Accreditation Policies

Program Requirements

Definition (2.08.A)
Program Requirements are used by the Accreditation Council to determine program compliance when reviewing programs for accreditation. The Accreditation Council is responsible for preparation of subspecialty-specific program requirements, common program requirements, and for periodic revisions to reflect current educational practice. Program requirements include common program requirements applicable to all UCNS subspecialties. Subspecialty-specific program requirements are developed by the subspecialty. Program requirements, including common program requirements, must be approved by the UCNS Board of Directors.

Periodic Review (2.08.B)
Periodic reviews of program requirements, during which time the Accreditation Council works with subspecialty-recommended consultants, must occur at least every five years. 

Effective Date of Revisions (2.08.C)
Ordinarily, the effective date for the revised common program requirements and revised subspecialty-specific program requirements shall be the June 1 or December 1 that is at least six months following the Board meeting at which the requirements were approved. Under special circumstances, UCNS may designate an earlier or later date and make this information available on the UCNS website.

Review of Accreditation Applications

Accreditation Documents (2.09)
The Accreditation Council is responsible for the development of  program initial and continuing applications, annual reports, and other documents required to attain and maintain accreditation. The completed forms serve as an application for a proposed program or for review of a currently accredited program. Submission of appropriately signed initial accreditation forms and payment of the initial fee by the program director and department chair constitutes a request by the program for review and accreditation. Submissions of an appropriately signed annual report constitutes a request by the program for review and maintaining accreditation. Submission of an appropriately signed continuing accreditation report constitutes a request by the program for review and continued accreditation.

Review (2.10)
The Accreditation Council reviews the completed applications and related correspondence in determining whether a program is in substantial compliance with the program requirements. The Accreditation Council designates an accreditation status for each program and identifies points of partial compliance and/or non-compliance with its standards. The program is evaluated on the basis of the program requirements that are effective at the time of the program review. A program director may be permitted to submit additional or revised information that arrives sufficiently in advance of the Council’s meeting to allow for proper review. During non-review years, programs submit an annual report to update UCNS of key program items.

Concurrent Training (2.11)
Programs requesting consideration of accreditation for concurrent training between subspecialties with common educational information, including programs that would simultaneously confer eligibility for two UCNS certification examinations or ABMS and UCNS certification examinations upon graduating from the program, must complete the UCNS accreditation application process, including submission of an appropriate application and fee. Programs shall be required to demonstrate complete compliance with the UCNS subspecialty's program requirements. Upon receipt of the program's application, the Accreditation Council will review the application using its standard process.

Fees (2.12)
The Board of Directors shall determine all fees for accreditation. Fees include:

• an application fee that must be submitted with each initial application, and 
• an annual fee that all accredited programs must pay in order to maintain accreditation for the applicable academic year, July 1-June 30.
• In addition, the Board shall determine a fee to be assessed in the event that a program appeals an adverse accreditation action.

Period of Accreditation (2.13)
When a program is initially accredited, accreditation commences on the date stipulated in the notification letter, which shall be June 1 or December 1 following the date of the decision by the Accreditation Council. Under special circumstances when accreditation is delayed beyond the requested start date, approval may be awarded retroactively to the original requested start date if there is documentation that the program conformed to the requirements on the originally requested start date. A program remains accredited until action is taken by the Accreditation Council to withdraw accreditation from the program. Withdrawal of program accreditation is outlined later in the policies and may occur due to substantial noncompliance with policies or failure to submit required review documents or fees.

Accredited programs are reviewed in accordance with cycles established for each accreditation action. The Accreditation Council may reduce the duration of the cycle for any action.

Accreditation Actions

The following actions may be taken by the Accreditation Council upon program review. The Accreditation Council may request a progress report from a program director. The Accreditation Council should specify the information to be provided. When a progress report is requested, a specific due date should be included in the request.

Provisional Accreditation (2.14.A)

Every initial accreditation of a program is provisional. Provisional accreditation may also be used in the unusual circumstance in which separately-accredited programs merge into one or an accredited program has been so altered that in the judgement of the Accreditation Council it is the equivalent of a new program.

Because provisional accreditation implies that a program is in a developmental state, the interval between accreditation and the next review of the program by the Accreditation Council should not exceed three years.

Full Accreditation (2.14.B)
The Accreditation Council may grant full accreditation in three circumstances:

1. When programs holding provisional accreditation have demonstrated that they have been in substantial compliance with the program requirements over the provisional period; or
2. When programs holding full accreditation have demonstrated upon review that they continue to be in substantial compliance with the program requirements; or
3. When programs holding probationary accreditation have demonstrated upon review that they are in substantial compliance with the program requirements. 

The maximum interval between reviews of programs holding full accreditation is five years. The Accreditation Council may specify a shorter cycle.

