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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.

 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.

 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.


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.). 
    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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