Understanding The ACGME Process

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1 Understanding The ACGME Process By: Shannon K. Reed Faegre Baker Daniels LLP I. Introduction. A. The Accreditation Council for Graduate Medical Education ("ACGME"). 1. Overview. Accreditation is a voluntary process of evaluation and review performed by an accrediting body. The ACGME is a private, nonprofit council that accredits graduate medical residency programs in the United States. The ACGME's mission is to "improve health care by assessing and advancing the quality of resident physicians' education through accreditation." 1 The ACGME's members include the American Medical Association, American Board of Medical Specialties, American Hospital Association, Association of American Medical Colleges and the Council of Medical Specialty Societies. Each of the foregoing appoint four members to the ACGME's Board of Directors. The Board also is comprised of two resident members, three public directors, the chair of the Council of Review Committees, one to four at large directors and a non-voting federal representative. Most medical and surgical specialty boards require a physician to complete an ACGME accredited residency program in order to be eligible for board certification in a specialty. In addition, board eligibility or certification may also be required in order to obtain a state license to practice medicine. Accordingly, understanding the accreditation process is important to not only residents, graduate medical education programs and sponsoring institutions, but to attorneys who represent programs and sponsoring institutions before the ACGME.

2 2. Review Committees. B. Recent Data. The ACGME delegates authority to accredit graduate medical education programs and institutions to its Review Committees comprised of peer specialists in the applicable field and resident physicians. There are three types of Review Committees ("RC"): the Residency Review Committee ("RRC"), Transitional Year Review Committee, and the Institutional Review Committee ("IRC"). Each RC sets accreditation standards and provides peer evaluation of residency programs and subspecialties or, in the case of the IRC, is responsible for the evaluation of sponsoring institutions. The purpose of the evaluation is to assess the degree of compliance by the program or institution with a published set of educational standards, and to confer accreditation on programs and institutions meeting those standards. 2 There are 28 RCs which include a RC for each of the 26 medical specialties for which the ACGME provides accreditation, one for a special one-year transitional-year general clinical program, and one for institutional review. All RCs are comprised of physician members, at least one of whom is a resident at the time of appointment. Members of the RRC are appointed by the AMA Council on Medical Education and the appropriate medical specialty boards and organizations. Members of the IRC and Transitional Year Committee are appointed by the ACGME Executive Committee and confirmed by the Board of Directors. During the academic year the ACGME was responsible for the accreditation of 8,887 residency programs in 133 specialties and subspecialties. A total of 113,142 residents (full-time and part-time) were enrolled in these residency programs. As stated by the ACGME in its Policies and Procedures, "Accreditation of residency programs and sponsoring institutions by the ACGME is a voluntary process of evaluation and review performed by a non-governmental agency of peers. The goals of the process are to evaluate, improve, and publicly recognize programs or sponsoring institutions in GME that are in substantial compliance with standards of educational quality established by the ACGME. Accreditation was developed to benefit the public, protect the interests of residents, and improve the quality of teaching, learning, research, and professional practice." Subject: 4.00 Definition of Accreditation, June 12,

3 The largest percentage of residents were enrolled in internal medicine programs (24%), followed by family medicine (10%) and pediatrics (8.8%). 3 Overview of The Accreditation Process. A. Written Documents for Review. 1. The Program Information Form ("PIF"). Programs: The Program Director is responsible for completing the PIF which is developed by the applicable RRC (or Transitional Year Review Committee) in preparation for a site visit. The PIF should contain information representing the program at the time of the site visit. The PIF, including all attachments and other documents designated by the Review Committee, is considered in determining the accreditation status of a new or existing program. Accordingly, submission of an accurate, comprehensive PIF that answers all questions and provides supporting data is crucial in the accreditation process. The PIF must be signed by the Designated Institutional Official ("DIO") prior to consideration by the RRC. TIPS: Before preparing the PIF, review the common program requirements, specialty specific program requirements and institutional requirements. Plan ahead allow sufficient time to gather data, prepare and review the PIF. Identify all individuals who will be involved in the process and make them aware of their responsibilities. Appropriate faculty and residents must review for accuracy. Establish internal deadlines. Do not rely on the site visitor. All information relevant to compliance with accreditation standards should be included in the PIF. PIF should be considered a living document that requires updating, not recreation. Pay attention to the details and follow the instructions. The PIF provides the first impression. 3 The Accreditation Council for Graduate Medical Education Data Resource Book Academic Year

4 Questions? Contact the RC staff. Institutions. The IRC develops the Institutional Review Document for completion by the DIO. Like the PIF, the institutional review document contains information concerning the sponsoring institution at the time of the site visit. 2. Other Documents. Programs. The applicable RRC may impose requirements concerning the submission of other documents along with the PIF. Other documents include policies and procedures; documentation of internal review; program goals (Common Program Requirements IV.A.); current program Letters of Agreement between programs and all participating sites (C.P.R. I.B.); resident files and evaluations (C.P.R. V.); documentation of resident duty hours (C.P.R. II.A.4.j.); curriculum vitae of faculty; and other documents that show substantial compliance with ACGME requirements. Institutions. Other documents considered during the review of a sponsoring institution or proposal for a new sponsoring institution include, but are not limited to, the sponsoring institution's policies and procedures; a written statement documenting the sponsoring institution's commitment to provide the necessary educational/financial/human resources to support GME signed by institution's governing body, administration and GME leadership (Institutional Requirement, I.B.2.); current master affiliation agreements between the sponsoring institution and all of its major participating sites (Inst. Req. I.C.2.); program letters of agreement between each program and all participating sites (Inst. Req. I.C.3.); written agreements with residents outlining the terms and conditions of their appointment to a program (Inst. Req. II.D.1.); and other documents evidencing compliance with the Institutional Requirements. TIPS: Consider what documents establish substantial compliance with any requirements with which the program/institution was cited for failing to comply during the last review cycle. Consider whether these should be submitted with the PIF or, at a minimum, make these documents available to the site visitor. 4

