Chapter VI: Institutional Policies

The policies relating to the relationships faculty members may have with business organizations, the government or other institutions are set forth in various policies contained in this Handbook, specifically, the policies regarding the use of the Mount Sinai name, the policy regarding consultative arrangements the restrictions on the activities of full-time faculty, the conflict of interest policy, and the policies on intellectual property. Nonetheless, in the event a faculty member has any concern about whether a particular proposed arrangement is appropriate or acceptable, the faculty member should consult the Dean's Office.

Updated August 2017

In conformity with the principles of academic freedom, faculty members are not required to obtain prior approval before submitting a manuscript for publication or to amend such manuscripts to comply with suggestions made by others. However, it is recommended that faculty members provide Department Chairs with copies of manuscripts prior to publication.

All original laboratory data in any format from which a publication is derived must be stored in the laboratory for a minimum of six years from the date of publication. If the senior author leaves Icahn School of Medicine before the six year period elapses, he/she will be required to retain or maintain and make available, if requested, to Icahn School of Medicine all these data until the completion of this minimum time period. In the case of large ongoing database related research, the responsible investigator must, if the data are stored on a specific device, retain the pertinent mass data storage device (tape, disk, etc., not necessarily in hard copy) containing the data on which a publication is based or maintain these data. Any stored or maintained data can be used for verification, as well as serve as the base for ongoing studies of the same project. In the latter instance, however, a clarifying statement which describes the nature and the composition of the reutilized and incremental data should accompany the publication. For cases in which a separate device is used, it cannot be reused for unrelated projects. Although it is understood that this rule governing database storage may not be appropriate in all situations and over time, individual modifications must be approved by the Dean or his designee.

Updated August 2017

The School of Medicine strongly believes in the importance of protecting whistleblowers from retaliation and addressing good faith allegations of such retaliation. Accordingly, the School affirms that it will adhere to any applicable policies and procedures promulgated by federal or other oversight agencies in dealing with such allegations. Whistleblower complaints of retaliation may be brought, where appropriate, to the School’s Faculty Council (see Chapter II), Grievance Committee (see Chapter II), or Department of Human Resources.

Copies of the policies and procedures of the Grievance Committee are available from the Office of the Dean, Reserve Section of the Levy Library, House Staff Affairs Office, Postdoctoral Affairs Office, Office of the Graduate School, and Office of Student Affairs. Human Resources policies are available from the Department of Human Resources.

Addressing Mistreatment and Other Unprofessional Behaviors Directed at Students and Trainees

Mount Sinai is dedicated to providing its students, postdocs, residents, faculty, staff and patients with a learning environment of respect, dignity, inclusion, trust, and support that protects civil and professional discourse and is free from mistreatment and other unprofessional behaviors directed at students and trainees. Mount Sinai is also committed to ensuring an environment in which students and trainees feel free to report such behaviors without fear of retaliation.

Educators (defined broadly to include anyone in a teaching or mentoring role, including faculty, postdocs, residents, fellows, nurses, staff, and students) bear significant responsibility in creating and maintaining this environment. As role models and evaluators, educators must practice appropriate professional behavior toward, and in the presence of, students and trainees, who are particularly vulnerable given their dependent status.

Everyone at Mount Sinai deserves to experience a professional learning and working environment. These guidelines supplement the institutional policies on professional conduct, discrimination, harassment, grievances and sexual misconduct; will assist in developing and maintaining optimal learning environments; and encourage educators, students and trainees alike to accept their responsibilities as representatives of ISMMS in their interactions with colleagues, patients and staff. This policy is closely aligned with our institution’s Cultural Transformation efforts, the ISMMS Racism and Bias Initiative, and related policies.

Mistreatment and unprofessional behaviors directed at students and trainees interfere with the learning environment, adversely impact well-being and the trainee-mentor relationship, and have the potential for negatively impacting patient care and research. Inappropriate and unacceptable behaviors can promote an atmosphere in which mistreatment and unprofessional behaviors directed at students and trainees is accepted and perpetuated in medical and graduate education. Reports relating to the clinical setting will be reviewed in accordance with the principles detailed in this policy as part of the relevant hospital’s quality assurance program.

