GME Policies and Procedures

The purpose of the David Geffen School of Medicine at UCLA policies is to ensure the quality and safety of both patient care and resident behaviors.
DGSOM chief residents

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Trainees

The GME Office is available to assist you with the interpretation of UCLA’s Academic Due Process Policy.  Please feel free to contact us at (310) 206-5674 or GME@mednet.ucla.edu to set up an appointment.

Programs

Please contact the GME Office for consultation prior to placing a trainee on leave or taking an Academic Disciplinary Action.  The GME Office must be notified when an Educational Notice of Concern is to be issued.  Please feel free to contact us at (310) 206-5674 or GME@mednet.ucla.edu

Academic Due Process Policy (PDF)

The academic titles Resident Physician I-IX and Resident Physician/Subspecialist IV-IX are assigned to individuals who are medical school graduates who have been awarded an MD or DO degree and are participating in the required number of years in a residency program accredited by the ACGME or ABMS.

Step assignment corresponds to the number of years of training acceptable for Board credit within the specialty. All trainees working at the same level must receive the same compensation. Additional training that is not required in the specialty does not result in a higher step or level of pay.

If there is more than one training path leading to Board certification in a subspecialty, all trainees at the entry level will receive the same compensation, at the higher step, regardless of the path selected.


Approved by GMEC: 3/6/06
Effective: 7/1/06

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Duty Hours Policy 

ACGME has established a number of policies in regards to duty hours. These can be reviewed at the ACGME website. UCLA fully subscribes and is in compliance with all components of the duty hours, including total weekly hours, 24-hour limits (with six hours for education and transfer of care), frequency of call, days off, recognition of fatigue and need to relieve house officers of duty and/or modify schedules. The ACGME allows for programs to request and be granted up to a 10% increase in the total weekly maximum of 80 hours per week averaged over a 4-week period (rotation or block). Even with approval of extension beyond the 80 hours, the 3-night call maximum, 24-hour limit and one day off per week, must still be preserved. Additionally, it is assumed that extensions beyond the 80 hours per week will be infrequent, rotation specific, closely monitored for fatigue and based on educational needs. Approval of exemptions to policy will require the following:

Procedures 
Approval of exemptions to policy will require the following:

  1. Application to the GMEC.
  2. Approval of GMEC with dual request of Program and GMEC for Program's RRC.
  3. Approval of Program RRC in writing.

We, the David Geffen School of Medicine at UCLA, aim for excellence in all tenets of healthcare, including education, research, community engagement, and clinical care. We believe that the core values of diversity and inclusion are inseparable from our institutional goal. DGSOM leadership is committed to fostering an environment that celebrates the unique backgrounds, contributions, and opinions of each individual. Through fair and deliberate recruitment, hiring practices, promotions, admissions, and education, DGSOM will draw its talent from across the community and provide the highest quality of service to everyone we encounter. We believe in a system that supports outstanding faculty, fellows, residents, staff, and students with different perspectives and experiences.  By a process of continual reevaluation, reflection, and shared responsibility, we are unwavering in our dedication to equality, communication, and respect.

 
Reviewed and Approved by GMEC on January 28, 2013

Disruptive Behavior Involving Members of the House Staff 

Confidential Report of Incident (PDF) →

Follow-Up Meeting (PDF) →

For purposes of this policy, this includes house staff in all departments including residents, fellows and those from other sponsoring institutions rotating through UCLA.

Purpose 

To create and maintain an environment free from intimidating, disruptive, threatening and violent behavior.

Policy 

It is the expectation of the house staff that members behave in a courteous, cooperative and professional manner. Disruptive behavior including verbal or physical attacks; inappropriate comments; demeaning criticism; is not permitted and will be addressed by corrective action.

A. For the purposes of this Policy, "disruptive behavior" means any conduct of behavior including, but not limited to, use of language that is profane, vulgar, sexually suggestive or explicit, degrading, or racially/ethnically/religiously slurring in any professional setting related to the care of its patients; any unwanted touching, sexually-oriented or degrading jokes or comments; obscene gestures or physical throwing of objects; oral or written threats to a person or property, whether in person, over the telephone, by email or through other means of communication.