5 B. The Site Visit. A site visit is conducted by a member of the ACGME field staff or a specialist site visitor. Ordinarily, a site visit of a program or sponsoring institution is required before the status of an accredited program or sponsoring institution may be changed. During the site visit, the site visitor is responsible for verifying and clarifying the information provided in the PIF and other documents submitted for review. The program director, DIO, administrators, faculty and residents are interviewed during a program review. Similarly, the site visitor for a sponsoring institution interviews the DIO, administrators, faculty and residents. Residents are asked questions that address aspects of the program relevant to them. All questions posed to residents are based on ACGME common program and specialty-specific requirements, other than general questions about program strengths and areas for improvement. The site visitor then prepares a report to the RC. The site visitor is not to make any judgments, recommendations or provide any opinions regarding the program's or sponsoring institution's accreditation status and does not participate in the RC's accreditation decision. New in 2011, the ACGME posted a "Checklist for the ACGME Accreditation Site Visit" on its website. 4 (Attachment 1). TIPS: Preparation for the site visit is an opportunity for program selfreflection Clarity to the site visitor is necessary for clarity to the RC Have documents immediately available ). Mark areas for review Follow instructions C. The Review Process. How it works. In general, the RC make accreditation decisions during their normally scheduled meetings. Prior to the meeting, the documents for accreditation concerning a specific program are forwarded to one or two members of the RC who are responsible for reviewing the materials prior to the meeting and preparing written comments concerning their review. The reviewer's comments are then considered by the RC in making a decision regarding the 4 5

6 accreditation status. The RC is responsible for evaluating each program or sponsoring institution based on applicable requirements in effect at the time of the site visit. According to the ACGME's Policies and Procedures, 5 "Nile Review Committee shall base its action on the following information: a. the history of the sponsoring institution and/or the program, as applicable; b. the most recent program information form submitted by the program director and the designated institutional official, or the most recent institutional review document submitted by the designated institutional official; c. the most recent site visitor's report; d. correspondence pertinent to the review; e. other information such as board scores, operative data, procedure logs, resident survey, case logs, and resident experience data, as required by the Review Committee; f. additional or revised information that may be submitted by the program director or designated institutional official, provided the information arrives sufficiently in advance of the committee meeting to allow for proper review; and, does not require verification by a site visit. This additional or revised information must be reviewed for accuracy by the sponsoring institution's graduate medical education committee and signed by the designated institutional official; and g. materials pertaining to a complaint against a program or institution to which the program or institution has had an opportunity to respond." 5 ACGME Accreditation Policies and Procedures, The Review Process, June 12,

7 On review, the RC decides the accreditation status of the program or institution and the approximate date for the next site visit, if applicable. The standard to be used by an RC is whether the program or institution is in "substantial compliance" with applicable ACGME accreditation requirements. If the RC makes a determination that the program or institution fails to substantially comply with an accreditation standard(s) or ACGME policy or procedure, the RC will issue a citation(s) based on its findings. 2. The accreditation cycle. The accreditation status of a program or institution is changed only by action of the RC. Accordingly, once accreditation is granted, a program or sponsoring institution remains accredited until the RC takes action to withdraw accreditation. The maximum length of the cycle of accreditation that is awarded is five years. The length of accreditation is based on the accreditation status, issues identified by the RC during its review and areas of noncompliance. The review cycle is calculated from the date of the meeting at which the final accreditation action was taken to the time of the next site visit. A program or institutional review cycle may be shortened if major changes occur between site visits. 3. Notification of accreditation status. After the RC meets and makes a decision regarding accreditation status, the RC issues a Letter of Notification to inform the program or sponsoring institution of the RC's action. Programs. The Letter of Notification concerning a program is issued to the program director, with a copy to the DIO, and includes a statement of the action taken by the RC, the current accreditation status, the length of the accredited program, the number of residents approved, the approximate date for the next site visit, and the approximate date for the next mid-cycle internal review. See Attachment 2, ACGME "Key to Standard Notification Letter for Status of Continued Accreditation" providing explanations, and a sample notice. Institutions. The Letter of Notification concerning an institution is issued to the DIO and identifies the action taken by the RC, the 7

