Institutional Policies

This page is designed to provide residents/fellows (trainees) the most up-to-date information on ACGME institutional policy and procedures, leave policies and procedures, and administrative policies and procedures.

Each program's policy manual must reference the institution manual and contain policies and procedures specific to the program. Some programs may have policies that are more rigid than the institution manual, in which case the program policy would be followed. Should a policy in a program manual conflict with the institution manual, the institution manual takes precedence.

Questions? Please email gme@umn.edu.

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View: Eligibility, Selection, & Transfer Policy

Policy Statement

Eligibility

Residents:

Prior to their program start date residency program applicants must provide their program with documentation of the following qualifications to be eligible for appointment:

  1. Graduation from a medical school that meets one of the following requirements: 
    1. Graduation from medical school in the United States or Canada and accredited by the Liaison Committee on Medical Education (LCME), OR
    2. Graduation from a college of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA), OR
    3. Graduation from a medical school outside of the United States or Canada meeting one of the following additional requirements:
      1. Holds a currently valid certificate from the Educational Commission for Foreign Medical Graduates (ECFMG), OR
      2. Holds a full and unrestricted license to practice medicine in Minnesota.
  2. Passing scores on Steps 1 and 2 (Clinical Knowledge) of the United States Medical Licensing Examination (USMLE) or an equivalent examination that qualifies for medical licensure (e.g., Comprehensive Osteopathic Medical Licensing Examination-COMLEX).
  3. Eligible for either a residency permit or a permanent medical license as granted by the Minnesota Board of Medical Practice.
  4. For those trainees entering a program after a Transitional or Preliminary PGY-1 year, a written or electronic verification of previous educational experiences and a summative evaluation of the resident performance addressing the six ACGME competencies.

Fellows:

In addition to the previous requirements listed under Residents, fellowship program applicants must also provide their program with documentation of the following qualifications to be eligible for appointment:

  1. Graduation from an appropriate ACGME residency program or a program with ACGME International (ACGME-I) Advanced Specialty Accreditation where recognized, or a Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited or College of Family Physicians of Canada (CFPC)-accredited residency program located in Canada (Residents who temporarily suspend their residency training to take a subspecialty fellowship position do not have to provide a completion certificate); and
  2. A passing score on USMLE Step 3 or an equivalent examination that qualifies for medical licensure (e.g., Comprehensive Osteopathic Medical Licensing Examination-COMLEX); and
  3. A written or electronic verification of previous educational experiences and a summative competency-based performance evaluation of the trainee.

Fellowship program applicants who have not completed an ACGME residency program, a program with ACGME International (ACGME-I) Advanced Specialty Accreditation, or a Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited or College of Family Physicians of Canada (CFPC)-accredited residency program located in Canada may be allowed under special circumstances, which require review and approval.  See the ACGME Fellow Eligibility Exceptions Guide or Non-Standard (Non-ACGME Accredited) Fellow Eligibility Exceptions Guide for more information.

Eligibility Exemption
Applicants who:

  • are non-physicians with a Ph.D. degree who are eligible to train in an ACGME-approved fellowship, as listed in the subspecialty program requirements, or
  • hold a MD/DO degree and a PhD but have not completed an ACGME-accredited GME Residency program who are eligible to train in ACGME-approved fellowship, as listed in the subspecialty program requirements are exempt from the eligibility requirements of this policy but are still subject to the selection criteria.
  • are International medical graduates applying for the Graduate Medical Education Global Breast Cancer Fellowship are exempt from the USMLE Step #3 requirement but are still subject to the other selection criteria.
     

Selection

  1. Programs select from among eligible applicants based on their educational preparedness, ability, aptitude, academic credentials, communication skills and personal qualities such as motivation and integrity. 
  2. The Medical School does not discriminate with regard to sex, race, color, creed, religion, national origin, age, marital status, disability, public assistance status, veteran’s status or sexual orientation.
  3. The Medical School participates in the National Residency Matching Program (NRMP). Each accredited residency/fellowship program that participates in the NRMP Match will abide by the rules and regulations of the NRMP.  Those programs using other Match programs will abide by their rules and regulations.

Trainee Transfers

In accordance with the ACGME’s Common Program Requirements prior to accepting a trainee from another residency or fellowship program the program director must obtain the following:

  1. Written or electronic verification of previous educational experiences and a summative competency-based performance evaluation of the transferring resident or fellow.
  2. Proof that the transferring resident or fellow has passed the USMLE Step 3 or equivalent licensing examination (e.g. COMLEX) for PGY-3 residents or higher.

A program director must provide timely verification of residency education and summative performance evaluations for residents and fellows who leave the program prior to completion.

Reason for Policy

To outline specific qualifications required for eligibility and selection of residents/fellows (trainees) entering a University of Minnesota Medical School Graduate Medical Education training program.

Responsibilities

Program Responsibilities: 

Monitoring and compliance of the eligibility requirements is expected at the Department/Program Level.

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Affiliation Agreements

Policy Statement

For all residency and fellowship programs, there must be an affiliation agreement between the program and each participating site outside of the sponsoring institution to which residents/fellows rotate for required education or assignments.

In addition, there must be an affiliation agreement under any of the following circumstances:

  • The participating site requires an agreement (for a list of major affiliates requiring agreements for all rotations, elective and required, see this document), OR
  • The participating site is outside of the United States, OR
  • There are financial terms associated with the resident/fellow experience at the participating site.

Programs are encouraged but not required to execute affiliation agreements for rotations not outlined above.

The agreement must identify the faculty who will assume both educational and supervisory responsibilities for residents/fellows; specify faculty responsibilities for teaching, supervision, and formal evaluation of residents/fellows; specify the duration and content of the educational experience; and state the policies and procedures that will govern the resident/fellow education during the assignment.

The agreement must be fully executed (signed and dated by all authorized signers) prior to the start date of the rotation.  The agreement must be renewed at least every ten  years or sooner if required by the University or the Participating Site. The increased length of the agreement is allowed per the ACGME Common Program Requirements as listed in the ACGME Program Director’s Guide to the Common Program Requirements.

Reason for Policy

The purpose of affiliation agreements is to protect the program’s residents/fellows by ensuring an appropriate educational experience under adequate supervision.  These agreements are educational documents which provide details on faculty, supervision, evaluation, educational content, length of assignment, and policies and procedures.  In addition, some affiliation agreements are legal documents which provide details on liability and financial arrangements.

Within the MMCGME community, affiliates rely on these agreements as part of their internal processes to track and plan for residents/fellows.

Given the value of these agreements, the University of Minnesota has adopted more stringent requirements than those outlined by the Accreditation Council for Graduate Medical Education (ACGME), and applies these requirements to all GME programs, including those not accredited by ACGME.

Procedures

Refer to the Affiliation Agreements webpage for up-to-date information about how affiliation agreements are processed.

Responsibilities

The GME Office assists with the process of executing affiliation agreements as an administrative service and to ensure that our programs are in compliance with requirements.  It is the program’s responsibility to ensure that the content of these documents accurately reflects regular, ongoing conversations about curriculum delivery that are taking place between the program and sites to which trainees rotate.

FAQ

  • ACGME Common Program Requirements FAQs: Pages 1-4
  • Q: My program is not ACGME-accredited.  Do I still need affiliation agreements?
  • A: Yes.  Affiliation agreements document regular, ongoing conversations between the program director and site director to ensure your trainee(s) are receiving an appropriate educational experience under adequate supervision.
  • Q: Which affiliates require agreements for elective rotations?
  • A: See this document for a current list of major affiliates who require agreements for all rotations, regardless of whether they are required or elective.  Note this list is not considered exhaustive, and you must verify with your affiliate what their agreement policy is when arranging a rotation at a new location.
  • Q: I have an agreement with ABC site for my trainees to rotate with Dr. Smith.  Dr. Smith wants the trainees to join him on rounds at XYZ site.  Can they go without an agreement with XYZ site since it’s the same supervising physician?
  • A: No.  Affiliation agreements are with site locations, not preceptors / site directors / physicians.  Each site location must be separately evaluated, and an affiliation agreement executed when necessary.

Definitions

  • Affiliate: The legal entity that is authorized to enter into legally-binding Agreements with the University, i.e.: Affiliation Agreements. Examples of Affiliates are: hospitals, clinics, pharmacies, universities, and government entities, but can be any legal business entity.
  • Participating Site: The physical location where an educational experience takes place.
  • Master Affiliation Agreement (MAA): An agreement between the University of Minnesota and an affiliate.  MAAs are created when an affiliate has sites used consistently by three or more UMN schools/colleges/departments for educational experiences.  All MAAs are negotiated by AHC Legal, and cover general terms agreed between the University and the affiliate.  Each MAA provides for further creation of associated Program Letters of Agreement (PLAs) between specific UMN programs and affiliate sites - see “Program Letter of Agreement (PLA)” below.
  • Program Letter of Agreement (PLA): A written document that addresses responsibilities between an individual program and a site other than the sponsoring institution at which residents/fellows receive a part of their education.  At the University of Minnesota, a PLA may reference back to an MAA (see “Master Affiliation Agreement (MAA)” above).  PLAs referencing back to an MAA have final execution in the GME Administration office.
  • Agreement of Institution and Program Affiliation (AIPA): At the University of Minnesota, this type of affiliation agreement is created when a Master Affiliation Agreement (MAA) is not in place and there is a need to document legal matters (e.g. when there are financial terms associated with the rotation, when the affiliate is outside the United States, etc).  The agreement is between a program or department and an affiliate, and documents legal and educational matters.  Any changes to the standard template language must be negotiated through AHC Legal, and all AIPAs have final execution via AHC Legal.
  • Financial Agreement Addendum (FAA): Financial addenda to an affiliation agreement contain the agreed-upon financial terms for each year (fiscal or calendar) during the term of the agreement.  If the parties don’t anticipate any changes to the financial arrangements during the term of the agreement, the financial arrangements may be spelled out in the body of the agreement.  If the financial terms will change each year, the agreement reflects that the terms for the first year are set forth on an attachment and that financial terms for each subsequent year must be set forth on a separate annual financial addendum (FAA) signed by the parties.

History

Effective:

January 26, 2021: Approved by Graduate Medical Education Committee (GMEC).   Possible agreement duration increased from 5 years to 10 years if both parties agree.

October 24, 2017: Approved by the Graduate Medical Education Committee (GMEC).  This policy replaces the Agreement of Institution and Program Affiliation (AIPA) Policy and the Master Affiliation Agreements (MAA) and Program Letters of Agreement (PLA) Policy.  Previously, all rotations for all programs required an agreement.  With this policy update, affiliation agreements are encouraged but not required for elective rotations within the United States that do not have funding arrangements.

Applicant Privacy & Record Retention Policy and Procedure

Policy Statement

Programs must limit the distribution of sensitive applicant data to those faculty and/or staff who are involved in the pre and post recruitment activities.  

Any printed materials with sensitive data must not be left in the open and must be filed in a locked cabinet when not in use.  Sensitive data saved on a computer must be in a secure folder. 

The GME Document Retention Policy applies to those applicants accepted into a University of Minnesota program.  

For those applicants not accepted into a University of Minnesota program, please follow University of Minnesota document retention recommendations which states “retain 1 year after term for which application processed provided no litigation is pending.”

Reason for Policy

To outline precautionary measures programs must take to protect applicant’s personal information pre and post recruitment season.

Certificate of Completion Policy

Policy Statement

Trainees who successfully complete all requirements of their training program must receive a certificate of completion. The certificate must include:

  • The official University of Minnesota name of the GME program as listed on the GME program inventory.
  • The trainee’s legal name at the time of graduation.
  • If the degree is listed on the certificate it must be the medical degree that was originally bestowed (i.e. MBBS vs. MD). 
  • The date on the certificate must match the actual start and end dates in the program.
    • If the trainee was on a leave of absence that extended their training the actual end date must be reflected on their certificate.
  • The certificate must be signed by the program director of record, AND the Dean of the Medical School and/or the Associate Dean of GME and/or the Department Chair. 

Programs must use the certificate paper provided by the Office of Graduate Medical Education.  Programs must retain an electronic copy of each certificate on file in the event that the original is lost or damaged.  

Certificates must not be reprinted for trainees requesting to have their name changed as the certificate must reflect their legal name at the time of graduation.  

Additional Resources

Click here for: Certificate of Completion Instructions.

Classification & Appointment Policy

Policy Statement

All residents and fellows in University of Minnesota (“University”) sponsored programs must have an appointment that is compliant with the structure listed within this policy.

  1. University of Minnesota Employed Residents and Fellows - Standard Classifications
    Residents and fellows in GME programs sponsored by the University, with the exception of those listed in sections 2 and 3 below, must have a University paid appointment in one of the classifications listed herein based on their status in the program.   The majority of residents and fellows will fall into the categories outlined directly below.  Reference: see sections 2 and 3 for exceptions  

Residents:

  • 9556 Medical Resident | Primary classification for residents
  • 9559 Medical Resident – Graduate Program | Classification for residents enrolled in a Graduate Program
  • 9582 NIH NRSA Medical Resident | Classification for residents paid on NIH NRSA grant (company UNS)
  • 9583 NIH NRSA Medical Resident – Graduate Program | Classification for residents enrolled in a Graduate Program and paid on NIH NRSA grant (company UNS)

Fellows:

  • 9555 Medical Fellow | Primary classification for fellows
  • 9554 Medical Fellow – Graduate Program | Classification for fellows enrolled in a Graduate Program
  • 9568 NIH NRSA Medical Fellow |Classification for fellows paid on NIH NRSA grant (company UNS)
  • 9569 NIH NRSA Medical Fellow – Graduate Program| Classification for fellows enrolled in a Graduate Program and paid on NIH NRSA grant (company UNS)

2. University of Minnesota Common-Paymaster Employed Fellows - as Instructors -Fellows in non-accredited fellowship programs may hold a common-paymaster appointment as a paid University Instructor (9404) with a UMP Physician appointment.

