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Policies and Procedures

Be informed about policies that guide and protect McGaw Medical Center of Northwestern University, trainees, and program staff.

 Disasters

A disaster is considered an event or set of events including natural or other, causing significant and prolonged alterations to the training experience for one or more McGaw training programs.

Upon McGaw’s declaration of a disaster, all GME personnel are to follow their member institution polices on disasters. McGaw will communicate with trainees using member institution cellular communication processes as well as via Northwestern email.

The McGaw Designated Institutional Official (DIO) is responsible for notification of the Accreditation Council of Graduate Medical Education (ACGME) of the occurrence of a disaster. The DIO will convene an ad-hoc GMEC meeting to review current training limitations, extent of alteration of training, and determine next steps. The DIO will then work with the Program Directors to communicate with the ACGME and appropriate ACGME Residency Review Committees (RRCs.)

If needed, Program Directors will assist in arranging temporary transfers to other institutions until McGaw is able to resume providing an adequate educational experience. Programs will make these transfer decisions expeditiously to maximize the likelihood that each trainee will finish training in a timely fashion. The Program Director will communicate with trainees the estimated duration of the temporary transfer and will update trainees on progress toward resumption of McGaw training. The Program Director will update ACGME RRCs as needed.

If it is determined that permanent reduction or closure of a training program is necessary, the Program Director will seek to arrange for permanent transfer of trainees to other accredited programs. To the extent possible, the institution will provide assistance in identifying programs willing to accept trainees. McGaw will remain responsible for maintaining trainee salary and benefits during a declared disaster and during temporary transfers. If a disaster results in program closure, McGaw will maintain trainee salary and benefits through the end of the academic year.

 Internationally Funded Training

Graduate medical education funded by external entities including foreign governments may represent an opportunity to train future regional and/or international thought leaders.  There are also a number of possible negative downstream consequences from engaging in such relationships.  In order to ensure centralized oversight of such funding partnerships, the following will be required:

  1. Prospective internationally funded trainees must have their prerequisite/prior training fully vetted by the sponsoring McGaw Program
  1. Trainees considering programs that utilize a national matching program (e.g. NRMP) should participate in the standard matching process
  1. Any prospective international funding must be approved by the McGaw Board of Directors prior to offering of a position or ranking a candidate
  1. The funds flow for international support must pass through the base hospital rather than McGaw, FSM, or the Department. Funding of the trainees will be the responsibility of the base hospital should the funding be delayed
  1. Internationally funding must extend for the entire duration of training at onset rather than annually renewable and include any unforeseen extension of training due to disciplinary action
  1. Internationally funded trainees are subject to all McGaw and base hospital policies and procedures, and
  1. Should a fellow undergo disciplinary action and training be terminated, the funding will not be recoverable by the funding entity.  

 Leaves of Absence

Any of the permissible leaves of absence are outlined on the Time Away from Training page under Benefits and Resources.

 Non-Competition

The McGaw Letter of Agreement does not include any non-competition limitations or requirements. No McGaw member institution nor any ACGME-accredited McGaw programs may require a trainee to sign a non-competition guarantee or restrictive covenant.

 Off-Cycle and Part Time Training

Training at McGaw is to be on-cycle (July-June) and full time with only extraordinary extenuating circumstances being considered for exception.  Off-cycle training will be considered when preliminary training is extended resulting in a delayed end date and may be approved administratively by the DIO.  All other requests for off-cycle training and/or part time training must be submitted by the Program Director to the GMEC in writing with supporting documentation for its review and approval.  This submission must include written support by any relevant ACGME RRC and/or specialty Board.  Any impact on trainee complement must be considered and approved by the RRC. Funding impact must be approved by the relevant funding partner.  

 Program Closure or Reduction in Complement

If a program is considering a reduction in complement, or closure of a training program, the Program Director will inform the DIO and the Graduate Medical Education Committee will review and approve the decision. All trainees in that program will be notified as soon as possible if a reduction in size of the program, or closure, is approved by McGaw. In the event of a program complement reduction, all currently enrolled trainees will be permitted to complete their training at McGaw. In the event of program closure, trainees will be permitted to complete the current training year or will be provided alternative educational opportunities to ensure training. The Program Director shall assist the trainees’ efforts to matriculate in other ACGME-accredited programs.

 Recruitment and Appointment of Housestaff

Housestaff are considered eligible for appointment to Accreditation Council for Graduate Medical Education (ACGME) accredited programs if they are graduates of U.S. or Canadian LCME-accredited medical schools, of U.S. colleges of osteopathic medicine accredited by the American Osteopathic Association, or of non U.S. or Canadian medical schools if they have a currently valid Educational Commission for Foreign Medical Graduates (ECFMG) certificate, a currently valid visa (including J-1, H-1B, or O-1; or alternatively, Immigrant [permanent resident] status), and a currently valid license from the Illinois Department of Financial and Professional Regulation (IDFPR). Housestaff are eligible for appointment only if they meet all requirements contained in the letter of appointment. Housestaff are eligible for programs accredited by the ACGME only if they meet both common and specialty specific ACGME requirements for appointment.