Also included are making inappropriate comments about each other or patients, which:

  • Jeopardize or are inconsistent with quality patient care, or interfere with the ability of others to provide quality patient care or be involved with the educational program
  • Are unethical; or
  • Constitute the physical or verbal abuse of others involved with providing patient care, or educational instruction.


B. Disruptive behavior by members of the house staff, or refusal to cooperate with the procedures described in this Policy, may result in corrective action. This policy shall not preclude the application of necessary actions to ensure a safe working environment or to prevent unlawful conduct in the medical center. Individuals who violate this policy may be subject to corrective action up to and including dismissal.

C. Disruptive behavior occurs in varying degrees, which are classified into three levels of severity. Level I behavior is the most severe violation of this Policy. Any corrective action will be commensurate with the nature and severity of the disruptive behavior. Repeated instances of disruptive behavior will be considered cumulatively and action taken accordingly.

D. Classification of severity shall follow these guidelines:

  • Level I: Physical violence or other physical abuse including sexual harassment involving physical contact.
  • Level II: Verbal abuse such as unwarranted yelling, swearing, or cursing; threatening, humiliating, sexual or otherwise inappropriate comments directed at a person or persons, or physical violence or abuse directed in anger at an inanimate object.
  • Level III: Verbal abuse that is directed at-large, but has been reasonably perceived by a witness to be disruptive behavior as defined above.

 
E. The training programs and clinical services shall promote continuing awareness of this Policy among the house staff and the faculty, including the following efforts:

  • Sponsoring or supporting educational programs on disruptive behavior to be offered to house staff members and faculty;
  • Disseminating this Policy to all current members upon the adoption of the Policy and to all new members of the house staff upon joining the staff;
  • Requiring that the Medical Staff Health Committee be available to assist a member of the house staff exhibiting disruptive behavior to obtain education, behavior modification, or other treatment to prevent further violations.
Procedure 

Complaints about a member of the house staff regarding alleged disruptive behavior must be in writing, signed, and directed to the trainee's Program Director. 

1. Level I: the Program Director or their designee, with the advice of legal counsel:

Interviews the complainant and, if possible, any witnesses within one working day of receiving the complaint and interviews the house staff member within one working day of receiving the complaint. He/she provides the trainee the opportunity to respond in writing. The Program Director, Department Chair or their designee does one or more of the following:

  • Determines that no action is warranted

  • Issues a warning

  • Requires a written apology to the complainant

  • Refers member to the Medical Staff Health Committee

  • Initiates corrective action pursuant to the Housel Staff Policies and Procedures.


2. Level II: the Program Director, Department Chair or designee:

Interviews the complainant and, if possible, any witnesses within 5 working days of receiving the complaint and interviews the house staff member within 5 working days. He/she provides the member the opportunity to respond in writing. The Program Director, Department Chair or designee may:

  • Determine that no action is warranted
  • Issue a warning
  • Require a written apology to the complainant
  • Refer member to the Medical Staff Health Committee
  • Initiate corrective action pursuant to the Medical Staff Bylaws


3. Level III: the Program Director, Department Chair or designee:

Interviews the complainant and, if possible, any witnesses within 10 working days of receiving the complaint. He/she provides the member the opportunity to respond in writing. The Program Director, Department Chair or designee may:

  • Determine that no action is warranted.
  • Issue a warning
  • Require a written apology to the complainant
  • Refer member to the Medical Staff Health Committee
  • Initiate corrective action pursuant to the Medical Staff Bylaws.
E

The special nature of residency programs requires ongoing communication between the trainees, the training programs, administrators and others at UCLA Medical Center, and affiliated institutions.

The general policy of the School of Medicine requires residents be available by email. Trainees are required to have a UCLA Mednet account, which is provided at no cost. Outside email accounts may be forwarded to the UCLA Mednet account. Trainees are responsible for the content of their email and must check their email at least once every three days, unless they are on approved leave.

