The programs and their sponsoring institutions that are accredited by the ACGME are expected to comply with the ACGME’s institutional and program requirements. Anyone having evidence of non-compliance with these standards by a program or institution may submit a formal complaint to the ACGME. Such complaints must be submitted in writing and bear the signature and mailing address of the complainant(s). Anonymous complaints or complaints submitted solely by e-mail will not be considered. Allegations of noncompliance which occurred prior to the current and preceding residency year are discouraged.
The ACGME requires that sponsoring institutions and programs provide an educational and work environment in which residents may raise and resolve issues without fear of intimidation or retaliation. The ACGME and its review committees address only matters regarding compliance with these published requirements. The ACGME will investigate potential noncompliance with accreditation standards that relate to program quality and does not adjudicate disputes between individual persons and residency programs or sponsoring institutions regarding matters of admission, appointment, credit, promotion, or dismissal of faculty, residents or fellows.
- Submitting a Formal Complaint
If the complainant is a resident, a member of the teaching staff, or other person affiliated with the program or institution in question, the following steps should be taken before submitting a complaint to the ACGME
- Contact the Program Director to discuss the problem.
- If the issue either involves the program director, cannot be discussed with the program director, or is not resolved by meeting with the program director, contact the institutional GME committee or similar oversight body. Oversight bodies may include the designated institutional official of the sponsoring institution, the GME office identified on the ACGME website (under Accredited Programs and Sponsors, ADS), or the resident representative(s) on any of these oversight groups.
- If the efforts above do not resolve the issue, or the complainant cannot discuss the complaint with the institutional officials, contact the ACGME Office of Resident Services (firstname.lastname@example.org) to discuss submitting a formal complaint. This initial contact can occur by telephone or email, but must be followed by submission of a formal written and signed complaint.
- If the complainant is someone outside the institution, or if a resident is fearful of retribution or retaliation within the institution, the ACGME Office of Resident Services may be contacted as the first step in the process. This initial contact can occur by telephone or email, but must be followed by submission of a formal written and signed complaint.
- Content of the Formal Complaint
When submitting a complaint that alleges non-compliance with the requirements, the complainant should identify the requirement(s) in question and provide both an explanation and evidence of non-compliance. The complainant should also specify steps that have been taken to resolve the issues within the program or institution prior to the submission of the complaint to the ACGME.
- Procedures for Processing a Formal Complaint
Upon receipt of a formal complaint, the ACGME Office of Resident Services will determine if additional information from the complainant is required. When sufficient information has been provided, the ACGME Office of Resident Services will request from the program director and the designated institutional official of the subject institution a written response to the allegation(s). This communication shall specify that a written response should be submitted within a time not to exceed one month of the date of the request. The name of the complainant will remain confidential except in the situations mentioned in 5. Confidentiality below. The response must be co-signed by both the program director and designated institutional official of the sponsoring institution.
Before submitting the complaint to the review committee for formal consideration, the ACGME Office of Resident Services will review the complaint and the response with the executive director of the relevant review committee who, in consultation with the review committee chair will determine whether the allegations were successfully rebutted or whether the complaint requires a formal consideration by the Review Committee. If the complaint is successfully rebutted, a progress report may be requested. If the review committee chair determines that the allegations were successfully rebutted, the program director, designated institutional official and complainant will be informed in writing by the ACGME Office of Resident Services.
- Review Committee Action;
Review Committees shall review the formal complaint and the program’s/institution’s response and shall determine one of the following:
- the response satisfactorily addressed the allegations and no further action is required;
- there is validity to the complaint and a subsequent progress report on correction is needed;
- there is validity to the complaint and the site visitor shall be directed to investigate the matter at the time of the next (regularly scheduled) site visit; and,
- the matter is sufficiently serious to warrant an immediate site visit and review. The full range of accreditation actions will be available to the review committee after a site visit precipitated by a complaint.
Following consideration by a review committee, the program director, and the designated institutional official shall be informed in writing of the Review Committee’s decision in its official notification letter. The ACGME Office of Resident Services shall inform the complainant in writing as to whether the complaint resulted in a change in accreditation status of the program or sponsoring institution.
If the complaint involves failure of a program or institution to provide due process, the name of the complainant must be used when a response to the allegation is requested from the program director or institutional official. In all other cases, the ACGME shall keep the name of the complainant confidential throughout its processing of the complaint, except when a complainant specifically waives the right to confidentiality.
- Complaint File
During the period when the complaint is being processed, the ACGME Office of Resident Services will maintain the relevant correspondence in a case file that is separate from the official program file. When the case has been closed, the file shall not be retained.
Complaints should be addressed to:
515 North State Street, Suite 2000
Chicago, Illinois 60654