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FAQs About Raising Issues With the ACGME

General

What are the biggest differences between reporting an issue to the Office of the Ombudsperson and filing a formal complaint?

The Office of the Ombudsperson offers an opportunity to anonymously report issues about residency programs and institutions without impacting their accreditation or Recognition status. Allegations presented to this office may or may not rise to the level of chronic and/or routine non-compliance with ACGME program or institutional requirements, but they should be within the scope of the ACGME’s oversight.

The Office of the Ombudsperson functions as an independent, impartial party, and will work with the institution to request an internal inquiry to further explore the issues raised. The institution will be asked to collaboratively create an action plan to address educational concerns that may be validated through this exploration. The institution will then submit a report detailing the review and the proposed solutions or action plans that may result.

Formal complaints may affect the accreditation or or Recognition status(es) of a Sponsoring Institution or program and, therefore, must include the complainant’s name and contact information. The designated institutional official (DIO) of the Sponsoring Institution and the program director have an opportunity to respond to the allegations in a formal complaint. The Review Committee for the specialty in question considers the allegations in the complaint, as as well as the Sponsoring Institution’s and program’s response, and decides whether further investigation is warranted. If the Review Committee believes further investigation is warranted, it may request additional information or schedule a site visit. The Review Committee could also decide that the complaint allegations have been adequately addressed and that the complaint should be closed with no further investigation.

Confidentiality

May I submit an issue or complaint anonymously and confidentially?

The Office of the Ombudsperson accepts anonymously-submitted reports, and will also strive to maintain the confidentiality of any individual who submits one to the extent possible in light of the need to take appropriate action. There may be times, however, when the Office of the Ombudsperson may request permission to identify the individual(s) in order to advocate for fair process and to identify options and strategies for resolution.

Providing valid contact information when submitting a concern is essential as it enables the opportunity for a dialogue with a staff member in order to get more information as needed.

The Office of Complaints does not accept anonymous complaints. Formal complaints must include the name of the complainant and his or her contact information.

The ACGME will not reveal a complainant’s name to the Sponsoring Institution or program, unless the complaint is about the lack of due process and/or the complainant gives the ACGME permission to share his or her name.

Will my original submission be shared with my DIO, program director, and the ACGME Review Committee?

Original letters or e-mails submitted to the Office of the Ombudsperson will not be shared with anyone unless the concerned party gives permission to do so.

Original complaint materials will not be shared as part of the complaint process unless the complainant gives permission to do so. If a complainant wishes for the Review Committee to see the original letter, the complainant must also give the ACGME permission to share the letter with the DIO and/or program director. There may be rare occurrences when the identity of the complainant may be disclosed as necessary for the ACGME to provide due process to a program or institution appealing an adverse accreditation action.

Will I be given a copy of the program’s or DIO’s response to my submission?

No. All communications between the ACGME and Sponsoring Institutions and programs are confidential. The ACGME can inform the author of the submission of the outcome of an Office of the Ombudsperson-initiated inquiry/investigation or whether a complaint has been reviewed, but cannot provide more detailed information with regards to what was submitted in response to a submitted concern or complaint made to either office. Anyone may monitor the accreditation status of Sponsoring Institutions and programs on the ACGME website. 

Scope

Does the ACGME address individual residency/fellowship credit and contract issues?

No. It is outside of the ACGME’s scope to address individual residency/fellowship credit and contract issues.

Through either the Office of the Ombudsperson or the Office of Complaints, does the ACGME address allegations of discrimination?

If the allegations of discrimination impact the aspects of the program that are within the ACGME’s educational accreditation scope, they may be considered. There may be allegations, however, that fall outside of the ACGME’s oversight. Discrimination may be a legal employment issue best handled by a lawyer or a legal organization. If you believe that you have been a victim of discrimination, it is recommended that you contact your institution’s Human Resources Department, Legal Counsel, or Compliance Officer, or the Equal Employment Opportunity Commission (www.eeoc.gov).

Does the ACGME act as a mediator or adjudicator in disputes between individuals and residency/fellowship programs/Sponsoring Institutions?

The Office of the Ombudsperson does not mediate or adjudicate. Instead, this office functions as an independent, impartial party and does not conduct formal investigations, or make judgments in disputes between individuals and residency/fellowship programs and/or Sponsoring Institutions.

The Office of Complaints does not act as a mediator or adjudicator for formal complaints. The ACGME only addresses matters regarding non-compliance with the published Institutional, Program, and/or Recognition Requirements and does not adjudicate individual disputes between persons in residency or fellowship programs or those programs’ Sponsoring Institutions.

Does the ACGME participate in any formal grievance process or offer opinions about administrative decisions?

No. The ACGME does not participate in any formal grievance process or offer opinions about administrative decisions

Can the ACGME assist residents and fellows in finding another residency or fellowship position?

No. The ACGME does not find positions for residents and fellows.

Can the ACGME provide legal advice?

No. The ACGME is an accreditor, not a legal organization.

Accreditation Impact

Will my submission affect the program’s and/or institution’s accreditation or Recognition status(es)?

Submitting a report to the Office of the Ombudsperson will not affect a program’s and/or institution’s accreditation or Recognition status(es).

Submitting a formal complaint may affect a program’s and/or institution’s accreditation or Recognition status(es). The DIO and program director will be asked to provide a signed response to a formal complaint, and the relevant Review Committee will consider the formal complaint and render a decision, which may affect the Sponsoring Institution’s and program’s accreditation or Recognition status(es).

When to Contact the ACGME

Must I inform my program director and/or the DIO of my concern(s) or formal complaint(s) before contacting the ACGME?

Please utilize all the resources available in the Sponsoring Institution and/or program before submitting a report or complaint to the ACGME, unless there is a valid reason for not utilizing these resources first (for example, if a report or formal complaint involves the program director and/or DIO, and the reporting party feels the existing channels of communication or dispute resolution have proven unsatisfactory).

Is there a time limit for submitting issues or allegations about a program or institution?

Yes. Issues or allegations of non-compliance that occurred prior to the current and preceding academic year should not be submitted.

Internal Resources

What resources are available within my institution or program to help me address the issues in my program?

GME Office: The institution’s graduate medical education (GME) office is responsible for overseeing grievances. The DIO is the person in the GME office who has oversight over all of the accredited programs at the institution. Many DIOs have different titles within the institution (e.g., Associate Dean of Graduate Medical Education). Contact the GME office to find the DIO. This information is also available here.

Ombudsperson: Many (but not all) institutions have a local ombudsperson who can help with conflict resolution. The role of an ombudsperson is to act as a neutral, impartial party and he or she can frequently help to locate resources for residents, mediate conflicts, and advocate for fair process. Your GME office can inform you if your institution has an ombudsperson.

Human Resources: The Human Resources office at your institution may be able to assist with questions about contracts, legal matters, salary disputes, and other employment-related issues.

Employee Assistance Program (EAP): If you are struggling professionally or personally, you may want to explore if your institution offers an Employee Assistance Program (EAP). If your employer offers an EAP, you can confidentially access the services offered. These could include access to counselling and legal advice.

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