 

A. A written evaluation of each house officer shall be made by the attending physician on each house officer's rotation(s). A written composite of all evaluations shall be made and a copy of the composite must be provided to the individual house officer. The house officer shall be given the opportunity to discuss their performance and the written composite with the program director at least annually or more often as necessary or requested. The house officer shall be notified within a reasonable time if an evaluation for a given rotation indicates unsatisfactory performance. Both annual and rotational evaluations shall be included in the house officer's records.

B. The records of each house officer shall be maintained as confidential, and he consent of the individual shall be required before access is allowed to such records except where permitted or required by law, or where directly or routinely required in the administration of the training program. House Officers will receive a written composite of their evaluations and other administrative materials upon request and in accordance with applicable University policy. Evaluations of individual performance are part of the training evaluation and per Medical Staff policy, are maintained as confidential.

C. Program advancement and appointment are not assured nor guaranteed to the resident, but are contingent upon the resident's satisfactory demonstration of progressive advancement in scholarship and continued professional growth. Unsatisfactory house staff evaluations can result in required remedial activities, temporary suspension from duties, or termination of appointment and residency education.

 

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The Educational Commission for Foreign Medical Graduates (ECFMG) assesses the readiness of IMGs to enter US residency or fellowship programs that are accredited by the ACGME. ECFMG certification is one of the eligibility requirements to take Step 3 of the USMLE, as well as to obtain a license to practice medicine in the U.S. Applicants wishing to be certified by ECFMG must meet medical education credential requirements and examination requirements, including USMLE Steps 1 and 2 (CS and CK).

Only the clinical J-1 visa sponsored by ECFMG is acceptable when applying to an ACGME accredited training program at UCLA. H1B visas will be considered if the applicant is a graduate from an LCME-accredited US or Canadian Medical School, or from a college of osteopathic medicine in the US, accredited by the American Osteopathic Association Commission on Osteopathic College Accreditation (AOACOCA).

View the complete policy 

ECFMG Certification & J-1 Visa Sponsorship
Educational Commission for Foreign Medical Graduates
3624 Market Street
Philadelphia, PA 19104
(215) 386-5900
http://www.ecfmg.org/

USMLE
3750 Market Street
Philadelphia, PA 19104-3190
Telephone: (215) 590-9700
http://www.usmle.org/

California Medical Board
2005 Evergreen Street, Suite 1200
Sacramento, CA 95815
(916) 263-2382 phone
http://www.mbc.ca.gov/

 

Approved by the GMEC on 04/27/2020

The UCLA Global Health Program have worked with the GME Office to organize the application process and requirements for participation in global health electives. We appreciate your careful review of the Global Health Pre-Travel Requirements that have been established for all residents and fellows travelling to international medical sites for training and research.

Details may be found at the UCLA Global Health Program website. This website is intended to assist residents and fellows in completing the UCLA GME requirements for international electives. It does not replace additional requirements that your program may request.

In short, requirements for application submission are the following:

  1. Completion of the Global Health Resident Elective Request Form.
  2. Viewing the Pre-Travel Health and Safety Video and completion of the associated quiz.
  3. Review and signature of the Code of Conduct and Risk Reduction Agreement.

Please contact the GME office with questions.

 

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Purpose 

UCLA Health System is committed to promoting a family-friendly work environment by providing programs and services to help house staff achieve success at work and in their personal lives. To that effect, employees and management are encouraged to be accepting of nursing mothers, and departments will provide a location and time to accommodate their lactation needs pursuant to state laws.

The law requires the UCLA Health System to provide nursing mothers a reasonable amount of time to express breast milk for their infant children. The hospital is also required to make reasonable efforts to provide appropriate private space to express milk that is in proximity to the work area.

Personnel 

This procedure covers all members of the UCLA house staff as it relates to accommodations for lactating mothers who have returned to the workforce.

Procedure 

1. A house officer who has a need for lactation accommodation should inform her chief resident or program director and discuss any relevant workload or scheduling issues.

