Assessment, Promotion, Discipline, and Dismissal of Fellows Policy of the Hematology/Oncology Fellowship Training Program

The hematology/oncology fellowship-training program will adhere to the official policies of Virginia Commonwealth University Health Systems (VCUHS) and its Graduate Medical Education (GME) program, which can be found on the GME website,

http://www.medschool.vcu.edu/gme/policies/index.html

The hematology/oncology fellowship-training program’s assessment structure and plan are as follows:

1.  The program director has primary responsibility for the monitoring and oversight of the competence and professionalism; of the promotion and certification; and of the counseling, probation or other remedial or adverse action related to the trainees in the hematology-oncology fellowship training program.

2.  A hematology/oncology education committee comprised of program faculty shall be appointed by the program director and will meet at a frequency of not less than semi-annually. The education committee will advise and coordinate with the program director in matters pertaining to the fellowship curriculum; conferences; and coordination of the spectrum of learners engaged within the division’s clinical services.

3.  In matters pertaining to performance review, promotion, probation, suspension, remediation and termination of a fellow, the education committee shall form the basis for the clinical competency committee. The program director shall appoint one faculty member to serve as the chair of the clinical competency committee. This individual should be well versed in the requirements of the ACGME; knowledgeable of the policies of the training program; and invested in education of the trainees.

4.  At times that the clinical competency meeting is convened, the chair shall preside over the conduct and deliberations of the committee meeting. The program director shall present to the committee, shall be present during the deliberations, and shall advise the committee as to the GME policies that apply. The program director will not serve as a voting member in determining the if and what remediation and disciplinary action(s) are to be taken.

5.  The chair of the clinical competency committee will be responsible for providing written notification to the program director of the recommendations of the committee in the event of a letter of concern or other adverse action being taken along with, if applicable, any remediation requirements. Upon receipt, the program director will sign the letter and notify the division chair—and where necessary the department chair/department associate chair of education, and the GME office per GME policy. The program director will then notify and discuss the actions of the clinical competency committee with the fellow along with any required remediation requirements.

6.  In the event of an urgent need to remove a fellow from clinical service due to concern regarding potential patient safety, the program director or division chair may immediately suspend the fellow’s clinical duties along with immediate notification of the division chair, the department chair/department associate chair of education, and the GME office. In such event, the clinical competency committee will be convened within three working days to make a determination of any action to be taken. Such determination will then be reported following the procedures otherwise outlined in #3 above.

7.  The clinical competency committee will meet at a minimum of twice annually for the purpose of reviewing each fellow’s performance evaluations and for making recommendations to the program director of each fellow’s progress. These committee reviews should occur in advance of the program director’s semi-annual performance reviews with the fellows. In the spring, the committee upon review of each fellow’s progress will make recommendations regarding each fellow’s promotion within the training program to the program director. Scheduled and ad hoc meetings of the clinical competency committee will be convened as necessary for the purpose of to regular performance monitoring and for evaluation a fellow’s progress with any remediation plans recommended by the committee.

8.  The clinical competency committee will additionally review the evaluations and progress of fellows requesting or holding moonlighting privileges. The committee will advise the program director in matters of granting approval for moonlighting privileges. Consistent with the program’s moonlighting policy, if at any time it is felt in the judgment of the program director and/or the clinical competency committee that moonlighting is interfering with the education of the fellow, moonlighting privileges may and will be suspended or revoked.

Reviewed and updated 6-25-2013, JCB