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 specifies the information to be provided. When a progress report is requested, a specific due date is included in the request.
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 will not exceed three years.
The Accreditation Council may grant full accreditation in three circumstances:
- When programs holding provisional accreditation have demonstrated that they have been in substantial compliance with the program requirements over the provisional period; or
- When programs holding full accreditation have demonstrated upon review that they continue to be in substantial compliance with the program requirements; or
- 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.
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
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.
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.
A program may request to voluntarily withdraw its accreditation. Circumstances in which this may occur include:
Involuntary Administrative Withdrawal (Revocation) of Accreditation
- 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.
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 Inactivity or Deficiency. The 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 the policy on inactive status.
Involuntary Withdrawal (Revocation) of Accreditation
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 programs 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 appointed to 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.
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."