8 current accreditation status and the approximate date for the next site visit. 4. Notifying residents and candidates. III. Accreditation Actions. 7 The DIO must notify all residents of the accreditation status of the sponsoring institution and must provide residents with written notice any time there is a change in accreditation status. Likewise, all program residents should be aware of the program's accreditation status and must be notified in writing following any change in accreditation when the RC takes an action. 6 A. Withheld Accreditation. (Adverse Action) The accreditation of a new program or sponsoring institution is withheld if the RC determines that the applicant has failed to demonstrate substantial compliance with ACGME requirements. The RC will first propose this status in order to provide the program or sponsoring institution with an opportunity to rebut the citations and document compliance with the requirements. If the applicant is unsuccessful in rebutting the proposed status and the RC withholds accreditation, this action constitutes an "adverse action" and the applicant is entitled to appeal the decision as further discussed in Section V. If a program or sponsoring institution re-applies for accreditation within two years of accreditation being withheld or proposed withheld, the program or sponsoring institution's history of the last accreditation action will be included as part of the file. Along with the new application, the program or sponsoring institution must include: 1. a statement rebutting each of the previous citations and documenting compliance with ACGME requirements (if apply after proposed withheld), and/or 2. a statement of the measures taken to comply with ACGME requirements relating to each previous citation (if applying after 6 See Section IV.4. discussing notification requirements in the event of an adverse action. 7 The accreditation actions discussed in this section apply to the accreditation of specialty programs, independent subspecialty programs, Transitional Year programs and sponsoring institutions. See, Policies and Procedures, Subject Accreditation Actions, June 12, See Section of ACGME Policies and Procedures identifying accreditation actions which may be taken for dependent subspecialty and sub-subspecialty programs. 8

9 B. Initial Accreditation. either proposed withheld or withheld accreditation status is granted). Initial accreditation is conferred upon a new program or sponsoring institution when the RC determines that a proposal for a new program or sponsoring institution substantially complies with ACGME requirements. Accordingly, this accreditation status may be conferred upon (1) a new program or sponsoring institution, (2) a previously accredited program or sponsoring institution who has applied for reaccreditation after having its accreditation withheld, withdrawn or voluntarily withdrawn, (3) a program or sponsoring institution resulting from the merger of previously separately accredited programs or sponsoring institutions, or (4) an accredited program or sponsoring institution that in the judgment of the RC has been so altered that it is the equivalent of a new program or sponsoring institution. The initial accreditation cycle of a new program or sponsoring institution is considered a developmental stage during which the proposal will be fully developed and implemented. The ACGME policies and procedures provide that a program or sponsoring institution should be reviewed within three years of the initial action. If, during the next review, the program or sponsoring institution has failed to demonstrate substantial compliance the RC may propose withdrawal or extend accreditation for one year with a warning. The program or sponsoring institution must demonstrate substantial compliance with ACGME requirements at the end of this additional one year or the program or sponsoring institution's accreditation will be withdrawn. 8 If withdrawal of accreditation is confirmed, the program or sponsoring institution shall be allowed to complete the current academic year and one additional academic year. C. Continued Accreditation. The accreditation status of "Continued Accreditation" is granted when the RC determines that a program or sponsoring institution has demonstrated substantial compliance with ACGME requirements. Accreditation is continued in three circumstances: 1. A program or sponsoring institution that holds initial accreditation status has demonstrated substantial compliance with ACGME requirements. 8 Accordingly, the maximum period of time that a program or sponsoring institution may hold the status of initial accreditation is four years. 9

10 2. A program or sponsoring institution that holds the status of continued accreditation has again demonstrated substantial compliance with ACGME requirements. 3. A program or sponsoring institution that holds the status of probationary accreditation has demonstrated, following a site visit and review, substantial compliance with ACGME requirements. D. Probationary Accreditation. (Adverse Action) The accreditation status ofprobationary accreditation is granted when the RC determines, following a site visit and review, that a program or sponsoring institution has failed to demonstrate substantial compliance with ACGME requirements. The status of probationary accreditation may not be awarded for longer than two years. The RC shall first propose this status in order to provide the program or sponsoring institution with an opportunity to rebut the citations as determined by the RC and document compliance with the requirements. The program or sponsoring institution's response must be reviewed and approved by the institution's Graduate Medical Education Committee and DIO (who must co-sign the submission) prior to submission to the ACGME. The decision of the RC to grant probationary accreditation is an adverse action subject to appeal as further discussed in Section V. A program or sponsoring institution granted probationary accreditation that demonstrates substantial compliance with ACGME requirements at its next site visit and review will be restored to continued accreditation status. If, however, a program or sponsoring institution fails to demonstrate substantial compliance at the next site visit and review, of if new areas of noncompliance are identified, the RC may confer an additional one year of probationary accreditation continued probationary accreditation.9 Similar to the status of probation accreditation, the status of continued probationary accreditation shall first be proposed in order to provide the program or sponsoring institution with an opportunity to rebut the citations and document compliance. If the program or sponsoring institution fails to demonstrate substantial compliance at the end of the additional one year (to return to the status of continued accreditation), the program or sponsoring institution's accreditation will be withdrawn. 9 A program or sponsoring institution may not hold the accreditation status ofprobationary (up to two years) and continued probationary accreditation (one year) for longer than thme years total. 10