  • Fellows in GME programs sponsored by the University, in the fellowship program types listed below, may hold a paid Instructor appointment. J1 visa holders are not eligible for this type of appointment and must be appointed in the appropriate classification in section 1 or section 2, see GME Visa Sponsorship Policy. 
  • Fellows in ACGME-accredited programs that are explicitly allowed to engage in the independent practice of their core specialty during their fellowship as outlined in their ACGME Fellowship Program Requirements, may hold a common-paymaster appointment as a paid University Instructor (9404) with a UMP Physician appointment. 

3. Non-University of Minnesota Employed Residents and Fellows - Employed by other organizations residents and fellows in GME programs sponsored by the University, whose employer is external to the University, may be paid by that employer. This is allowed in the following situations: 

  • GME Programs:
  • Family Medicine - Duluth Residency, employed by Essentia Health
  • Family Medicine - Methodist Hospital Residency, employed by Park Nicollet
  • Family Medicine - St. Cloud Hospital Residency, employed by Centracare
  • Forensic Psychiatry Fellowship, employed by the State of Minnesota
  • TRIA Orthopedic Sports Medicine, employed by Park Nicollet
  • Competency Based, Time Variable Hospice and Palliative Medicine Fellowship Pathway
  • University residents/fellows who are funded by an agency of the United States Government (for example, the U.S. Military) may be paid directly by the Federal Government
  • Visiting residents/fellows who continue to be paid by their own sponsoring institutions may participate in specified rotations or training experiences at the University of Minnesota without compensation from the University of Minnesota.
  • University of Minnesota faculty in a Graduate Medical Education program retaining their faculty appointment may be payrolled through their faculty appointment.

Reason for Policy

To clarify the appropriate classification and appointment types for residents/fellows.

History

Amended:
June 2023: Amended to add option for independent practice (section 2b) and include information about externally employed residents/fellows that was previously included in the Without Salary Appointment Policy.  The WOS policy was sunset when the content was moved to this policy.  

July 25, 2017: Amended to clarify the policy for trainees in non-accredited programs.

Effective

August 1, 2002

Clinical and Educational Work Hours Policy

Policy Statement 

The following policy applies to all Graduate Medical Education training programs sponsored by the University of Minnesota Medical School, both ACGME-accredited and non-accredited, and to all Graduate Medical Education trainees when assigned to any other institution or clinical site as part of their training program.

All programs are required to adhere to and monitor compliance of their trainees with the ACGME clinical and educational work hours standards as outlined in the ACGME Common Program Requirements. Training programs must also follow program-specific guidelines as outlined by their individual Review Committees. The sponsoring institution monitors training program adherence to the clinical and educational work hour requirements.

Management of clinical and educational work hours is a shared responsibility of programs and trainees.  The trainees must adhere to the policy and report violations. The program must structure clinical activities to adhere to, monitor and enforce compliance with the requirements. The institution must provide oversight to the programs and address non-compliance.

Reason for Policy 

The purpose of this policy is to define clinical and educational work hour requirements for Graduate Medical Education trainees, define oversight and monitoring for compliance with the regulations, and define the responsibilities of the trainees, the programs, and the sponsoring institution. 

Definitions

Clinical and Educational Work Hours 

Time spent at the worksite performing clinical and/or academic activities required by the trainee’s GME training program, including: 

    • Patient care activities, both inpatient and ambulatory, whether scheduled or not. 
    • Administrative activities that are related to patient care. 
    • In-hospital “on call”, regardless of what the trainee activities are during such periods. 
    • Scheduled academic activities. 
    • Time spent on direct patient care activities and in-hospital during home call.
    • Time spent moonlighting, if allowed.

Trainee Responsibilities

Trainees are responsible for adhering to the schedule created by their programs to provide both educational and clinical experience opportunities, as well as reasonable opportunities for rest and personal activities. Trainees have a personal role in accurately reporting their clinical and educational work hours. Trainees that are at risk of violating work hour rules have an obligation to inform program leadership so that coverage can be arranged to avoid violation.

Trainees are required to report the following work activities and all work hour violations to their program leadership for review and process improvement.

  • Patient care:

    • Inpatient and outpatient care occurring at the hospital or while at home.
    • Administrative duties related to patient care occurring at the hospital or while at home.
    • Electronic Medical Record (EMR) note writing, preparation of discharge summaries, phone calls related to patient care, while at home or at the training site.
    • The provision for transfer of patient care and sign-outs.
    • Time spent in-house during call activities.
  • Education/Academic:

    • Scheduled academic activities such as conferences or unique educational events.
    • Research.
    • Time spent at academic conferences and meetings when attendance is required by the program, or when the trainee is acting as a representative of the program. Only actual meeting time counts towards work hours.
    • Work hours spent on activities that are required by the accreditation standards or that are accepted practice in training programs.
  • The following activities are excluded from work hour reporting:

    • Academic preparation time.
    • Travel and non-conference time when at a conference or meeting.

Concerns about continuous work hour violations not adequately addressed by their program can be reported to the Designated Institutional Official at gme@umn.edu. Anonymous reporting of work hour violations can occur via a Qualtrics form. Trainees may also report violations directly to the ACGME.

Program Responsibilities

Programs are responsible for knowing the clinical and educational work hours requirements set forth in the ACGME Common Program Requirements and in their program-specific requirements. 

    • Programs must design an effective program structure that is configured to provide trainees with educational and clinical experience opportunities, as well as reasonable opportunities for rest and personal activities, within the bounds of ACGME requirements. 
    • Each program is required to have a written clinical and educational work hours policy consistent with this Institutional Policy. Specific night float requirements should be articulated in this policy as well as any exemptions if they are approved by the Review Committee.
    • The program's clinical and educational work hours policy and trainee relief procedures must be communicated to all members of the faculty and trainee staff.
    • Programs must implement a system to monitor compliance with clinical and educational work hour requirements and outline the protocol in their Program Manual. 
    • Programs must report work hour violations to the GME office quarterly and articulate a process for addressing those violations.
    • Programs must provide alternative coverage for a trainee’s clinical responsibilities if the trainee is too fatigued to continue their assigned clinical responsibilities. 

Sponsoring Institution Responsibilities

Oversite

    1. The Sponsoring Institution must oversee clinical and educational work hours across all programs and address areas of non-compliance in a timely manner. The Graduate Medical Education office will review work hour violations as reported by programs quarterly and partner with programs to address non-compliance or concerning trends.
    2. The Sponsoring Institution must oversee systems of care, learning and working environments, and education programming that facilitate fatigue mitigation for trainees. In partnership with training programs, the Sponsoring Institution must ensure safe, quiet and private sleep facilities and safe transportation options for trainees who may be too fatigued to safely return home.

History

November, 2019: Revised for consistency with ACGME Institutional Requirements and ACGME Common Program Requirements.

January 2003: Approved by Graduate Medical Education Committee

Appendix

  1. Policy Implementation

    1. Program Implementation Timeline

      • January 1, 2020: Programs are expected to develop a program level policy and process to comply with the revised GME policy and list their program policy in their program manual.

      • January 31, 2020: Programs must communicate the new policy and monitoring process to their residents or fellows and implement their plan.

    2. Graduate Medical Education Implementation Timeline

      • April 1, 2020: GME Administration emails a quarterly survey to programs asking them to certify that quarterly work hours (for period 1/1/2020 - 3/31/2020) have been reviewed and that violations have been addressed.

      • April 30, 2020: Programs complete the survey by this date.

      • May 1, 2020 to mid May 2020: GME Administration analyzes and reviews program responses to the survey. GME prepares the data to present to the GMEC.

      • May, 2020 (4th Tuesday): GME Administration presents data to the GMEC and shares the data with the respective programs and departments.

  2. Policy Monitoring

    1. Program Policy Monitoring: Example Methods 

      • Send out a monthly survey to residents or fellows for all of their rotations (sample survey)

      • Send out a survey quarterly to track low risk rotations

      • Do biopsy monitoring of all learners for a particular time frame (sample biopsy form)

      • Do biopsy monitoring of learners only on high risk rotations

      • Use RMS to conduct daily monitoring of high risk rotations

    2. Graduate Medical Education Monitoring

    3. Oversight

      • GME will compare the quarterly hours attestation with the trainee surveys (Annual Program Evaluation and the ACGME Annual Resident Fellow Survey.) Discrepancies must be explained by the program.

  3. Reporting

    1. Trainee Reporting Survey

Resource List

Completion of Step 3 of the Appropriate Licensing Exam (USMLE, COMLEX)

Policy Statement

All trainees must provide their program with documentation of a passing score on the United States Medical Licensing Examination (USMLE) Step 3 or an equivalent examination qualifying for medical licensure (e.g. Comprehensive Osteopathic Medical Licensing Examination-COMLEX) by six months into their PGY2 year (typically January 1).

Trainees who do not notify their program of a passing score by six months into their PGY2 year (typically January 1) may be dismissed from the program based upon the Program Director’s discretion.

Upon application to the program, trainees who transfer into a University program (PGY-3 and beyond) are required to provide documentation of a passing score on their examination.

Refer to your Program Manual for additional program specific guidelines.

Policy Exemption

Applicants who:

  • are non-physicians with a Ph.D. degree who are eligible to train in an ACGME-approved fellowship, as listed in the subspecialty program requirements, or 
  • hold a MD/DO degree and a PhD but have not completed an ACGME-accredited GME Residency program who are eligible to train in ACGME-approved fellowship, as listed in the subspecialty program requirements

are exempt from the requirements of this policy.

Reason for Policy

To ensure that residents/fellows (trainees) complete the required licensing examination within the specified timeframe so that upon graduation from their program they will have completed the preliminary requirements to practice medicine in the United States.

Responsibilities

Program Responsibilities

Departments and programs are responsible for overseeing and ensuring compliance with these examination requirements. 

Related Information

Eligibility and Selection Policy

Federation of State Medical Boards: http://www.fsmb.org/ 

National Board of Osteopathic Medical Examiners: http://www.nbome.org/ 

History

5/22/2018: Removed language specific to contract non-renewal if a trainee fails to meet the January 1 deadline as contracts are now issued for the entire duration of the program and clarified the passing score requirement timeline.

9/26/2017 - Reviewed and updated by the GMEC. Changes include removing reference to ACGME Institutional Requirement IV.A.2.c).(2).

 

Disability Accommodations Policy

Policy Statement

The Graduate Medical Education (GME) training programs provide reasonable accommodations to residents/fellows who have a documented disability (physical,learning, psychiatric, vision, hearing, or systemic) that may affect their ability to participate in training activities or meet program requirements.To be eligible for reasonable accommodations, residents/fellows must work with Disability Services. Disability Services is the University of Minnesota office that has responsibility to review disability documentation and recommend reasonable accommodations for employees and students with disabilities, including residents/fellows participating in a GME training program.

Disability Services assists residents/fellows in securing documentation of disability conditions, determines whether a trainee is covered under disability laws, and if so, works with the resident/fellow and the training program to fashion reasonable accommodations for the individual. Disability Services also provides information, referral and consultation. The Disability Services office is located in the McNamara Alumni Center,Suite 170, (612) 626-1333 (voice or TTY), email: ds@umn.edu.

In order to successfully complete a residency or fellowship program, all residents/fellows must meet the essential requirements of their training program; residents/fellows with disabilities must be able to meet the essential requirements, with or without reasonable accommodations.

Related Information

Board of Regents Disability Services Policy

History

 None

Disaster (Substantial Disruption) Planning Policy

Policy Statement

In response to a disaster or other substantial disruption in patient care or education that may alter the ability of the Sponsoring Institution and its programs to support graduate medical education, , the Designated Institutional Official (DIO will notify the ACGME as soon as reasonably possible. The University of Minnesota DIO will be the primary institutional contact with the ACGME.

The University of Minnesota will provide assistance for continuation of salary, benefits, professional liability coverage, and resident and fellow assignments. The University of Minnesota will continue to provide the same level of financial and administrative support, to the extent possible, as it did prior to the disaster.

If leadership determines that the Sponsoring Institution can no longer provide adequate educational experience for its trainees for a temporary period, the Sponsoring Institution will, to the best of their ability, arrange for temporary transfer of trainees to programs at other Sponsoring Institutions until such time as the Sponsoring Institution is able to resume providing the educational experience.  The University of Minnesota and its affected programs will follow the steps listed in the ACGME Policies and Procedures guide

Related Information

U of M Health Emergency Response Office; Minnesota Statute 12.61 

Discipline, Dismissal, Failure to Advance Policy & Procedure

Policy Statement

Trainees can be disciplined for both academic and non-academic reasons. Forms of discipline include, but are not limited to: warning, required compliance, probation, suspension, failure to advance, and dismissal. There are separate grounds and procedures for each type of discipline as outlined below.

Procedures

Discipline/Dismissal for Academic Reasons

Grounds

As students, GME trainees are required to maintain satisfactory academic performance. Academic performance that is below satisfactory is grounds for discipline and/or dismissal. Below satisfactory academic performance is defined as a failed rotation; relevant exam scores below program requirements; and/or marginal or unsatisfactory performance, as evidenced by faculty evaluations and other assessments, in the areas of clinical diagnosis and judgment, medical knowledge, technical abilities, interpretation of data, patient management, communication skills, interactions with patients and other healthcare professionals, professionalism, and/or motivation and initiative.

To maintain satisfactory academic performance, residents/fellows also must meet all eligibility requirements throughout the training program. Failure or inability to satisfy licensure, registration, fitness/availability for work, visa, immunization, or other program-specific eligibility requirements are grounds for dismissal or failure to advance in the program.

