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Program Review and Accreditation
(Reproduced with permission from the Graduate Medical Education Directory, pp. 12-16, 1997-1998)

REVIEW AND ACCREDITATION
The review committee reviews the program information in detail, evaluates the program, and determines the degree to which it meets the published educational standards (Essentials). The review committee decides upon an accreditation status for the program and identifies areas of noncompliance with the Essentials.

Actions Regarding Accreditation of General Specialty Programs
The following actions may be taken by a review committee regarding the accreditation status of general specialty programs and by the Transitional Year Review Committee regarding the status of transitional year programs.

Withhold Accreditation
A Review committee may withhold accreditation when it determines that the proposal for a new program does not substantially comply with the Essentials. The review committee will cite those areas in which the proposed program does not comply with the Essentials.

Provisional Accreditation
Provisional accreditation is granted for initial accreditation of a program or for a previously accredited program that had its accreditation withdrawn and has subsequently applied for reaccreditation. Provisional accreditation my also be used in the unusual circumstances in which separately accredited programs merge into one an accredited program has been so altered that in the judgment of the review committee it is the equivalent of a new program. When a program is accredited on a provisional basis, the effective date of accreditation will be stipulated. Under special circumstances, the effective date may be made retroactive; however; unless specifically justified, it should not precede the beginning of the academic year during which the program is accredited. Provisional accreditation implies that a program is in a developmental stage. It remains to be demonstrated that the proposal for which accreditation was granted will be implemented as planned. A review committee will monitor the developmental progress of a program accredited on a provisional basis. Following accreditation, programs should undergo a site visit in approximately 2 years in preparation for review by the respective committee. The interval between accreditation and the next review of the program should not exceed 3 years. In the course of monitoring a program's development, a review committee my continue provisional accreditation; however, the total period of provisional accreditation should not exceed 5 years for programs of 4 years' duration a less, or the length of the program plus 1 year for programs of 5 years' duration or longer. With the exception of special cases as determined by a review committee, if full accreditation is not granted within either of these time frames, accreditation of the program should be withdrawn.

Full Accreditation
A review committee may grant full accreditation in three circumstances:

When programs holding provisional accreditation have demonstrated, in accordance with ACGME procedures, that they are functioning on a stable basis in substantial compliance with the Essentials;
When programs holding full accreditation have demonstrated, upon review, that they continue to be in substantial compliance with the Essentials; and
When programs holding probationary accreditation have demonstrated, upon review, that they are in substantial compliance with the Essentials.

The maximum interval between reviews of a program holding full accreditation is 5 years; however, a review committee may specify a shorter cycle.

Probationary Accreditation
This category is used for programs holding full accreditation that are no longer considered to be in substantial compliance with the Essentials. The normal interval for review of programs holding probationary accreditation is 2 years; however, a review committee my specify a shorter cycle. In reviewing a program holding probationary accreditation, a committee may exercise the following options: grant full accreditation; withdraw accreditation; or, in special circumstances, continue probationary accreditation. A program should not hold probationary accreditation for more than 4 consecutive years until it is returned to full accreditation or the review committee acts to withdraw accreditation. This period my be extended for procedural reasons, as when a program exercises the right to appeal procedures or the review schedule exceeds 4 years. The probationary period is calculated from the date of the initial decision for probation. The Procedures for Proposed Adverse Actions and Procedures for Appeal of Adverse Actions, in subsequent text, provide further details on adverse actions.

Withdrawal of Accreditation
Accreditation of a program may be withdrawn under the following conditions:

