ACCREDITATION COUNCIL FOR GRADUATE …

1 ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION policies AND procedures Effective: February 3, 2018 acgme Approved: 2/3/2018 acgme Approved: 9/23/17 acgme Approved: 6/10/2017 acgme Approved: 2/4/2017 acgme Approved: 9/24/2016 acgme Approved: 2/6/2016 acgme Approved: 6/13/2015 acgme Approved: 2/7/2015 acgme Approved: 1/1/2015 acgme Approved: 9/27/2014 acgme Approved: 6/14/2014 acgme Approved: 1/31/2014 acgme Approved: 6/8/2013 acgme Approved: 9/29/2012 acgme Approved: 6/11/2012 (NAS Effective 7/1/2013) acgme Approved: 2/7/2011 acgme Approved: 9/27/2010 acgme Approved: 2/8/2010 acgme Approved: 9/14/2009 acgme Approved: 6/15/2009 acgme Approved: 2/9/2009 acgme Approved: 9/15/2008 acgme Approved: 6/9/2008 acgme Approved: 2/12/2008 acgme Approved: 6/12/2007 acgme Approved: 9/12/2006 acgme Approved: 6/27/2006 acgme Approved: 2/14/2006 acgme Approved: 6/28/2005 acgme Approved: 9/2002 acgme Approved: 9/2001 acgme Approved: 9/2000 acgme Approved: 6/1992 ACCREDITATION COUNCIL for GRADUATE Medical Education Table of Contents Page i Effective 2/3/2018 Table of Contents acgme STRUCTURE AND FUNCTION Table of Contents.

2 I Mission and Scope, Vision and Values .. 1 Purpose of ACCREDITATION by the ACCREDITATION COUNCIL for GRADUATE Medical Education ( acgme ).. 3 Employee and Volunteer Whistleblower Policy .. 4 Executive Committee of the acgme .. 6 policies and procedures Advisory Committee to the Executive Committee .. 6 Committees of the acgme .. 7 Description .. 7 Committee on Finance .. 8 Purpose .. 8 Composition .. 8 Operational Guidelines and procedures .. 8 Audit Committee .. 9 Description .. 9 Responsibilities .. 9 Compensation Committee .. 10 Committee on Requirements .. 11 Purpose .. 11 Composition .. 11 Operational Guidelines .. 11 procedures for Revision of Requirements .. 11 Resolution of Inter-Specialty and Multi-Specialty Conflicts .. 12 Monitoring Committee .. 13 Purpose .. 13 Composition.

3 13 Operational Guidelines and procedures .. 13 Governance Committee .. 16 Composition .. 16 Responsibilities .. 16 Awards Committee .. 17 Purpose .. 17 Composition .. 17 Journal Oversight Committee .. 18 Purpose .. 18 Education Committee .. 20 Purpose .. 20 Composition .. 20 Policy Councils of the acgme .. 22 Descriptions .. 22 acgme COUNCIL of Review Committee Chairs .. 23 Purpose .. 23 Composition .. 23 ACCREDITATION COUNCIL for GRADUATE Medical Education Table of Contents Page ii Effective 2/3/2018 acgme STRUCTURE AND FUNCTION (continued) COUNCIL of Review Committee Residents .. 24 Purpose .. 24 Appointment .. 24 COUNCIL of Public Members .. 25 Purpose.

4 25 Appointment .. 25 acgme Conduct .. 26 Fiduciary Duty .. 26 Conflict and Duality of Interest Policy (Directors and Review Committee Members) .. 27 Definitions .. 28 Procedure Conflict of Interest Contract or Transaction .. 29 Procedure Addressing Number of Persons Voting .. 31 Duality of Interest .. 32 Procedure Specialties under Consideration .. 33 procedures Consultants / Site Visitor .. 34 Failure to Disclose Conflict and Duality of Interest .. 34 Annual Disclosure - Directors / Committee Members .. 35 Confidentiality .. 36 Published Information Released through acgme .. 36 Confidentiality Administration .. 37 policies Governing Review Committee Member Conduct .. 38 Board and Review Committee Attendance .. 39 Directors Attendance at Board Standing Committee Meetings.

5 40 .. 41 Fee Structure .. 41 Expenses .. 42 Review Committees and Recognition Committees .. 43 Review Committees acgme Delegation of Authority to Review and Recognition Committees .. 48 Procedure to Evaluate Requests for ACCREDITATION Authority from an acgme Residency Review Committee .. 49 procedures to Evaluate Requests to Recognize Other Educational Periodic Review of a Review Committee s Activities .. 50 ACCREDITATION 51 Conduct of Review Committee Meetings .. 52 Recognition Committee Recognition Committees Responsibilities .. 53 procedures for Osteopathic Recognition .. 54 procedures for the Development and Approval of 55 New or Revised 55 Revision of Requirements .. 56 Editorial Revisions of Existing Requirements .. 58 Revisions to the Common Program Requirements.

