Sponsoring Institutions oversee and provide assurance for the quality of the learning and working environment in all their ACGME-accredited programs. Each Sponsoring Institution must achieve and maintain institutional accreditation before it can sponsor one or more ACGME-accredited programs. Applications for institutional accreditation must be initiated by the designated institutional official (DIO) through the ACGME’s Accreditation Data System (ADS). The ACGME’s Institutional Review Committee reviews applications for compliance with the ACGME requirements and provides or withholds institutional accreditation based on the findings of its reviews.

Steps to Achieving Institution Accreditation

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The Sponsoring Institution identifies a DIO who will have responsibility for ensuring compliance with all applicable ACGME requirements. The DIO is responsible for the preparation and submission of the application for institutional accreditation.

The Institutional Requirements outline the responsibilities of the Sponsoring Institution, and the FAQ provides helpful clarifications of the requirements. (Be sure to review the version of the Requirements currently in effect.) The DIO should review the Institutional Requirements and FAQs to assess the Sponsoring Institution’s readiness to begin the application process.

The DIO submits a complete Intent to Apply for Institutional Accreditation form and then receives a username and password to access ADS.

The DIO logs in to ADS and begins the application. In ADS, the DIO can identify institutional coordinators who are also able to view and edit the institutional profile and application.

The DIO completes and submits the application, which consists of all information requested in the “Application Overview” tab of the institutional profile in ADS. This information includes data entry fields and document uploads that require substantial advance preparation. The Sponsoring Institution Application Form is one of the document uploads. Applications must be complete to be accepted for review by the Institutional Review Committee. Complete applications are typically scheduled for a review at a given Institutional Review Committee meeting if received by the corresponding agenda closing date published in the Institutional Review Committee section of the ACGME website. Questions regarding the application should be directed to institutional accreditation staff members.

The Institutional Review Committee meets to review the application and, if the application demonstrates substantial compliance with the ACGME Institutional Requirements, grants a status of Initial Accreditation to the Sponsoring Institution. The Institutional Review Committee withholds institutional accreditation if the Sponsoring Institution fails to demonstrate substantial compliance; in such cases, the Sponsoring Institution has opportunities to appeal the decision or to reapply for accreditation pursuant to ACGME policies and procedures.

The DIO receives notification of the accreditation status directly following the Institutional Review Committee meeting at which the application is reviewed. Sponsoring Institutions with Initial Accreditation are identified on the ADS public site. Upon notification of Initial Accreditation, the DIO may open applications for program accreditation. After the Institutional Review Committee meeting, the DIO receives the accreditation Letter of Notification, which includes any institutional citations that describe non-compliance with ACGME requirements. Upon receipt of this letter, the DIO initiates required institutional oversight processes to address any citations.