Procedures

Before dismissing a trainee or failing to advance for academic reasons, the program must give the trainee: 

  • Notice of performance deficiencies;
  • An opportunity to remedy the deficiencies; and
  • Notice of the possibility of dismissal or failure to advance if the deficiencies are not corrected.

Trainees disciplined and/or dismissed for academic reasons may be able to grieve the action through the Conflict Resolution Process for Student Academic Complaints Policy. This grievance process is not intended as a substitute for the academic judgments of the faculty who have evaluated the performance of the trainee, but rather is based on a claimed violation of a rule, policy or established practice of the University or its programs.

Academic Probation

Trainees who demonstrate a pattern of unsatisfactory or marginal academic performance will undergo a probationary period. The purpose of probation is to give the residents/fellows specific notice of performance deficiencies and an opportunity to correct those deficiencies. The length of the probationary period may vary but it must be specified at the outset and be of sufficient duration to give the trainee a meaningful opportunity to remedy the identified performance problems. Depending on the trainee’s performance during probation, the possible outcomes of the probationary period are: removal from probation with a return to good academic standing; continued probation with new or remaining deficiencies cited; non-promotion to the next training level with further probationary training required;failure to advance in the program, or dismissal.

Discipline/Dismissal for Non-Academic Reasons

Grounds

Grounds for discipline and/or dismissal of a trainee for non-academic reasons include, but are not limited to, the following: 

  • Failure to comply with the bylaws, policies, rules, or regulations of the University of Minnesota, affiliated hospital, medical staff, department, or with the terms and conditions of this document.
  • Commission by the trainee of an offense under federal, state, or local laws or ordinances which impacts upon the abilities of the trainee to appropriately perform his/her normal duties in the residency/fellowship program.
  • Conduct, which violates professional and/or ethical standards; disrupts the operations of the University, its departments, or affiliated hospitals; or disregards the rights or welfare of patients, visitors, students, hospital/clinical staff, or others involved in the training program.

Procedures

Prior to the imposition of any discipline for non-academic reasons, including, but not limited to, written warnings, probation, suspension, or termination from the program, a trainee shall be afforded:

  • Clear and actual notice by the appropriate University or hospital representative of charges that may result in discipline, including where appropriate, the identification of persons who have made allegations against the trainee and the specific nature of the allegations; and,
  • An opportunity for the trainee to appear in person to respond to the allegations.
  • Following the appearance by the trainee, a determination should be made as to whether reasonable grounds exist to validate the proposed discipline. The determination as to whether discipline would be imposed will be made by the respective Medical School department head or his or her designee. A written statement of the discipline and the reasons for imposition, including specific charges, witnesses, and applicable evidence shall be presented to the trainee.

After the imposition of any discipline for non-academic reasons, a trainee may avail themselves of the following procedure:

  • If within thirty (30) calendar days following the effective date of the discipline, the trainee requests in writing to the Dean of the Medical School a hearing to challenge the discipline, a prompt hearing shall be scheduled. If the trainee fails to request a hearing within the thirty (30) day time period, his/her rights pursuant to this procedure shall be deemed to be waived.

    • The hearing panel shall be comprised of three persons not from the residency/fellowship program involved: a chief resident; a designee of the Dean of the University of Minnesota Medical School; and an individual recommended by the Chair of the Graduate Medical Education Committee. The panel will be named by the Dean of the Medical School or his or her designee and will elect its own chair. The hearing panel shall have the right to adopt, reject or modify the discipline that has been imposed.

At the hearing, a trainee shall have the following rights:

  • Right to have an advisor appear at the hearing. The advisor may be a faculty member, trainee, attorney, or any other person. The trainee must identify his or her advisor at least five (5) days prior to the hearing;
  • Right to hear all adverse evidence, present their  defense, present written evidence, call and cross-examine witnesses; and,
  • Right to examine the individual's residency/fellowship files prior to or at the hearing.
  • The proceedings of the hearing shall be recorded.
  • After the hearing, the panel members shall reach a decision by a simple majority vote based on the record at the hearing.
  • The residency/fellowship program must establish the appropriateness of the discipline by the weight of the evidence.
  • The panel shall notify the trainee in writing of its decision and provide the trainee with a statement of the reasons for the decision.

Although the discipline will be implemented on the effective date, the stipend of the trainee shall be continued until his or her thirty (30) day period of appeal expires, the hearing panel issues its written decision, or the termination date of the agreement, whichever occurs first.

The decision of the panel in these matters is final, subject to the right of the trainee to appeal the determination to the President's Student Behavior Review Panel. 

The University of Minnesota, an affiliated hospital, and the department of the trainee each has a right to impose immediate summary suspension upon a trainee if his or her alleged conduct is reasonably likely to threaten the safety or welfare of patients, visitors or hospital/clinical staff. In those cases, the trainee may avail he or she of the hearing procedures described above. The foregoing procedures shall constitute the sole and exclusive remedy by which a trainee may challenge the imposition of discipline based on non-academic reasons.

Failure to Advance

In instances where a trainee fails to advance, the University of Minnesota Medical School ensures that its ACGME accredited programs provide the trainee(s) with a written notice of intent not to advance a trainee(s) agreement no later than four months prior to the end of the trainee’s current program year. However, if the primary reason(s) for failure to advance occurs within the four months prior to the end of the program year, the University of Minnesota Medical School ensures that its ACGME-accredited programs provide the trainee(s) with as much written notice of the intent not to advance as the circumstances will reasonably allow, prior to the end of the program year.

Trainee(s) will be allowed to implement the institution’s grievance procedures if they have received a written notice of intent not to advance them in the program.

 

ECFMG Required J-1 Visa Holder Notification Policy

Policy Statement

Residents and fellows (trainees) who are sponsored by the Education Commission on Foreign Medical Graduates (ECFMG) as a J-1 visa holder must notify ECFMG whenever they are experiencing a qualifying required notification event such as; off-site rotations, leave of absences, physician resignation, dismissal, remediation, or an incident/allegation against them, or a J-2 dependent. Federal regulations require that ECFMG maintain up-to-date records on the locations, and activities of the exchange visitor physicians it sponsors. Failure to communicate a qualifying required notification event of a J-1 visa holder to ECFMG can result in premature expiration of the trainee’s DS-2019, which can cause major disruptions to training, or incompletion of program.

Required Notification Events

  1. Off-site rotations: ECFMG must be informed at least 30 days in advance of any proposed off-site rotation or elective that will be conducted at a location other than the approved “Sponsoring Institution” or a “Participating Site” for the training program as reported to and recognized by the ACGME, including international rotations.
  2. Leave of Absence: ECFMG must be informed in advance of any planned LOA including, but not necessarily limited to, medical, parental, or academic leave. Once notified of a planned LOA, ECFMG will review the plan to ensure that eligibility for J-1 visa sponsorship is not impacted and that sponsorship can be maintained for the full duration of the leave. Additional documentation may be requested upon review. Once ECFMG has fully evaluated the plan and any supporting documentation provided, ECFMG will follow-up with the exchange visitor physician and the Training Program Liaison (TPL) at the host institution. NOTE: ECFMG does not sponsor, or extend time for personal leaves of absence.
  3. Physician Resignation: When a J-1 physician resigns, ECFMG must amend a physician’s Student and Exchange Visitor Information System (SEVIS) record upon a physician’s resignation from his/her training program. Therefore, ECFMG must be informed immediately of a physician’s plans to leave his/her training program in advance of the program end date listed on Form DS-2019. Once notified of a resignation, ECFMG will adjust the individual’s SEVIS record to reflect the new program end date and an e-mail will be sent to the physician notifying him/her of the action taken by ECFMG. Exchange visitor physicians who resign are federally required to depart the United States within 30 days of an amended SEVIS end date. 
  4. Physician Dismissal: ECFMG is required to monitor the activities of the exchange visitor physicians it sponsors and to update the Student and Exchange Visitor Information System (SEVIS) if/when an exchange visitor physician is released from the approved training program and site of activity. Therefore, ECFMG must be informed immediately of any exchange visitor physician’s dismissal in advance of the originally-approved program end date listed on Form DS-2019 and/or prior to program completion. Once notified of a dismissal, ECFMG will adjust the individual’s SEVIS record to reflect the new program end date and an e-mail will be sent to the exchange visitor physician notifying him/her of the action taken by ECFMG. 
  5. Remediation: ECFMG requires notification of anyformalremedial action for a trainee,  
  6. Incident or Allegation: As an exchange visitor program sponsor, ECFMG must monitor the well-being of exchange visitor program participants and report incidents involving exchange visitor physicians and/or their accompanying J-2 dependent(s) to the U.S. Department of State (DoS). Therefore, ECFMG must be notified of any serious matter involving an exchange visitor physician or accompanying J-2 dependent. The DoS has indicated that any incident or event that impacts the health, safety, or welfare of J visa holders or that could bring the DoS exchange visitor program “notoriety or disrepute” is reportable. 

Procedures

Program Responsibility 

The program and/or J-1 is required to report any qualifying notification event listed above to the GME office Training Program Liaison (TPL). The TPL will upload the form to the J-1 visa holders appointment profile within ECFMG.  

  • Up to date forms for each incident type can be located on the ECFMG website, linked here.

After the form is submitted, ECFMG may require additional information, or verification such as; 

  1. written confirmation from the J-1 that they will hold/held health insurance and will not/did not train outside their current approved training program during the time of leave

  2. letter from the program director (on letterhead) outlining the exact dates used for time extending the J-1’s programand break down of the allotment of time (vacation, sick leave, paid leave of absence, unpaid leave of absence);

  1. revised contract/offer letter with the new projected exact end date of the training program for the academic year in question.

 

Emergency Paid Leave- COVID-19 Pandemic (2023)

Residents and Fellows (trainees) who are payrolled through the University are eligible for Emergency Paid Leave. Starting January 1, 2023-December 31, 2023 trainees have access to up to two weeks of University Emergency Paid Leave.

  • The time should be tracked by the Program Coordinator to ensure that board requirements are met. If time exceeds the allowed amount per the board, time can extend training.
  • Programs should use the Leave of Absence Summary and Leave of Absence Form to report time used, and to ensure that time is tracked like all other types of leaves. Time from 2022 does not roll over to 2023.
  • More information: UMN Emergency COVID Leave 

Effective Dates for Stipends and Benefits Policy and Procedure

Policy Statement

The first recognized day in their program is hereby defined as the first mandatory day the resident/fellow is required to report to their GME training program.  This is typically the first day of orientation or the first day of their rotation whichever comes first.

Trainees must be paid at the appropriate stipend rate as set forth by the Stipend Level Policy and receive their benefits, defined as health, dental, life and disability insurance, upon the first recognized day of employment in their respective program.

Reason for Policy

To ensure that trainees receive their stipend and benefits effective upon the first day in their program per the ACGME institutional requirements.

 

Eligibility and Selection Policy and Procedure

Policy Statement

Eligibility

Residents:

Prior to their program start date residency program applicants must provide their program with documentation of the following qualifications to be eligible for appointment:

  1. Graduation from a medical school that meets one of the following requirements: 

    1. Graduation from medical school in the United States or Canada and accredited by the Liaison Committee on Medical Education (LCME), OR

    2. Graduation from a college of osteopathic medicine in the United States accredited by the American Osteopathic Association (AOA), OR

    3. Graduation from a medical school outside of the United States or Canada meeting one of the following additional requirements:

      1. Holds a currently valid certificate from the Educational Commission for Foreign Medical Graduates (ECFMG), OR

      2. Holds a full and unrestricted license to practice medicine in Minnesota.

  2. Passing scores on Steps 1 and 2 (Clinical Knowledge) of the United States Medical Licensing Examination (USMLE) or an equivalent examination that qualifies for medical licensure (e.g., Comprehensive Osteopathic Medical Licensing Examination-COMLEX).

  3. Eligible for either a residency permit or a permanent medical license as granted by the Minnesota Board of Medical Practice.

  4. For those trainees entering a program after a Transitional or Preliminary PGY-1 year, a written or electronic verification of previous educational experiences and a summative evaluation of the resident performance addressing the six ACGME competencies.

Fellows:

In addition to the previous requirements listed under Residents, fellowship program applicants must also provide their program with documentation of the following qualifications to be eligible for appointment:

  1. Graduation from an appropriate ACGME residency program or a program with ACGME International (ACGME-I) Advanced Specialty Accreditation where recognized, or a Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited or College of Family Physicians of Canada (CFPC)-accredited residency program located in Canada (Residents who temporarily suspend their residency training to take a subspecialty fellowship position do not have to provide a completion certificate); and

  2. A passing score on USMLE Step 3 or an equivalent examination that qualifies for medical licensure (e.g., Comprehensive Osteopathic Medical Licensing Examination-COMLEX); and

  3. A written or electronic verification of previous educational experiences and a summative competency-based performance evaluation of the trainee.

Fellowship program applicants who have not completed an ACGME residency program,  a program with ACGME International (ACGME-I) Advanced Specialty Accreditation, or a Royal College of Physicians and Surgeons of Canada (RCPSC)-accredited or College of Family Physicians of Canada (CFPC)-accredited residency program located in Canada may be allowed under special circumstances, which require review and approval.  See the ACGME Fellow Eligibility Exceptions Guide or Non-Standard (Non-ACGME Accredited) Fellow Eligibility Exceptions Guide for more information.

Eligibility Exemption
Applicants who:

  • are non-physicians with a Ph.D. degree who are eligible to train in an ACGME-approved fellowship, as listed in the subspecialty program requirements, or
  • hold a MD/DO degree and a PhD but have not completed an ACGME-accredited GME Residency program who are eligible to train in ACGME-approved fellowship, as listed in the subspecialty program requirements are exempt from the eligibility requirements of this policy but are still subject to the selection criteria.
  • are International medical graduates applying for the Graduate Medical Education Global Breast Cancer Fellowship are exempt from the USMLE Step #3 requirement but are still subject to the other selection criteria.
     