2. Chief residents or program directors who receive a lactation accommodation request are advised to direct nursing mothers to the House Staff On Call Quarters located on the B level, RRUCLA. Private rooms which lock from the inside are available. There is a refrigerator in the adjacent House Staff Lounge for storing milk that is appropriately labeled.

3. UCLA Health System may refuse to accommodate a nursing mother only if its operations would be "seriously disrupted" by providing lactation time in accordance with applicable laws. Any intent to refuse accommodation by a chief resident or program director must be made on a case-by-case basis and must include prior consultation with their departmental Human Resources office.

4. Nursing mothers who feel they have been denied appropriate accommodation are encouraged to contact their departmental Human Resources Office.

Approved by GMEC: 2/23/09

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To strengthen institutional compliance practices with duty hour requirements, the following procedures have been implemented.


1. All training programs are required to monitor their residents' duty hours on each rotation.

2. The Program Director shall review the residents hours no less than quarterly. It is the responsibility of the Program Director to ensure compliance with duty hour requirements.

3. Resident duty hours must be logged on all rotations where compliance is a potential concern. The GMEC may mandate that residents log duty hours on specific rotations if concerns arise.

4. The Program Director shall provide a written report annually to the GMEC with the following components: 
- confirm the adequacy of resident compliance with logging duty hours
- identify all areas of non-compliance
- provide action plan for non-compliant areas
- report on implementation of corrective action and results achieved on previously identified areas of non-compliance 
The institution shall collate this information and make it available to Program Directors on an as-needed basis to facilitate remediation on any areas of non-compliance.


5. The GME Office will review the Program Director's annual report and the results of the ACGME online survey for duty hours. Written Program Director response on any noncompliant items will be required. The survey and the Program Director response will be reviewed at GMEC meetings and action will be mandated as appropriate.

Approved by GMEC: 9/12/06

Policy

Moonlighting Policy →

Important information in regard to DGSOM GME Moonlighting Policy:

  • The ACGME and UCLA GME policies require program director pre-approval of all moonlighting activity. Any residents or clinical fellows moonlighting without written pre-approval will be subject to disciplinary action.
  • All moonlighting is voluntary.
  • All moonlighting counts towards the weekly 80-hour maximum weekly limit.
  • All internal moonlighting must be documented in the trainee's time sheet in MedHub.
  • Internal moonlighting may only occur within the scope of practice in which any licensed physician, board eligible physician or board certified physician would be eligible to practice (whichever is most appropriate).
  • Trainees may not function in the clinical specialty in which they are training.
  • Moonlighting activities must not interfere with the resident or clinical fellow's training program. It is the responsibility of the trainee to ensure that moonlighting activities do not result in fatigue that might affect patient care or learning.
  • The program director will monitor trainee performance to ensure that moonlighting activities are not adversely affecting patient care, learning, or trainee fatigue. If the program director determines resident or clinical fellow performance does not meet expectations, permission to moonlight will be withdrawn.
Moonlighting Request Process

For Trainees:

For Program Directors and Departments:

 

All residents and fellows who participate in Post-Graduate training in Accreditation Council for Graduate Medical Education (ACGME) accredited programs must comply with State of California Physician Licensure requirements.  Requirements are located on either the California Medical Board website: https://www.mbc.ca.gov/Licensing/

Or Osteopathic Medical Board website: https://www.ombc.ca.gov/

Residents and fellows will be notified when they commence training that their appointment will be contingent upon compliance with California physician licensure requirements.

Residents and fellows who fail to meet California physician licensure requirements by the start date of their training program will not be appointed.  For trainees enrolled in ACGME accredited programs at UCLA, failure to comply with California physician licensure requirements will result in administrative action per the Academic Due Process Policy.

Training programs are required to notify the California Medical Board or Osteopathic Board in the event of a change in status for trainees working under a PTL within 30 days of the event, including but not limited to resignation, termination, or any disruption in training.

Medical Licensure Policy (PDF) - Revised February 2022

 

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The University of California does not discriminate on the basis of race, color, national origin, religion, sex, physical or mental disability, medical condition, ancestry, marital status, age, sexual orientation, citizenship or status as a covered veteran. This policy applies to all employment practices, including recruitment, selection, promotion, transfer, merit increase, salary, training and development, demotion, separation. This policy is intended to be consistent with the provisions of applicable State and Federal laws and University policies.