Noncompliance with Essentials. Accreditation of programs holding either provisional accreditation or probationary accreditation may be withdrawn as follows:
1. For programs holding provisional accreditation, once a review committee has notified a program director that the program has not developed as proposed to establish and maintain substantial compliance with the Essentials, the program will be subject to withdrawal of accreditation for failure to be in substantial compliance with the Essentials.
2. For program holding probationary accreditation, once a review committee has notified a program director that the program is accredited on a probationary basis, the program will be subject to withdrawal of accreditation for continued failure to be in substantial compliance with the Essentials.
3. In giving notification, as indicated in 1 and 2 above, a review committee must indicate the areas in which the program is judged not to be in substantial compliance with the Essentials. It is understood that these areas may change in the course of multiple reviews conducted from the time a program is first given notice that it is not in compliance until withdrawal of accreditation may occur.
Request of Program. Voluntary withdrawal of accreditation may occur at the request of the program director in the following ways:
1. A program director may request voluntary withdrawal of accreditation of a program, without prejudice. It is expected that if a program is deficient for one or more of the reasons set forth in E below the director will seek voluntary withdrawal of accreditation. Normally such requests would come from the program director, with a letter of confirmation from the sponsoring institution's chief executive officer.
2. Two or more programs may be merged into a single new program. If the review committee accredits the new program, it will take concurrent action for withdrawal of accreditation, without prejudice of the previously separate programs. The review committee will consider the expressed preference of the program director in establishing the effective date for withdrawal of accreditation of the program(s).
Delinquency of Payment. Programs that are judged to be delinquent in payment of fees are not eligible for review and shall be notified by certified mail, return receipt requested, of the effective date of withdrawal of accreditation. On that date, the program will be removed from the list of ACGME accredited programs.
Noncompliance with Accreditation Actions and Procedures. A program director may be deemed to have withdrawn from the voluntary process of accreditation and a review committee may take appropriate action to withdraw accreditation if that director refuses to comply with the following actions and procedures:
1. To undergo a site visit and program review;
2. To follow directives associated with an accreditation action; and
3. To supply a review committee with requested information.
Program Inactivity or Deficiency. A review committee may withdraw accreditation from a program, regardless of its current accreditation status, under the following circumstances:
1. The program has been inactive for 2 or more years.
2. The program has incurred a catastrophic loss, or complete change of resources, eg, faculty, facilities, or funding, such that the program is judged not accreditable.
Withdrawal of accreditation for reasons noted in the above paragraphs (Delinquency of Payment, Noncompliance with Accreditation Actions and Procedures, and Program Inactivity or Deficiency) is an administrative action and is not subject to the appeals process.
The following policies apply when action is taken to withdraw accreditation (except for establishment of an effective date in the case of voluntary withdrawal of accreditation or withdrawal of accreditation because of inactivity or deficiency);
1. The effective date of withdrawal of accreditation shall not be less than 1 year from the date of the final action taken in the procedures to withdraw accreditation.
2. The effective date of withdrawal of accreditation shall permit the completion of the training year in which the action becomes effective.
3. Once notification has been made of the effective date of withdrawal of accreditation, no residents may be appointed to the Program.
4. When action has been taken by a review committee to withdraw accreditation of a residency program and the program has entered into appeal procedures, an application for reaccreditation of the program will not be considered until the appeal action is concluded.
The Procedures for Proposed Adverse Actions and Procedures for Appeal of Adverse Actions, provided in this document, contain further details.

Actions Regarding Accreditation of Subspecialty Programs
There are two procedural models for the accreditation of subspecialty programs:

When the accreditation status of a subspecialty program is not directly related to, or dependent upon, the status of a general specialty/parent program, the subspecialty programs are accredited in accordance with the same procedures used for general specialty programs as heretofore described.
When the accreditation status of a subspecialty program is directly related to, or dependent upon, the status of a general specialty/parent program, the following accreditation actions are used:
1. Withhold Accreditation. A review committee may withhold accreditation when it determines that the proposal for a new subspecialty program does not substantially comply with the Essentials. The review committee will cite those areas in which the proposed program does not comply with the Essentials.
2. Accreditation. The subspecialty program has demonstrated substantial compliance with the Essentials and is attached to a general specialty program that holds full accreditation or is otherwise deemed satisfactory by the review committee.
3. Accreditation With Warning. The accredited subspecialty program has been found to have one or more areas of noncompliance with the Essentials that are of sufficient substance to require correction.
4. Accreditation With Warning, Administrative. The general specialty program to which the subspecialty program is attached has been granted accreditation on a probationary basis. This action simultaneously constitutes an administrative warning of potential loss of accreditation to any subspecialty program that is attached to the general specialty program.
5. Withdraw Accreditation. An accredited subspecialty program is considered not to be in substantial compliance with the Essentials and has received a warning about areas of noncompliance
6. Withdraw Accreditation, Administrative. If a general specialty program has its accreditation withdrawn, simultaneously the accreditation of any subspecialty program that is attached to the general specialty program is administratively withdrawn.
7. Other Actions by a Review Committee. The policies and procedures on withdrawal of accreditation of general specialty programs, as well as those on deferral of action, resident complement, participating institutions, and progress reports governing general specialty programs, also apply to the actions concerning subspecialty programs.