Selection

  1. Programs select from among eligible applicants based on their educational preparedness, ability, aptitude, academic credentials, communication skills and personal qualities such as motivation and integrity. 

  2. The Medical School does not discriminate with regard to sex, race, color, creed, religion, national origin, age, marital status, disability, public assistance status, veteran’s status or sexual orientation

  3. The Medical School participates in the National Residency Matching Program (NRMP). Each accredited residency/fellowship program that participates in the NRMP Match will abide by the rules and regulations of the NRMP.  Those programs using other Match programs will abide by their rules and regulations.

Trainee Transfers

In accordance with the ACGME’s Common Program Requirements prior to accepting a trainee from another residency or fellowship program the program director must obtain the following:

  1. Written or electronic verification of previous educational experiences and a summative competency-based performance evaluation of the transferring resident or fellow.

  2. Proof that the transferring resident or fellow has passed the USMLE Step 3 or equivalent licensing examination (e.g. COMLEX) for PGY-3 residents or higher.

A program director must provide timely verification of residency education and summative performance evaluations for residents and fellows who leave the program prior to completion.

Reason for Policy

To outline specific qualifications required for eligibility and selection of residents/fellows (trainees) entering a University of Minnesota Medical School Graduate Medical Education training program.

Responsibilities

Program Responsibilities: 

Monitoring and compliance of the eligibility requirements is expected at the Department/Program Level.

 

Health Insurance Requirement for Health Sciences Students

The GME office abides by the Academic Health Center Policy for health insurance requirements

International Medical Graduates Policy

Policy Statement

All International Medical Graduates (IMGs) must meet all criteria found in the Eligibility and Selection of Resident/Fellow Policy to qualify for a residency/fellowship at the University of Minnesota.

Procedures

All IMGs, including American citizens who are IMGs, must provide a current, valid copy of the ECFMG certificate or other appropriate documentation to MMCGME Services as required audit documentation. MMCGME Services will enter IMG resident/fellow information into the Residency Management Suite (RMS), our current system for tracking Medicare-reimbursable information.  
 
Copies of required documentation should be sent to MMCGME Services.  See http://www.mmcgmeservices.org/ for contact information.
 
Inform residents whose ECFMG certificate was issued prior to June 14, 2004 of the importance of getting their "Valid Indefinitely" sticker as soon as possible. They should go to the ECFMG forms library at the website http://www.ecfmg.org/pubshome.html for the current application.
 
If a copy of the ECFMG certificate is not available, please contact the ECFMG Training Program Liaison to request Certification Verification via the ECFMG website.

Responsibilities

Programs:
Must ensure that all required documentation for all IMGs is distributed to the appropriate office for tracking.

Related Information

All IMGs must be in a residency/fellowship program for two years before they are eligible for licensure in Minnesota. See: MBMP Licensing Process

Leave Policy

Policy Statement

Residents and fellows (resident/fellow) may request time away from their program by accessing the leaves outlined in this policy. The trainee must give notice, in writing, of intent to use a leave of absence to their program director at least eight (8) weeks in advance, except under unusual circumstances. A leave of absence is only available to those who request the leave in compliance with program policy and receive approval from the program. Questions regarding leave must be directed to the program director and program coordinator. Refer to your program manual for specific program expectations.


Each program is responsible for maintaining accurate records of the amount of leave time taken by each trainee. The American Board of Medical Specialties requirements must be reviewed by the program director and trainee to ensure that the trainee understands if their training will be extended.


The program manual for the residency or fellowship will have specific policies and procedures that apply to the resident/fellow in compliance with the program board requirements.
Unused vacation days are not paid out at the end of the academic year.


Residents/fellows on unpaid leaves of absences must provide the Office of Student Health Benefits with payment information for the employee share of benefits so they can continue to receive medical and dental benefits during the unpaid leave
 

Reason for Policy

The program is responsible for defining and communicating their program leave policies and processes, in their program manual.


Programs are responsible for tracking time off for all leaves. They must ensure that specialty board requirements are met prior to resident/fellow graduation from the program. They must inform the trainee if their leave will extend training.


Programs are responsible for notifying all stakeholders of a trainee leave of absence. The program must submit a leave through the Office of Graduate Medical Education using the LOA submission process outlined in the OGME HR Google Site. 


Programs must work with their resident/fellow to report all leaves in the Residency Management Suite (RMS) according to instructions received by MMCGME Services.  Programs must also forward documentation to MMCGME Services for leaves that extend the resident/fellow time in the program.


Leaves of absence for resident/fellow on J-1 visas must be approved by ECFMG. Programs are required to submit the ECFMG Required Notification of LOA form to the GME Office before a trainee who is on a J-1 visa is planning to take a leave of absence. The form will then be submitted by the Training Program Liaison (TPL) to ECFMG for approval. ECFMG will email the TPL and the trainee when a determination is made about the leave. The approval will be forwarded to the program so they are able to move forward with processing the leave. 

If the leave extends training, financial support for the additional training time must be determined by the program when arrangements are made for the leave.


See your program manual for specific departmental policies and procedures.
 

Types of Leave

Bereavement Leave:

Bereavement Leave is available to support residents and fellows experiencing a significant personal loss due to the death of an immediate family member, other family members, and colleagues. Bereavement Leave will allow you to:

  • Attend funeral services, ceremonies, and interment
  • Make necessary arrangements, including travel if necessary
  • Serve as pallbearers

Immediate Family: (See definition of immediate family member below in definitions)

Granted up to three workdays paid bereavement leave. Up to two additional workdays of paid leave may be granted at the discretion of the program director upon consideration of the funeral location (local or long distance), cultural expectations, rituals, ceremonies, etc. and other pertinent factors.    

Death of other family members:

Granted up to one workday paid bereavement leave. 

Death of a colleague:

Granted reasonable paid (typically less than one day) bereavement leave time away from work to attend the funeral or service. Leave is subject to the needs of the program as determined by the program director and the department or administrative unit head. 

Extended Absence:

Absences not covered by paid bereavement leave provisions are accommodated by the use of available vacation time and/or unpaid personal leave at the discretion of the program director. To be supportive of residents and fellows who are experiencing a significant personal loss, the University strongly encourages flexibility in granting requests for additional paid (as available and appropriate) and unpaid leave time beyond the paid bereavement leave provisions.

Earned Sick and Safe Time (ESST) 


Earned sick and safe time (ESST) is paid leave employers must provide to employees working in Minnesota. The Minnesota Department Labor and Industry identified specific situations when the time can be used including when an employee is sick, to care for a sick family member, to seek assistance if an employee or their family member has experienced domestic abuse, or if there is a work or school closure that prevents an employee from being able to work. 


The University of Minnesota Office of Human Resources in consultation with the Office of General Counsel determined that Medical Residents and Medical Fellows in job codes 9554, 9555, 9556 and 9559 are considered salaried employees and will accrue Minnesota Earned Sick and Safe Time (ESST). Medical Residents and Medical Fellows in NIH-NRSA job codes 9582, 9583, 9568 and 9569 will not accrue Minnesota ESST as they are in company UNS.


The Office of Graduate Medical Education is mandated to adhere strictly to the Employee Sick and Safe Time (ESST) guidelines as stipulated in the Office of Human Resources Policy. Each program is required to delineate, within its program manual, a process detailing the procedure for requesting ESST, as well as the mechanisms for accruing and tracking ESST. 

  • Programs may allow an additional bank of sick/health time in addition to the ESST. 
  • If ESST is more than the allowable days for board certification, the resident/fellow may need to extend their time in training to meet board requirements. See individual program manual.
  • ESST utilization is permissible only after the accrual of time in 4-hour increments. In instances where ESST is unavailable on the intended date of use, residents or fellows are required to utilize Paid Time Off (PTO) or other designated time allocated by their respective program. It is essential that any retroactively entered ESST into the payroll system accurately reflects the date of its utilization.
  • ESST is not paid out at the end of training. ESST ends and is not paid out if a resident/fellow moves onto a T32 grant. 
  • For more information view the Frequently Asked Questions (FAQ).

 

Medical | Caregiver Leave Concurrent with Family Medical Leave Act (FMLA and non-FMLA)
Once during training, residents and fellows are eligible for pay at 100 percent of their stipend for the first six weeks of the first approved medical, or caregiver leave of absence. Any subsequent leaves for medical, or caregiver leave will be paid only out of the PTO/Sick/Vacation time that the trainee has available at the time of the leave. Medical/Caregiver leaves are eligible to take intermittently up to 6 weeks paid.


Any previously paid parental leave counts as one instance of paid at 100% of stipend for 6 weeks leave and cannot be applied to any medical/caregiver leave following the parental leave.

Residents/fellows can reserve one week of paid time off to use outside of the six weeks of the first approved medical, or caregiver leave(s) of absence taken during an academic year. 

The remaining time outside of the reserved one week will be paid by the trainee's vacation/sick/PTO allotment, department (if extends training), or a combination to equal 100% of the trainee's stipend.

Family Medical Leave Act & non-FMLA (FMLA):

The Family Medical Leave Act, or FMLA is a federal law that allows residents and fellows, who are eligible, up to 12 weeks of protected leave per academic year. Residents/fellows must consult with their program to determine if they are eligible.


All FMLA leave types that are non-FMLA eligible for medical, caregiver, or parental leave will follow the FMLA eligible leave process.

With the proper medical documentation and supervisor approval, FMLA can be used for:

  1. Your own serious health condition
  2. The serious health condition of an immediate family member
  3. Caring for a newborn or newly-placed adopted child or foster child
  4. The urgent need of an immediate family member who is on active duty in the military services

Leave shall not exceed 12 weeks in any 12-month period.  The 12-month period is based on an academic year (07/01-06/30).  The trainee may be eligible for Short Term and Long Term Disability benefits.  Department Human Resources staff will determine FMLA eligibility and will provide the trainee with the appropriate paperwork.

Holiday Leave:

Holiday leave is dependent on the requirements of the rotation to which the resident/fellow is assigned. The educational requirements and the 24-hour operational needs of the hospital are taken into consideration when scheduling holiday time off.

Residents/fellows are not eligible to receive an annual University of Minnesota issued personal holiday.

Military, Court Appearance, or Civic Duty Leave: R

Residents/fellows may be absent from work for military leave, jury duty, appearance in court, and voting or serving as an election judge in federal or state elections as outlined in this policy. Residents/fellows must notify the program as soon as they are called to active military duty.  It is incumbent upon the program director to notify both the individual RRC and the Board of this change in status.

Military Leave:

Military leave, whether voluntary or involuntary, is taken for service including activities such as training, active duty, full-time National Guard duty, and fitness for military duty examinations.

Military leave applies to trainees who are members of the following: the National Guard and Air National Guard; an armed forces branch of the United States military, regular or reserve, (Army, Navy, Air Force, Marines, Coast Guard); commissioned corps of the Public Health Service; or any other category of persons designated by the President of the United States in time of war or national emergency.

Residents/fellows are granted military leave in accordance with federal and state laws and regulations and University policy. Residents/fellows are granted leave with pay, not exceeding 15 days in any calendar year, for required service in the National Guard or any of the armed services reserve forces. Additional leave without pay is granted for the duration provided within federal and state laws and regulations.

Residents/fellows are entitled to resume University service following their military leave. Residents/fellows who are re-employed after a military leave of 30 to 180 days may not be discharged without cause for six months after the date of re-employment. Trainees who are re-employed after a military leave of 181 days or more may not be discharged without cause for one year after the date of re-employment.

For military family leaves associated with a resident or fellow's immediate family member being on or receiving a federal call to active duty status in support of a contingency operation or having a serious injury or illness incurred while on active duty, refer to the FMLA Policy.

Appearance in Court

Residents/fellows are granted paid leave when testifying before a court or a legislative committee on matters concerning federal or state government, the University, or when called to testify as an expert, so long as their testimony or consultation is unpaid.  Residents/fellows who are victims of certain crimes are provided unpaid personal leave in accordance with, and as defined by law.

Jury Duty

Residents/fellows are granted paid leave when serving on a jury, including the jury selection process. When the jury is recessed, the trainee is expected to be working during any normal work time.

Voting and Election Judge Leave

Residents/fellows are eligible for a paid leave of absence to vote in any state-held general election, primary special election, and special primary for the time necessary to appear at the trainees polling place, cast a ballot, and return to work on the day of that election. Paid leaves to vote cover only those hours the trainee is regularly scheduled to work and are provided to only those trainees who specifically request time off to vote.

Residents/fellows are eligible for a paid leave of absence to serve as a precinct election judge. To be eligible, a trainee, at least 20 days in advance, must provide a written leave request accompanied by certification from the appointing authority stating the hours of service.

Parental Leave:

Parental leave provided by this policy is available to residents and fellows on 50% appointment or greater and who is becoming a parent through birth, adoption, gestational surrogacy or to a trainee who is a gestational carrier.

Upon request, eligible trainees may take up to six weeks paid parental leave. The parental leave will begin at a time requested by the trainee, but not more than two weeks prior to the due date or adoption event, and no later than 13 weeks - after the birth or adoption event, or longer at the discretion of the program. In the case where the child must remain in the hospital longer than the birth parent, the leave must begin no later than 13 weeks after the child leaves the hospital. Parental leave is a paid benefit for all residents/fellows, which will not be deducted from other paid time away. This leave must be consecutive and without interruption, and must be taken during the term of appointment. 

