UCLA GME Working and Training at Affiliated Organizations Policy

Working and Training at Affiliated Organizations as a University of California (UC) Employee or as a Trainee Enrolled in a UC-Sponsored Training Program

UC’s academic health centers and health professional schools have affiliations with other health care organizations to improve quality and access for the people of the state of California, particularly those in medically underserved communities, and to support the University’s education, research and public service mission.

Some of these organizations have policies that are different from those of UCLA Health. For example, some restrict certain evidence-based health care services, such as abortion, contraception, assisted reproductive technologies, gender-affirming care, and end-of-life care, that otherwise would be offered at a UC or other health care location. These organizations are “covered affiliates” under Regents Policy 4405 and systemwide policy.

The University of California is committed to delivering patient-centered, evidence-based, comprehensive medical care that addresses the needs of patients, advances health equity, and is free from discrimination. Accordingly, when UC providers are working or training at any UC or non-UC facility, they are expected to:

  • Make clinical decisions consistent with the standard of care and their independent professional judgment, respecting each individual patient’s needs and wishes. Trainees are expected to make decisions under the appropriate level of supervision by a licensed clinician as outlined in the local UC school and program supervision policies.
  • Inform patients of all health care options, regardless of whether those options are available through the covered affiliate, prescribe any interventions that are medically necessary and appropriate, and transfer or refer patients to other facilities when it is in the patient’s interest.
  • Provide any item or service deemed necessary and appropriate in the event of an emergency, without restriction, and without seeking approval from any non-licensed health care provider.
  • Transfer or refer patients to other facilities whenever it is determined that it is in the patient’s interests, including providing any necessary items or services to any patient for whom referral or transfer to another facility would risk material deterioration to the patient’s condition.

Covered affiliates may ask for confirmation of adherence to their policies while working or training at their facilities. However, the major private, non-profit health systems in California with policy-based restrictions have acknowledged in their agreements with the University that their policies permit all of the above activities; and all covered affiliates will have done so no later than December 31, 2023, or the University will exit the agreement.

In addition to these organizations, many government-operated facilities are prohibited by law from performing certain services and have adopted policies implementing those laws. They also have confirmed that they expect their medical staff and personnel providing services at their clinical sites to make clinical decisions consistent with the standard of care and their independent professional judgment, considering the needs and wishes of each individual patient. As with all UC-sponsored training programs, trainees are expected to make decisions under the appropriate level of supervision by a licensed clinician as outlined in the local UC school and program supervision policies.

These government-operated organizations have verified that they comply with federal anti-discrimination laws and that they do not bar advising, prescribing, or referring patients, nor do they bar performing emergency services.

UCLA Health has identified the following non-governmental covered affiliates that have care-restricting policies. This list is not exhaustive and may change over time based on the policies of these organizations or the addition of new agreements with other health care organizations:

  • Providence Health
  • Adventist Health
  • Dignity Health
  • Loma Linda University
  • QueensCare Health Centers

The University expects that UC employees and trainees will deliver evidence-based health care services and, in those locations where a required service cannot be delivered, appropriate referrals or transfers must be made.

Faculty and trainees must be educated on the transfer process for services that may be restricted at an affiliate site.  Contact information for UCLA Health programs and clinics that offer such services and additional community resources can be found at UCLA Health’s webpage about Getting Care at Affiliated Organizations.  Any questions or barriers to the transfer of care must be immediately directed to the appropriate contact described below.

If at any time a UC employee or trainee is asked to do otherwise, or a patient has a complaint, the University should be immediately informed as described below. If patients have any concerns or complaints about care received at a covered affiliate’s location, they may contact UCLA’s Office of Patient Experience at 310-267-9113.

If UCLA Health Sciences employees or trainees believe their professional judgment or freedom to counsel, prescribe, refer, transfer, or provide emergency care has in any way been impeded at a covered affiliate’s facility, they should immediately contact:

If for any reason, UC employees or UC trainees are unable to contact the individuals identified above, the following should be contacted: UCLA Health, Office of Compliance Services, at compoffice@mednet.ucla.edu. Concerns may also be reported through the University’s Whistleblower Hotline at universityofcalifornia.edu/hotline or (800) 403-4744.

More information can be found in the full text of the Regents Policy 4405 Policy on Affiliations with Healthcare Organizations that Have Adopted Policy-Based Restrictions on Care.