Warning Notices
A review committee may use a special procedure to advise a program director that it has serious concerns about the quality of the program and that the program's future accreditation status may be in jeopardy. In keeping with the flexibility inherent in the accreditation process, each review committee may use this procedure in accordance with its own interpretation of program quality and the use of the different accreditation categories. This procedure is not considered an adverse action and therefore is not subject to the appeal procedures.
The warning procedure my be used as follows:

For a program with provisional accreditation. A review committee may elect to continue provisional accreditation, but include in the letter of notification a statement that the program will be reviewed in approximately I year, following a site visit, at which time withdrawal of accreditation will be considered if the program has not achieved satisfactory development in establishing substantial compliance with the Essentials.
For a program with full accreditation, A review committee may elect to continue full accreditation, but include in the letter of notification a statement that the program will be reviewed in approximately 1 year, following a site visit, at which time probationary accreditation will be considered if the program is not in substantial compliance with the Essentials.
Review committees may extend the interval before the next review to 2 years, as in cases where program improvements may be addressed more appropriately within 2 years rather than 1 year.

Deferral of Accreditation Action
A review committee may defer a decision on the accreditation status of a residency program. The primary reason for deferral of accreditation action is lack of sufficient information about specific issues, which precludes an informed and reasonable decision. When a committee defers accreditation action, the residency program retains its current accreditation status until a final decision is made.

Size of Resident Complement
The complement of residents in a program must be commensurate with the total capacity of the program to offer each resident an educational experience consistent with accreditation standards; thus, a review committee may indicate that a residency program is accredited to train a specific number of residents as a maximum at any one time. In addition, a committee my indicate the number residents to be trained in each year of the program. A review committee may also indicate that a minimum number of residents is considered necessary in each program to provide an effective learning environment.

Participating Institutions
The sponsoring institution of a residency program may utilize one or more additional institutions to provide necessary educational resources. In such cases, a review committee may evaluate whether each participating institution contributes meaningfully to the educational program.

Progress Reports
A review committee may request a progress report from a program director. The committee should specify the exact information to be provided and a specific due date for the report.

NOTIFICATION OF ACCREDITATION STATUS

Letters of Notification
Accreditation actions taken by a review committee are reported to program directors by formal letters of notification. The accreditation status of any program will change only by subsequent action of the review committee. The notification letters usually contain reference to the approximate time of the next site visit and review of the program.

Notifying Residents and Applicants
All residents in a program, as well as applicants (that is, all candidates invited to come for an interview), should be aware of the accreditation status of the program and must be notified of any change in the accreditation status. When an adverse action is taken, program directors must notify all current residents as well as applicants to the program in writing. For applicants, the information on accreditation status must be provided in writing prior to having candidates come to the program for an interview. Copies of the letters to residents and applicants must be kept on file by the program director and a copy must be sent to the executive director of the review committee within 50 days of receipt of the notification of the adverse action. Additional information regarding notification letters is contained in the Procedures for Proposed Adverse Actions and Procedures for Appeal of Adverse Actions.

Duration of Accreditation
When a residency program is initially accredited, accreditation commences with the date specified in the letter of notification. A program remains accredited until formal action is taken by a review committee to withdraw accreditation. The action to withdraw accreditation will specify the date on which accreditation ends. ACGME accreditation does not lapse merely because of the passage of time. The time interval specified in the letter of notification is the time of the next site visit and review; it does not imply that accreditation will end when the time of next review occurs.

Identification of Programs in ACGME Records
Because numerous users consult and reference ACGME records, the ACGME retains the right to identify programs in a way that is consistent and will not give unfair advantage to any program. The following standards are followed:

The program title clearly identifies the sponsoring organization.
Only one sponsoring organization is identified.
Participating institutions are identified in the program listing only if they provide major teaching sites for resident education. This means that, in a 1 year program, residents must spend at least 2 months in a required rotation at the site for it to be listed; in a 2 year program, the rotation must be 4 months, and in a program of 3 years or longer, the rotation must be at least 6 months. Review committees retain the right to grant exceptions to this formula.
Outpatient facilities and ambulatory clinics are not listed.
Units that do not operate under a separate license are not listed as discrete training sites.

PROCEDURES FOR PROPOSED ADVERSE ACTIONS AND PROCEDURES FOR APPEAL OF ADVERSE ACTIONS

Procedures for Proposed Adverse Actions (Effective January 1, 1993)

The following procedures will be implemented when a Residency Review Committee (RRC) determines that a program is not in substantial compliance with the Essentials of Accredited Residencies in Graduate Medical Education (Essentials). [Note: Here and elsewhere in the Procedures for Proposed Adverse Actions and the Procedures for Appeal of Adverse Actions, reference to "Residency Review Committee" also includes the ACGME's Transitional Year Review Committee.]

