Back to the Basics: What are the 24 Accreditation Statuses Issued by the ACGME?


 Authors: Treven Cade, Intern, Univ. Dayton &
 Gabrielle Phillips, Consultant
 


 

The ACGME has 24 different types or statuses, of accreditation. There are four main
categories that the majority of these statuses can fall under initial accreditation, continued
accreditation, withholds and probation, and withdrawals. In its own, separate, category is
Osteopathic Recognition which is, “an ACGME-accredited program that is in substantial
compliance with the Osteopathic Recognition Requirements.” Initial accreditation is a
developmental stage before a full accreditation. These statuses can come with their own
warnings with specific requirements. Continued accreditation, contrarily, is granted with
ongoing instances of compliance; however, some statuses of continued accreditation can
come with requisites or warnings, similar to initial accreditation. Probation and withhold are
primarily brought about by not demonstrating compliance with the accreditation. Lastly,
withdrawals occur when a program is previously accredited but no longer fit the
requirements of the accreditation, such as missing ACGME fee payments, not
demonstrating compliance, and voluntarily withdrawing. Accreditation statuses represent a
legitimate endorsement from the ACGME Review Committees when a program is compliant
with certain requirements.

The ACGME issues five different statuses of initial accreditation:
  1. Initial Accreditation
  2. Initial Accreditation with Warning
  3. Initial Recognition,
  4. Initial Recognition with Warning
  5. Pre-Accreditation
Initial Accreditation is, “when a Review Committee determines that an application for a new
program or sponsoring institution substantially complies with the requirements. Initial
accreditation is considered a developmental stage.” Initial Accreditation with Warning can
occur on further reviews if compliance is not demonstrated, and this status lasts for a year.
Following this year, a program can be granted Continued Accreditation or another Initial
Accreditation with Warning. Initial Recognition, with its corresponding warning statuses,
follows a similar metric. Additionally, during the five-year period of 2015-2020, the ACGME
had a status of Pre-Accreditation as they switched to a new accreditation system. Initial
accreditation is the beginning of the accreditation status process, and they are needed
before a continued accreditation.

There are six instances of continued accreditation given by the ACGME:
1.   Continued Accreditation
2.   Continued Accreditation without Outcomes
3.   Continued Pre-Accreditation
4.   Continued Recognition
5.  Continued Recognition with Warning
6.   Continued Recognition without Outcomes

Continued Accreditation is a status that, “will confer an accreditation status of Continued
Accreditation based on ongoing substantial compliance of the Sponsoring Institution or
program with the applicable requirements.” These statuses are accrued after periods of
initial accreditation. If a program does not have substantial data to support a Continued
Accreditation, they can be granted Continued Accreditation without Outcomes. Continued
Pre-Accreditation is an extension of the temporary Pre-Accreditation, and it used when
programs with Pre-Accreditation do not demonstrate compliance or if a program does not
surpass Initial Accreditation. Continued Recognition demonstrates compliance with
recognition requirements. Similar to other statuses, Continued Recognition with Warnings,
or without Outcomes, can be given to a program that demonstrates some non-compliance
or if they have insufficient data. Contrary to initial and continued requirements, the ACGME
also has statuses for programs that are not compliant with requirements.
 
The withhold and probation category includes four of the accreditation statuses:
1.   Administrative Probation
2.   Accreditation Withheld
3.   Probationary Accreditation
4.   Recognition Withheld
 
Probationary Accreditation is granted to programs that do not demonstrate compliance with
their accreditation requirements. This status can only be held for two years, where it is then
followed by a withdraw, Continued Accreditation, or Continued Accreditation with Warning.
Administrative Probation is a specific status to programs that do not visit the CLER site, and
it can last 18-24 months. In regard to statuses being withheld, Accreditation or Recognition
Withheld are statuses for programs that do not meet accreditation or recognition statuses
respectively. Along with probation and withholds, accreditation can also be withdrawn.
 
Out of the 24 ACGME accreditation statuses, eight are of the withdrawal category:
1.   Administrative Withdrawal of Accreditation
2.   Administrative Withdrawal of Accreditation due to Withdrawal of Sponsoring Institution’s
Accreditation
3.   Voluntary Withdrawal of Accreditation
4.   Withdrawal of Accreditation
5.   Withdrawal of Accreditation under Special Circumstances
6.   Withdrawal of Recognition
7.   Voluntary Withdrawal of Recognition
8.   Administrative Withdrawal of Recognition
 
The ACGME has six requirements that must be upheld for programs to not get withdrawn:
conduct a site visit, follow accreditation directives, supply the Review Committee with
expected information, maintain sufficient data, have a CLER site visit (if on Administrative
Probation), and have residents for the next six-year period. Specifically, for Administrative
Withdrawal of Accreditation, this status is given to those programs that do not appropriately
pay their fees. Withdrawal of Accreditation under Special Circumstances can be granted if
large errors can be seen outside of the six previous requirements. A program can also
voluntarily withdrew its accreditation. Similar metrics are used for the various statuses of
recognition withdrawals.
 
Source:
https://www.acgme.org/Portals/0/PDFs/ab_ACGMEglossary.pdf

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