Probationary Accreditation (2.14.C)
The Accreditation Council may impose probationary accreditation on accredited programs that are no longer considered to be in substantial compliance with the program requirements. In reviewing a program that holds probationary accreditation, the Accreditation Council may exercise the following options: grant full accreditation, withdraw accreditation, or, continue probationary accreditation. Before a program is placed on probationary accreditation, it shall be given the opportunity to submit a response demonstrating substantial compliance with the UCNS-approved program requirements. If the response is not received by the response date set by the Accreditation Council, or if the program is found to be still substantially non-compliant with the program requirements, the program shall be placed on probationary accreditation status. A program must notify enrolled and applying fellows of its probationary accreditation status. Notification must be in writing.

The normal interval for review of programs holding probationary accreditation is two years; however, the Accreditation Council may specify a shorter cycle. A program should not hold probationary accreditation for more than four consecutive years before it is returned to full accreditation status, or the Accreditation Council acts to withdraw accreditation. The probationary period is calculated from the date of the Accreditation Council meeting during which probationary accreditation was imposed. 

Deferral of Accreditation Action (2.14.D)
The Accreditation Council may defer a decision on the accreditation status of a program. The primary reason for deferral of accreditation is lack of sufficient information about specific issues that precludes an informed decision. At the next regular meeting following the deferral, the Accreditation Council shall make an accreditation decision using all current information submitted by the program. Failure to submit a response by the response date set by the Accreditation Council may result in proposed withholding of accreditation for a new program, or proposed probationary accreditation, or withdrawal of accreditation for accredited programs.

The Accreditation Council may defer an accreditation decision for a maximum of one regular meeting. Programs with exceptional circumstances may be allowed an additional deferral at the Accreditation Council’s discretion. Programs shall be notified of the deferral and given a date by which to respond. Typically, the date shall ensure review at the next Accreditation Council meeting. 

Withhold Accreditation (2.14.E)
The Accreditation Council may withhold accreditation when it determines that the proposal for a new program does not substantially comply with the UCNS-approved program requirements for the subspecialty. The Accreditation Council shall cite those areas in which the proposed program does not comply with the standards. 

Before accreditation is withheld, a program shall be given the opportunity to submit a response either requesting to voluntarily withdraw its application or demonstrating substantial compliance with the UCNS-approved program requirements. If the response is not received by the response date set by the Accreditation Council, or if the program is found to be still substantially non-compliant with the program requirements, accreditation shall be withheld.

Voluntary Withdrawal (2.14.F)
A program may request to voluntarily withdraw its accreditation. Circumstances in which this may occur include:  

• a department chair may request voluntary withdrawal of accreditation without prejudice. Such requests must be made in writing.
• two or more subspecialty programs merging into a single new program. If the new program achieves accreditation, concurrent action for voluntary withdrawal of accreditation, without prejudice, of the previously separate programs shall also occur. 

Involuntary Administrative Withdrawal (Revocation) of Accreditation (2.14.G)
Accreditation may be administratively withdrawn if a program fails to comply with UCNS’s administrative requirements. An administrative withdrawal cannot be appealed. Administrative requirements include, but are not limited to: 

• Delinquency of Payment. Programs that do not pay required fees are not eligible for review. If the fees are 90 days past due, the program shall be notified by certified mail of the effective date of withdrawal of accreditation. On that date, the program shall be removed from the list of UCNS accredited programs.
• Noncompliance with Accreditation Actions and Procedures. A program may be deemed to have withdrawn from the process of accreditation and the Accreditation Council may take appropriate action to withdraw accreditation if the program director refuses to comply with the following actions and procedures: 
  • To undergo a program review.
  • To follow directives associated with an accreditation action.
  • To supply the Accreditation Council with the requested information.
  • To promptly notify UCNS of a change in the program director of sponsoring institution.
• Program Accreditation Council may withdraw accreditation of a program if it has been inactive for two or more years without requesting, and being granted, inactive status pursuant to Section I below. 

Involuntary Withdrawal (Revocation) of Accreditation (2.14.H)
Accreditation may be withdrawn from accredited programs that are found to be substantially non-compliant with the program requirements. Before a program’s accreditation is withdrawn, it will be given the opportunity to submit a response demonstrating substantial compliance with the UCNS-approved program requirements. If the response is not received by the response date set by the Accreditation Council, or if the program is found to be still substantially non-compliant with the program requirements, the program’s accreditation shall be withdrawn.

The following policies apply when action is taken to withdraw accreditation:

• The effective date of withdrawal of accreditation shall permit the completion of the training cycle for any actively training fellow(s).
• Once notification has been made of the effective date of withdrawal of accreditation, no fellows may be enrolled in the program.
• When action has been taken by the Accreditation Council to withdraw accreditation of a program, and the program has entered into appeal procedures, an application for reaccreditation of the program, or any other program request, shall not be considered until the appeal action is concluded.

Inactive Status (2.14.I)
A program otherwise in good standing may request “inactive status” in lieu of withdrawal of accreditation if it contemplates reactivating the program within the next two years. The Accreditation Council may stipulate what assurances must be provided for reactivation to assure that the program continues in substantial compliance. Programs with fellows may not elect to become inactive until all fellows have left the program. Programs with “inactive status” are responsible for paying all accreditation fees, including annual fees. A program may not retain inactive status for more than four consecutive years without fellows, even with “inactive status.” 

