ACGME Accreditation Council for Graduate Medical Education

Egregious Violations

ACGME Procedures for Alleged Egregious Events
Subject 20.00, page 102, ACGME Manual of Policies and Procedures

If the Review Committee upon review of a complaint recommends invocation of the “Egregious Violation” policy, the following policy will apply.

The occurrence of an alleged egregious accreditation violation affecting programs or institutions must be reported to the Chief Executive Officer of the ACGME. Individuals involved in graduate medical education have a professional responsibility to report such matters promptly. The Chief Executive Officer of the ACGME will initiate an investigation to determine credibility and the degree of urgency. When the Chief Executive Officer of the ACGME determines that the matter disclosed is of sufficient importance and urgency to require a rapid response, the following procedures shall be initiated:

a. The Chief Executive Officer of the ACGME will consult with the Chair of the ACGME Board, and the Chair of the ACGME Council of Review Committee Chairs. The Chief Executive Officer of the ACGME may request a formal and prompt response from the appropriate responsible individual(s). The Chief Executive Officer of the ACGME may decide that a review of the affected program or institution under this policy should occur, or recommend that the matter be referred to the appropriate Review Committee for action.

b. If the Chief Executive Officer of the ACGME decides that a site visit should occur, he or she shall assemble a site visit team and inform the appropriate responsible individual(s) at the program and the institution of the site visit and the stated reason(s).

c. The site visit shall address all matters related to the allegation(s). At the conclusion of the site visit, the site visit team shall submit a written report to the Chief Executive Officer of the ACGME. He or she shall then forward the report to the Executive Committee of the ACGME Board, with his or her recommendations, for consideration at the next regular meeting of the Executive Committee, or at a meeting specifically convened to address the site visit findings.

d. The Executive Committee will recommend to the ACGME Board for its final approval, disposition of the matter, which may include, without limitation, the following accreditation actions:

(1) No change in current accreditation status
(2) Probationary Accreditation
(3) Withdrawal of Accreditation

e. If an adverse accreditation decision is rendered, the program or institution may request reconsideration by the ACGME Board. This request must be made in writing to the Chief Executive Officer of the ACGME within 30 days of receipt of written notification of the decision. The result of the reconsideration will be final.

Accreditation Policies and Procedures
Effective Date:  7/1/2013