Applies to: Residents and fellows in all accredited post-graduate medical training programs (residency and fellowship) and non-accredited clinical fellowship programs in WSU Elson S. Floyd College of Medicine Graduate Medical Education (GME) Sponsoring Institution.
Date: March 18, 2021
1.0 Policy Statement
It is the policy of the WSU College of Medicine Office of Graduate Medical Education (GME) that all Trainees participating in GME programs sponsored by WSU are thoroughly prepared and meet criteria for their training programs and patient care responsibilities. Washington State University Office of GME is focused on the need of the communities, collaborating with them to help improve access and quality of care. GME is committed to fostering rigorous, high-quality, comprehensive, and culturally relevant graduate medical education programs. This includes a responsibility to the health, welfare, and safety of patients and others at the facilities where residents train minimizing unreasonable risk, particularly where the nature of a trainee’s past criminal conviction directly and/or substance abuse bears on the individual’s fitness, judgement or ability to perform his or her duties and responsibilities as a resident or fellow. Upon completion of residency or fellowship, WSU has an obligation to society to graduate a fully prepared, board eligible, license eligible physician. Thorough appointment and reappointment processes and criteria are critical to ensuring a high-quality program graduate.
2.0 Definitions
Accreditation Council for Graduate Medical Education (ACGME)
Accredits Sponsoring Institutions and residency and fellowship programs, confers recognition on additional program formats or components, and dedicates resources to initiatives addressing areas of importance in graduate medical education.
Designated Institutional Official (DIO)
The individual in a Sponsoring Institution who has the authority and responsibility for the institution’s ACGME-accredited programs.
Program Director (PD)
The individual designated with authority and accountability for the operation of the residency/fellowship program.
Resident
A physician-in-training at an ACGME-accredited graduate medical education program. In this policy, the term includes interns, residents, and fellows or other trainees enrolled in an educational program whose education falls under the purview of the WSU College of Medicine Office of Graduate Medical Education.
3.0 Responsibilities
Program Director, DIO
4.0 Procedures
4.1 Trainee Application Process
Washington State University participates in the National Resident Matching Program (NRMP) and utilizes the application process within ERAS.
If a resident is considered for appointment outside of the NRMP matching process, a similar application process is utilized.
4.2 Trainee Appointment Process
All residents and fellows must meet all requirements for appointment. These required items, as well as successful background check and drug screen include:
- Applicants must provide for initial appointment:
- Copy of Medical school diploma
- Copy of ECFMG Certificate (if applicable)
- Copy of USMLE Step 1 & 2, or COMLEX Level 1 & 2 score report transcript
- Copy of USMLE Step 3 or COMLEX Level 3 score report transcript, if PGY-3 or higher
- Signed Physician In Training Agreement (PITA)
- National Provider Identifier (NPI) Number
- Immunization documentation
- Summative Evaluation from previous program (if applicable)
During the onboarding process, residents are required to apply for a State of Washington physician training license and other states as required by the program and register for a DEA registration number. Residents must meet eligibility requirements for a provider license and a DEA number for appointment.
4.3 Trainee Background Check
Following the residency or fellowship match and as part of the onboarding process, pre-employment screenings and criminal background checks will be completed. Trainees must consent to a background check through a national background check screening service provider and several federal regulatory checks as part of onboarding.
A formal background investigation will be conducted by an Investigation Vendor and includes:
- Social Security Number Validation and Search
- County Criminal Records Search
- Statewide Criminal Records Repository
- Washington State Patrol (WATCH)
- Federal Criminal Records Search
- National Criminal Database
- National Sexual Offender Database Search
- National Practitioner Databank
- OIG / SAM (Formerly GSA) EPLS Search – search covers the federally mandated HHS Office of Inspector General’s (OIG) List of Excluded Individuals/Entities (LEIE), and the System for Awards Management (SAM) – Excluded Parties List (EPLS)
- Search covering sanctions, disciplinary and administrative actions taken federal and state healthcare regulatory authorities, including FDA, NIH, OFAC, terrorist watch lists and more
The Investigation Vendor will provide Human Resource Services with a copy of the Background Investigation report for each trainee and will include information on all prior criminal convictions and sexual offender registry status. Prior arrests or detention orders that did not result in criminal convictions or pleas or were expunged, or sealed convictions, shall not be considered.
Upon receipt of a Background Investigation report with no adverse record, trainee onboarding will be processed by the GME Office.
Should an adverse record be received as a result of information obtained from the Background Investigation, the results will be reviewed on a case-by-case basis with advisement from HRS and the AG Office.
If the decision is made to rescind the offer to the trainee to join the program, the decision must be communicated to the trainee and Program Director in writing. If the trainee is joining the program through the NRMP, a Match Waiver must be requested.
A copy of the background investigation report will be confidentially kept in the trainee’s file within Human Resource Services. This record may be provided to others as the need arises such as regulatory audit, ACGME accreditation review, and legal proceedings.
4.4 Trainee Drug Screen
Following the residency or fellowship match and as part of the onboarding process, pre-employment screenings that include a drug screen are required. All incoming trainees are subject to a 10-panel urine-based drug test provided by an investigation vendor.
Confidential results of the drug screen are provided to the GME office. Upon receipt of a drug screen report with no adverse items, trainee onboarding will be processed by the GME Office.
Should a drug screen report with adverse results, the report will be reviewed by the DIO. If warranted, the report will be reviewed by a review committee consisting of the DIO, Program Director, HRS representative, and AG office representative. The results will be reviewed on a case-by-case basis. This committee will make a recommendation and it is the responsibility of the DIO to make the final decision.
If the decision is made to rescind the offer to the trainee to join the program, the decision must be communicated to the trainee and Program Director in writing. If the trainee is joining the program through the NRMP, a Match Waiver must be requested.
A copy of the drug screen report will be confidentially kept in the trainee’s file within the residency management system with restricted access only by the GME Office. This record may be provided to others as the need arises such as regulatory audit, ACGME accreditation review, and legal proceedings.
4.5 Trainee Re-Appointment
Upon eligibility of trainee for reappointment and/or promotion to the next level of training, it is the trainee’s responsibility to maintain and update the documentation required and provided at time of appointment. Trainees are subject to a criminal background check and drug screen prior to reappointment.
5.0 Related Policies
- GME Qualifications, Eligibility and Selection of Residents Policy
- GME Promotion and Appointment Renewal Policy
6.0 Revision History
GMEC Approval: March 16, 2021, March 18, 2025
Revision/Review Date(s): March 18, 2025
Responsible Office: WSU College of Medicine Sponsoring Institution
Policy Contact: Designated Institutional Official
Supersedes: N/A