POLICY:

While individuals might perceive behaviors differently, examples of unprofessional behaviors prohibited by this policy include, but are not limited to being:

  • threatened with physical harm or physically harmed
  • required to perform personal services
  • subjected to offensive remarks related to gender, sexual orientation, national origin, race, color, religion, or any other category protected by law 
  • denied opportunities for training or rewards based upon membership in a protected group
  • subjected to lower evaluations or grades solely because of membership in a protected group
  • publicly embarrassed or humiliated
  • subjected to unwanted sexual advances
  • asked to exchange sexual favors for grades or other rewards
  • subjected to the threat of revoking visa status for foreign nationals

Mount Sinai has a zero-tolerance policy towards unprofessional behaviors directed at students and trainees. Zero tolerance means that all reported incidents are scrutinized and result in an action plan that may include feedback, remediation, or disciplinary action. Although under certain circumstances unprofessional behavior directed at students and trainees may require disciplinary action, we recognize in such episodes an opportunity to develop, improve, and remediate behaviors that detract from a learning and working environment of which we can all be proud.

PROCEDURE:

Reporting and Consulting Mechanisms - Introduction

As discussed below, students and trainees may seek advice and guidance about how to handle mistreatment and unprofessional behaviors directed at them, and may formally report these incidents. There are several ways for learners to share concerns, including through real-time reporting mechanisms and mechanisms for periodic review (course evaluations or periodic surveys). All reports, whether made in real-time or in the course of periodic review, must be submitted via the Feedback Form or as specified below. Reports will be reviewed by the respective office that oversees the learner/trainee. The person submitting a real-time report can also designate whether he or she wants to have the concern addressed immediately or to delay the review until a period of time has passed. Anonymous reports of mistreatment and unprofessional conduct may be submitted; however, Mount Sinai’s ability to investigate an anonymous report may be limited. Reports of alleged mistreatment and unprofessional behavior directed at students and trainees will be reviewed and handled in a timely manner. Seeking advice or guidance is not considered filing a report. Reports may only be made through the Feedback Form referenced above or the avenues specified below.

Resources for Seeking Guidance or Reporting

Each of the resources identified below for the purposes of seeking guidance can assist with advice, advocacy, recommendation, or referral. Contact information for all resources is listed at the end of this policy.

Medical Students

    • Seeking Guidance:
      • Course Directors
      • Clerkship Directors
      • Faculty Advisors, instructors, mentors, and Deans
      • Title IX Coordinator.
      • Ombuds Office
      • Mistreatment Resource Panel or Class Representative to Panel.
    •  Reporting for Aggregate Review:
      • Course evaluations
      • Clerkship evaluations
      • Compliance Hotline or Compliance Online Form: Compliance Hotline reports are shared quarterly unless the report is determined to be time-sensitive.

Graduate Students

    • Seeking Guidance:
      • Course or Program Directors.
      • Faculty Advisors, instructors, mentors, and Deans
      • Title IX Coordinator
      • GSBS Mistreatment Resource Panel
      • Office of Human Resources
      • Ombuds Office
    • Reporting for aggregate review:
      • Course evaluations
      • Compliance Hotline or Compliance Online Form: Compliance Hotline reports are shared quarterly unless the report is determined to be time-sensitive.

Residents and Clinical Fellows

 

    • Reporting for aggregate review:
      • The GME Office will review any negative evaluation of a faculty by a resident or fellow, including reviewing prior evaluations to determine if a pattern of unprofessional behavior exists.  The GME Office will batch such evaluations over a period of six months or four evaluations, whichever occurs sooner, and review them with the Chair or Program Director to maintain anonymity. 
      • Regular resident evaluations of faculty in New Innovations (the GME Office batches these evaluations with no less than three others to protect the anonymity of the trainee). 

