Program Requirements are used by the Accreditation Council to determine program compliance when reviewing programs for accreditation. The Accreditation Council is responsible for preparation of subspecialty-specific program requirements, common program requirements, and for periodic revisions to reflect current educational practice. Program requirements include common program requirements applicable to all UCNS subspecialties. Subspecialty-specific program requirements are developed by the subspecialty. Program requirements, including common program requirements, must be approved by the UCNS Board of Directors.
Periodic reviews of program requirements, during which time the Accreditation Council works with subspecialty-recommended consultants, must occur at least every five years.
Effective Date of Revisions
Ordinarily, the effective date for the revised common program requirements and revised subspecialty-specific program requirements shall be the June 1 or December 1 that is at least six months following the Board meeting at which the requirements were approved. Under special circumstances, UCNS may designate an earlier or later date and make this information available on the UCNS website.
The Accreditation Council is responsible for the development of program initial and continuing applications, annual reports, and other documents required to attain and maintain accreditation. The completed forms serve as an application for a proposed program or for review of a currently accredited program. Submission of appropriately signed initial accreditation forms and payment of the initial fee by the program director and department chair constitutes a request by the program for review and accreditation. Submissions of an appropriately signed annual report by the program director and department chair constitutes a request by the program for review and maintaining accreditation. Submission of an appropriately signed continuing accreditation report by the program director and department chair constitutes a request by the program for review and continued accreditation.
The Accreditation Council reviews the completed program information forms and related correspondence in determining whether a program is in substantial compliance with the program requirements. The Accreditation Council designates an accreditation status for each program and identifies points of partial compliance and/or non-compliance with its standards. The program is evaluated on the basis of the program requirements that are effective at the time of the program review. A program director may be permitted to submit additional or revised information that arrives sufficiently in advance of the Council’s meeting to allow for proper review. During non-review years, programs submit an annual report to update UCNS of key program items.
Programs requesting consideration of accreditation for concurrent training between subspecialties with common educational information, including programs that would simultaneously confer eligibility for two UCNS certification examinations or ABMS and UCNS certification examinations upon graduating from the program, must complete the UCNS accreditation application process, including submission of an appropriate application and fee. Programs shall be required to demonstrate complete compliance with the UCNS subspecialty's program requirements. Upon receipt of the program's application, the Accreditation Council will review the application using its standard process.
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 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.
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.
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."
UCNS reviews grievances alleging that an accredited program is not in substantial compliance with the program requirements. Grievances must be submitted in writing (electronic submission is allowed), and include the following: the program's name, the complainant's name, a description of how the program is non-compliant, and details demonstrating that the complainant has exhausted all institutional avenues to remedy the situation.
Accreditation Council Procedures for Adverse Actions
The following procedures shall be used when the Council determines that a program is not in substantial compliance with the program requirements.
Senior Manager, Accreditation