Health Law

Graduate Medical Education Accreditation

If your institution provides graduate medical education (GME) training to physicians, you confront numerous hurdles in the accreditation process, such as proper evaluation of data, preparation of program information forms, complying with general competency standards, and planning for site surveys. You have to avoid accreditation difficulties, while at the same time strategize on how to maintain compliance with institutional and program requirements of the Accreditation Council for Graduate Medical Education (ACGME) and by the Liaison Committee on Medical Education (LCME).

Our Health Law attorneys advise scores of academic medical centers and teaching hospitals across the country on their GME programs, compliance obligations, and accreditation-related issues. We assist them in their challenges to adverse ACGME or Residency Review Committee (RRC) decisions. Our experience extends across the range of disciplines and specialties in which training is provided under the auspices of ACGME. Institutions cited as deficient in specific areas by the applicable RRC turn to us to review the citations and to provide advice on appropriate courses of action, including representing them in administrative appeals, or filing a new set of program information forms. We can also provide advice if your institution decides to combine or streamline its GME program in the context of a merger or consolidation, or decides to reduce or eliminate programs for economic or other business reasons.

Representative Experience

  • We filed an administrative appeal in connection with the ACGME’s proposed expedited withdrawal of the accreditation of a hospital’s Residency in Anesthesiology. We worked with the program and the hospital, a member of a large health system, to prepare and submit to the ACGME several volumes of material in response to the nine separate citations of noncompliance that were levied against the program. We were successful in convincing the ACGME to rescind the proposed expedited withdrawal of accreditation, and to restore the program’s accreditation.
  • We secured five-year accreditation cycles — the longest available — for two New York City hospitals’ Residencies in Surgery and a third New York City hospital’s Residency in Anesthesiology. We evaluated their data and assisted them in preparing their Program Information Forms, met with their faculty members and residents to discuss prior citations and how they had been addressed, and conducted mock site visits to prepare the programs for their Residency Review Committee site visits.
  • We assisted a Residency in Pediatrics in securing continued full accreditation after a period of probation. We worked with the program to develop new goals and objectives, revised its affiliation agreements, and presented its involvement in scholarly activity in a clear and coherent fashion.
  • We secured a reversal of the Residency Review Committee’s determination to withdraw the accreditation of a New Jersey hospital’s Cardiovascular Disease Fellowship Program outside of the scope of the ACGME’s appeals rules. The RRC’s decision to withdraw the program’s accreditation was premised on one basic assumption — that the program had 13, rather than 15, peer-reviewed publications — and that assumption was wrong. Rather than pursuing a costly and time-consuming appeal, or going through the process of preparing a new application and undergoing a new site visit, we submitted a letter of clarification that corrected this factual error on the part of the RRC.