Liaison Committee on Medical Education
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Process for Appeal of an Adverse Action: Denial or Withdrawal of Accreditation


The appeal shall be limited to the time and circumstances that triggered the LCME action (e.g., a survey visit, status report, etc) and shall be based solely on the information contained in the final survey report. Descriptions of changes made since that time will not be considered, except as expressly provided herein.

 

Notice of LCME Action

Upon a finding that a program of medical education is not in substantial compliance with the LCME's published accreditation standards, and imposition of an appealable action affecting accreditation by the LCME, the LCME Secretariat shall promptly notify the sponsoring institution in writing of the action and of the specific areas of noncompliance that support the imposition of the action. The Secretariat also shall inform the sponsoring institution of the right to appeal.

 

Notice of Appeal

If it wishes to appeal the LCME's decision, the sponsoring institution must notify the LCME Secretariat within thirty (30) calendar days from the date of receipt of the notice of the LCME action. Such Notice of Appeal must be addressed to the LCME Secretariat and must contain a concise statement of why the institution believes that the LCME's action (1) was based on a procedural error that materially affected the outcome of the accreditation review process, or (2) the adverse action imposed by the LCME is arbitrary and capricious.

 

If a Notice of Appeal is not received by the LCME within thirty (30) days, the LCME's initial action shall constitute final action by the LCME.


LCME APPEAL PROCESS FOR ADVERSE ACTIONS

The LCME appeal process for adverse actions consists of a final appeal to an independent Appeals Panel. No person shall be present for or participate in the final appeal by the independent Appeals Panel if he or she has a conflict of interest as determined under the LCME Conflict of Interest Guidelines except as provided below.

 

APPEAL AT A HEARING BEFORE AN INDEPENDENT APPEALS PANEL

The appeal process consists of a hearing before an independent Appeals Panel. The Appeals Panel shall be appointed by the LCME Secretariat in consultation with the Co-Chairs and shall include individuals who are former LCME members or who otherwise meet the qualifications for membership on the LCME, such as educator or practitioner status as defined by the LCME. There will be three members of the Appeals Panel, including a representative of the public, and three alternate members, including a representative of the public, who will be called upon to participate if an Appeals Panel member must be excused.

 

No person shall be included on an Appeals Panel for a given program if he or she has participated in a survey visit that triggered the adverse action; reviewed recent survey findings, status reports, or other LCME findings or conclusions regarding that program on behalf of the LCME; or has a conflict of interest as determined under the LCME Conflict of Interest Guidelines.

 

Once the Appeals Panel has been established, neither the sponsoring institution nor any member of the LCME shall contact any member of the Appeals Panel concerning the matter under appeal.

Information Presented to the Appeals Panel

The LCME Secretariat shall forward to each member of the Appeals Panel the following materials, which shall constitute the Appeal Record: the survey report that was available to the LCME and upon which the LCME relied in the action that is the subject of the appeal, a copy of the Letter of Accreditation notifying the institution of the adverse action, and a copy of the institution's Notice of Appeal and supporting documentation. No new information will be presented to or will be considered by the Appeals Panel; provided that, if (1) the adverse action that is the subject of appeal was based solely upon a failure by the institution to meet an accreditation standard pertaining to finances, (2) the information was unavailable to the institution prior to the decision by the LCME to take the adverse action, and (3) the information is significant and bears materially on the financial deficiencies identified by the LCME, that information also will be forwarded to and may be considered by the Appeals Panel.

Timing of and Representation at the Appeals Panel Hearing

The Chair of the Appeals Panel shall notify the institution in writing of the date, time and place of the hearing. The notice shall be provided at least forty-five (45) calendar days prior to the hearing. The notice shall advise the institution that it:

  1. may send representatives to appear before the Appeals Panel;
  2. may be represented by legal counsel; and
  3. may submit a written response to the LCME's cited areas of noncompliance. Such response must be limited to the time and circumstances that triggered the adverse action and shall be based solely on the information contained in the final survey report. Descriptions of changes made since that time, may not be submitted unless otherwise provided herein.

 

The institution's written intent to send representatives to appear before the Appeals Panel, the names of the representatives and, if any, the legal counsel who will attend the hearing, must be received by the Chair of the Appeals Panel no later than twenty-one (21) calendar days before the scheduled date of the hearing.

 

The institution will be notified that failure to appear without good cause or failure to notify the Chair of the Appeals Panel at least ten (10) calendar days before the scheduled date of the hearing that it will not appear may result in the Appeals Panel making its decision based on the information before it with no further opportunity for an appearance by the institution.

 

During the hearing, the LCME will be represented by one co-chair, one member of the Secretariat, and legal counsel.

Conduct of the Hearing Before the Appeals Panel

While strict adherence to the formal rules of evidence shall not be required, irrelevant or unduly repetitious statements may be ruled out of order. The hearing shall follow the following general format:

a. Introductory statement by the Chair of the Appeals Panel

b. Oral presentation by the LCME Co-Chair presenting the grounds for the adverse action (30 minutes).

c. Oral presentation by the institution (one hour).

d. Questions by the Appeals Panel.

e. Appeals Panel executive session (15 minutes).

f. Additional questions by the Appeals Panel.

g. Closing statement by the institution (15 minutes).

h. Adjournment. A record of the hearing shall be made by a certified court reporter.

 

Decision of the Appeals Panel

At the conclusion of the hearing, the Appeals Panel shall meet in executive session to review the proceedings and to reach a decision. The Appeals Panel shall consider the Appeal Record and the information presented during the hearing. The Appeals Panel shall determine by majority of those members present whether substantial evidence supports the existence of each of the cited areas of noncompliance with accreditation standards, and whether the adverse action should be affirmed, modified or reversed.

 

The Appeals Panel shall make one of the following decisions :

a. Affirm the adverse action; or

b. Reverse or modify the adverse action; or

c. Remand the matter back to the LCME for further consideration, identifying specific issues that the LCME must address.

 

If the Appeals Panel determines that there is no reason to alter the adverse action, it shall affirm the action. If the Appeals Panel determines that the adverse action is not supported by the evidence, or was not made in substantial accordance with LCME policies and procedures, it shall reverse or modify the adverse action, or remand the matter back to the LCME for further consideration, identifying specific issues that the LCME must address.

 

The Appeals Panel determination and instructions to the LCME shall be submitted to the LCME using the format of the LCME's Appeal Decision Template, which includes a written report of the Appeals Panel decision and the reasons therefore, and specific implementation instructions for the LCME, if any.

 

The Appeals Panel process, including the filing of the report with the LCME, shall be completed within ninety (90) days from the time that the institution files its Notice of Final Appeal.

 

The decision of the Appeals Panel shall constitute the final decision of the LCME, except as provided below.

LCME Implementation of the Appeals Panel Decision

The LCME shall act in a manner consistent with the Appeals Panel decision or instructions. If the matter was remanded back to the LCME for further consideration, (1) the LCME shall reconsider the matter paying close attention to the specific issues identified by the Appeals Panel and, in such circumstance, (2) the decision of the LCME shall be final.

 

The LCME Secretariat shall notify the institution in writing of the Appeals Panel decision, and the action taken by the LCME to implement such decision, including the reasons therefore, within thirty (30) calendar days after receipt of the Appeals Panel Report.