Non-Compliance Reports (NCR)

Non-compliance reports are a mechanism by which individuals can report to the ACGME that a graduate medical education (GME) program or Sponsoring Institution may not be complying with ACGME accreditation and/or recognition requirement.

Before submitting a non-compliance report (“report”), individuals are encouraged to review the following information about the ACGME, its scope, and the potential implications and use of a report, particularly relating to accreditation and/or recognition.

The ACGME accredits and recognizes US residency and fellowship programs and their Sponsoring Institutions based on determination of substantial compliance with accreditation standards (the Institutional and Program Requirements) and recognition standards (Recognition Requirements). 

Review and Recognition Committees, comprised of volunteer physicians, including at least one resident/fellow representative, as well as a non-physician public member, monitor ACGME-accredited residency and fellowship programs and Sponsoring Institutions for substantial compliance with all applicable accreditation and recognition requirements.

The Review and Recognition Committees collect and review information on accredited programs or institutions within their purview to make decisions on each program’s or Sponsoring Institution’s accreditation and recognition status.

Reports of alleged non-compliance with ACGME program, institutional, or recognition requirements can provide additional information that may inform the ACGME’s accreditation or recognition function. Anyone who has evidence of a Sponsoring Institution’s or program’s non-compliance with accreditation or recognition requirements may submit a report.

When a report is submitted, the ACGME reviews it along with other available information to determine if it is relevant to include in the information considered when making an accreditation or recognition decision about the program or Sponsoring Institution.  

If the report is judged to be relevant to accreditation or recognition, the ACGME invites the program director and/or the designated institutional official (DIO) to respond to the allegations of non-compliance. The relevant ACGME Review or Recognition Committee then reviews the report, the response, and other available information to determine if the alleged non-compliance has been adequately addressed. If not, next steps are determined, which may include a site visit.

If a site visit is conducted, Accreditation Field Representatives write a report summarizing the data collected during the visit. The Review or Recognition Committee will consider the Site Visit Report in its assessment of whether the program or Sponsoring Institution is in substantial compliance with the applicable ACGME requirements and the resulting accreditation or recognition decision.

This module will help a potential reporter determine when it is appropriate to submit a report to the ACGME by providing information about the ACGME, its scope, and the potential use of such a report as it relates to accreditation or recognition.

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Review: Frequently Asked Questions (FAQs) about Non-Compliance Reports

Allegations of significant and widespread non-compliance with specific accreditation or recognition standards (“requirements”), usually manifest by multiple lapses or occurrences, are appropriate to report to the ACGME.

The ACGME does not adjudicate disputes between individuals and programs and/or Sponsoring Institutions or intervene in matters such as dismissal/reinstatement, employment or academic disputes, academic appeals, remediation or probation decisions, content of evaluations, content of verification of training documentation, resident/fellow selection, The Match®, personnel decisions (e.g., removing individuals from roles), funding, or salaries/benefits.

Reports should address alleged non-compliance occurring in the current or immediately preceding academic year (July 1 to June 30). Reports of non-compliance that occur before that time are not accepted.

Before submitting a non-compliance report to the ACGME, reporters are encouraged to use all available mechanisms within the program and/or Sponsoring Institution to report and address concerns. Consider these potential resources to help address concerns within a program, Sponsoring Institution, or another appropriate external avenue.

In preparation for submitting a report, the reporter should review the ACGME’s Institutional Requirements  and the Program Requirements for the applicable specialty or subspecialty,  or the Recognition Requirements, as applicable, on the ACGME website to ensure the allegations to be reported are within the scope of the ACGME’s oversight.

A reporter should determine whether they wish to give the ACGME permission to share their identity with the Sponsoring Institution, program, and relevant ACGME Review and Recognition Committee(s), or if they wish to keep their identity confidential. The ACGME will not share a reporter’s identity without the reporter’s consent.

Non-compliance reports must be submitted electronically, using this form.

The ACGME cannot accept non-compliance reports via phone, email, mail, or fax.

Reports must include the accurate name and contact information of the reporter(s). The ACGME does not accept anonymous non-compliance reports. As noted above, the ACGME will take steps to maintain confidentiality, and will not share a reporter’s identity without the reporter’s consent.

The report submission process involves several steps, beginning with identification of the relevant program or Sponsoring Institution, using the search function provided.

In the non-compliance report form, the reporter will be asked to:

• provide a narrative describing the alleged non-compliance with accreditation requirements, including concise examples; and,
• describe attempts to use internal program and/or institutional reporting mechanisms to resolve the alleged non-compliance.

The ACGME recommends that reporters draft these portions outside of the electronic form with close attention to the noted word limits.

Reporters receive confirmation of receipt with outlined next steps upon submission. The ACGME will communicate when the report is filed (i.e., when an allegation letter has been sent to the program director and/or designated institutional official (DIO) and/or when the process has reached a final conclusion, and the report is closed.

Program and Sponsoring Institution accreditation and recognition statuses, and site visit dates can be viewed in ACGME Cloud | Analytics by clicking the "Institution and Program Finder" button on the Explore Public Data page. Consistent with ACGME confidentiality policies, the ACGME cannot share actions taken by the organization or specific information regarding accreditation and recognition decisions, citations, or correspondence between the ACGME and the program/Sponsoring Institution.

Due to the intensive review process and the accreditation and recognition cycle, closure of a report may not occur for many months after its submission.