11 E. Withdrawal of Accreditation. (Adverse Action) Accreditation of a program or sponsoring institution that, after a site visit and review, has failed to demonstrate substantial compliance with ACGME requirements may be withdrawn. Before being withdraw, the status shall first be proposed to provide the program or sponsoring institution with an opportunity to rebut the citations and document compliance. The response submitted by the program or sponsoring institution must be reviewed and approved by the institution's Graduate Medical Education Committee and co-signed by the DIO. A program or sponsoring institution notified of the effective date of withdrawal of accreditation many not accept any new residents and will be allowed to complete the current academic year and one additional academic year. If a program or sponsoring institution whose accreditation has been withdrawn or proposed withdrawn reapplies for accreditation within two years of the decision to withdraw/propose withdrawal, the accreditation history of the last accreditation action is included as part of the file when reapplication is made. The program or sponsoring institution must include the following with the new application: (1) a statement rebutting each citation and documenting compliance with ACGME Requirements (in the case of application after proposed withdrawal), and/or (2) a statement of the measures the program or institution has taken to comply with ACGME Requirements relating to each citation in the last letter of accreditation (in case of application after either proposed withdrawal or withdrawal). Sponsoring Institution. If the IRC confirms withdrawal of accreditation of a sponsoring institution, all ACGME-accredited programs sponsored by that institution will be administratively withdrawn. F. Expedited Withdrawal of Accreditation Programs Only. (Adverse Action) A program's accreditation status may be withdrawn in an expedited process following a site visit and review if the RC determines that clear evidence of noncompliance with accreditation standards exists as follows: (1) a catastrophic loss of resources, including faculty, facilities, or funding, or (2) egregious noncompliance with accreditation requirements. 1 1

12 The RC shall first propose this status to allow the program an opportunity to rebut the citations and document compliance with ACGME requirements. In response to the notice of proposed expedited withdrawal, the program may: (1) accept the decision; (2) submit a written response, reviewed by the institution's Graduate Medical Education Committee prior to submission and co-signed by the DIO, contending the program is in substantial compliance; 10 or (3) request voluntary withdrawal of accreditation. If a response is submitted, the RC shall meet within 21 days of receipt of the response to determine whether the proposed expedited withdrawal should be confirmed. If not confirmed, the program's accreditation status reverts to its previous status; if, however, the previous status was continued accreditation, the RC may grant probationary accreditation which shall be subject to the expedited withdrawal appeal procedures." If confirmed, the RC shall determine the effective date, allowing a reasonable time for resident placement, not to exceed six months from the time the action was confirmed. Additionally, no new residents may be appointed to the program after the RC confirms withdrawal and the program is notified of the effective date. The last accreditation action taken concerning a program that reapplies for accreditation after accreditation has previously been expeditiously withdrawn or proposed expeditiously withdrawn is included with the program's file when considering a new application. Along with the new application, the program must include: (1) A statement rebutting each citation and documenting compliance with ACGME Requirements (in the case of application after proposed expedited withdrawal), and/or (2) A statement of the measures the program has taken to comply with ACGME Requirements relating to each citation in the last letter of accreditation (in the case of application after proposed expedited withdrawal or expedited withdrawal) Written information must be received by the RC's Executive Director within 30 days of the program's receipt of notification of the proposed expedited withdrawal of accreditation In the case of a dependent subspecialty, if the proposed expedited withdrawal is not confirmed, the program's accreditation status shall revert to its previous status. 12

13 To expedite matters, the RC may meet telephonically or in person to consider the status of proposed expedited withdrawal or confirm an expedited withdrawal of accreditation. G. Voluntary Withdrawal of Accreditation. Programs/Institutions. A program or institution that decides to no longer participate in ACGME accreditation may request voluntary withdrawal of accreditation. Circumstances which may prompt a voluntary withdrawal include a merger, loss of resources, lack of any residents enrolled in the program or if the specialty or subspecialty is no longer accredited by the ACGME. A request for voluntary withdrawal or accreditation by a program must be approved by the DIO and GME Committee, provide an effective date which coincides with the end of the current academic year and explain the plan for the placement of all residents. A sponsoring institution's request must be approved by the GME Committee, include the effective date of withdrawal and a detailed plan for placement of all residents. Once the request is made, a program may not accept new residents, request "reversal" of the action but may seek reaccreditation by undergoing the application process. Pending Adverse Action. A program or sponsoring institution may request voluntary withdrawal of accreditation when the program/institution has a pending adverse accreditation status. The request must be submitted to the applicable RC or IRC, be signed by the DIO, propose an effective date and provide a plan for placement of all residents. If the program or institution reapplies for accreditation after being voluntary withdrawn, the last accreditation action (including any proposed action) will be part of the file. The new application must include: 1. A statement rebutting each citation and documenting compliance and/or 2. A statement of the measures taken to comply with ACGME requirements relating to each citation. 13

14 H. Reduction in Resident Complement. (Adverse Action) Resident complement of a program may be reduced by an RC that designates resident complement if the program cannot demonstrate the capacity to provide each resident with a sufficient educational experience. This status shall be proposed. Iv. Procedures for Adverse Actions. A. Adverse Actions. 1. Programs: 12 accreditation withheld probationary accreditation withdrawal of accreditation reduction in resident complement 2. Sponsoring Institutions. B. Procedure. accreditation withheld probationary accreditation withdrawal of accreditation 1. Notice of proposed adverse action. The RC shall give notice to the program director and DIO (for a program) or, if the adverse action is proposed against a sponsoring institution, to the DIO of the proposed adverse action. The notice must include the citations that form the basis of the proposed adverse action, a copy of the site visitor's report if a site visit occurred, and the date by which the program/institution may submit its written response. 2. Written response. The program/institution may provide the RC with written information revising, correcting or expanding factual information previously submitted; challenging the site visitor's finding; rebutting the RC's interpretations and conclusions; demonstrating 12 The following accreditation actions are adverse actions applicable to specialty specific programs, Transitional-Year programs, and independent subspecialty programs. 14