During parental leave, medical coverage will continue to be available for the residents/fellows and any dependents who are enrolled under the Office of Student Health Benefits Resident, Fellow, and Intern plan. While on parental leave, the continued coverage will be provided on the same basis as available to the resident/fellow during the course of employment. 

While on unpaid leave not covered by FMLA, the continued coverage will be available at the resident/fellow's expense. The Office of Student Health Benefits will provide trainees with information about benefits and premiums due while on leave. If premiums are due, the OSHB will request the resident/fellow to complete a payment authorization form to pay these dues to ensure continuous coverage.

Residents/fellows may be eligible for other leaves that occur prior to or after parental leave under other applicable leave policies. In all cases, FMLA runs concurrently with paid parental leave and other applicable paid leaves.

Note: The first two weeks of the paid parental leave covers the required fourteen day wait period before the parent who gave birth may be eligible to receive short-term disability benefits. See Short Term Disability Policy at: https://shb.umn.edu/residents-fellows-and-interns/disability

Residents/fellows who give birth may also receive the short-term disability benefit while on a paid parental leave. 

Personal Leave:

Personal Leave is for residents/fellows who need time away from work to attend to matters that affect their lives, that are unrelated to their training in graduate medical education, and that significantly interfere with their ability to meet their work responsibilities.

Examples of personal leave may include, but are not limited to:

  • Your own serious health condition (for trainees who are not eligible for FMLA)

  • Extension beyond FMLA period of 12 weeks per academic year

  • The serious health condition of an immediate family member (for trainees who are not eligible for FMLA)

  • Caring for a newborn or newly-placed adopted child or foster child (for trainees who are not eligible for FMLA)

  • The urgent need of an immediate family member who is on active duty in the military service (for trainees who are not eligible for FMLA.

Professional Leave:

The Institution supports a culture of excellence and is committed to providing its trainees with opportunities to participate in professional development, education, and training activities. Programs may provide time off for their residents/fellows that is not deducted from their paid time away allocation.

Examples of professional leave may include, but are not limited to:

  • Academic
  • Continuing Medical Education (CME)
  • Interviewing
  • Professional Conference Attendance/Presentation

Vacation Leave:

Vacation leave is paid time away from work for you to use for your personal activities and to create a healthy balance between your work and personal life.

Availability and Requesting Vacation Leave

The amount of vacation leave available to you, and the guidelines for using vacation leave varies by program. Refer to your program manual for details.

Definitions:

Immediate Family Member

  • An immediate family member is described as; (1) The spouse or domestic partner, (2) the resident/fellow: (a) biological, adoptive, step, or foster child or ward; (b) parent or parental equivalent; or (c) sibling, and (3) the resident/fellow's spouse’s or domestic partner’s: (a) biological, adoptive, step, or foster child or ward; (b) parent or parental equivalent; or (c) sibling.

Residents/Fellows

  • Graduate Medical Education Professionals in Training who are classified as one of the paid or unpaid appointments at the University of Minnesota on the Classification & Appointment Policy.

Resources for Programs, Residents, and Fellows

 

 

Licensure Policy

Policy Statement

The Minnesota Board of Medical Practice (MBMP) is the state entity that regulates physicians practicing in Minnesota.  All trainees must hold an active residency permit or a physician license from the MBMP as determined by each individual residency/fellowship program. The statute can be found at: https://www.revisor.mn.gov/statutes/?id=147.0391. Trainees must pass the required licensing examinations (i.e. USMLE, COMLEX, etc) prior to obtaining a medical license.

Responsibilities

The Permit/License Guide is kept up-to-date.  Review the guide to ensure your understanding of the process. 

Residency permits are valid through the term specified on the original permit application and are program specific. If a trainee extends their residency/fellowship, the program is responsible for ensuring that a permit extension request form is submitted to the MBMP and an extended permit is in place prior to the current permit end date and must cover all dates of clinical training. If a trainee transfers to another program a new permit must be obtained. 

Trainees who moonlight outside their training program must have a physician license. Minnesota licenses are renewed annually based on birth month.  Once a Minnesota license is obtained, the permit is no longer valid and the trainee and program must ensure the license is renewed annually.

Programs are responsible for monitoring renewal deadlines and ensuring that trainee’s permits or licenses do not expire.  Please note there is no grace period when a permit or license expires.  Trainees whose permit or license expires are pulled from their rotation until the paperwork is received and processed by the MBMP.

Related Information

Trainees holding a Minnesota medical license do not need to be credentialed as an independent provider by the hospitals they are rotating to as long as they are performing duties within the scope of their training program and not billing for their services. A physician holding a Minnesota license has to be credentialed by the hospital if they are acting as an independent physician where there will be patient billing (i.e. moonlighting). Please refer to the MBMP website for licensure guidelines and fees. 

Additional information related to visiting residents and fellows is available on the GME website

Contact:

Minnesota Board of Medical Practice
335 Randolph Ave
St Paul, MN 55102

Telephone: (612) 617-2130, Fax: (612) 617-2166
Email: Medical.Board@state.mn.us
mn.gov/boards/medical-practice

History

April 24, 2018: Specific Minnesota Board of Medical Practice process details removed from policy.

  • Origination Date: July 2011
  • Last Review Date: July 26, 2022

Life Support Certification Policy

Policy Statement
Depending on program requirements and hospital site requirements, trainees may be expected to have life support certification upon entering training, and maintain certification throughout training. 

Responsibilities

Certification Responsibilities: It is the program's responsibility to ensure that trainees are certified throughout training, if required.  Requirements could come from:

  • Accrediting body Program Requirements
  • Specialty Boards
  • Specialty Societies
  • Training Sites
  • Other

If life support certification is required by the training  site, it is the site’s responsibility to notify the program and resident/fellow. It’s the program’s responsibility to understand if other non training site entities require certification. Fees: If life support course certification is required, the program may elect to cover the expense.  

Documentation: Documentation and record-keeping of initial certification and recertification will be maintained in RMS by the trainee’s program if applicable.
 

Related Information

Additional information is available on the Life Support Certification webpage.

Moonlighting Policy

Policy Statement

Trainees must not be required to engage in moonlighting activities.

PGY-1 residents are not permitted to moonlight.

Programs are not required to permit moonlighting for their trainees and may choose to disallow these activities as a matter of program policy.

Moonlighting must not interfere with the trainee's ability to achieve the goals and objectives of the training program.

Moonlighting activities are not considered to be part of the educational curriculum in University of Minnesota residency and fellowship programs.

Time spent moonlighting must be reported as a part of duty hours monitoring and must be included in assessments of compliance with ACGME duty-hour requirements.

Trainees on J-1 visas are not permitted to be employed outside their training program and are not permitted to moonlight.

Trainees on H-1B visas must obtain separate H-1B visas for each facility where the trainee works outside the training program.

Trainees must seek and receive written permission from their program director BEFORE engaging in moonlighting activities, and the program must retain a copy of this correspondence in the trainee's personnel record in RMS. This permission must acknowledge the trainees understanding that

  • their trainee professional liability coverage through the University of Minnesota does not cover moonlighting activities,
  • moonlighting activities must not interfere with their achieving program goals and objectives, including compliance with duty hour regulations, and
  • the program director may review moonlighting activities at a later date and reserves the authority to withdraw permission to moonlight.

Reason for Policy

The purpose of this policy is to provide residents/fellows (trainees) and their programs with information on managing moonlighting in compliance with ACGME requirements, CMS regulations, immigration law and the Minnesota Board of Medical Practice. If statements in this policy contradict those of ACGME, CMS, immigration law or the Minnesota Board of Medical Practice, those policies take precedence.

Procedures

  1. The trainee thoroughly reviews the institutional moonlighting policy, their program moonlighting policy and the moonlighting request form.
  2. If the trainee’s program allows moonlighting, the trainee must complete the University of Minnesota Graduate Medical Education Standard Moonlighting Request Form (see below in forms)
  3. The trainee must complete all sections of the form and present it to their program director for review.
  4. The program director may deny or approve the request.
  5. If the program director approves the request the trainee may proceed with applying to moonlighting at the approved site.
  6.  If the program director denies the request, the trainee may not moonlight.
  7. The fully executed moonlighting request form (all signatures obtained) will be uploaded to RMS by the program.  It will reside in the files and notes section of the trainee’s personnel record in RMS.
  8. The program must use this naming standard as they scan and save the completed form: Moonlighting Request Form Year/Month_Last Name, First Name (e.g. Moonlighting Request form 2013.10_Smith, John)

Forms/Instructions

University of Minnesota Graduate Medical Education Standard Moonlighting Request Form

Responsibilities

Trainee:

  1. Trainees who wish to moonlight must obtain prior permission from their program directors, using the approved University of Minnesota Graduate Medical Education Standard Moonlighting Request Form. Failure to get prior approval is grounds for discipline under Section VI of the Residency/Fellowship Agreement.
  2. Trainees must report moonlighting as a part of their duty hours in the Residency Management Suite (RMS).

Program:

  1. The Program Director determines the moonlighting policy for all trainees within their program.
  2. Program directors will acknowledge in writing (via approval of the moonlighting form) their awareness that a trainee is moonlighting and will include this information in their training file.
  3. Program directors may withdraw permission to moonlight for any given trainee or group of trainees at their discretion.

Multidisciplinary Program Policy

Policy Statement

Multidisciplinary training programs involve several distinct specialties in order to meet curricular requirements. An ACGME-accredited multidisciplinary program must be aligned with, and function as, an integral part of multiple residency program(s) at the sponsoring institution, as reflected in the respective program requirements. For multidisciplinary programs, only one ACGME-accredited program can exist within a sponsoring institution.

There must be collaboration among the multiple disciplines and professions involved in educating the fellows in a multidisciplinary program. The educational resources required to support the program necessitate cooperation of all the involved disciplines. A single multidisciplinary oversight committee must regularly review the program's resources and its attainment of its stated goals and objectives.  

Procedures

The program director of a multidisciplinary training program must maintain a membership roster for the multidisciplinary oversight committee and minutes of its meetings.

Definitions

Multidisciplinary programs are co-sponsored by multiple specialties and accredited by multiple Residency Review Committees (RRCs). They require the collaboration of several distinct specialties to meet curricular requirements.

This policy applies to all ACGME-accredited multidisciplinary programs at the University of Minnesota.  As of the time of last policy review, this includes:

  • Clinical Informatics (in development)
  • Endovascular Surgical Neuroradiology
  • Molecular Genetic Pathology
  • Pain Medicine

History

2/23/2016: Approved by Graduate Medical Education Committee.

9/26/2017: Policy reviewed by GMEC. List of UMN multidisciplinary programs updated.

 

Nepotism Policy and Procedure

Policy Statement

GME Administration follows Nepotism Policy set forth by the University of Minnesota Board of Regents.  Please see the links below for further details:

University of Minnesota Board of Regents Nepotism and Personal Relationships Policy 

Managing Nepotism and Personal Relationships 

Reason for Policy

To clarify the process that should be followed when a nepotism situation arises.

Procedures

When a Department/Program learns of a possible personal relationship involving one or more employees in the unit, the Department/Program must contact the Office of Equal Opportunity and Affirmative Action at 612.624.9547.  EOAA will provide guidance on the proper steps that need to be taken and assist the Department/Program in developing an agreement between all parties to anticipate any conflicts of interest that may arise.

NIH NRSA Training Grant Appointment


Policy Statement

Residents/fellows (trainees) who are moved to one of these four NIH NRSA appointments:

  • 9582 NIH NRSA Medical Resident
  • 9583 NIH NRSA Medical Resident – Graduate Program
  • 9568 NIH NRSA Medical Fellow
  • 9569 NIH NRSA Medical Fellow – Graduate Program

must be given thirty (30) days notification of change in appointment from their program.  See program responsibility.

Trainees on NIH NRSA Training Grants:

  • Are exempt from FICA withholdings and must have non-service appointments in one of the four approved classifications.
  • Have health, dental, life, long and short-term disability and malpractice insurance.
  • Receive benefits from the UCard such as access to the libraries, discount tickets, ADCS computer labs, etc.
  • Have access to the Recreational Center but will have to pay membership fees.
  • Have access to the Residency Assistance Program (RAP).

Trainees on NIH NRSA Training Grants:

  • Are not eligible for Health Care Reimbursement account or Dependent Care Reimbursement account.
  • Are not eligible to participate (withhold funds from your pay) in the Optional Retirement Plan (ORP) or the University of Minnesota Section 457 Deferred Compensation Program (457 Plan).
  • Are not eligible to deduct parking fees on a pre-tax basis 

Reason for Policy

Per NIH policy, training grants are to be used for trainees pursuing academic research careers and are not provided as a condition of employment, which means that benefits associated with employees cannot be provided to trainees on National Research Service Award (NRSA) training grants from the National Institutes of Health (NIH).

Procedures

Trainees on NIH NRSA Training Grant and Enrolled in Graduate School will:

Continue to be registered for courses and tuition and fees will be paid. The payment of tuition and fees for your graduate courses, along with keeping your registration current, will continue your status as a fee paying student and allow you access to the U of M Recreation Center.  

Responsibilities

Program

Provide trainee with a letter of notification of change in appointment no later than 30 days prior to the change in appointment.

Per our stipend level appointment policy, “Trainees in all programs at the same level of training must be paid in accordance with the stipends set by the Graduate Medical Education Committee (GMEC).  Trainees may not be paid less than or in excess of the stipend set by the GMEC for their level of training.” Programs must supplement the funds received by the NIH NRSA training grant in order to pay the trainee at the approved stipend for their level of training.

History

In 2005, the University’s general counsel and external legal counsel reviewed NIH and IRS regulations in partnership with a workgroup. The workgroup consisted of staff from various departments within the University (Tax, Payroll, HR, Sponsored Projects Administration, General Counsel, Graduate School and Medical School).  The policy and procedure is the work product of the work group.