Discrimination Policy

 

Process

Step 1 - Complete the New Program Request and the Funding Documentation Template. Submit both forms to the GME Director for review by the Expansion Committee. All forms must be submitted 2 weeks prior to the scheduled committee meeting in order to be considered for review. Please contact the GME office for the date of the next Expansion Committee meeting.

Step 2 - The UCLA Expansion Committee reviews the overall rationale and financing/resources of the request. If approved by the committee, the request and supporting documentation is presented at the following GMEC meeting.

Step 3 - The UCLA GMEC assesses the educational content, impact and objectives of the request. If approved by the GMEC, applicants will be notified.

Step 4 - Programs may submit a request for the new program to the ACGME.

Requests to specific ACGME / RRC's must not be made until after approval by the Expansion Committee and the GMEC. No residents or fellows should be hired or made promises for positions until there has been approval by each group noted above.

GME Expansion Committee Submission and Meeting Dates

The Expansion Committee is comprised of UCLA Health and DGSOM Leadership who review requests for new programs, complement changes, and sponsorship changes. For any requests and more information, please contact the GME Office.

The 2021-2022 dates follow below:

Meeting

Step 1: GME Submissions Deadline

Step 2: Expansion Committee Date

Step 3: GMEC Date

Summer

July 29, 2021

August 12, 2021

August 23, 2021

Fall

October 28, 2021

November 18, 2021

December 6, 2021

Winter

January 6, 2022

January 20, 2022

January 24, 2022

Spring

April 8, 2022

April 21, 2022

April 25, 2022

Summer

July 29, 2022

August 11, 2022

August 22, 2022

Fall

November 4, 2022

November 17, 2022

December 5, 2022

 

The appointment of Program Directors for the ACGME accredited residencies and fellowships at UCLA have always rested with the department chairs. In compliance with ACGME policy, the GMEC must now review and approve, prior to submission to the ACGME, appointment of new program directors. At the same time, it is imperative that departments continue to select and support their residency and fellowship program directors. To comply with the requirement and meet the needs of the departments and their training programs, the GMEC has developed the following protocol for new program director appointments.

Procedure

The Chair of the Department should identify and recommend a candidate for the residency/fellowship director to the GMEC. The department chair may want to consult with the Designated Institutional Official (DIO) during the selection process. It is the responsibility of the department chair to review the program's ACGME Program Requirements to determine eligibility of the candidate. The chair should submit a completed New Program Director Appointment Letter to the GMEC, recommending the candidate for appointment. 

The letter includes the following elements:

  • Explanation/rationale for change in program director
  • Candidate's qualifications, including their educational, clinical and faculty background
  • Verification that candidate meets ACGME/RRC Program Director Qualifications
  • Guarantee of departmental support for the program director's responsibilities, including: 
    • Staff support (program coordinator)
    • Salary support
    • Dedicated time to administer the program
  • Request for documents:

The GMEC will review the New Program Director Appointment letter and associated documents at its next monthly meeting. If the candidate is endorsed, the DIO will prepare a letter for the joint signatures of the department chair and DIO. Only after the letter is signed and submitted to the ACGME, can the program coordinator update the program director information on the ACGME website.


Approved by the GMEC: 7/25/05

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Policy for Department Support of Residency and Fellowship Program Director

The ACGME Common Program Requirements state that a program must ensure that the Program Director has sufficient financial support and protected time for his or her educational and administrative responsibilities to the program.  (Common Program Requirements I.A.)

For specific specialties, the ACGME may require a defined percentage of financial support and protected time that the Department Chair must provide; however, in the absence of such requirement the Graduate Medical Education Committee has set the following guidelines:

  • Program Directors must have a minimum of 20% protected time to fulfill the administrative and educational responsibilities of maintaining the residency or fellowship program (at least one full day per week).
  • A minimum of 20% of the Program Director's base salary (the "X") must be guaranteed by the Department for the Program Director for the administrative responsibilities of directing the residency or fellowship program.

