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Resident Forum
June 10, 1998

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

Author Affiliations


JAMA. 1998;279(22):1782N. doi:10.1001/jama.279.22.1782N-JRF80015-2-1

The occurrence of an alleged egregious accreditation violation or a catastrophic institutional event that because of its urgency, must be addressed outside 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 Executive Director determines that the matter disclosed is of sufficient importance and urgency to require expedited action, the following process will be initiated:

First, the Executive Director will make direct contact with the appropriate responsible individuals and will request a formal and prompt response.

Second, the Executive Director will consult with a committee composed of the Executive Director, the Chair of the Institutional Review Committee, and the Chair of the Residency Review Committee Council. This committee may decide that an immediate on-site survey and consultation should occur.

Third, if the committee decides that an immediate on-site survey and consultation should occur, an ad hoc survey team, composed of 3 knowledgeable individuals, will be appointed by the Executive Director and the other committee members. The ad hoc survey team will be selected from current and former members of the ACGME, Institutional Review Committee, or the Residency Review Committees.

Fourth, the ad hoc survey team will conduct a focused survey of the institution considering all matters related to the alleged egregious or catastrophic accreditation violation. At the conclusion of the survey, the team will submit a written report to the institution and the Executive Director. The Executive Director will forward the report to the Institutional Review Committee or the relevant Residency Review Committee for consideration at the next regular meeting.