Accreditation Decisions
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Accreditation Status Definitions
Initial Accreditation Accreditation is conferred initially when a Review Committee determines that a proposal for a new program or sponsoring institution substantially complies with the requirements.
  1. This initial cycle is considered a developmental stage which the proposal for the new program or sponsoring institution will be fully developed and implemented. A program or sponsoring institution should be reviewed within three years of the initial action.
  2. Initial accreditation may be granted to a new program or sponsoring institution or a previously-accredited program or sponsoring institution, which had its accreditation withheld or withdrawn and has subsequently applied for re-accreditation.
  3. Initial accreditation may also be used when separately-accredited programs or sponsoring institutions merge into one, or when an accredited program or sponsoring institution has been so altered that in the judgment of the Review Committee it is the equivalent of a new program or sponsoring institution.
N.B.: The Review Committee may warn the Program Director or sponsoring institutional DIO of areas of noncompliance that may jeopardize the program’s or sponsoring institution’s future accreditation status. A warning is not an adverse action and is not appealable.
Continued Accreditation Accreditation is continued when a Review Committee determines that a program or sponsoring institution has demonstrated substantial compliance with the requirements. Typically, the maximum length of the cycle awarded by the Review Committee is five years. A Review Committee may grant continued accreditation in three circumstances:
  1. Programs or sponsoring institutions holding initial accreditation that have demonstrated substantial compliance with the requirements;
  2. Programs or sponsoring institutions holding continued accreditation that have demonstrated substantial compliance with the requirements; or
  3. Programs or sponsoring institutions holding probationary accreditation that have demonstrated, following a site-visit and review, substantial compliance with the requirements.
Probation Probationary accreditation is conferred when the Review Committee determines that a program or sponsoring institution, following a site-visit and review, has failed to demonstrate substantial compliance with the requirements. The length of the review cycle for this status may not exceed two years.

Following the next site-visit and review, if the program or sponsoring institution does not demonstrate substantial compliance with the requirements, or if new areas of noncompliance are identified, the Review Committee may confer an additional one year of probationary accreditation (continued probationary accreditation). At the end of this additional one-year period, the program or sponsoring institution must demonstrate substantial compliance with the requirements, or the accreditation of the program or sponsoring institution will be withdrawn. Alternatively, a program or sponsoring institution documenting substantial compliance with the requirements will be restored to continued accreditation status.
Probation Under Appeal When a program requests a hearing before an appeals panel, the program holds the accreditation status determined by the Review Committee with the term “under appeal” affixed to the status. This accreditation status shall remain in effect until the ACGME makes a final determination on the accreditation status of the program.
Expedited Withdrawal under Appeal When a program requests a hearing before an appeals panel, the program holds the accreditation status determined by the Review Committee with the term “under appeal” affixed to the status. This accreditation status shall remain in effect until the ACGME makes a final determination on the accreditation status of the program.
Voluntary Withdrawal A program or sponsoring institution may request voluntary withdrawal of accreditation when a decision has been made to no longer participate in ACGME accreditation.
  • A program director may request voluntary withdrawal of a program’s accreditation (i.e., due to merger, loss of resources, having no residents or fellows enrolled in the program for several years, the specialty or the subspecialty no longer being accredited).
  • A designated institutional official may request voluntary withdrawal of institutional accreditation (i.e., due to merger, loss of resources, having no residents or fellows enrolled in programs for several years or the specialties of subspecialties are no longer being accredited).
  • If two or more programs are merged into a single program and a Review Committee accredits the merged program, the Review Committee shall take concurrent action for voluntary withdrawal for the previously-accredited programs.
Accreditation Withdrawn A Review Committee may withdraw accreditation of a program or sponsoring institution under probationary accreditation when a Review Committee determines, following a site-visit and review, that a program or sponsoring institution has failed to demonstrate substantial compliance with the requirements.
Administrative Withdrawal A program or sponsoring institution that is delinquent in payment of fees, according to ACGME policies and procedures, is not eligible for review, and shall be notified by Federal Express, signature required, of the effective date of administrative withdrawal of accreditation.

A program or sponsoring institution may be deemed to have withdrawn from the voluntary process of accreditation, and a Review Committee may take action to administratively withdraw accreditation, if the program or the sponsoring institution does not comply with the following actions and procedures:
  1. Undergo a site-visit and program/sponsoring institution review;
  2. Follow directives associated with an accreditation action;
  3. Supply a Review Committee with requested information (e.g., Progress Report, operative data, resident survey); and,
  4. Maintain current data through Web ADS
Expedited Withdrawal Regardless of a programs accreditation status, the Review Committee, following a site-visit and review, may withdraw the accreditation of a program in an expedited process based on clear evidence of noncompliance with accreditation standards as follows:
  1. A catastrophic loss of resources, including faculty, facilities, or funding, or
  2. Egregious noncompliance with accreditation requirements.
Initial Accreditation Dependent Subspecialty Only
A Review Committee may grant accreditation when the dependent subspecialty program has demonstrated substantial compliance with the requirements.
Continued Accreditation Dependent Subspecialty Only
Accreditation is continued when a Review Committee determines that a program has demonstrated substantial compliance with the requirements. Typically, the maximum length of the cycle awarded by the Review Committee is five years. Cycle length is based upon the accreditation status, issues identified by the Review Committee, and areas of non-compliance.
Accreditation with Warning, Administrative Dependent Subspecialty Only
A Review Committee must grant accreditation with warning, administrative, when a specialty program to which a subspecialty program is attached has been granted probationary accreditation. This constitutes an administrative warning of potential loss of accreditation to a subspecialty program.
Accreditation Withdrawn, Administrative Dependent Subspecialty Only
If a specialty program has its accreditation withdrawn, the accreditation of any subspecialty program that is attached to the general specialty program is administratively withdrawn simultaneously.