Frequently Asked Accreditation Questions

General

What is accreditation?
Accreditation is the process of peer review that ensures an educational training program meets the minimum program requirements established by the subspecialty to produce a competent fellow. 

What are program requirements?
The subspecialty program requirements are used by the Accreditation Council to review training programs. All training programs must meet the requirements set forth in the program requirements as they are the minimum standards established by the subspecialty for an educational training program.

Applying for Accreditation

How do I apply for accreditation?
Applications are submitted online. You will begin by creating a username and password and a profile. You will then be able to start the application by clicking “+Get Started.”

What must I do to begin the accreditation process?
All programs seeking accreditation must complete the online accreditation application and pay the application fee. Applications submitted without the appropriate fee will not be reviewed.

When can I submit my application?
Applications may be submitted anytime for review during one of the two application periods. Deadlines are January 31 for spring review and July 31 for fall review.

Online Accreditation Application

Why can’t my program have multiple usernames and passwords?
Access to the application system is given to the program, not to individual users. The username and password are provided to the program director. The program director may share the login information with whomever he or she wishes. 

How do I reset my password?
You may reset your password by clicking “Forgot Password” on the login screen.

What is carried over from previous submissions?
Most information submitted in a previous submission will carry into the next submission. The primary exceptions to this include fellow information (because it changes annually) and some institutional and personnel information. 

I’ve completed my submission – now what?
Program submissions will first be reviewed by UCNS staff for completeness. If information is missing, the program will be contacted and asked to edit its submission through the interface. Once the submission is completed, it will be locked and sent to the Accreditation Council for review. 

Continuing Accreditation

How do I maintain my accreditation?
Accreditation is awarded for a specific duration (term or cycle) and programs must submit continued accreditation documentation to maintain accreditation when the term or cycle is completed. Your original notification letter will indicate the length of your accreditation term and estimated date of next review. UCNS staff will contact you in advance of the review requesting necessary documentation.

How long is an accreditation term or cycle?
Accreditation terms are determined by the Accreditation Council depending upon the strength of the application. Provisional accreditation is generally two to three years. Full accreditation is generally three to five years. The Accreditation Council reserves the right to shorten an accreditation term if the program is out of compliance with its subspecialty program requirements.

Will I be notified when I need to apply for continuing accreditation?
Yes. Prior to your continued accreditation review UCNS staff will e-mail you the necessary instructions to complete your reaccreditation application.

My program is accredited for Neurocritical Care. When does it become accredited by ACGME?
The Accreditation Council for Graduate Medical Education (ACGME) Neurocritical Care accreditation is different from UCNS accreditation. Programs wishing to become accredited by ACGME will have to undergo the ACGME’s accreditation process. UCNS will continue to serve the Neurocritical Care subspecialty by offering accreditation and certification services to the subspecialty, as it has for the past decade.

Program Changes

What do I do if I am retiring as program director?
UCNS must be notified in advance of a change in program director. A letter from the Department Chair describing the change and his/her selection for a new program director must be submitted to the Accreditation Council accompanied by the new program director’s CV. A template letter, template CV, and description of the program change request process may be found on the Program Change page. 

How can I change the number of fellows enrolled in my program?
UCNS must be notified in advance if a program wishes to increase the approved complement of fellows. The Accreditation Council determines the fellow complement based on the faculty-to-fellow ratio. Faculty considered for the ratio are core faculty. If a program has sufficient certified or eligible faculty, the program director may submit a program change request. A template letter and description of the process may be found on the Program Change page.

Do I need to contact UCNS if the duration of my program changes?
Yes. Subspecialties have specific parameters regarding program duration. Your notification letter indicates the duration of training for which your program is approved. If you would like to request a different duration, please consult your subspecialty program requirements and submit a request to the Accreditation Council with supporting documentation describing the curriculum for your proposed program. Templates needed to submit the request may be found on the Program Change page.

Fees

What fees are associated with accreditation?
Programs are required to remit an initial application processing fee and an annual accreditation fee. The current fee structure is as follows:

• Initial Application Fee: $2,000
• Annual Fee: $2,000

Will you send an invoice when annual accreditation fees are due?
Yes, accredited programs are invoiced when annual fees are due. Programs seeking initial accreditation are not invoiced.