When an RRC determines that an adverse action is warranted, the RRC will first give notice of its proposed adverse action to the program director, the chief administrative officer, and the educational coordinator, if one is identified, of the sponsoring institution. This notice of proposed adverse action will include the citations that form the basis for the proposed adverse action, a copy of the site visitor's report, and the date by which the program may submit, in writing, its response to each of the citations and to the proposed adverse action. [Note: Here and elsewhere in the Procedures for Proposed Adverse Actions and the Procedures for Proposed Adverse Actions, the word "action" reflects delegation of accreditation authority to the RRC. In the event of a decision by an RRC not holding delegated authority, read "recommendation of an RRC and action by the ACGME" throughout the procedures.]
The program may provide to the RRC written information revising or expanding factual information previously submitted; challenging the findings of the site visitor; rebutting the interpretation and conclusions of the RRC; demonstrating that cited areas of noncompliance with the published standards did not exist at the time when the RRC reviewed the program and proposed an adverse decision; and contending that the program is in compliance with the standards. The RRC will determine whether the information may be considered without verification by a site visitor.
The RRC will complete its evaluation of the program at a regularly scheduled meeting, as indicated to the program director in the notice of proposed adverse action. The RRC may confirm the adverse action or modify its position and take a nonadverse action.
If an RRC confirms the adverse action, it will communicate to the program director the confirmed adverse action and the citations, as described above, including comments on the program director's response to these citations
The letter of notification, which will include information on the right of the program to appeal the RRC's decision to the ACGME, will be sent to the program director, as well as to the persons or agencies entitled to receive copies. The program director may appeal the decision; otherwise, it is final. If the decision is accepted as final, the program director may subsequently request a new review in order to demonstrate that the program is in compliance with the standards.
Upon receipt of notification of a confirmed adverse accreditation action, the program director must inform, in writing, the residents and any applicants who have been invited to interview with the program that the adverse action has been confirmed, whether or not the action will be appealed. A copy of the written notice must be sent to the executive director of the RRC within 50 days of receipt of the RRCs letter of notification.

Procedures for Appeal of Adverse Actions (Effective January 1, 1993)

If a Residency Review Committee (RRC) takes an adverse action, the program may request a hearing before an appeals panel. [Note: Here and elsewhere in the Procedures for Proposed Adverse Actions and the Procedures for Appeal of Adverse Actions, reference to "Residency Review Committee" also includes the ACGME's Transitional Year Review Committee.] [Note. Here and elsewhere in the Procedures for Proposed Adverse Actions and the Procedures for Proposed Adverse Actions, the word "action" reflects delegation of accreditation authority to the RRC. In the event of a decision by an RRC not holding delegated authority, read "recommendation of an RRC and action by the ACGME" throughout the procedures.] If a written request for such a hearing is not received by the executive director of the ACGME within 30 days following receipt of the letter of notification, the action of an RRC will be deemed final and not subject to further appeal. [Note, Letters should be sent express mail in care of the Executive Director, Accreditation Council for Graduate Medical Education, 515 North State Street, Suite 2000, Chicago, IL 60610.] If a hearing is requested, the panel will be appointed according to the following procedures:
1. The ACGME shall maintain a list of qualified persons in each specialty as potential appeals panel members.
2. For a given hearing, the program shall receive a copy of the list of potential appeals panel members and shall have an opportunity to delete a maximum of one third of the names from the list of potential appeals panel members. Within 15 days of receipt of the list, the program shall submit its revised list to the executive director of the ACGME.
3. A three member appeals panel will be constituted by the ACGME from among the remaining names on the list.
When a program requests a hearing before an appeals panel, the program reverts to its status prior to the appealed adverse action until the ACGME makes a final determination on the status of the program. Nonetheless, at this time residents and any applicants who have been invited to interview with the program must be informed in writing as to the confirmed adverse action by an RRC on the accreditation status. A copy of the written notice must be sent to the executive director of the RRC within 50 days of receipt of the RRC's letter of notification.
Hearings conducted in conformity with these procedures will be held at a time and place to be determined by the ACGME. At least 25 days prior to the hearing the program shall be notified of the time and place of the hearing.
The program will be given the documentation of the RRC action in confirming its adverse action.
The documents comprising the program file and the record of the RRC's action, together with oral and written presentations to the appeals panel, shall be the basis for the recommendations of the appeals panel.
The appeals panel shall meet and review the written record, and receive the presentations. The appropriate RRC shall be notified of the hearing, and a representative of the RRC may attend the hearing to be available to the appeals panel to provide clarification of the record.
Proceedings before an appeals panel are not of an adversary nature as typical in a court of law, but rather, provide an administrative mechanism for peer review of an accreditation decision about an educational program. The appeals panel shall not be bound by technical rules of evidence usually employed in legal proceedings.

