Accreditation Decisions

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Average Cycle Length by Status (2006-2007) Frequency of Accreditation Statuses (2005-2006) Average Cycle Length by Status (2005-2006) Institutions Currently With Unfavorable Decisions Programs Currently With Unfavorable Decisions Frequency of Accreditation Statuses (2004-2005) Average Cycle Length by Status (2004-2005)

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. a) This initial cycle is considered a developmental stage during 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. b) Initial accreditation may be granted to a new program or sponsoring institution or a previously-accredited program or sponsoring institution, which had had its accreditation withheld or withdrawn and has subsequently applied for re-accreditation. c) 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. If a program or sponsoring institution has not demonstrated substantial compliance on the next review, the Review Committee may take action to extend accreditation with warning for one year. At the end of this additional one year, the program or sponsoring institution must demonstrate substantial compliance with the requirements, or the accreditation of the program or sponsoring institution shall be withdrawn. 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: a) programs or sponsoring institutions holding initial accreditation that have demonstrated substantial compliance with the requirements; b) programs or sponsoring institutions holding continued accreditation that have demonstrated substantial compliance with the requirements; or c) 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. This status shall first be proposed, providing the program or sponsoring institution with an opportunity to rebut the citations and document compliance with the requirements. 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, an additional one year of probationary accreditation may be granted. 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. (NB: for either P1 or P2)
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 without prejudice when a decision has been made to close the program or sponsoring institution. A Program Director may request voluntary withdrawal of a program accreditation without prejudice (i.e., due to program inactivity, merger, loss of resources, or because the specialty is no longer being accredited). A DIO may request voluntary withdrawal of institutional accreditation without prejudice, due to inactivity or loss of resources. A program that has not had residents enrolled within four years should request voluntary withdrawal. If voluntary withdrawal without prejudice is not requested, the Review Committee shall take formal action and withdraw accreditation. If two or more programs or institutions are merged into a single program and a Review Committee accredits the merged program, the Review Committee shall take concurrent action for voluntary withdrawal without prejudice 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 if the program or the sponsoring institution does not comply with the following actions and procedures: (a) undergo a site-visit and program/sponsoring institution review; (b) follow directives associated with an accreditation action; (c) supply a Review Committee with requested information (e.g., Progress Report, operative data, resident survey); (d) maintain current data through Web ADS.
Expedited Withdraw	Regardless of a program’s 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: a) a catastrophic loss of resources, including faculty, facilities, or funding; or (b) egregious noncompliance with accreditation 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	Dependent Subspecialty Only A Review Committee may grant accreditation with warning when the dependent subspecialty program has been found to have one or more areas on non-compliance with the requirements that are of sufficient substance to require prompt correction. In such cases, a resurvey shall be conducted within either one or two years.
Accreditation with Warning, Administrative	Dependent Subspecialty Only A Review Committee may grant administrative accreditation with warning, 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.