NIH NRSA Training Grant Policy and Procedure

Policy Statement

Residents/fellows (trainees) who are moved to one of these four NIH NRSA appointments:

  • 9582 NIH NRSA Medical Resident
  • 9583 NIH NRSA Medical Resident – Graduate Program
  • 9568 NIH NRSA Medical Fellow
  • 9569 NIH NRSA Medical Fellow – Graduate Program

must be given thirty (30) days notification of change in appointment from their program.  See program responsibility.

Trainees on NIH NRSA Training Grants:

  • Are exempt from FICA withholdings and must have non-service appointments in one of the four approved classifications.
  • Have health, dental, life, long and short-term disability and malpractice insurance.
  • Receive benefits from the UCard such as access to the libraries, discount tickets, ADCS computer labs, etc.
  • Have access to the Recreational Center but will have to pay membership fees.
  • Have access to Vital WorkLife & the Physician Wellness Collaborative.

Trainees on NIH NRSA Training Grants:

  • Are not eligible for Health Care Reimbursement account or Dependent Care Reimbursement account.
  • Are not eligible to participate (withhold funds from your pay) in the Optional Retirement Plan (ORP) or the University of Minnesota Section 457 Deferred Compensation Program (457 Plan).
  • Are not eligible to deduct parking fees on a pre-tax basis

Reason for Policy

Per NIH policy, training grants are to be used for trainees pursuing academic research careers and are not provided as a condition of employment, which means that benefits associated with employees cannot be provided to trainees on National Research Service Award (NRSA) training grants from the National Institutes of Health (NIH).

Procedures

Trainees on NIH NRSA Training Grant and Enrolled in Graduate School will:

Continue to be registered for courses and tuition and fees will be paid. The payment of tuition and fees for your graduate courses, along with keeping your registration current, will continue your status as a fee paying student and allow you access to the U of M Recreation Center.  

Responsibilities

Program

Provide trainee with a letter of notification of change in appointment no later than 30 days prior to the change in appointment.

Per our stipend level appointment policy, “Trainees in all programs at the same level of training must be paid in accordance with the stipends set by the Graduate Medical Education Committee (GMEC).  Trainees may not be paid less than or in excess of the stipend set by the GMEC for their level of training.” Programs must supplement the funds received by the NIH NRSA training grant in order to pay the trainee at the approved stipend for their level of training.

Nursing Mother Policy

Policy Statement

In accordance with State and Federal laws, residency and fellowship training programs must provide adequate break time for nursing mothers to express milk for up to one year after the birth of their child.  Trainees and program directors/chief residents must develop a schedule that works for the trainee but does not cause undue hardship to the training program. 

The University of Minnesota provides Nursing Mother's’ rooms which are located across campus that are quiet, comfortable rooms where a nursing mother can express and store their breast milk. Under The Patient Protection and Affordable Care Act, nursing mothers cannot be required to use a public/private bathroom to express milk.

Procedures

Mothers wishing to continue nursing after returning to work should develop a plan with their program director or chief resident to insert reasonable breaks during the day to express milk. 

Nursing mothers rotating to other hospitals/sites should contact the GME coordinator or site director to identify a private room where you can express as well as arrange breaks during your rotation.

Please refer to this webpage under header "I need help with personal care needs" for more information: z.umn.edu/gmesupport

Related Information

The University of Minnesota Graduate Medical Education administration and training programs supports your decision to continue to provide breastmilk for your baby.  Breastfeeding has been shown to significantly improve the health and wellbeing of your baby and you.

 

 

 

 

Orientation Policy

Policy Statement

All incoming residents and fellows, starting in both ACGME-accredited and non-ACGME accredited programs, are required to attend a GME orientation session.  This requirement includes those residents or fellows moving from one University of Minnesota program to another.
 

Leaders in programs whose residents or fellows are employed by an organization other than the University of Minnesota may consult with the University of Minnesota Office of Graduate Medical Education annually to determine orientation content that is  duplicative and develop a plan to address it. 

Reason for Policy

Central orientation provides valuable information about GME at the University of Minnesota, promotes interaction with important resources, welcomes residents and fellows to the sponsoring institution, and provides them an opportunity to network across programs.

Forms/Instructions

Updated orientation requirements and procedures are communicated via email and on the Incoming Residents & Fellows Orientation page.

Responsibilities

Programs are expected to support and encourage attendance at the institutional GME orientation, and to facilitate attendance through their management of resident and fellow schedules.
 

The Office of Graduate Medical Education will work  with programs to finalize resident or fellow attendance, and will communicate directly with trainees regarding orientation and onboarding requirements.
 

 

Professional Dress Code Policy

Policy Statement

Every resident/fellow is a representative of the University of Minnesota and of the hospital at which they are completing their GME training. Resident/Fellows are expected to project a professional and positive image to patients, visitors, and fellow employees. Residents/Fellows should present a good appearance, including good personal grooming and hygiene, appropriate dress for the work being performed, and by wearing proper hospital identification while training. Trainees are expected to dress according to generally accepted professional standards appropriate for their training program.  Each individual’s training program may set more specific guidelines for dress code. Each individual’s training program may evaluate and make determinations regarding dress code policy compliance.

Reason for Policy

To establish guidelines to ensure that the resident/fellows portray a professional image to the patients, visitors, and fellow employees that allows for the safe performance of job duties when working at a trainee hospital location. 

Forms/Instructions

General Dress Guidelines

The resident/fellow’s personal appearance while on duty, or in areas where contact with patients or their families is possible, shall be neat, clean, professional.

Professional Dress

Professional Dress

Blouses, sweaters, suit or sport jackets,professional shirts, dress shirts, sweaters, polo-type shirts, turtlenecks, dress pants, slacks,trousers, khaki type slacks, skirts, dresses, skirted suits, professional dresses and skirts with or without slits should be knee length or longer.

Tight fitting or revealing garments, blue jeans, or items of clothing imprinted with advertising or objectionable language are prohibited.  

Footwear

Closed-toed shoes that completely cover and protect the tops and sides of feet should be worn.

Lab Coat/ Scrub Suits

Lab coats and scrub suits should be worn as directed by the applicable program, and should be clean and without signs of wear or stains.

ID Badge

The trainee’s identification badges are to be worn at all times at the trainee hospital. ID Badges need to be visible and worn above the waist.

 

Grooming Guidelines

Cologne/Perfume

Fragrance is strongly discouraged due to patient sensitivities and allergies.

Facial Hair

Mustaches and beards should be clean, neatly groomed, and moderate. 

Fingernails

Fingernails are to be kept clean and neatly trimmed and of an appropriate length to perform job duties.  Artificial nails are prohibited from being worn by any direct patient care staff. 

Hair

Hair shall be neat, clean, of a natural occurring or naturally occurring dyed color. Extreme haircuts are inappropriate.

Jewelry

Jewelry or body piercing should not interfere with direct patient care or other on duty responsibilities.

 

History

Amended:

February 28, 2017 -The Professional Dress Code Policy was reviewed by the Resident Leadership Council in comparison to Dress Code Policies of similar GME hospital sites, locally and regionally. The comparison provided a need for more specific descriptions to the current policy. The policy statement language was updated completely to encompass an overview of the policy and recognizes that each program specifically may have separate guidelines. General dress guidelines were established. An in-detail description of appropriate and inappropriate ‘Professional Dress’ and ‘Grooming Guidelines’ were established. The GMEC approved the updated Professional Dress Code Policy on February 28th, 2017 at the GMEC monthly meeting.

 

Program Director Appointment Letter Policy & Workflow and Resources

Policy Statement

The Department Chair or faculty designee must submit the Program Director Appointment Letter to GME Administration at least 30 days prior to the anticipated change effective date along with the other required documents for review by the GMEC and the ACGME or other applicable governing boards. All required fields within the letter must be complete. 

Reason for Policy

The creation of the appointment letter documents that the department chair and new program director have discussed and understand the roles, responsibilities, and sources of support for the position.  If applicable, the letter also acknowledges that the chair and director have read and understand the ACGME requirements for program directors in the applicable discipline.

Procedures

As soon as the department/program identifies that a program director transition will occur, they must contact gme@umn.edu to discuss the transition plan with the DIO. After consultation with the DIO, the program director and chair (or faculty designee) meet to discuss the program director roles, responsibilities, and sources of support. They use the appropriate resources listed below and follow the detailed workflow to complete the process.

ACGME Accredited Program Process: 

This section provides an overview of the workflow to receive approval for a program director that will direct an ACGME accredited program.

Non-ACGME Accredited Program Process:

This section provides an overview of the workflow to receive approval for a program director that will direct a non-ACGME accredited program. Programs accredited by other governing boards are required to adhere to the requirements and responsibilities set for by that governing board and the University of Minnesota Graduate Medical Education Committee (GMEC) which is the governing body of GME programs at the University of Minnesota.

Appointment Letter Templates

General Resources:

Program Director Leave of Absence Coverage Policy

Policy Statement

GME programs are required to have program director (faculty-level) leadership. When a program director is away from work for 4 consecutive weeks or longer for any reason, the program must formally name another faculty member to serve as interim program director during their absence.  Appropriate departmental support should be provided to the individual assuming this role.

Reason for Policy

Program director level leadership must be identified and in place at all times. 

Responsibilities

Program Responsibility
Programs must complete the program personnel change form and submit it to GME Administration at gme@umn.edu. GME will provide a checklist to indicate which entities need to be informed (i.e. ACGME, NRMP, etc.) Programs must also notify appropriate department and program leadership, core faculty and trainees in the program.

Programs are not required to notify ACGME of interim program director assignments. The interim program director must work with the program coordinator to manage all aspects of program oversight, including satisfying requirements from ACGME, the program’s specialty board(s) and the GME Office at the University of Minnesota.

GME Responsibility
The University of Minnesota GME Office must update institutional records, such as mailing lists, based on the data provided in the administrative changes in program form.

 

Release of Trainee Contact Information for Solicitation Purposes

Policy Statement
External vendors shall not solicit, without the program director or trainees’ expressed permission, any resident/fellow while at any of the training locations performing their duties.

Solicit (contact) includes individual, face-to-face meetings, email, phone calls or pages. Any individual who violates this policy should be reported to the Office of Graduate Medical Education and/or the program director and appropriate action(s) will be taken.

Solomon Amendment: All requests from military recruiters/personnel should be directed to the University of Minnesota Data Request Center at https://umn.nextrequest.com/ . The Solomon Amendment states that Universities could lose their federal funding if they don’t allow military personnel access to resident/fellow information. The Data Request Center will manage compliance with these requests.

Procedures

Program Responsibility
When a program receives requests to solicit trainees, the program director should discuss with the trainees whether the contact should be allowed. Programs should not release any contact information, including email, pager or cell phone numbers to solicitors without expressed consent from the resident/fellow.

Trainee Responsibility
In an effort to reduce access to residents and fellows the trainees are instructed on how to manage their information (home address, home phone, pager or cell phone numbers. etc.) on the University’s OneStop site as well as in the National Provider Identification Database.

Related Policies
UMN Policy Public Access to University Information
GME Vendor/Conflict of Interest Policy

Resident/Fellow File Contents and Document Retention Policy and Procedure

Policy Statement

All University of Minnesota Graduate Medical Education programs are required to maintain a program file for each resident/fellow (trainees) that includes the required documents outlined in the Document Retention Grid. The documents that are required to be in a trainee’s file are outlined in the guide, as well as retention timeframes. Document types marked in bold* are required to be in the file for an ACGME Site Visit. 

These files must be kept in a secure location and can be either paper or electronic. Access to the file must be limited to the program director, coordinator, trainee and DIO’s Office. Others may be allowed access with written permission from the trainee for credentialing or accreditation purposes. Programs should review trainee files at least twice a year for completeness.

Files must also be reviewed well in advance of an ACGME site visit to ensure they are up to date. Please note that ACGME site visitors may require additional materials be in the trainee file. It is highly recommended that you communicate with your site visitor to ensure you have the documents in the trainee file that they require.

Resident/Fellow Fitness for Duty Policy

Policy Statement

Trainees are required to report to work physically and mentally capable of safely performing the functions of their job.  Trainees must not report to work if they are impaired for any reason.  Trainees must not consume alcohol, cannabis or any federally prohibited controlled substance while on call, including “at home call.”  Trainees must self-regulate their use of prescribed or over the counter medications to ensure these medications do not cause impairment.  Trainees must manage their sleep to avoid excessive fatigue. Programs have a responsibility to remove trainees from patient care activities if the trainee’s impairment poses a threat to patient safety.

Reason for Policy

The purpose of this policy is to define expected trainee conduct as it relates to fitness for duty, to provide guidance and direction on how to proceed when confronted with a potentially impaired trainee, and to help trainees in obtaining assistance when needed.

The purpose of this policy is to define expected trainee conduct as it relates to fitness for duty, to provide guidance and direction on how to proceed when confronted with a potentially impaired trainee, and to help trainees in obtaining assistance when needed.

We are committed to providing healthy, safe, and supportive training environments for all trainees, as well as safe, high-quality care for patients.  Trainees practicing while impaired can have serious adverse effects on patient safety, and negative impacts on their own performance and safety as well as that of others in the workplace.

Reporting

  • Responsibility to Report: Anyone who is aware of signs of impairment displayed by a trainee has an obligation to make a report to the trainee’s Program Director or supervisor on duty.

  • Self-Reporting: Any trainee who believes they themselves may be impaired is required to contact their Program Director or supervisor on duty to report the situation. If a trainee is approached by a co-worker or patient who is concerned the trainee may be impaired due to fatigue or any other reason, the trainee has a professional responsibility to contact their Program Director to inform them of the concern.

