ACGME Accreditation Council for Graduate Medical Education

ACGME Procedures for Proposed Adverse Actions
(Approved by the ACGME June 28, 2005)

The following accreditation actions are considered adverse actions for specialty specific programs, Transitional-Year programs, and independent subspecialty programs: 

  • accreditation withheld
  • probationary accreditation 
  • withdrawal of accreditation
  • a reduction in resident complement by the Review Committee

Procedures for Adverse Actions 

  1. When the Review Committee determines that an adverse action is warranted, it shall first give notice of its proposed adverse action to the Program Director and the DIO of the sponsoring institution. This notice of proposed adverse action shall 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 its response in writing.
  2. The program may provide to the Review Committee written information revising, correcting or expanding factual information previously submitted; challenging the findings of the site-visitor; rebutting the interpretation and conclusions of the Review Committee; demonstrating that cited areas of noncompliance with the requirements did not exist when the Review Committee initially reviewed the program and proposed an adverse decision (i.e., the date of the Review Committee meeting); and contending that the program is in substantial compliance with the requirements that were in effect at the time of the site-visit. 
  3. The Review Committee shall determine whether the information that is submitted may be considered without verification by a site-visitor. The Review Committee shall complete its evaluation of the program at a scheduled meeting.
  4. The Review Committee may confirm the adverse action, or modify its position. If the Review Committee confirms the adverse action, it shall communicate the confirmed adverse action and the citations, as described above, including comments on the program’s response to these citations. The date of the next survey shall be specified.
  5. This Letter of Notification shall be sent to the Program Director and copied to the DIO. The Program Director may appeal a confirmed adverse action; otherwise, the adverse action is final.
  6. Upon receipt of notification of a confirmed adverse action, the Program Director must inform, in writing, the residents and any candidates (applicants who have been invited to interview with the program) that the adverse action has been confirmed in compliance with procedures in these Policies and Procedures. The Program Director must inform residents and candidates, regardless of whether or not the action is appealed. A copy of this written notice must be sent to the Executive Director of the Review Committee within 50 days of receipt of the Review Committee’s Letter of Notification.