Additional eligibility will be determined by each individual training program’s policy on recruitment and appointment and will be based on preparedness, ability, aptitude, academic credentials, communication skills, and personal qualities such as motivation and integrity. Programs shall not discriminate with regard to gender, sex, race, age, religion, color, national origin, disability, or veteran status. Selection of residents should occur through the National Resident Matching Program (NMRP) if that program is included in the NRMP. Program Directors shall comply with the regulations and the spirit of the NRMP.

All potential out-of-match and transfer candidates’ application materials must be reviewed and approved by McGaw’s GMEC prior to a program’s offer of a position. The GMEC will conduct a holistic review of all candidates’ submitted documents which will include consideration of current Dean’s housestaff metrics.

 Renewal, Promotion, Dismissal, and Evaluation

Purpose

The purpose of this policy is to establish uniform expectations and procedures regarding housestaff promotion, appointment renewal, and dismissal. Each McGaw training program must determine the criteria for promotion, appointment renewal, and dismissal.

Promotion and Renewal

Programs must use evaluations of the trainee as well as the Clinical Competency Committee (CCC) recommendations to determine eligibility for contract renewal and promotion. Programs must provide a trainee with written notice of intent when that trainee’s agreement will not be renewed, when that trainee will not be promoted to the next level of training, or when that trainee will be dismissed. McGaw provides trainees with due process relating to suspension, non-renewal, non-promotion, and dismissal (include link to disciplinary policy). Trainees may elect to use the appeals process as outlined in the disciplinary policy.

Policy on Evaluation

Rationale: 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, any disciplinary action, and dismissal. McGaw’s Graduate Medical Education Committee (GMEC) has mandated the use of New Innovations as the electronic evaluation system for all McGaw training programs.

Evaluation Criteria: 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.

Anonymity of Evaluations: All evaluations complete by housestaff must be confidential from program leadership and faculty.

Timeliness of Evaluations

The faculty must evaluate housestaff performance in a timely manner during each rotation or similar educational assignment and document this evaluation at the completion of the assignment in New Innovations.

Formative and Final Evaluations of Housestaff

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;
  • document semi-annual face-to-face meeting with the Program Director; and
  • provide a written final evaluation for each resident/fellow upon completion of the program including approved ACGME verbiage: the resident/fellow has “demonstrated the knowledge, skills, and behaviors necessary to enter autonomous practice”. The evaluation must become part of the resident/fellow’s permanent record maintained by the institution and includes dates and signatures on the evaluation by both the Program Director and resident/fellow.

Training Files

The Program Director must maintain a training file for each resident/fellow. The evaluations of resident/fellow performance must 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
  • meeting’s minutes must include the date of the meeting and a list of those in attendance identifying residents/fellows and faculty.

 Telemedicine

Telemedicine can represent an excellent learning opportunity for McGaw trainees.  The possibility for a service over educational imbalance does exist. It is McGaw policy that any experience for McGaw trainees must include the following:

  1. A clear program policy for faculty oversight including faculty documentation in the electronic medical record (EMR) after all housestaff telemedicine encounters.
  2. A specific plan for trainee education and faculty driven feedback after all telemedicine encounters. 
  3. Any telemedicine experience must have documented formal goals and objectives.
  4. A tracking system to assess the service / educational balance for any telemedicine experience.
  5. A process to review of all telemedicine experiences at the annual program review (APR).
  6. A process for tracking all time spent performing telemedicine.  All work hours including evening and nighttime hours spent performing telemedicine tasks must be included in work hour logs as per ACGME program requirements.
  7. Telemedicine may not be a moonlighting activity.

 Trainee File Requirements

Each trainee’s file/binder should contain the following:

  1. Photo of Resident/Fellow
  2. Application
  3. Curriculum Vitae (CV)
  4. Letter of Agreement (LOA)
  5. Certificate(s)
  6. New Hire Paperwork
  7. Licenses/Certifications
  8. Evaluations
  9. Research/Scholarly Activity
  10. Procedure Logs
  11. Work Hours
  12. Rotation Schedules
  13. Letters of Standing
  14. 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

  1. Photo: Can be a black and white, color, or photocopy.
  2. Application: May be either ERAS, McGaw, or from another service as used by program. 
  3. Curriculum Vitae (CV): May be from ERAS or document provided by trainee. 
  4. Letter of Agreement (LOA): Copy of the fully-executed annual Letter of Agreement between McGaw and the trainee.   
  5. Certificate(s): For fellows include a copy of their Certificate of Completion from Residency.
  6. New hire paperwork: A copy of all new hire paperwork submitted to the GME office, including transfer letters from other departments or institutions.
  7. 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.
  8. 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.). 
    Example:
    TAB 2015-2016

    • 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)
  9. Research/Scholarly Activity: All publications, presentations, and quality improvement and safety projects.
  10. Procedure Logs: At least quarterly summaries of procedures completed.
  11. Work hours: At least quarterly work hour summaries printed from NI.
  12. Rotation Schedules: Rotation schedules by week, month, or year.  
  13. 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.   
  14. Exam Scores: Core curriculum completion summaries, all USMLE/COMLEX scores, and must include board scores after graduation if received by the program.

Of Note

  • 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. 

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