Postdoctoral Fellows

    • Seeking Guidance:
      • Faculty Director, Office of Postdoctoral Affairs
      • Program Manager, Office of Postdoctoral Affairs
      • Head of lab or trainee’s direct supervisor in lab
      • Office of Human Resources
      • GSBS Mistreatment Resource Panel
      • Ombuds Office

 

Ombuds Office

The Ombuds Office is not a mechanism for reporting mistreatment and unprofessional behavior. Ombudspersons are available to provide neutral, confidential, and informal assistance with conflict resolution. The Ombuds Office follows best standards of practice that are necessary to promote fair and equitable outcomes. (https://icahn.mssm.edu/about/ombuds-office)

 

Triage/Investigation

A Committee on Student/Trainee Learning Environment overseeing UME, GSBS, GME and postdoctoral learning environments will meet quarterly. The Committee membership includes the Dean for GME, Dean for Medical Education, Dean of the Graduate School of Biomedical Sciences, Dean for Diversity Affairs, CWO, Dean for Gender Equity in Science and Medicine, Title IX Coordinator, Director of the Ombuds Office, Chair of the Physician’s Wellness Committee, Mount Sinai Hospital Chief Medical Officer, Human Resources representative, student, postdoctoral fellow, and housestaff representatives.

This Committee (as a group or through designated members) will review all reports of alleged mistreatment and unprofessional behavior directed at students/trainees and will handle or refer as appropriate consistent with institutional policies.  Matters involving the clinical environment will be handled through the quality assurance process of the respective hospital. In cases where the report does not identify the person alleged to have engaged in unprofessional behavior, the report will be forwarded to the Chair of the relevant department and may also be reported to the Dean of the Medical School. The Chair will collaborate with the Dean for UME and/or Dean of the Graduate School and/or Dean for GME to implement any needed improvements to the learning environment or other steps (for example, special grand rounds, consultation with the CWO, Physician Wellness Committee, Employee Health Service, leadership of ODI, Dean for Gender Equity).

Graded Response Policy

Unprofessional behavior can range from a single, first-time episode that is not egregious, to persistent low-grade mistreating behavior, to incidents that require disciplinary action. Below are examples of possible graded responses, each of which will be tailored to the circumstances of the conduct at issue.

  • Counseling
  • Monitoring the behavior of the person accused of unprofessional behavior
  • Mandatory meeting with a senior member of the Committee on Student/Trainee Learning Environment
  • Formal letter to Chair and Dean of ISMMS, mandatory meeting with the Chair
  • Formal letter to Chair and Dean of ISMMS, mandatory meeting with the Chair as well as the Dean for UME and/or Dean for GSBS and/or Dean for GME, and/or the CMO. May or may not require referral to the Physician Wellness Committee, Employee Health Service, or Student-Trainee Mental Health
  • Disciplinary action, up to and including dismissal.
  • Other appropriate action

 

Closing the loop

Quarterly aggregated and de-identified reports will be sent to students, residents, postdoctoral fellows, ISMMS Dean, all chairs, CMOs, and hospital presidents, head of Nursing and Director of Social Work for the Health System.

ACGME and the AAMC Graduation Questionnaire data are also shared with students, residents, postdoctoral fellows, ISMMS Dean, all chairs, CMOs, and hospital presidents, head of Nursing, and Director of Social Work for the Health System.

When the Complainant’s identity is known, a senior representative of the Committee on Student/Trainee Learning Environment will reach out to the Complainant at the conclusion of the process.

 

PROTECTION FROM RETALIATION

Retaliation against or intimidation of any individual who seeks advice, raises a concern, or reports unprofessional misconduct or mistreatment in good faith will not be tolerated. Anyone who deliberately makes a false accusation with the purpose of harming or retaliating against another member of the ISMMS community will be investigated and appropriately addressed.

CONTACT INFORMATION

Compliance:

Mistreatment Resource Panel:

  • Graduate School: mrp@mssm.edu or contact Mistreatment Panel representative directly
  • Medical Education: email studentmistreatmentpanel@mssm.edu or contact Mistreatment Panel class representative directly
  • GME Office: 212-241-6694

Office of Human Resources: 212-241-4097

Ombuds Office: 212-659-8848

 

Title IX Coordinator:

 

Updated September 2019

It is the policy of the Icahn School of Medicine that all decisions regarding educational and employment opportunities and performance are made on the basis of merit and without discrimination because of race, sex, color, creed, age, national origin, handicap, veteran status, marital status, or sexual orientation. In keeping with its efforts to achieve a broad representation of women and minority groups throughout the institution, Icahn School of Medicine has an Affirmative Action Program. This Program is designed to realize the School's commitment to equal educational and employment opportunities, to achieve compliance with federal, state, and local laws and regulations, and to implement equal opportunity objectives by meeting the spirit as well as the letter of the law and contractual requirements.

