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Internal Medicine Policies & Guidelines

VCU Internal Medicine Training Program
Assessment/Clinical Competency Committee Policy

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Residency Program Assessment Structure and Plan

The program director has primary responsibility for monitoring the competence and professionalism of Internal Medicine residents for the purposes of recommending promotion and certification, and for initial counseling, probation or other remedial or adverse action. Residents will be evaluated on individual specialty requirements as well as program requirements. All residents will be evaluated on compliance with University and Hospital policies, which include but are not limited to: computer ethics, sexual harassment, conflict of interest, intellectual property, Medicare compliance rules, moonlighting, infection control, drug free workplace, pre-employment drug testing, and completion of medical records.

The departmental Clinical Competency Committee (CCC) is appointed by the chair of the department and assists the program director in these functions. The Clinical Competence Committee (CCC) for the Internal Medicine Residency Program is charged with monitoring housestaff performance and making appropriate disciplinary decisions and recommendations to the program director. At all times, the procedures and policies of the Clinical Competence Committee will comply with those of the Graduate Medical Education Committee as outlined in the Graduate Medical Education Grievance Policy and Procedure. Where circumstances warrant, the membership of the committee may be altered to avoid a potential conflict of interest, or to protect the privacy of the resident.


  • Performance Reviews
    • The training program must provide evaluation and assessment information to residents in a continuous manner throughout the year. In addition, the training program must provide written summary performance reviews to residents at least semi-annually, in person. A review of the resident’s experience and competence in performing clinical procedures must be included in these summaries. A review of the resident’s progress in meeting ABIM and program requirements must also be performed at this time. Summary performance reviews may be written by program directors, designated faculty members, or members of the CCC. It is also recommended that the resident acknowledge receipt of each summary performance review in writing.
  • Promotion
    • Those residents judged by a program to have completed satisfactorily the requirements for a specific level of training will be promoted to the next higher level of responsibility unless the resident specifically is enrolled in a training track of limited duration, not designed to achieve full certification (e.g., a one-year preliminary position). Except for shared residency positions, no resident may remain at the same level of training for more than 24 months, exclusive of leave. A resident whose performance is judged to be satisfactory will advance until the completion of the program/certification requirements. Promotion decisions require approval by both the Program Director and the CCC.
    • Residents commencing their post graduate medical education in 2009 and beyond must pass Step 3 of the USMLE or NBOME in order to be promoted to the PGY 3 level.
  • Department of Internal Medicine Clinical Competency Committee
    • The Department Chair appoints the Chair of the Clinical Competence Committee. Members of the Committee are chosen by the Committee Chair and may include the Key Clinical Faculty. In addition, the Program Director, Associate and Assistant Program Directors, and one Chief Medical Resident serve as members. The Program Director is a non-voting member.
    • Members attend monthly meetings as well as ad hoc meetings. The Chair or his/her designee will keep detailed minutes of all meetings.
    • A resident may be brought up for discussion by the CCC for any of the following reasons: recommendation by the Program Director for any reason, consistently low or unsatisfactory evaluation scores, consistent lack of adherence to program requirements, or a specific incident that requires review by the CCC for possible probation or dismissal.
    • The committee may make the following recommendations:
      • No further action necessary
      • Letter of concerns with specific terms and remediation recommendations
      • Probation with specific terms and remediation recommendations
        • May be with or without extension of time at level of training
      • Termination
      • Delay or denial of promotion or board recommendation
    • At each meeting, the Committee will review progress of residents who are currently on probation, and decide to lift or continue the probation. Additionally, residents previously on probation may be continually discussed for clinical and programmatic performance.
  • Probation
    If, after documented counseling, a resident is not performing at an adequate level of competence, demonstrates unprofessional or unethical behavior, engages in misconduct, or otherwise fails to fulfill the responsibilities of the program in which she/he is enrolled, the resident may be placed on probation by the program director or the CCC. The resident must be informed in person of this decision and must be provided with a probation document which includes the following:
      • A statement of the grounds for probation, including identified deficiencies or problem behaviors;
      • The duration of probation which, ordinarily, will be at least three months;
      • A plan for remediation and criteria by which successful remediation will be judged;
      • Notice that failure to meet the conditions of probation could result in extended probation, additional training time, and/or suspension or dismissal from the program during or at the conclusion of the probationary period, and;
      • Written acknowledgment by the resident of the receipt of the probation document. The status of a resident on probation should be evaluated by the committee at 3 months. If, at the end of the initial period of probation, the resident’s performance remains unsatisfactory, probation either may be extended or the resident may be suspended or dismissed from the program. Probationary actions must be reported to VCU IM Clinical Competency Committee Policy and the Graduate Medical Education (GME) Office. Probation documents must be forwarded to the GME Office for review before they are issued.
  • Clinical suspension
    A resident may be suspended from clinical activities by the program director, department chair, or by the faculty director of the clinical area to which the resident is assigned. This action may be taken in any situation in which continuation of clinical activities by the resident is deemed potentially detrimental or threatening to patient safety or the quality of patient care. Unless otherwise directed, a resident suspended from clinical activities may participate in other program activities. A decision involving suspension of clinical activities of a resident must be reviewed within three working days by the CCC to determine if the resident may return to clinical activities, and/or whether further actions is warranted (including, but not limited to, counseling, probation, fitness for duty evaluation, or summary dismissal).
  • Program Suspension
    A resident may be suspended from all program activities and duties by the program director, the CCC, the Associate Dean for Clinical Activities or Graduate Medical Education, or the Dean of the School of Medicine or Dentistry. Program suspension may be imposed for conduct that is deemed to be grossly unprofessional, incompetent, erratic, potentially criminal, or threatening to the well-being of patients, staff, or the resident. A decision involving program suspension of a resident must be reviewed within three working days by the CCC to determine if the resident may return to some or all program activities and duties and/or whether further action is warranted (including, but not limited to, counseling, probation, fitness for duty evaluation, or summary dismissal).
  • Dismissal During or at the Conclusion of Probation
    Probationary status in a residency program constitutes notification to the resident that dismissal from the program can occur at anytime (i.e., during or at the conclusion of probation). Dismissal prior to the conclusion of a probationary period may occur if conduct, which gave rise to probation, is repeated or if grounds for Program Suspension or Summary Dismissal exist. Dismissal at the end of a probationary period may occur if the resident’s performance remains unsatisfactory or for any of the foregoing reasons. Prior to dismissal, the GME office must be notified of any dismissal of any resident during or at the conclusion of a probationary period.
  • Summary Dismissal
    For serious acts of incompetence, impairment, or unprofessional behavior, the Clinical Competency Committee may immediately suspend a resident from all program activities and duties for a minimum of three days and, concurrently, issue a notice of dismissal effective at the end of the suspension period. The resident does not need to be on probation, nor at the end of a probationary period, for this action to be taken. The resident must be notified in writing of the reason for suspension and dismissal, have an opportunity to respond to the action before the dismissal is effective, and be given a copy of the GME Appeals Process. Prior to dismissal the GME office must be notified of any dismissal of any resident during or at the conclusion of a probationary period.
  • Appeals
    • In the event a resident is not promoted, is dismissed from a program, or is the subject of any adverse action which is reported to the State Board of Medicine or American Board of Internal Medicine, the resident may appeal such non-promotion, dismissal, or adverse action . The Internal Medicine program follows the Institutional procedure for appeals as outlined in the GME assessment policy.

The VCU IM Residency Program is in accordance with the following GME Policies:


REVISED DATE: 7/1/2011
ISSUED BY: Stephanie A. Call, MD, MSPH

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