The program may not amend the statistical or narrative descriptions on which the decision of the RRC was based. The appeals procedures limit the appeals panel's jurisdiction to clarification of information as of the time when the adverse action was proposed by the RRC. Information about the program subsequent to that time cannot be considered in the appeal. Furthermore, the appeals panel shall not consider any changes in the program, or descriptions of the program, which were not in the record at the time when the RRC reviewed the program and confirmed the adverse decision. [Note. Option: When there have been substantial changes in a program and/or correction of citations after the date of the proposed action by the RRC, a program may forego an appeal and request a new evaluation and accreditation decision. Such an evaluation will be done in accordance with the ACGME procedures, including an on site survey of the program. The adverse status will remain in effect until a reevaluation and an accreditation decision have been made by the RRC.] Presentations shall be limited to clarifications of the record, to arguments to address compliance by the program with the published standards for accreditation, and to the review of the Program in the context of the administrative procedures governing accreditation of programs.

The appellant shall communicate with the appeals panel only at the hearing or in writing through the executive director of the ACGME.

The appeals panel shall make recommendations to the ACGME whether there is substantial, credible, and relevant evidence to support the action taken by the RRC in the matter that is being appealed.. The appeals panel, in addition, will make recommendations as to whether there has been substantial compliance with the administrative procedures governing the process of accreditation of graduate medical education programs.
The program my submit additional written material within 15 days after the hearing. The intention to submit such material must be made known to the appeals panel at the hearing.
The appeals panel shall submit its recommendations to the ACGME within 20 days after receipt of additional written material. The ACGME shall act on the appeal at its next regularly scheduled meeting.
The decision of the ACGME in this matter shall be final. There is no provision for further appeal.
J. The executive director of the ACGME shall, within 15 days following the final ACGME decision, notify the program under appeal of the decision of the ACGME.
Expenses of the appeals panel members and the associated administrative costs shall be shared equally by the appellant and the ACGME.

PROGRAM ORGANIZATION

The organization of a program may involve any of several administrative forms. For example, a program may be conducted within a single institution, that is, the assignment of residents is limited to that institution; or a program may involve more than one institution, that is, the resident assignments are not limited to the sponsoring institution.

Some RRCs have specific requirements relating to program organization. These may be found in the appropriate Program Requirements (see Section II). In all cases, however, a single, clearly identified sponsoring organization must exercise oversight over the educational program.

INSTITUTIONAL REVIEW

Procedures for review of sponsoring institutions for compliance with the Institutional Requirements of the Essentials have been established, in addition to the process of review and accreditation of programs in graduate medical education. The purpose of the review is to determine whether the sponsoring institution has established, documented and implemented institutional policies as required by the Institutional Requirements of the Essentials for the governance of all residency programs under its sponsorship.

Institutions that sponsor two or more programs will undergo an institutional site visit and will have formal Review by the Institutional Review Committee of the ACGME. Institutions that sponsor only one residency program will undergo an institutional review as part of their program site visit and will be reviewed by the appropriate RRC .

Results of institutional review evaluation for institutions with two or more programs are reported as either favorable or unfavorable in a formal letter of report. The date of the next institutional review will be identified in this letter. Results of institutional review for institutions with a single residency are incorporated into the letter of notification concerning program accreditation.

An Institution that has received an unfavorable evaluation can request another institutional review earlier than the specified review cycle. Two successive unfavorable reviews of an institution will lead to a warning and a third successive unfavorable review to the withdrawal of accreditation of all the residency programs sponsored by the institution. An appeals mechanism has been established for the latter contingency.

FEES FOR EVALUATION AND ACCREDITATION

Fees charged for the accreditation of programs are determined annually by the ACGME. As of January 1, 1997, the following fee schedule is in effect.

Application Fee

A fee is charged for processing applications for programs seeking initial accreditation or reaccreditation, including subspecialty programs. The charge for applications is $2,500. It is normally billed at the time the application is received.

Program Site Visit and Review

A fee is charged for the site visit and review of programs. The charge for a site visit and review by an ACGME field representative is $2,650, and by a specialist in the appropriate discipline, $2,750. This fee applies to all accredited programs, including subspecialty programs. This fee applies also to site visits for institutional review.

Annual per Resident Fee

An annual fee is charged for each position filled in an accredited residency training program. The fee is calculated on the number of residents/fellows/trainees in each program as of September 1 of each given academic year. Programs are billed around January 1 of each academic year The fee charged in 1996 1997 was $45 per resident.

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