Oath of Allegiance

The New York State Education Law requires citizens of the United States who are faculty members of educational institutions to take an oath to support the Federal and State Constitutions. The oath which Mount Sinai Faculty are asked to sign as a condition for appointment, is as follows:

"I do hereby pledge and declare that I will support the Constitution of the United States of America and the Constitution of the State of New York, and that I will faithfully discharge my duties as a member of the faculty of the Icahn School of Medicine at Mount Sinai according to the best of my ability."

Licensure

Faculty of the School of Medicine whose professional activity includes patient care in the Mount Sinai Hospital or affiliated institutions must be licensed as physicians by the State of New York.

Immigration Status

Every faculty member who is not a United States citizen must provide evidence that he/she is permitted by Federal law to work in the capacity for which he/she is hired. Further, compliance with the Immigration Control and Reform Act requires that all newly hired faculty who are not United States citizens must also complete an I-9 form and provide the necessary identification to comply with the law.

Pre-employment Toxicology Screening and Physical Examination

All newly hired faculty must consent to pre-employment toxicology screening and a complete physical examination.

Security Check

All newly hired faculty must consent to a security check.

Icahn School of Medicine is committed to lawful and ethical behavior in all of its activities and requires all staff and employees to conduct themselves in a manner that complies with all applicable laws and regulations. Every employee and staff member of Mount Sinai should be aware of the legal and ethical requirements governing the performance of his or her employment responsibilities or other relationship to Mount Sinai. Mount Sinai has established a compliance program for maintaining and ensuring fidelity to those standards of conduct required of all employees and staff members. This program includes the establishment of written policies setting forth standards of conduct and the establishment of a "hotline" for the reporting of illegal or unethical behavior. In addition, a chief compliance officer has been appointed with responsibility for implementing the compliance program. Information concerning the compliance program will periodically be sent to employees and staff and is also available directly from the compliance officer.

Mount Sinai maintains a vigorous compliance program and strives to educate its work force on fraud and abuse laws, including the importance of submitting accurate claims and reports to the Federal and State governments. It is expected that employees who are aware of any occurrences of fraud, waste and/or abuse report their concerns directly through the Compliance Helpline at (800) 853-9212. There shall be no reprisals for good faith reporting of actual or possible incidence.

Mount Sinai has adopted an extensive set of programs in the Health System for detecting and preventing fraud, waste, and abuse. The Compliance Department oversees these programs and depending on the nature of the allegations, works collaboratively with the Audit Services Department and the Office of the General Counsel to conduct investigations in these areas. Periodically, please check Mount Sinai's Policies and Procedures for Detecting and Preventing Fraud and Abuse to keep current with the latest regulatory changes.

The Mount Sinai Health System is committed to ensuring the safety and well-being of all persons on Health System property or engaged in Health System activities. Recognized hazards that could cause injury or illness to faculty, staff, students, patients, or visitors are controlled and monitored. Appropriate oversight also protects Health System facilities from risk of damage from unsafe acts or conditions.

All members of the Mount Sinai Health System community, including all faculty, are expected to share this concern for workplace safety and are required to participate in institutional efforts to encourage safety and control risk in all activities. It is each person’s responsibility to be alert to actual or potential hazards and to take appropriate steps to control them.

Research and clinical laboratories present particular concerns for safety. Faculty engaged in laboratory instruction or research are obligated to assure compliance with applicable safety protocols and regulations in their laboratories.

Faculty and staff who fail to comply with internal policies and external regulatory requirements will be subject to disciplinary action up to and including dismissal.

The Office of Environmental Health and Safety (AskEHS@mssm.edu; 212-241-7233) is available to consult with faculty and staff on all safety-related questions, policies and procedures. Any safety issue, concern or question can be directed to this office. Inquiries can be treated confidentially.

Updated June 2015

Icahn School of Medicine and each member hospital in the Mount Sinai Health System Emergency have in place emergency response procedures, with responsibility for activities assigned to pre-designated individuals as needed. For School faculty, emergency response assignments originate with the Chairperson of the faculty members' primary appointment.

In accordance with the requirements of the Education Law of the State of New York, the Trustees of Icahn School of Medicine at Mount Sinai has adopted rules for the maintenance of order in the School and have established a program for their enforcement. Learn Campus Rules and Regulations.