Approved by GMEC: 4/22/2013

 

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Restrictive covenants are prohibited for residents and fellows at UCLA. Housestaff are not, and will not, be required to sign non-compete agreements.

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Sleep quarters are to be safe, comfortable and private (one person per room). Lavatory and shower facilities must be in close proximity to the sleep rooms. All house staff, faculty and medical students needing overnight sleep rooms are eligible to use the on call rooms located in either the main Resident Quarters on the B level or the on call rooms located on the floors throughout the hospital. The GME House Staff Office is responsible for the management of room allocations, in consultation with Hospital Administration. Utilization of beds will be reviewed at least annually, and re-assignments made as necessary.

Eligibility 

Eligibility/Priority Order for Sleep Rooms

  • House staff scheduled overnight call
  • Faculty required in-house overnight call
  • House staff likely to stay in-house
  • Medical students on Sub-internships
  • Faculty likely to stay in-house
  • House staff who might be called back to the hospital and are unable to return home
  • Medical students on inpatient rotations
  • Faculty who might be called back to the hospital and are unable to return home
  • House staff or faculty who are post call and require a nap before going home

Ineligible for Rooms but In-House Overnight

  • Physicians and others doing overnight call but on shift rotations are ineligible for sleep quarters (i.e. Emergency Medicine physicians, Nurse Practitioners, etc.)
Location

Centralized Resident Quarters on B Level (40 private rooms)
Blocks of rooms to be allocated by service based on scheduled in-house call.

Assignments

Assignments
Allocated beds are assigned on a scheduled basis by service according to the on call schedule.

Daytime Use
Rooms that are designated as hotelier are available from 8:00 a.m. - 4:00 p.m. for rest or naps for house staff and others who have been on call overnight

Allocation of Sleep Rooms Outside of Main Resident Quarters

  • There must be a critical, time-sensitive need for close proximity to the patient related to patient acuity and management, OR
  • There is a requirement by an accreditation body for juxtaposition of sleep quarters to the patient unit
  • Clinical services which require on call rooms to be located in close proximity to specific patient care areas may be assigned sleep rooms either on a floor above or below the patient care area, if necessary.

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Residents will be required to sign a statement at the time of appointment, acknowledging that they understand and will comply with this policy.

 USMLE STEP 1 & 2/COMLEX LEVEL 1 & 2
  • Incoming PGY 1 residents are required to take and pass the first two steps of the applicable Licensing Exam, either USMLE or COMLEX, to be eligible for employment at UCLA.
  • Trainees starting at the PGY 2 level from an outside institution must pass all three steps of the Licensing Exam prior to the start of training at UCLA.
USMLE STEP 3

Failure to pass all steps of the US Medical Licensing Exam and obtain a full and unrestricted Medical License in accordance with Medical Board Licensing regulations will result in automatic suspension in accordance with the Academic Due Process policy.

Licensing Exam Policy

Reviewed and accepted by GMEC 2/28/2022

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Sleep and rest, eating, bathroom, and shower facilities that provide privacy, security, sound proofing, quiet, good ventilation, and convenient telephones are provided.

Ancillary support services that provide, in as far as possible; 24-hour phlebotomy and IV services; 24-hour access to medical records, and to radiology, laboratory, and other diagnostic services; and access to transport, escort, and ward secretarial services are available.

The laboratory and radiologic information retrieval system is online 24 hours/day. The medical records system that documents the course of each patient's illness and care is available 24 hours/day online and from the File Room.

Security and personal safety measures are provided to residents in all locations, including parking facilities, hospital and institutional grounds.

The UCLA Graduate Medical Education Committee has been designated as the authoritative body to review concerns related to work conditions, as well as issues related to the program and/or faculty. Residents who have concerns about their work conditions, program or faculty, should address their Program Director and/or Chair. If problems or concerns are not resolved at this level, these should be brought to the attention of the GMEC or Resident Action Committee, a subcommittee of the GMEC for review and recommendations. The GMEC is then charged with the resolution or the concern or issue.