15 that the areas of noncompliance cited by the RC did not exist on the date of the RC's meeting when the RC initially reviewed the program/institution and proposed an adverse action; and contenting the program/institution is in substantial compliance with the ACGME requirements in effect at the time of the site visit. The RC will determine whether the information submitted may be considered without verification by a site visitor. 3. The RC's consideration of the Program/Institution's response. The RC will complete its review of the program/institution at its next scheduled meeting and can either confirm the adverse action or modify its position. If the decision is made to confirm the adverse action, the RC shall send a Letter of Notification, including comments on the program/institution's response to each citation. The program/institution may appeal an adverse action confirmed by the RC as set forth in Section V below. If not appealed, the adverse action becomes final. 4. Notification of Residents and Candidates. A program director notified that an adverse action has been confirmed must provide written notice to the residents and any applicants who have been invited to interview with the program that the adverse action has been confirmed. 13 A DIO notified that an adverse action has been confirmed concerning the accreditation status of a sponsoring institution must provide written notice to residents and any applicants who have been invited to interview with the programs in the institution. This notification must be provided to residents and candidates regardless of whether the program/institution appeals the decision. A copy of the program director's/dio's written notice to residents and applicants must be sent to the RC's Executive Director or, in the case of a sponsoring institution, the Executive Director of the IRC, within 50 days of receipt of the Letter of Notification. 13 All program residents and applicants of a general specialty and any dependent subspecialty programs must be advised in writing. Additionally, when accreditation is withheld concerning a proposed program or sponsoring institution, residents enrolled in a formerly accredited program, as well as applicants who anticipated accreditation of the proposed program/sponsoring institution, must be advised in writing. 15

16 V. Appeal of Adverse Actions. 14 A. Request for a Hearing. A program/institution that desires to appeal an adverse action must submit a written request to the Chief Executive Officer of the ACGME. The written request must be received by the ACGME within 30 days following receipt of the Letter of Notification. If the written request is not received by that time, the action of the RC is deemed final and not subject to further appeal. B. Hearing Panel. The appeal shall be heard by a three-member panel selected from a list of panel members maintained by the ACGME. The ACGME shall forward a list of qualified potential panel members to the program/institution who shall delete a maximum of one-third of the names from the list. The program/institution must submit its revised list to the CEO of the ACGME within 15 days of its receipt of the list. The ACGME will appoint a panel from the remaining names. The program may not communicate with the appeals panel other than during the hearing or in writing through the CEO of the ACGME. C. Policies and Procedures that Apply on Appeal. 1. Accreditation status on appeal. While on appeal, the program/institution shall hold the accreditation status determined by the RC with the term "under appeal" affixed. This status remains in effect until the ACGME makes a final determination on appeal. 2. Notifying residents and candidates. Residents and any applicants who have been invited to interview with the sponsoring institution must be informed in writing of the RC's decision to confirm an adverse action. A copy of the written notice must be sent to the RC's Executive Director within 50 days of receipt of the Letter of Notification. 3. Time/Place of Hearing. The ACGME shall determine the time/place of the hearing and will notify the program/institution at least 25 days prior to the hearing. The panel will meet to review the written record and receive any presentations. A representative 14 ACGME Policies and Procedures, Sections , , June 12,

17 of the RC may attend the hearing to clarify the record. The rules of evidence do not apply. 4. Basis for recommendation by the Appeals Panel. The program/institutional file, record of the RC's action, and any oral and/or written presentations made to the appeals panel shall be the basis for the panel's recommendation. On appeal, the program/institution shall be provided with copies of the documents before the RC when it confirmed the adverse action. 5. Jurisdiction on appeal. On appeal, the file of the program/institution is considered "frozen" and the program/institution is not to amend the statistical or narrative descriptions on which the RC based its decision. The ACME limits the jurisdiction of the appeals panel to clarifying information at the time when the adverse action was confirmed by the RC (information subsequent to that time is not be considered on appeal; nor is the panel to consider any program/institutional changes or descriptions not in the record before the RC). 6. The Hearing. On appeal, a program/institution may make a written and oral presentation. The ACGME's policies and procedures limit presentations to clarifying the record and argument addressing compliance by the program/institution with the ACGME's requirements and the RC's compliance with administrative procedures. A program/institution may submit additional written material within 15 days after the hearing. The program/institution must inform the panel at the hearing of its intention to do so. Oral presentations are limited to two hours. 7. Panel recommendation. The appeals panel is charged with making a recommendation to the ACGME as to whether (a) "substantial, credible, and relevant" evidence exists to support the action by the RC, and (2) there has been "substantial compliance" with the ACGME's administrative procedures governing the accreditation process. The panel shall make its recommendations to the ACGME within 20 days after receipt of any additional written information from the appellant. 8. Final decision. The decision of the ACGME is final. The ACGME will act on the appeal at its next regularly scheduled meeting and notify the program/institution within 15 days of making its final decision. 17