Accreditation Decisions

What does provisional accreditation mean?
Provisional accreditation is granted for initial accreditation of a program or for a previously accredited program that had its accreditation withdrawn and has subsequently applied for reaccreditation. Provisional accreditation implies that a program is in a developmental stage. It remains to be demonstrated that the proposal for which accreditation was granted will be implemented as planned. Accordingly the Accreditation Council will monitor the developmental progress of a program accredited on a provisional basis. 

What is a progress report?
Programs may be awarded accreditation under circumstances in which additional clarification and follow up is needed. A progress report is a specific response to questions or concerns that have arisen in the process of Accreditation Council deliberations. The Council’s accreditation recommendation may be reversed if the progress report is not received or does not address the question or concern. It is important to submit this information by the date identified in your notification letter.

What does deferral of accreditation mean and how do I respond appropriately?
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 which precludes an informed and reasonable decision. A response is required to each item listed in your notification letter to assure the Accreditation Council has all the necessary information to make a decision. Please submit your responses by the due date indicated in your notification letter to ensure that your program will be reviewed. If you have questions, notify UCNS staff.

What does withhold accreditation mean and how do I respond appropriately?
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 will cite those areas in which the proposed program does not comply with the standards. The proposed withhold status is intended to allow the program the opportunity to respond to the deficiencies identified by the Accreditation Council without requiring a new application and application processing fee. Please submit your responses by the due date indicated in your notification letter to ensure your program will be reviewed. If you have questions, notify UCNS staff.

Can a program’s accreditation end?
Accreditation may be withdrawn from a program if the program is found to be in substantial noncompliance with the program requirements. Programs are given the opportunity to respond to any areas of noncompliance before accreditation is withdrawn. A program may also request voluntary withdrawal of its accreditation. Additional details regarding withdrawal of accreditation may be found in the Accreditation Policies.

Annual Reports

What is an annual report?
An annual report is an abbreviated application that programs complete every year and it collects some of the same information collected during full review cycles. UCNS implemented an annual reporting system in place of regularly scheduled site visits. The annual report allows UCNS to ensure that it has the most current information for all accredited programs. The annual report also allows programs to update its information between continuing accreditation reviews, which will allow for a more streamlined full accreditation process.

When is the annual report due? Will I be notified?
Annual reports are due each March. Programs will receive notification in January when they may begin completing the annual report.

Do I have to complete an annual report if I’m due for reaccreditation?
No. Because the information requested in the annual report is also requested during a reaccreditation review, you will not need to submit an annual report during a reaccreditation year.

I was just reaccredited last fall, do I have to complete the annual report?
Yes, programs who recently completed a reaccreditation review still need to complete the next annual report. Only programs currently in a reaccreditation review will not be required to complete the annual review.

Is there a fee due with the annual report?
No. The annual fee is not due with the annual report. Annual fees are invoiced in June and due in August.

Institutions

What is the difference between the Sponsoring Institution, Primary Institution, and Participating Institution?
UCNS defines the various educational institutions as follows:

• Sponsoring Institution: The institution that assumes the ultimate responsibility for a program of GME. This entity is typically responsible for multiple GME programs and is overseen by a Designated Institutional Official. This terminology is the ACGME’s and UCNS follows the ACGME model.
• Primary Institution: The institution that is used most heavily for actual clinical training during the fellowship.
• Participating Institution: An institution to which fellows rotate for a required experience.

Is a program required to have each of the type of institution?
Each program must have a designated sponsoring institution, and a primary institution, which may or may not be the sponsoring institution. Educational programs may take place at only one location; however, UCNS allows programs to utilize multiple educational centers to ensure students receive all required educational experiences.

J-1 Visas

Are fellows in UCNS-accredited fellowships eligible to apply for J-1 Visas?
Regulations for non-standard training (NST) has transitioned from ABMS-member board approval to ACGME approval. ACGME institutions must be recognized in order to host NST programs for J-1 exchange visitor physicians. This change does not impact the UCNS subspecialties that are considered “non-standard training programs” as long as the institutions where the programs are located become recognized by ACGME. Information for recognition to offer NST at your institution may be found at the ACGME’s website for Non-Standard Training Recognition.

Staff Contact

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