Acceptable Protocol Used to File a Complaint against an Accredited Provider:
If an Accredited Provider was suggested to be NOT in compliance with the American Association of Continuing Medical Education® Accreditation Standards & Policies in one or more of its program activities (including conferences, satellite meetings, enduring material, …etc.) the following are the adequate protocol used to handle a complaint against the accredited provider, in addition to completing the Quality Incident Report Form:
1. Complaint must be filled out and signed by the person(s) or organization filing the Complaint.
Statute of limitation of the length of time an accredited provider is must be held accountable for any complaint is 24 months from the date of the activity in dispute.
The length of time for a CME provider to be held accountable for a Satellite Meeting, Enduring Materials (publications, including but not limited to CD-ROM, Video and Audio Cassettes) will be 24 months from the from the date of the activity in dispute.
2. Complaint MUST be mailed by registered mail (or carrier that provide verification of receipt).
3. Once the Complaint is received, a member of Accreditation Quality Auditing Committee (AQAC) will review it to determine whether it is in violation of American Association of Continuing Medical Education® Accreditation Standards & Policies.
4. If the Complaint was determined not to be in violation of the Accreditation Policies & Standards, the complainant will receive a detailed explanation to the action taken.
5. If the Complaint was determined not to be in violation of the Accreditation Standards & Policies, the QAC will issue a Letter of Dispute/Investigation to the accredited provider detailing the nature of the Complaint and informing them of the Committee’s action to initiate an immediate investigation to determine its validity. The Letter of Dispute will also ask the accredited provider to provide a detailed explanation with supporting documents.
a) If the accredited provider fails to respond to the Letter of Dispute/Investigation within 30 days, the Accreditation Quality Auditing Committee (AQAC) may choose to change the provider’s accreditation status “PROBATIONARY”.
b) If the accredited provider responds, the QAC will determine if an on-site visit is necessary to determine the validity of the Complaint.
6. If the QAC determines that the information provided is satisfactory, one of the following actions may be taken:
a) If the matter is clear and proves that the accredited provider was, in fact, in violation of the Accreditation Standards & Policies, the QAC will raise a Recommendation of Action to the Accreditation Review Committee (ARC).
b) If the matter is unclear and incomprehensible, the matter will be referred to the Investigation Committee (IC) who will look into the Accreditation Standards & Policies in depth to determine the action to be taken. This may require the Investigation Committee to hold a meeting with the accredited provider and require additional materials from the accredited provider to predetermine the finite details of the violation.
c) If the members of the Investigation Committee (IC) cannot capitulate on a proposition, the Committee will issue a detailed compendium report and present it to the president-elect who will form a Disciplinary Committee (IC) and call for a meeting with the Accreditation Quality Auditing Committee, Investigation Committee and the Accreditation Review Committee (Along with the formed Disciplinary Committee) to review the compendium and take votes from all members.
7. Based upon the decision taken by the three committees, the Accreditation Review Committee (ARC) will make its proposition to the Disciplinary Committee (DC) and the Disciplinary Committee will make its final determination of the action to be taken.
a) Notice of Compliance
i. If the accredited provider was found to be in conformity with the Accreditation Standards & Policies, the Disciplinary Committee will issue a “Letter of Compliance” in lieu to this Complaint.
ii. A copy of the “Letter of Compliance” will be mailed by First Class Registered Mail to the accredited provider and the complainant.
b) Notice of Compliance
i. If the accredited provider was found to be NOT in conformity of the Accreditation Standards & Policies the Disciplinary Committee will issue a “Letter of Non-Compliance” will be mailed by First Class Registered Mail to the accredited provider and the complainant.
ii. The “Letter of Non-Compliance”, which includes the Committee’s decision, enumerated area(s) of non-compliance, Letter of Dispute, accredited provider’s response, Letter of Complaint/Investigation, and the Investigation Committee’s Compendium Report will be documented in the accredited provider’s file and a copy will be sent to the accredited provider.
iii. The accredited provider will be requested to provide documentation of corrective action to the Accreditation Review Committee (ARC) (cc: Investigation Committee, Accreditation Quality Auditing Committee). Additionally, the Committee may request from the accredited provider to submit an Auditing Report. Failure to comply with that may affect the accreditation provider’s accreditation status.
iv. If the accredited provider fails to respond to the Request for notice of Corrective Action, the Accreditation Committee may request an immediate change of accreditation status to “PROBATIONARY”.
v. Once the Auditing Report is received, the Accreditation Review Committee will determine its commensuration:
a. If the Report is Sufficient, the Accreditation Review Committee will recommend its acceptance. This Report will be documented in the accredited provider’s file will be considered for future re-accreditation.
b. If the Report was Insufficient, the Accreditation Review Committee may request additional information from the provider or recommend a change in accreditation status to “PROBATIONARY”.
vi. If the accredited provider fails to provide the requested Auditing Report, the Accreditation Review Committee may request a team of surveyors to conduct an on-site visit or a change in accreditation status to “PROBATIONARY”.
Do you have a complaint about a quality of continuing medical education activity at an accredited provider’s organization? The American Association of Continuing Medical Education® wants to hear from you as a health care professional. Send us your complaint by fax or e-mail. Summarize the issues in one to two pages and include the name, street address, city, state and country of the health care organization (Accredited Provider).
The following is a Quality Incident Report Form needed to start an investigation/dispute regarding an accredited provider, suggested to be NOT in compliance with the Accreditation Policies & Standards. In addition to this form, as a complainant, you are required to read the information on How to File a Complaint against an Accredited Provider, which provides you with the appropriate procedure for filing a complaint regarding an Accredited Provider, prior to completing this Form. You may download a copy of the How to File a Complaint against Accredited Provider information, Click here to download the form.
