COMLEX Step 3 Examinations.

    • Promotion to the PGY-2 level requires that the trainee must pass the USMLE or COMLEX step 3 examination.

      a. If a trainee has not shown successful completion of one of these exams prior to December 30th of the PGY-1 year, the trainee will have further disciplinary action including but not limited to probation.

      b. If documentation of successful completion of this exam is not provided within 3 months of the probation start date the trainee may be dismissed, placed on continuing probation, unpaid leave of absence; or remain retained at the current PGY level depending on the circumstances.

      c. A resident who is on probation due to failure of passing the USMLE step 3 or COMLEX level 3 examinations will be paid at the PGY-1 level during the probationary period.

  4. Program directors shall notify the DIO:

    • As soon as academic or disciplinary issues are identified which may lead to delay in the promotion or progression of a resident, or disciplinary action involving suspension or termination of the resident's participation in a residency program.
    • Of any suspected or known impairment that may be impacting the resident's ability to perform the resident's duties, including the resident's ability to perform patient care duties.
    • Of any intention not to renew a resident's contract for any reason.

Notification should include a description of the proposed action and the reasons for the action, a draft of the proposed notice to the resident, and a summary of the plan for remediation, including a timetable for a final decision about a resident's continuation in the program.

After review by the DIO and other institutional experts, including human resources and legal counsel, programs shall notify residents promptly in writing about any decision to delay their promotion, place them on probation, initiate disciplinary action or non-renewal of contract (the institutional policy for Non-Renewal of Contract shall apply). A three month notice of non-renewal will be given to the resident.

The resident has a right to appeal decisions as outlined in the Resident Due Process policy, and this policy supersedes any hospital's problem resolution policy applicable to non-resident employees.

Responsibility

GMEC & DIO

Policy History

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

The date (month and year) of each review and revision of the Policy.

Last update: April 22, 2026