Steps to Apply: Accreditation Polices and Procedures


The Academic General Pediatrics Accreditation Committee (AGPAC)
October, 2009

Accreditation Polices and Procedures

AGP Accreditation Policies and Procedures

  • Types of Fellowship Programs
    • Discipline
      The APA will provide accreditation and consultation to fellowships that are considered "general academic pediatric" in content, and that do not currently have opportunity for accreditation by the ACGME. This includes, but is not limited to: academic general pediatrics, health services research, hospitalist, community pediatrics, pediatric primary care, environmental health, clinical effectiveness, quality, pediatric education, and advocacy.
    • Domain
      Accreditation and consultation will be performed regarding the academic training components. Fellowships will need to delineate the components that are included under academics. As described above, the three major domains include research, education, and career development. The clinical training component will also be reviewed, including documentation of goals and objectives (defined by the individual fellowship program) as well as evaluation of experiences.
    • Tracks
      Fellowship programs that have more than one track (e.g., primary care and hospitalist) will be considered as a single unit if the academic components are the same across tracks. If the academic training varies across tracks, separate review for accreditation may be required.
    • Multiple programs within an institution
      Some institutions may have more than one AGP fellowship program (for example, separate community and hospitalist training programs). If the programs have distinct academic training components, they need to be considered separately for accreditation. If the programs are integrated, with common academic training, they can be considered "tracks" as described above.

  • The Review Process
    • Written documents for accreditation
      Documents for programs applying for accreditation include:
      • Program Requirements
      • Appendix A: Core Curriculum Requirements
      • Appendix B: Goals and Objectives
      • Fellowship Description Form, to be completed by the program with guidance from the documents listed above.
    • The accreditation site visit
      • A site visit is a part of the accreditation process. Most site visits will be scheduled between September and April.
      • A completed Fellowship Program Description form must be submitted a minimum of 2 weeks before the scheduled visit. Information needed to complete the form is included in the Program Requirements, Appendix A: Core curriculum requirements, and Appendix B: Goals and Objectives. If requested, a conference call will be arranged to answer questions as programs are preparing the fellowship program description form.
      • The site visit team will be made up of two persons, who will tour the facility and meet with the program director, faculty, department chair and trainees. A dinner meeting will be scheduled the night before the visit to orient the site visitor to the program. After the visit, site visitors will discuss the program's strengths and weaknesses, and compliance with accreditation standards.
    • The consultation site visit
      • Programs are invited to arrange a consultation site visit to help them develop a new program and/or prepare for a future accreditation review. AGPAC's consultation team will provide advice on all aspects of the proposed academic training program, with an emphasis on the three major domains of research, education, and career development. The clinical training component will also be reviewed.
      • Consultation site visits will be similar in format to accreditation site visits, but the purpose is formative rather than summative: i.e., it is to discuss a program's strengths and weaknesses and provide advice on strategies to improve the program in order to make it eligible for future accreditation.
      • A completed Fellowship Description Form should be sent to the consultation team a minimum of 2 weeks before the scheduled visit. Information needed to complete the form is included in the Program Requirements, Appendix A: Core Curriculum Requirements, and Appendix B: Goals and Objectives. If requested, a conference call can be arranged to answer questions as programs are preparing the Fellowship Program Description form. A review of this form will help the consultation team to know where to focus their advice.
      • The consultation team will include one or two members. The program will set the schedule, including a dinner meeting the night before the visit to orient the visitors to the program. Site visitors will tour the facility, talk with stakeholders (including trainees) as needed, and meet with those involved in leading the fellowship program.
    • The review process
      • Following the site visit, and subsequent review of the site visit report and the Fellowship Description Form, the AGPAC will meet to decide on the accreditation outcome for all programs reviewed in a yearly cycle. All programs will receive with their accreditation decision a detailed review of areas that fail to meet requirements or need improvement. See also 5. Notification of AGPAC Actions.
      • Accreditation decisions yield the following outcomes:
        • Initial accreditation for 3 years
        • Accreditation for 2 to 5 years
        • Denial of Accreditation for new applicants OR Probation for previously accredited programs
      • Accreditation decisions are made based on the criteria below:
        • Summary rating for program infrastructure, including:
          • Structural Requirements
          • Institutional Organization
          • Duration and Scope of Training
          • Program Personnel
          • Facilities and Resources
        • Subtotal rating for education, including:
          • Educational Program
          • Evaluation, Guidance, and Oversight
        • Failure to meet any of the following 7 requirements may lead to denial of accreditation:
          • The institution must provide sufficient support to the Program Director, support staff and trainees to show an ongoing commitment to fellowship education.
          • AGP fellowship programs must provide at least two years of training.
          • The director must possess the requisite educational, investigative, and administrative abilities and experience and have an appointment in good standing to an academic institution participating in the program.
          • Each trainee must have at least one faculty member who will guide the fellow's career decisions through the training period. The mentor must supervise the academic advancement of the fellow, be certain that the Scholarship Oversight Committee is active and effective, and oversee the professional well being of the trainee.
          • Education must be provided in three academic competency domains: 1) Academic Development and Leadership, 2) Research and 3) Education.
          • The program director, in consultation with the teaching staff and Scholarship Oversight Committee, must provide a written final evaluation for each AGP fellow who completes the program. This final evaluation should be part of the AGP fellow's permanent record, which must be maintained by the institution.
          • Annual review and evaluation of the program in relation to the educational goals, the quality of the curriculum, the needs of the AGP fellows, and the clinical and research responsibilities of the faculty must be documented. At least one AGP fellow representative should participate in these annual reviews. Formal input should be provided from fellows, faculty and important stakeholders (e.g. department chair, funders).
    • The Accreditation Cycle
      • Typically, the maximum length of the cycle that may be awarded by the Academic General Pediatrics Accreditation Committee (AGPAC) is five years. This cycle length is based upon the accreditation status, issues identified by the AGPAC, and any areas of noncompliance.
      • When a new program is accredited, the effective date of accreditation shall be clearly stipulated. In most cases, once a program is approved by the AGPAC, accreditation will begin no later than the following July 1
      • The accreditation status of a program changes only by action of the AGPAC. A program or sponsoring institution remains accredited until action is taken to withdraw accreditation by AGPAC.
      • If major changes occur between site-visits, a program review cycle may be shortened, and the Program Director shall be notified.
    • Notification of AGPAC Actions
      • The AGPAC Director ensures that the Letter of Notification for each program or sponsoring institution is prepared consistent with the AGPAC action.
      • The Program Letter of Notification shall state the action taken by the AGPAC, the current accreditation status, the length of the accredited program, and the approximate date for the next site-visit.
      • After the initial accreditation, fellows and applicants must be notified by individual fellowship programs of the accreditation status of those programs within 3 months of notification by the AGPAC.

