The programs and their Sponsoring Institutions that are accredited by the AC GME are expected to comply with the AC GME’s Institutional and Program Requirements. Anyone having evidence of non-compliance with these standards by a program or institution may submit a formal complaint to AC GME. Such complaints must be submitted in writing and bear the signature and mailing address of the complainant(s). Anonymous complaints or complaints submitted solely by e-mail will not be considered. Complaints addressing subject matter, the entirety of which occurred prior to the residency year preceding the current residency year, are discouraged.

1. Submitting a Formal Complaint
   
   

   If the complainant is a resident, a member of the teaching staff, or other person affiliated with the program or institution in question, the following steps should be taken before submitting a complaint to the ACGME:

   1. Contact the Program Director to discuss the problem.
   2. If the issue either involves the Program Director or is not resolved by meeting with the Program Director, contact the institutional GME committee or similar oversight body, the DIO of the sponsoring institution, the GME office identified on the AC GME website (under Accredited Programs and Sponsors, ADS), or the resident representative on any of these oversight groups.
   3. If the efforts above do not resolve the issue, contact the AC GME Complaint Officer to discuss submitting a formal complaint. If the complainant is someone outside the institution, the AC GME Complaint Officer may be contacted as the first step in the process.
   
   
   
2. Content of the Formal Complaint
   
   When submitting a complaint that alleges non-compliance with the requirements, the complainant should identify the requirement(s) in question and provide both an explanation and evidence of non-compliance. The complaint should also specify steps that have been taken to resolve the issues within the programs or institution prior to the submission of the complaint to the ACGME.
   
3. Procedures for Processing a Formal Complaint
   
   

   Upon receipt of a formal complaint, the Complaint Officer shall determine if additional information from the complainant is required. When sufficient information has been provided, the Complaint Officer shall request from the Program Director or the DIO of the subject institution a written response to the allegation(s). This communication shall specify that a written response should be submitted within a time not to exceed one month of the date of the request. The name of the complainant shall remain confidential except in the situations mentioned in (5) Confidentiality below. The response must be co-signed by the DIO of the sponsoring institution.

   The Complaint Officer shall review the complaint and the response with the Executive Director of the Review Committee to determine whether the allegations were successfully rebutted or whether the complaint requires a formal consideration by the Review Committee.

4. Review Committee Action
   
   A Review Committee may determine that:
   
   
   1. the response satisfactorily addressed the allegations and no further action is required;
   2. there is validity to the complaint and a subsequent report on correction is needed;
   3. there is validity to the complaint and the site-visitor shall be directed to investigate the matter at the time of the next (regularly scheduled) site-visit;
   4. the matter is sufficiently serious to warrant an immediate site-visit and review.
   
   
   Following consideration by a Review Committee, the Program Director, and the DIO shall be informed in writing of the Review Committee’s decision on the complaint, and the complainant shall be informed in writing as to whether the compliant resulted in a change in accreditation status of the program or sponsoring institution.
   
   
5. Confidentiality
   
   If the complaint involves failure of a program or institution to provide due process, the name of the complainant must be used when a response to the allegation is requested from the Program Director or institutional official. In all other cases, the AC GME shall keep the name of the complainant confidential throughout its processing of the complaint, except when a complainant specifically waives the right to confidentiality.
   
   
6. Complaint File
   
   During the period when the complaint is being processed, the Complaint Officer shall maintain the relevant correspondence in a case file that is separate from the official program file. When the case has been closed, the file shall not be retained.