6 59 Waivers to the Common Program Requirements for Multicenter Educational Research Trials .. 60 Impact Statement .. 61 ACCREDITATION COUNCIL for GRADUATE Medical Education Table of Contents Page iii Effective 2/3/2018 acgme STRUCTURE AND FUNCTION (continued) procedures for Developing Program Requirements for Specialties Using a Common Set of Program Requirements in a Multidisciplinary Subspecialty .. 62 procedures for Designation of Core Specialties, Subspecialties, and Sub- Subspecialties for Which ACCREDITATION Will Be Offered .. 63 Criteria for Designation of a Core Specialty for Which ACCREDITATION Will Be ..63 Criteria for Designation of a Subspecialty or Sub-Subspecialty for which ACCREDITATION Will Be Offered ..65 procedures for Designation of a Medical or Medical-Related Field that is not a Core Specialty, Subspecialty, or Sub-Subspecialty for Which ACCREDITATION Will Be Offered.

7 66 Criteria for Designation of a Medical or Medical-Related Field that is not a Core Specialty, Subspecialty, or Sub-Subspecialty for Which ACCREDITATION Will Be Offered .. 66 Monitoring the Recognition of Specialties and Subspecialties .. 68 procedures for Review Committees to Accredit the Same Subspecialty .. 69 Models for ACCREDITATION of the Same Subspecialty .. 69 Recognition for a New Subspecialty .. 71 ACCREDITATION COUNCIL for GRADUATE Medical Education Table of Contents Page iv Effective 2/3/2018 ACCREDITATION policies AND procedures Sponsoring Institutions and Types of GRADUATE Medical Education Programs .. 72 Clinical Learning Environment Review (CLER) .. 74 Overview .. 74 Program Focus Areas .. 75 CLER Site Visit Team Composition and Activities .. 76 CLER Reports .. 77 CLER Evaluation Committee.

8 78 Purpose .. 78 Composition .. 78 Appointment .. 78 .. 78 Failure to Undergo a CLER Site Visit .. 79 The ACCREDITATION Process .. 80 Continuous ACCREDITATION .. 81 The Site Visit .. 83 Types of Site Visits .. 83 Focused Site Visit .. 83 Full Site Visit .. 83 Site Visit for Alleged Egregious Violations .. 84 Application Process .. 86 Review of Applications .. 87 Continued ACCREDITATION .. 88 The 10-Year ACCREDITATION Review .. 91 Notification to Programs and Sponsoring Institutions of Review Committee Actions .. 92 ACCREDITATION and Recognition Actions; Pre- ACCREDITATION .. 93 ACCREDITATION Actions ACCREDITATION Withheld .. 94 Initial ACCREDITATION and Initial ACCREDITATION with Warning .. 95 Continued ACCREDITATION without Outcomes, Continued ACCREDITATION , Continued ACCREDITATION with Warning.

9 96 Probationary ACCREDITATION .. 98 Withdrawal of ACCREDITATION .. 99 Administrative Probation .. 101 Administrative Withdrawal .. 102 Voluntary Withdrawal of ACCREDITATION .. 103 Reduction in Resident Complement .. 105 Other Actions .. 106 Request for Clarifying Information / Progress Reports .. 106 Participating Sites .. 107 Integrated Site .. 107 Change in Sponsorship .. 107 Resident Complement .. 108 Administrative Actions .. 101 ACCREDITATION Actions for Dependent Subspecialty and Sub-specialty Programs .. 109 ACCREDITATION COUNCIL for GRADUATE Medical Education Table of Contents Page v Effective 2/3/2018 ACCREDITATION policies AND procedures (continued) Pre- ACCREDITATION Pre- ACCREDITATION .. 110 Reapplication .. 111 Initial ACCREDITATION after Pre- ACCREDITATION .

10 111 Recognition Actions .. 112 Recognition Actions .. 112 Recognition Withheld .. 113 Initial Recognition and Initial Recognition with Warning .. 114 Continued without Outcomes, Continued Recognition and Continued Recognition with Warning .. 115 Withdrawal of Recognition .. 116 Voluntary Withdrawal of Appeals of Adverse Actions and Adverse Recognition Actions .. 119 Appeals of Adverse Actions Adverse Actions for Programs and Sponsoring Institutions .. 119 procedures for an Adverse Action .. 120 procedures for Appeal of Adverse Actions .. 121 Appeals of Adverse Recognition Actions Adverse Recognition Actions .. 124 procedures for an Adverse Recognition Action .. 125 procedures for Appeal of Adverse Recognition Actions .. 126 Procedure for Alleged Egregious Events .. 139 acgme Policy and procedures to Address Extraordinary Circumstances.