  • Accreditation Actions
    The following actions may be taken by the AGPAC in the accreditation of Academic General Pediatric Fellowship programs:
    • Initial
    • Accreditation
    • Continued
    • Withheld
    • Probationary
    • Withdrawn
    Accreditation withheld, probationary accreditation, and withdrawal of accreditation are adverse actions and subject to an appeals process.
    • Initial Accreditation
      • Initial accreditation is conferred to programs which have not yet graduated the inaugural group of fellow trainees but the proposal substantially complies with requirements (see Section B.4. Review process). The total length of initial accreditation will be for no more than 3 years. Initial accreditation may be awarded prior to a site visit. The site visit will occur within 2 years after initial accreditation is awarded.
    • Accreditation
      • Accreditation is conferred initially when the AGPAC determines that a proposal for a new program substantially complies with the requirements (see Section B.4. Review Process). Thee are typically programs with an existing track record of fellowship training. The AGPAC may confer accreditation on a program prior to a site visit. Such programs will be site-visited within two years of the initial action.
    • Continued Accreditation
      • Accreditation is continued when the AGPAC determines that a program, following a site-visit and review, has demonstrated substantial compliance with the requirements since a prior accreditation action (see Section B.2.). Typically, the maximum length of the cycle awarded by the AGPAC is five years. Cycle length is based upon issues identified by the AGPAC, including areas of non-compliance.
      • Continued Accreditation status may be offered after a cycle of initial accreditation, a previous cycle of continued accreditation, or satisfactory resolution of issues identified in a probationary accreditation action.
    • Withheld Accreditation
      • Accreditation shall be withheld when the AGPAC determines that the application for a program not previously accredited does not demonstrate substantial compliance with the requirements (see Section B).
      • If Withheld Accreditation is proposed, the program will given an opportunity to rebut the citations and document compliance with the requirements.
    • Probationary Accreditation
      • Probationary accreditation is conferred when the AGPAC determines that a program, previously given an initial or continued accreditation, has failed to demonstrate substantial compliance with the requirements (see Section B) after a site-visit and review of the Fellowship Description Form and other required documents.
      • When the AGPAC proposes this status, it will give the program an opportunity to rebut the citations and document compliance with the requirements. The length of the review cycle for this status may not exceed two years.
      • Following the next site-visit and review, a program documenting substantial compliance with the requirements will be restored to continued accreditation status. If the program does not demonstrate substantial compliance with the requirements, or if new areas of noncompliance are identified, an additional one year of probationary accreditation may be granted. At the end of this additional one-year period, the program must demonstrate substantial compliance with the requirements, or the accreditation of the program will be withdrawn.
      • Withdrawal of Accreditation will occur after probationary accreditation, only if the program has failed to achieve substantial compliance with the requirements.
    • Withdrawal of Accreditation
      • Withdrawal of Accreditation after Probationary Accreditation: see B.4. Probationary Accreditation
      • Voluntary Withdrawal of Accreditation
        • A fellowship program can request to withdraw voluntarily from the accreditation process, without prejudice, under the following circumstances:
          • Termination of the fellowship
          • Inactivity (no fellows for 4 years)
          • Merger of the program with another training program
          • Loss of resources
          • Other reasons clearly outlined by the program director
      • Requests must be sent to the Chair of the ACPAC, and must be signed by both the program director and Department Chair. Requests must clearly indicate (a) reasons for withdrawal, (b) plans for completing training of current fellows, and (c) termination date.
      • Administrative Withdrawal
      • Administrative withdrawal by the ACPAC can occur under the following circumstances:
        • Failure to pay fees by December 1 (invoices will be issued July 1)
        • Failure to comply with one or more of the following:
          • Site visit review
          • Provision of requested information (e.g., progress reports, data about fellows) to site visitors or to the ACPAC
          • An accreditation action requiring a response from the program regarding areas of non-compliance