18 TIPS: Carefully review the RC's explanation of citations Consistent with ACGME requirements? ) Correct assessment of the facts? Consistent with site visitor's findings? >. Are incorrect, unsupported assumptions made? No quantifiable criteria/measurement that must be met to ensure compliance Consider indicia of success Board scores Fellowships )=. Award winning research D. Appeal of an Expedited Adverse Action. 15 The procedures for the appeal of an expedited adverse action are similar to those stated in Section V.C. other than as follows: Request for a Hearing. A written request for a hearing must be received by the ACGME within 21 days following receipt of the Letter of Notification. If the written request is not received by that time, the action of the RC is deemed final and not subject to further appeal. 2. Hearing Panel. The appeals panel will consist of the ACGME Executive Committee, plus one public director of the ACGME. The action of the panel constitutes the final action of the ACGME. Thus, the panel does not make a recommendation but makes the final decision concerning the appeal. 3. Time/Place of Hearing. The CEO of the ACGME will set an expedited schedule for the appeal. The hearing may occur telephonically or otherwise as determined by the ACGME. Prior to the hearing, the appeals panel shall establish the length of the hearing. 4. Notifying residents and candidates. As stated above, Residents and any applicants who have been invited to interview with the sponsoring institution must be informed in writing of the RC's decision to confirm an adverse action. However, the copy of the 15 See, Policies and Procedures, Procedures for Appeal of Expedited Adverse Actions, June 12,

19 written notice must be sent to the RC's Executive Director within 21 days of receipt of the Letter of Notification. 5. Hearing. The program may submit additional written material following the hearing and must do so within the time determined by the panel. The intention to submit additional material must be made known at the hearing. 6. Panel Decision. The decision of the panel constitutes the final action of the ACGME and shall be made within 20 days following receipt of any additional written information. 1 9

20 CHECK LIST FOR THE ACGME ACCREDITATION SITE VISIT Please check off the items as you complete them during your preparation for the ACGME program site visit. Forward a copy of the completed check list to your site visitor along with the PIF. This will ensure that all documents needed for the accreditation site visit are complete and available on the day of the site visit. Many thanks in advance. Site Visit Document Preparation Please follow the instructions on your Review Committee's web page to determine the documents you need to complete. Once completed, ask your Designated Institutional Official (DIO) to review and sign the PIF. After signatures are obtained, make 4 hard copies of the PIF documents. One copy must be single sided; the remaining three copies may be double sided, if preferred. Send one (1) single-sided copy of the documents to the site visitor at the above address of the site visitor 14 days before the date of the site visit. Provide the remaining tluee (3) sets to the ACOME site visitor on the day of the visit. Notify residents of the site visit interview. In programs with ten or fewer residents, the site visitor will interview all residents on duty on the day of the visit. In programs with more than 10 residents, the site visitor will interview 10 to 12 peer-selected residents, representing all years of training. Extra-year chiefs may not participate. Include the Following Documents with the PIF Materials You Send to the Site Visitor A copy of the site visit schedule with names and titles of all the participants. Detailed directions to the institution and the meeting room in which the visit will be conducted. The contact number of the program director or another staff member, ideally with a cell phone or pager number for the site visitor to contact the program if an emergency or other urgent need to contact the program arises. On the Day of the Visit, Please Have these Documents Available for Review by the Site Visitor Common Program Requirements 1. Policy for supervision of residentsdellows (addressing progressive responsibilities for patient care, and faculty responsibility for supervision); 2. Program policies and procedures for residents' duty hours and work environment; 3. Moonlighting policy; 4. Overall educational goals for the program; 5. Competency-based goals and objectives for each assignment at each educational level 6. Transfer protocols and sample educational materials related to handovers/transfers, 7. Sample schedules that inform all members of the health care team of attending physicians and residents/fellows currently responsible for each patient's care; 8. Protocols defining common circumstances requiring faculty involvement (care of a ATTACHMENT 1

21 complex patient, ICU transfer, DNR or other end of life decision (by year/level of training); 9. Protocol and (completed) sample documents for episodes when residents/fellows remain on duty beyond scheduled hours; 10. Policies to ensure that residents/fellows have adequate rest between daily duty periods and after in-house call (showing differences by year/level of training); 11. Sample documents offering evidence of resident participation in Quality Improvement and Safety Projects; 12. Current Program Letters of Agreement (PLAs); 13. Files of current residents/fellows and most recent program graduates: If applicable, files of current residents/fellows who have transferred into the program including documentation of previous experiences and competency-based performance evaluations; If applicable, files of residents/fellows who have transferred out of this program into another program; 14. Evaluations of residents/fellows at the completion of each assignment;* 15. Evaluations showing use of multiple evaluators (e.g., faculty, peers, patients, self, and other professional staff); 16. Documentation of residents'ffellows' semiannual evaluations of performance with feedback; 17. Final (summative) evaluation of residents/fellows, documenting performance during the final period of education and verifying that the resident/fellow has demonstrated sufficient competence to enter practice without direct supervision; 18. Completed annual written confidential evaluations of faculty by the residents/fellows; 19. Completed annual written confidential evaluations of the program by the residents/fellows; 20. Completed annual written confidential evaluations of the program by the faculty; 21. Documentation of program evaluation and written improvement plan; 22. Documentation of duty hours for resident/fellows in this program Additional Documents if specified by the RRC: a. Review of Case/Procedure logs; b. Documentation of conference attendance; C. * Programs using computerized evaluation system may generate and print summary reports, rather than show individual records.