Guidelines

Due to the safety-sensitive nature of their work, trainees must manage their off-duty exposure to substances that may cause impairment, including prescription medications. Because these substances affect each person differently, there are no universally applicable standards.  In the case of alcohol, we reference U.S. FAA regulations for airline pilots as a guideline. These regulations prohibit pilots from operating an aircraft within 8 hours of the consumption of any alcohol, or while having a blood alcohol content of 0.04% or greater regardless of length of time since last consumption [FAR 91.17]. The institution expects trainees to refrain from alcohol consumption within 8 hours of reporting for duty or being on call.

Definitions

An impaired resident/fellow (trainee) is defined as any trainee who is unable to safely care for patients, perform duties normally expected of a trainee physician, or engage in peer interaction necessary for patient care for any reason, including but not limited to: personal stress; fatigue; medical condition (including physical disability or mental illness); use of alcohol or controlled substances, including drugs prescribed by a physician; or use of over the counter medication.

Fit for duty is defined as being physically and mentally capable of safely performing the functions of one’s job.  Fitness for duty includes being free of alcohol and drugs that have not been legitimately prescribed, and being free from impairment that affects job functioning for any reason, including but not limited to personal stress, fatigue, use of drugs prescribed by a physician, or use of over the counter medication.

Procedure:

Reach out the Office of Graduate Medical Education (gme@umn.edu).

Residency/Fellowship Agreement Policy

Policy Statement

The residency/fellowship (trainee) agreement is a required, binding contract between the trainee and the institution. The effective date of the initial agreement is the first mandatory date the trainee is required to report to their GME training program.

If the resident/fellow is in satisfactory standing, the agreement will be automatically renewed on an annual basis for the duration of the training program.

Residents/fellows are free to compete for any physician or academic positions in any geographic area following completion of their training. Restrictive covenants and non-competes are not allowed for any University of Minnesota GME programs. Per ACGME Requirement IV.L, the sponsoring institution and its programs can not require a resident/fellow to sign a non-competition guarantee or restrictive covenant.

Procedures

The agreement template is reviewed no less than annually by the Office of Graduate Medical Education (OGME) in collaboration with the Office of the General Counsel.  OGME presents recommended revisions to the Graduate Medical Education Committee (GMEC) for their review, discussion and approval.

OGME ensures that each trainee’s agreement is fully executed (all parties have signed and dated the document) prior to the effective date, and saved to the trainee’s RMS Personnel Record. The electronic copy is the official agreement.

 

Resident/Fellow Standing and Promotion Policy

Policy Statement

Resident/Fellow Standing

A trainee whose performance conforms to established evaluation criteria in a consistent and satisfactory manner will be considered to be in “good standing” with the program and institution.  Misconduct, failure to comply with the policies and procedures governing the program or unsatisfactory performance based on one or more evaluations may adversely affect the trainees standing in the program.  In these cases, the program will make an effort at remediation as outlined in the Discipline, Dismissal, Non-Renewal Policy & Process

Promotion

After satisfactory completion of each level of GME experience, as attested to by the program director, a resident/fellow in good standing will be promoted to the next level of training subject to the terms, limitations and conditions described in this document and the Resident/Fellow Agreement. 

Promotion to the next level of training is determined by the program and the Sponsoring Institution.  The decision to promote is dependent on several factors, which include, but are not limited to:

  1. satisfactory completion of all training requirements
  2. satisfactory trainee performance
  3. documented competence commensurate with level of training
  4. successful completion and passing of the USMLE Step 3, COMLEX, etc. prior to entering the PGY-3 level
  5. full compliance with all terms of the Resident/Fellow Agreement
  6. continuation of the Sponsoring Institution and program ACGME accreditation

A trainee who is on probation may be promoted at the discretion of the program director.  If the decision to promote is made, the probationary status remains in effect until the terms of the remediation agreement are met. 

Reason for Policy

Each training program is structured to assure that trainees assume increasing levels of responsibility commensurate with individual progress in experience, skill, knowledge, and judgment.                                       

The initial term of the University of Minnesota Resident/Fellow Agreement is one year.  However, candidates accepting appointments have an expectation that they will be allowed to complete their training having shown satisfactory progress in meeting the training requirements of their program.  This policy outlines the considerations to take into account when promoting trainees to the next level.

Resignation or Transfer Policy

Policy Statement

Residents/fellows who wish to resign before completing their training program must give at least a 30 day notice unless an exception is made by the Program Director, who must notify the Associate Dean for GME in writing.  Notice must be given in writing to the Program Director.  All conditions of appointment will terminate on the effective date of the resignation.

Procedures

Procedure for Resignation

  1. The resident/fellow must submit a letter of resignation (template at this link) to the Program Director at least 30 days prior to the projected date of resignation.
  2. The Program Director must acknowledge receipt of the resignation in writing.
  3. The Program Director must notify GME Administration/Associate Dean for GME in writing. 
  4. The Program Director must provide information reviewing the circumstances of the resignation and any counseling/services/remediation rendered.
  5. Department/program must follow the steps outlined in the graduating/transitioning checklist.

Procedure for Transfer

  1. Resident/fellow must submit a letter of intent to transfer to the Program Director at least 30 days prior to projected transfer date.
  2. The Program Director must acknowledge receipt of the intent to transfer in writing.
  3. The Program Director must communicate in writing with the Program Director where the resident/fellow is transferring. 
  4. Department/program notifies GME Administration/Associate Dean for GME of the intent to transfer to another program.
  5. The Program Director must provide information reviewing the circumstances of the transfer and any counseling/services/remediation rendered.
  6. Department/program follows the steps outlined in the graduating/transitioning checklist.

Related Information

Verification of Training and Summary for Credentialing Policy and Procedure

Social Media Policy for AHC Students, Residents and Fellows

This policy provides guidance and parameters for social media (see Definitions) usage by students, residents and fellows enrolled in Academic Health Center (AHC) educational programs. While social media tools are a very popular mode of engagement and communication and facilitate education, collaboration, research, business, and remote work, its usage by AHC students, residents and fellows presents unique risks to clients/patients. Because of the risks associated with inappropriate use of social media, misuse must be addressed through professionalism training, usage guidelines, and appropriate corrective and disciplinary action when warranted. The use of social media requires a conscious recognition of the profoundly public and long-lasting nature of communication via social media which provides a permanent record of postings. Each student, resident and fellow is responsible for appropriate behavior using social media just as they are with communications in other areas of their professional life.

Special Review Policy

Policy Statement

Annually, the Program Evaluation Subcommittee (PES) will identify programs for special review. The review will be administered by the PES through a special review team.  In addition, any interested parties are free to request a special review of their program, even if the program has not been identified by the PES as needing review.  The special review process will result in a report describing the program’s quality improvement goals, corrective actions, and plan for future monitoring of outcomes by the Graduate Medical Education Committee (GMEC).

Reason for Policy

The ACGME requires that the Graduate Medical Education Committee (GMEC) demonstrate effective oversight of underperforming programs through a special review process.  The purpose of the special review process is to assist programs to improve in targeted areas which are meaningful to program quality and predictive of important outcomes. The review is not punitive; rather, it is intended to aid in program quality improvement.

Forms/Instructions

The PES and GME Administration Office will provide programs and special review teams with detailed instructions about how to carry out the review.  The Special Review Process Map provides an overview of the review steps and timeline.

Responsibilities

Program Evaluation Subcommittee (PES): This subcommittee of the Graduate Medical Education Committee (GMEC) is responsible for establishing relevant metrics to determine which programs will undergo a special review, and for establishing and overseeing the execution of the special review process.

Programs: Programs that are selected for special review will complete a self-study and engage with their special review team to identify quality improvement goals and generate an action plan.  Programs will implement the plan, and report on their progress to their special review team and the GMEC.

Special Review Team: Members of the special review team will engage with the program to understand areas of underperformance, then assist with setting quality improvement goals and generating an action plan to report to the GMEC.  The team will share best practices, and the team’s chair will attend follow-up progress meetings with the program.  See also Special Review Team Roles.

Stipend & Benefit Funding from External Organizations Policy and Procedure

Policy Statement

Residents/fellows (trainees) with funding from an external organization (e.g. private practice) must be:

  • hired by the University of Minnesota,
  • appointed in the appropriate job classification see Classification and Appointment Policy, and
  • receive their stipend and benefits through the University of Minnesota in alignment with the GME Stipend Level Policy and  the Effective Dates for Stipend and Benefits Policy.
     

The external organization (with the exception of University of Minnesota Physicians - UMP) must provide funding to the University of Minnesota  for the first year, at least 30 days prior to the beginning of the appointment. It is expected that the funding will continue through the duration of the training and be received annually, at least 30 days prior to the beginning of each year of training.

Expenses related to stipends, benefits, administrative and other costs associated with the training program may be charged to external organizations. The terms of said agreement and mechanism for invoicing the organization are not dictated by this policy. 

Reason for Policy

This policy is written to clarify the process for accepting a resident/fellow (trainee) into a Graduate Medical Education Program with stipend and/or benefit funding from an external organization such as a foreign country.  

Responsibilities

Program Responsibility

University of Minnesota Medical School departments/programs are required to notify Graduate Medical Education Administration if the external organization is not able to follow this policy.

Definitions

An example of an external organization is a foreign country that provides funding (for stipend and benefits) to one of its citizens to obtain graduate medical education training in a residency or fellowship program in the United States.  This does not apply to funding by a training grant or a military organization.

Related Information

Classification and Appointment Policy

Effective Dates for Stipend and Benefits Policy

Pro Forma Budget Template: Programs can use this template to compile the costs associated with training and use it to negotiate the financial terms with the organization.

Stipend Level Policy

 

Stipend Level Policy

Policy Statement

Trainees in all programs must be paid in accordance with the stipends set by the Graduate Medical Education Committee (GMEC).  For every program, each program level is associated with a standard stipend step.  Trainees may not be paid less than or in excess of the stipend step set for their program level of training, except as noted below.

Exceptions

  • H-1B visa holders must be paid the higher of the prevailing wage determined by the U.S. Department of Labor, or their program level stipend step.

Reason for Policy

To provide consistency regarding stipend levels within individual programs and across the institution, and clarity for residents/fellows, faculty, and program and department staff.

Related Information

It is recognized that there are trainees accepted into training programs who have completed additional GME training above and beyond what is required for the training program they are entering (e.g. additional fellowships, an additional year chief residency, etc.).  Trainees may have also spent time in non-GME activity (e.g. employment, graduate school, etc.).  While these accomplishments are noteworthy, they do not impact the stipend level.

See also:

History

Amended:

July 25, 2017: Instituted standard stipend steps for each program level of training.  All trainees at the same level in a program will receive the same standard stipend step.  (For instance, all trainees in XYZ Fellowship training at Program Level 1 will receive Stipend Step 5, regardless of their individual prior training history.)  The association between program level and stipend step will be set on a program-by-program basis.

April 25, 2017: Removed exception for trainees on NIH NRSA grants to be paid at the rate set by the grant.

Prior revision dates: June 27, 2003; October 4, 2005; April 13, 2006; April 11, 2007; March 31, 2008

Effective:

January 24, 2003: Approved by the Graduate Medical Education Committee (GMEC).

 

Supervision Policy

Policy Statement 

There must be sufficient institutional oversight to assure that trainees are appropriately supervised. Appropriate supervision means that a trainee is supervised by the teaching faculty in such a way that the trainees assume progressively increasing responsibility according to their level of education, proven ability, and experience. On-call schedules for teaching faculty must be structured to ensure that supervision is readily available to trainees on duty. The level of responsibility accorded to each trainee must be determined by the program director and the teaching faculty.

Path of escalation:

  • Trainees should bring forward concerns of possible violations to their program (including but not limited to the program director, associate program director, site director, chief resident, mentor, advisor, vice chair for education or department head).
  • If resolution is not achieved, the trainee should bring forward their concern to the Office of Graduate Medical Education (including but not limited to the associate dean for GME, assistant DIO, Organizational Development Manager, Vice Dean for Education). The trainee may complete the (link to survey).
  • Anonymous reporting to the institution can occur through the trainee (survey) or through the Office of Compliance (UReport). 
  • Investigation of anonymous reports have been limited by the ability to collect detailed data around violations. Therefore, the DIO encourages confidential reporting to GME (to the DIO or to the Organizational Development Manager) over anonymous reporting to expedite investigation at gme@umn.edu.

Reason For Policy 

It is the responsibility of individual program directors to establish detailed written policies describing trainee supervision at each level for their residency/fellowship programs.  The policies must be maintained in the Program Manual. 
 
The requirements for on-site supervision will be established by the program director for each residency/fellowship in accordance with ACGME guidelines and should be monitored through periodic departmental reviews, with institutional oversight through the GMEC internal review process.

Conflicts of interest (COI) in supervisory relationships can occur. In the case of nepotism (family members) the GME Nepotism Policy must be followed. In the case that a supervising faculty member is a medical provider for a trainee, the trainee or the faculty may request recusal from completing formal evaluations of the trainee. The program director will entertain requests for recusal for potential COI. Evaluation by the supervising faculty may be necessary (for example the only faculty available in a required subspecialty rotation). In the case of an expressed COI but no option to recuse, the Clinical Competency Committee (CCC) should be informed of the potential conflict prior to review of the evaluation so that there is transparency during holistic review of trainee assessments during deliberations of the committee


Programs should establish policies that support Effective Supervisor Behaviors.