  • Procedures for Adverse Actions
    • When the ACPAC decides on an adverse action (includes accreditation withheld, probationary accreditation or withdrawal of accreditation), it will notify the program director and the Department Chair, delineating the specific citations that caused the adverse action, the most recent site visit report, and other relevant information. Programs will be provided with instructions for response (including timelines).
    • Programs may respond in writing to correct misinformation, provide additional information, or challenge findings. The ACPAC will review the response and decide whether to alter the adverse action, request another site visit, or maintain the adverse action. This will generally require a meeting of the ACPAC (potentially by conference call). The updated decisions will be communicated in writing to the program director and Chair, including explanations.
    • The program director may appeal a confirmed adverse action. In addition, the program director must notify all fellows and candidates within 30 days of the adverse action, even if an appeal occurs.
    • Procedures for Appeal of Adverse Actions
      • Programs may request an appeal of an adverse action in writing, within 30 days of receipt of the Letter of Notification; otherwise the adverse action is final.
      • If an appeal occurs, the ACPAC will appoint an Appeals Panel, drawn from an existing list of individuals. Programs will review the list of potential individuals, and can delete up to 50% of names. They must return the list of names within 2 weeks. A 3-member Appeals Panel will be formed from the remaining list. During this time the file is "frozen".
      • The program can request a hearing before the appeals panel. During this time the accreditation status will be "under appeal" (e.g., "probation, under appeal"), until the ACPCA makes final determination of accreditation status. Fellows and candidates must be informed, with copies sent within 30 days to the ACPAC. The hearing will be conducted at a time agreeable to the program. The program will receive all relevant documents, and can appeal its case in writing and orally. The Appeals Panel will meet to review the appeal and within 3 weeks will notify the APA Board of its decision. The Appeal Panel will decide whether substantial, credible, and relevant evidence exits to refute or support the AGPAC's decision.
      • If the program has instituted substantive changes following the site visit, the program should request a new site visit and new evaluation rather than requesting an appeal. The adverse status will remain active until the new evaluation.
      • The post-appeal decision by the AGPAC will be final, with no further appeals. The Committee will notify the program within 2 weeks.
      • The program will be responsible for the fee for the appeal.

  • Programs must notify current fellows and applicants of its accreditation status, including any final adverse actions. Copies of this notification must be sent to the AGPAC. If the program fails to comply with these procedures, the AGPAC will notify the Department of Pediatrics Chair.




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