22 K. to tan ard Notifica otter for S atus of Conti ed Ascreclitotion (Text in italics provides explanations of the sections in the letter; nonitalicized text is standard text of the letter) A C Ps, Accradttation Council for Gradual* Medical Education 515 North State Street Sae 2000 Map IllinoIs Phone 31L7S S Web wmurcpcorg Date Program Director Name Director, Residency Program Program Name Address Line -1 Address Line 2 City State Zip Dear Dr. Program Director: The Residency Review Committee for X, functioning in accordance with the policies and procedures of the Accreditation Council for Graduate Medical Education (ACGME), has reviewed the information submitted regarding the following program: Specialty Name of Program Sponsoring Institution City, ST Program Based on all of the information available to it at the time of its recent meeting, the Review Committee accredited the program as follows: Status: This is the accreditation status assigned to the program or institution by the Review Committee following review of the program or institution. Length of Training: This is the number of postgraduate years of resident education that the program is accredited to provide. Maximum Number of Residents: If the Review Committee approves resident complement, this section lists the maximum number of residents that may be appointed to the program at any given time. Residents per Level: If the Review Committee approves resident complement by year, this section specifies the maximum number of residents that may be appointed at each level of the program. Effective Date: This is the effective date of the accreditation action and, per ACGME policy, is the date of Review Committee Meeting. ATTACHMENT 2 1

23 Approximate Date of Next Site Visit: This is the target date (month and year) for the next site visit of the program or institution, based on the length of the accreditation cycle specified by the Review Committee and will include whether the site visit will be performed by a member of the ACGME Field Staff (FS) or by a Specialist Site Visitor (SSV). Programs generally are scheduled in a day window around the next site visit month. On occasion, a site visit may occur on an earlier or later date because each Field Staff visits three programs per week and the date can be moved forward or moved back to allow three programs to be scheduled in a given city. In addition, Transitional Year (TY) programs and some subspecialties with one required year of education are generally scheduled during the last nine months of the academic year in order to give the residents/ fellows an opportunity to gain experience with the program prior to participating in the resident/ fellow interview at the time of the site visit. Approximately days before the scheduled site visit, the Department of Field Activities staff will send to the program director and institutional DIO information about the actual site visit date and logistics for the site visit. Cycle Length: This is the number of years between the Review Committee meeting at which the accreditation action was confirmed and the approximate date of the next site visit of the program or institution. Approximate Date of the Mid-Cycle Internal Review: This is the approximate date when internal reviews must be documented in the GMEC minutes as being in process. This date is calculated using the effective date (see above) and the approximate date of the next site visit (see above). Progress Report Due: If the review committee requests a progress report, the due date is included in this section. Areas Not in Substantial Compliance (Citations) (Required Section) Each letter will include this section, listing areas in which the program is not in compliance with ACGME Requirements for Graduate Medical Education. These areas of noncompliance are also referred to as citations. Each citation will include a descriptive heading, the actual institutional or program requirement for the area that is not in compliance and the Review Committee's brief explanation of non-compliance. If no citations were identified by the Review Committee, this section will include a statement of commendation to the program or institution for demonstrating substantial compliance with the requirements without citation. If the program received a 4 or 5 year review cycle, this section will include a commendation for demonstrating substantial compliance with the ACGME Requirements for Residency Education, as well as a list of areas of noncompliance, or citations. If the program received a I or 2 year review cycle, this section will include a list of the areas of noncompliance, or citations, as well as a statement warning that the program's or institution's accreditation will be in jeopardy at the time of the next review if these areas have not been adequately addresses, and/or other major areas warranting citation develop.

24 Standard format for the text for each citation: Line 1 Descriptive Header for topic: Line 2 Institutional or Program Requirement Number Line 3 Texts of the Institutional or Program Requirement Next line is a space Next line provides the Review Committees explanation of non-compliance Next line includes sources listed in parentheses (e.g., pages from the Institutional Review Document or Program Information Form, Site Visitor Repot case logs, ACGME Resident Survey) Reduction in Resident Complement: If the Review Committee approves resident complement, and the Review Committee determines that a reduction in the number of residents is necessary; this section includes the citations for the proposed reduction in resident complement and the following statements. Before final action is taken to reduce resident complement, the program director has the opportunity to respond to the citations by submitting written information for review by the Review Committee. The program director may provide information revising, correcting or expanding factual information previously submitted; rebutting the interpretation of the Review Committee; demonstrating that areas cited as not in compliance did not exist when the Review Committee initially reviewed the program and proposed an adverse action (i.e., the date of the Review Committee meeting); and contending that the program has demonstrated the capacity to provide each resident with a sufficient educational experience. The response must be reviewed and approved by the sponsoring institution's Graduate Medical Education Committee and co-signed by the Designated Institutional Official prior to submission to the ACGME. In order to be considered by the Review Committee, the response must be received, in triplicate, by the date indicated above. If the program director chooses not to respond, the reduction in resident complement will be confirmed by the Review Committee. Guidelines on responding to the proposed reduction in resident complement, "Procedures for Proposed Adverse Actions", and a copy of the Site Visitor's Report (SVR) will be included with the letter of notification. Program Strengths (Optional Section): If the program or institution received a 3, 4, or 5 year review cycle, the Review Committee may highlight program strengths or acknowledge areas in which the program or institution has improved substantially since the last review. Resident Complement Updates: If the Review Committee approves resident complement by year, this section provides greater detail and directions for how the program will accomplish the increase. Request for Progress Report If a progress report is requested, this section will include a list of citations which must be addressed, including detail regarding the specific type of 3