Grievances

UCNS reviews grievances alleging that an accredited program is not in substantial compliance with the program requirements. Grievances must be submitted in writing (electronic submission is allowed), and include the following: the program's name, the complainant's name, a description of how the program is non-compliant, and details demonstrating that the complainant has exhausted all institutional avenues to remedy the situation.

Adverse Action Appeals (2.16)
UCNS programs may appeal adverse actions as set forth in this policy. Unless the context clearly indicates otherwise, the following definitions apply to this policy:

1. "Adverse Actions" includes the following accreditation actions: probationary or continued probationary accreditation, withheld accreditation, and withdrawal of accreditation.
2. "Appealing program" means a program that has received an adverse action notification and has filed an appeal.
3. "Council" means the UCNS Accreditation Council.

Accreditation Council Procedures for Adverse Actions (2.16.B)
The following procedures shall be used when the Council determines that a program is not in substantial compliance with the program requirements.

1. The Council shall give notice of its proposed adverse action to the program director. This notice of proposed adverse action shall include:
   
   • the citations that form the basis for the proposed adverse action,
   • the date by which the program may submit, in writing, its response to each of the citations and to the proposed adverse action, and 
   • the date of the next regularly scheduled meeting at which the Council shall complete its evaluation
2. In response to the Council's notice, the program may provide to the Council written information demonstrating why the adverse action should not be taken.
3. The Council may do one of the following after its evaluation of the program's response:
   
   • Confirm the adverse action. The Council shall send a letter of notification to the program director confirming that adverse action and include:
     • a listing of the citations, including comments on the program director's response to these citations, and
     • a copy of this appeals policy.
   • Withdraw its decision to take adverse action. 
4. The Council shall promptly serve its decision by certified or registered mail to the program.
5. Upon receipt of notification of an adverse action, the program director must inform, in writing, the fellows and any applicants who have been invited to interview with the program that the adverse action has been confirmed, whether or not the action will be appealed. A copy of the written notice must be sent to the UCNS Executive Director within 15 days of receipt of the Council's letter of notification.
6. A program that disagrees with a decision of the Council may file a written notice of appeal to the UCNS Board of Directors. The notice of appeal must be filed with the UCNS Executive Director within 30 calendar days of the date of the adverse action notification letter and include a nonrefundable $5,000 appeal fee.
7. Until the appeal is completed, the adverse action remains in effect. 
8. Within 10 calendar days after filing the notice of appeal, the program shall submit documentation that supports the appeal to the UCNS Executive Director. The format of the documentation must be a detailed letter explaining the basis of the appeal accompanied by enclosures that support statements within the letter. The appeal shall include all information upon which the program relies for the contention that the Council's adverse action is erroneous.
9. When the UCNS Executive Director has received notice of appeal and any supporting documentation, he or she shall submit the Council's decision and appealing program's documents to the UCNS Board of Directors.
10. Appeal Hearing.
    
    • The Board of Directors shall schedule a hearing within 120 calendar days after the Executive Director received the program's documents described in paragraph nine.
    • The Board shall determine the time and place for the hearing and may choose to conduct the hearing by teleconference.
    • At least 30 days prior to the hearing, the Board shall notify the program of the time and place of the hearing.
    • The hearing format is to be informal in nature and structured as deemed appropriate by the Board.
    • A representative of the Council may attend the hearing to be available to the Board to provide clarification of the record.
    • The appealing program may give presentations at the hearing. Presentations shall be within the scope of appeal and limited to clarifications of the record and arguments to address compliance by the appealing program with the published standards for accreditation. Presentations may include written and oral elements.
    • The appealing program shall pay the following costs associated with the appeal in the event there is travel: actual reasonable expenses for travel, meals, and hotel for the Board of Directors and Council member.
11. The appealing program may not amend the statistical or narrative descriptions on which the decision of the Council was based. The appeal is limited to clarification of information as of the time when the adverse action was taken. Information about the appealing program subsequent to that time cannot be considered in the appeal. Furthermore, the Board shall not consider any changes in the appealing program or descriptions of the appealing program that were not in the record at the time when the Council reviewed the appealing program and confirmed the adverse decision. The adverse status shall remain in effect until a re-evaluation and an accreditation decision have been made by the Council. When there have been substantial changes in an appealing program and/or correction of citations after the date of action by the Council, a program may forego an appeal and request a new evaluation and accreditation decision.  
12. The Board shall make its decision within seven days of the hearing. The Chair shall determine whether to convene the Board for a formal meeting (in person or by telephone conference) or to rule on the appeal by an e-mail vote. The decision of the Board of Directors is final.
13. The UCNS Executive Director shall promptly serve the Board's decision by certified or registered mail to the appealing program.
14. The UCNS Executive Director shall retain all documents related to the adverse action and any appeal for five years. The UCNS Executive Director may provide a copy of the record to the appealing program upon payment of a reasonable fee. 

Staff Contact

Amanda Carpenter
Senior Manager, Accreditation
[email protected]
(612) 928-6065