 

Definitions 

Direct – 

  • the supervising physician is physically present with the resident or fellow during the key portions of the patient interaction; or,
    •  Residency: PGY-1 residents must initially be supervised directly, only as described in VI.A.2.c).(1).(a). 
  • the supervising physician and/or patient is not physically present with the resident or fellow and the supervising physician is concurrently monitoring the patient care through appropriate telecommunication technology. (ACGME Common Program and Requirements VI.A.2.c).(1))
     

Indirect - “the supervising physician is not providing physical or concurrent visual or audio supervision but is immediately available to the resident or fellow for guidance and is available to provide appropriate direct supervision.” (ACGME Common Program and Requirements VI.A.2.c).(2))
 

Oversight – the supervising physician is available to provide review of procedures/encounters with feedback provided after the care is delivered. (ACGME Common Program and Requirements VI.A.2.c).(3))

Training Program Reduction/Closure OR Sponsoring Institution Closure Policy

Policy Statement

In the event of a program closure or reduction in program complement that impacts current trainees, the Program Director and the DIO must inform the GMEC and the affected residents or fellows , in writing. The Sponsoring Institution must allow residents or fellows in the affected program(s) to complete their education at the Sponsoring Institution or assist them in enrolling in another ACGME-accredited program(s) where they can continue their education.

In the event of closure of the Sponsoring Institution, the DIO must inform the GMEC, Program Directors and affected residents and fellows in writing. The Sponsoring Institution will work with the GMEC, Program Directors of the affected programs and their residents or fellows to support them through this transition, and  ensure all ACGME requirements are followed. The University of Minnesota and its affected programs will follow the steps listed in the ACGME Policies and Procedures guide.

Transportation and Safety Policy

Policy Statement

Residents and fellows (trainees) rotating at the affiliated sites listed below, who are too impaired (or are identified by their peers as being impaired) to drive home safely, can request a transportation voucher.  

Residents and fellows (trainees) rotating at the affiliated sites listed below, who are too impaired (or are identified by their peers as being impaired) to drive home safely, can request a transportation voucher.  

Trainees identifying risk and safety while arriving and/or departing work should seek security services at the site they are training at to address those needs.  Security services for each site are listed below in the procedures.

Procedures

Each site has individual instructions on how to obtain a transportation voucher and the amount granted per request listed below.  The transportation fare may be used to the trainee’s home or a closer location if the trainee so chooses.

Resource: Transportation and Safety Procedures.

For additional site-specific transportation and safety information, visit the MedEd To Go website or download the app.

University of Minnesota Policy on Racial or Ethnic Harassment

Policy Statement

The University of Minnesota Medical School follows the policy of the University of Minnesota:

University of Minnesota Policy on Sexual Harassment, Sexual Assault, Stalking and Relationship Violence

Policy Statement

The University of Minnesota Medical School follows the policy of the University of Minnesota: 

Procedures

The University of Minnesota Medical School follows the procedure of the University of Minnesota

Vaccination and Immunization Policy for Learners in the Health Sciences

The GME office abides by the Academic Health Center Policy for immunizations.

Vendor Interactions/Conflict of Interest Policy

Policy Statement
In accordance with guidelines set forth by the American Medical Association Statement on Gifts to Physicians, acceptance of gifts from industry vendors is discouraged. Any gifts accepted by residents/fellows (trainees) should be of nominal value. Accordingly, textbooks, modest meals and other gifts are appropriate only if they serve a genuine educational purpose. Acceptance of gifts should not influence prescribing practices or decision to purchase a device. Any gifts from patients accepted by trainees should be of nominal value.

Reason for Policy
To clarify the considerations residents and fellows should take into account when interacting with industry representatives. The term “industry” includes but is not limited to pharmaceutical, biomedical device, equipment and other health-care related industries.

Program Responsibilities
Program Directors are responsible for educating their trainees on the proper protocol for interacting with industry representatives. Program Manuals may have specific policies. Hospitals may also have specific policies.

Verification of Training and Summary for Credentialing Policy

Policy Statement

Each GME program is required to complete the ACGME approved Verification of Training Form (using the Verification of Training Form Guide to assist them) when a resident/fellow completes or leaves their current training program. This form must be completed by the program director, after a thorough review of the trainee file, within 30 days (ACGME Common Program Requirements (Residency, Fellowship, one-year fellowship)II.A.4.a).(14))  of completion or departure from the program.  

A resident’s/fellow's final evaluations prior to graduation should be the primary source of information when completing the form.  If the program director is not able to review the file, the department chair or their designee conducts the file review and completes the form.
 
In order to ensure that GME Administration has access to trainee verification data, the form must be uploaded to their personnel record in the Residency Management Suite (RMS) (Personnel Record > Files & Notes > Training Verification Folder).  The completed form provides documentation required to comply with the ACGME’s Common Program Requirements on Summative Competency-Based Performance Evaluations.

Reason for Policy

This policy outlines the requirement that all University of Minnesota GME programs (herein referred to as programs) use the Verification of Training Form (herein referred to as form) and Cover Letter

The form and cover letter provide a uniform process for documenting requirements and also serve as the Summative Competency-Based Performance Evaluation. This information is used to respond to requests for information from entities where the trainee has given signed authorization of release.

Forms/Instructions

Within 30 days of completion or termination of training, the program director, or designee as stated above, conducts a thorough review of the resident/fellow file and completes the form (if authorized by the program director, their electronic signature can be used).  The program uses the Verification of Training Form Guide to assist them. Other information may be used in the process as determined by the program.  
 
The completed form must be uploaded to the trainee’s personnel record in RMS (Personnel Record > Files & Notes > Training Verification Folder).  
 
Upon receipt of a verification of training request from an entity (such as a credentialing agency) the program reviews the authorization of release of information.  The program ensures that the information provided in the form is covered in the release.

The program completes the cover letter, which is printed on department letterhead, attaches the completed form, and sends the documentation to the entity along with necessary data on clinical procedures performed by the trainee.

Related Information

Resignation/Transfer Policy

Visa Sponsorship Policy

Policy Statement

To outline the acceptable and not acceptable visa types at the University of Minnesota for Graduate Medical Education training programs. 

Visa Types

Acceptable visa types for a residency/fellowship are:

  1. J-1 visa—Alien Physician: the preferred visa for residents/fellows who are not United States citizens or permanent residents, issued by the Education Commission on Foreign Medical Graduates (ECFMG);
  2. J-2 visa: issued to the dependent of a J-1 visa holder (read J-2 Visa Procedure below);
  3. H-1B visa: requires GME approval (read H-1B Visa Procedure below);
  4. Permanent Residence Application pending: candidates in this situation will be issued an Employment Authorization Document (EAD) card which must be renewed annually.  Contact Visa Manager for further information.

Not Acceptable visa types for a residency/fellowship are:

  1. F-1 student visa: issued only to students who are attending college/university (including medical school), high school, private elementary, seminary, conservatory, or another academic institution, including a language training program in the United States.
    • An F-1 Student can train in a Graduate Medical Education program on a F-1 Post Graduation Optional Practical Training (OPT): an extension to F-1 visa for the first year of residency training.  Requires additional permissions from International Students & Scholar Services (ISSS).  Contact Visa Manager immediately if the candidate is interested in OPT for requirements and procedures.
  2. M-1 Student Visa: issued for vocational or other recognized nonacademic institution, other than a language training programs;
  3. O-1 visa: nonimmigrant visa is for  individuals who possess extraordinary ability in the sciences, arts, education, business, or athletics, or who has a demonstrated record of extraordinary achievement in the motion picture or television industry and has been recognized nationally or internationally for those achievements. 

Procedures

J-1 Visa—Alien Physician Procedure

The J-1 alien physician visa is sponsored by the Education Commission for Foreign Medical Graduates (ECFMG), and is the preferred visa of University of Minnesota Medical School residencies and fellowships. Please contact your Program Coordinator to verify if J-1 visa sponsorship is allowed in your program.

All ECFMG J-1 applications originate online via EVNet, and are initiated by the ECFMG Training Program Liaison (TPL) for the University of Minnesota.  Information on the required documents for the J-1 application can be found on the ECFMG website:http://www.ecfmg.org/evsp/application-online.html.

ECFMG requires notification on trainees who are on a J-1 visa for elective rotations, remediations, leave of absences, dismissal, resignation, and any incidents/allegations. To learn more about the required notifications please see the Required J-1 Visa Holder Notification Policy.  

J-2 Visa Procedure

Any residents/fellows training on a J-2 visa are required to obtain an EAD card on an annual basis.  Renewal can take up to six (6) months processing time.  The J-2 spouse is responsible for ensuring that the J-1 spouse applies for J-1 visa renewal annually and allows enough time for EAD card renewal for the J-2 spouse.  The J-2 spouse must also inform the program of any changes to the J-1 spouse’s visa sponsorship, as J-2 sponsorship is directly linked to J-1 sponsorship.  The program must obtain a signed J-2 offer letter from the Program Director and signed by the J-2 spouse annually; contact the Visa Manager for the template. 

H-1B Visa Procedure

At the discretion of the individual training programs, the H-1B visa may be considered for candidates who have passed the USMLE Step 3 exam and who provide documentation that meets one or more of the following criteria:

  1. Applicant currently holds a valid H-1B visa at this university or another institution (provide copy of Form I-797, Notice of Action)
  2. Applicant is the spouse/registered domestic partner of a U.S. citizen, permanent resident (“green card” holder), or individual holding an  H-1 or O-1 visa (provide copy of marriage certificate or H-4 document)
  3. Applicant/applicant’s spouse has a permanent resident petition pending with a likely chance of success (provide copy of proof of petition)
  4. Applicant is not eligible for or would face a hardship on a J-1 visa due to unique immigration circumstances (e.g., applicant already obtained a J-1 waiver; applicant who has to return home periodically  to care for ill parent faces higher risk of being denied re-entry on J-1 visa ) (provide letter explaining reason for hardship)
  5. Applicant’s spouse/registered domestic partner is employed by the University in a faculty or other continuing position (provide letter identifying spouse’s position)
  6. Applicant is a graduate of a medical school in the United States, Canada or Puerto Rico accredited by the Liaison Committee on Medical Education (LCME) (provide copy of medical school diploma)
  7. The department has offered or is strongly considering the applicant for a faculty or research position after applicant completes the training program (provide letter identifying intentions of department after applicant finishes training program)

In addition to meeting allUMN eligibility and selection criteria, H-1B visa applicants must meet additional eligibility requirements: they must have passed USMLE Step 3 and also hold a MN residency permit (at minimum, or MN medical license if applicable) prior to submitting their H-1B visa application. 

Prior to scheduling an interview, the program must provide all applicants with a copy of the institutional visa policy and the program-specific policy on offering H-1B visas.

To obtain GME approval for all H-1B visas, the program must submit a completed H-1B Visa Request Form and the documentation that supports one or more of the criteria for offering an H-1B visa to an incoming resident or fellow.  The GME office will respond in writing to the department/program indicating whether the request to apply for the H-1B visa is approved or denied. 

Training programs are responsible for ALLcosts and fees associated with preparing and filing H-1 B visas for residents/fellows.  This includes supplementing stipends to meet the prevailing wage requirements, if applicable.  Training programs are required to use the services of International Student and Scholar Services (ISSS) or work through the Office of the General Counsel at the University to obtain outside legal counsel for this purpose.

If a training program terminates or non-renews a resident/fellow appointment before the individual’s H-1B visa expires, the training program is responsible under U.S. Citizenship and Immigration Services regulations to pay the H-1B physician’s airfare back to his/her home country.

Responsibilities

PROGRAM RESPONSIBILITY

Ensure that visa sponsorship forms are completed annually or before the current visa’s expiration date, whichever comes first.

FAQ

MOONLIGHTING

  • Moonlighting for residents/fellows on J-1 visas is not permitted under any circumstances.
  • A resident/fellow on an H-1B visa wishing to moonlight must obtain a separate H-1B visa for each facility where the resident/fellow works outside the training program. 

Related Information

History

8.2020: The Visa Sponsorship Policy was updated in August 2020 to address the O-1 visa. The updated policy states that the O-1 is not an eligible visa type for Graduate Medical Education.  

Previously the GME office was approving O-1 visas to those candidates that met our Eligibility and Selection Policy (Extraordinarily Qualified Candidate) pending the immigration attorney's determination  of extraordinary ability. Because trainees are learners they do not fit the definition of extraordinary ability required for this visa.To more clearly define what is acceptable and not acceptable Graduate Medical Education visa types, the section above was split into two sections.

 

Workers' Compensation Procedure

Policy Statement

University of Minnesota Policy: Reporting Workers Compensation Related Injuries

Procedures

View detailed information about management of needle sticks, blood borne pathogen exposure (BBPE), and tuberculosis exposure here: Occupational exposures and worker’s compensation claims

Review this policy for information on all other medical resident or fellow worker’s compensation injuries.

The University is committed to providing medical residents and fellows with comprehensive medical care for on-the-job injuries. When a resident or fellow is injured during training, they must take immediate steps to report the injury to the University.

Complete an Online Electronic First Report of Injury (eFROI)

You are REQUIRED by the Department of Labor and Industry to submit an e-FROI within 8 business hours (1 workday).  It is also necessary for a worker’s compensation (WC) claim to be filed so that the bills incurred as a result of the injury are paid. 

  1. Access the online eFROI via the UMN Risk Management Office.  You are required to complete the ONLINE version. 

 

  1. Campus Selection: Choose "Twin Cities All Other" in the drop-down for the campus in the e-FROI.

  1. Supervisor: List the supervisor on duty when the incident occurred (ex. Attendee, Program Director, Chief Resident, etc).

  1. You will hear from an adjuster at Sedgwick Claims Management (SCM) within 3 business days of submission of the completed eFROI. If you do not hear from SCM within 3 business days, contact the Office of Risk Management at 612-624-5884 or e-mail to orm@umn.edu to make sure that your e-FROI was received at Sedgwick. 

  1. If you receive a bill as a result of the injury, please retain the bill and fax it to Sedgwick Claims Management at 952-826-3785.