25 information requested in response to a particular citation, such as resident case logs. If the Review Committee determines that the information submitted by the program or institution in response to the progress report request does not adequately address the citations included in the progress report, the Review Committee may shorten the program or institution's review cycle. Additional Text: The letter may include additional text such as: Approval of a change in participating institutions. Comment on recent or anticipated changes in the program. A list of areas that will receive attention during the next accreditation review, sometimes referred to as areas for improvement. These are typically areas in which the program or institution is marginally in compliance, and the Review Committee is concerned that the program or institution is in jeopardy of falling below the threshold of compliance in these areas. While not citations, because the program/institution is in compliance, the program or institution may be advised to monitor compliance in this area, and the Review Committee will follow up at the time of the programlinstitution's next accreditation review. Closing Statement: It is the policy of the ACGME and of the Review Committee that each time an action is taken regarding the accreditation status of a program, the residents and applicants (those invited for interviews) must be notified. This office must be notified of any major changes in the organization of the program. When corresponding with this office, please identify the program by number and name as indicated above. Changes in participating institutions and changes in leadership must be reported to the Review Committee using the ACGME Accreditation Data System. Sincerely yours, Executive Director Residency Review Committee for X cc: Designated Institutional Official Core Program Director for letters about dependent subspecialty program Dependent Subspecialty Program Director for letters about core program Participating Sites This section includes a list of all regular and routine participating sites listed in the ACGME Accreditation Data System (ADS). DAQ_SVP

26 Accreditation Council for GraAluet Medical Education 515 North State Street Suisist 2000 Chicago, Illinois Rorie Faut It Web Sample of Notification Letter for Continued Accreditation October 15, 2007 Jane Doe, M.D. Department of Neurosurgery Jasper University Hospital Metropolis, IL Dear Dr. Doe: The Residency Review Committee for Neurological Surgery, functioning in accordance with the policies and procedures of the Accreditation Council for Graduate Medical Education (ACGME), has reviewed the information submitted regarding the following program: Neurological Surgery Jasper University Program Metropolis, IL Program Number: Based on all of the information available to it at the time of its recent meeting, the Review Committee accredited the program as follows: Status: Continued Accreditation Length of Training: 6 Maximum Number of Residents: 9 Residents Per Level: Effective Date: 09/27/2007 Approximate Date of Next Survey: 09/2009 FS Cycle Length: 2.0 Year(s) Progress Report Due: 01/01/2008 Approximate Date for Internal Review: 10/01/2008 AREAS NOT IN SUBSTANTIAL COMPLIANCE (CITATIONS) The Review Committee cited the following areas as not in substantial compliance with the ACGME requirements for Graduate Medical Education: Citation #1 Program Director Qualifications Program Requirement 11.A.3. "Qualifications of the program director must include a requisite specialty experiise and documented educational and administrative experience acceptable to the Review Committee." The credentials reported for Dr. Doe, program director, show no recent academic participation in academic neurosurgery prior to appointment to the University. In addition, Dr. Smith, another key faculty member reports one AC C.- M

27 publication, and no review articles, chapters, or textbooks from the last five years. His specialty certification in neurosurgery expired January (Program Information Form, pages 8 and 9; Site Visit Report, page 4) Citation #2 Participating $ites Program Requirement II.B.1 "At each participating site, there must be a sufficient number of faculty with documented qualifications to instruct and supervise all residents at that location." Dr. Jones is listed as based mainly at University Hospital, and is reporied as the only faculty member assigned to this participating site. The credentials reported for Dr. Jones list no current professional activities or committees, peer-reviewed publications or journal articles, review articles, chapters or textbooks, or participation in local, regional, and national organizations, or funded grants from the last five years. (Program Information Form, pages 7, 10 and ill; Site Visit Report, pages 4 and 5) Citation #3 Faculty Qualifications Program Requirement II.B.2: "The physician faculty must have current certification in the specialty by the American Board of Neurological Surgery, or possess qualifications acceptable to the Review Committee." Dr. Smith and Dr. Jones do not indicate any certification. (Program Information Form, pages 12 and 13) Citation #4 Resident Operative Experiences Program Requirement IV.A "Residents must participate in the management (including critical care) and surgical care of adult and pediatric patients and experience should include the full spectrum of neurosurgical disorders." The program offers an inadequate experience in five operative categories (head trauma, spinal instrumentation, peripheral nerve, pediatric brain tumor, transsphenoidal). (Program Information Forms, pages 59 through 66) REQUEST FOR PROGRESS REPORT The Review Committee requests a progress report in which each of the following citations is addressed. This information is requested in triplicate by the date given above. As specified in the ACGME Institutional Requirements, the report should be reviewed and approved by the sponsoring institution's

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