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ACGME Procedure for Rapid Response to Alleged Egregious Accreditation Violations or Catastrophic Institutional Events

The occurrence of an alleged egregious accreditation violation or a catastrophic institutional event which, because of its urgency, must be addressed outside of the established processes of the ACGME should be reported promptly to the Executive Director of the ACGME. Any component of the ACGME accreditation process having knowledge of such an occurrence, including residents in training or member organizations, has a responsibility to report the matter promptly and directly to the ACGME Executive Director who will initiate an investigation to determine credibility and degree of urgency of the matter. Whenever the ACGME Executive Director determines that the matter disclosed is of sufficient importance and urgency to require expedited action, the following process will be initiated:

  1. The ACGME Executive Director will consult with an ad-hoc advisory committee composed of the ACGME Executive Director, the Chair of the Institutional Review Committee, and the Chair of the Residency Review Committee Council provided said individuals do not exhibit or declare a conflict of interest. This committee may request a formal and prompt response from the appropriate responsible individual(s) or decide that an immediate on-site survey should occur.

  2. If the committee decides that an immediate on-site survey should occur, a focused survey will be conducted by one or more members of the ACGME field staff or other knowledgeable individuals appointed by the ad-hoc advisory committee. The ACGME Executive Director will inform the appropriate responsible individual(s) at the institution of the focused site visit and the stated reasons(s).

  3. The site visitor(s) will conduct a focused survey of the residency program or institution considering all matters related to the alleged egregious or catastrophic accreditation violation. At the conclusion of the survey, the site visitor(s) will submit a written report to the ACGME Executive Director. The ACGME Executive Director will forward the report to the Institutional Committee or the relevant Residency Review Committee for consideration at the next regular meeting and may share the report with the responsible individual(s) at the institution.
ACGME APPROVED PROCEDURE
9/25/00