American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Existing AEIs—Maintaining Accreditation

The ACS-AEI Program sent out an announcement regarding the new Continuous Monitoring Model of Accreditation. Review the memo for additional information.

View memo

Maintaining Accreditation

During the five-year accreditation cycle, Institutes, on a yearly basis, are required to:

  • Attest to continued compliance with the Standards
  • Keep documentation/evidence of compliance, and live by the letter and spirit of the Standards
  • Maintain their contacts in the Portal to ensure communications are received
  • Submit an Annual Compliance Report in the off-years (2, 3, 4)
  • Pay an annual fee

The Annual Compliance Report

AEIs must complete an Annual Compliance Report in their off-years to enable the ACS-AEI Program to monitor continuing compliance with the Standards. The Report is not optional and is required for several reasons, including:

  • To demonstrate and attest to continued compliance with the Standards
  • To keep accredited programs continually aware of the Standards and educated on how to best meet the requirements, particularly when there is a leadership/staff change at the Institute
  • To provide accredited programs the opportunity to receive feedback on any changes that may affect their accreditation status and to receive suggested actions to take to maintain compliance with the Standards
  • To provide accredited programs with data to help them determine how they are performing as compared to their peers

Annual Compliance Reports are administered through the AEI Portal and reviewed by AEI staff. In turn, AEIs will receive an annual Report Card that indicates whether or not the criteria are being maintained. Any criteria that are not being maintained will be reviewed by the Accreditation Review Committee (ARC). In limited situations, the annual report may provide data leading to a progress report after ARC review, if the AEI fails to respond or its response demonstrates intended lack of compliance with the Standards.

Reaccreditation and Site Visits

At year five, all AEIs will complete an application and participate in a virtual site visit with an assigned surveyor. The surveyor will also have access to the AEIs’ previously submitted Annual Compliance Reports and Report Cards. The results of the virtual site visit will be reviewed by the Accreditation Review Committee and a decision will be made to reaccredit for another five years. Please note at year ten, an on-site visit by one surveyor is required.

Access the AEI Accreditation Portal

For questions about maintaining accreditation or to schedule an “Accreditation 101” session for new/existing staff at your AEI, contact Cathy Sormalis, Manager of the Program for Accreditation of Education Institutes, at csormalis@facs.org or 312-202-5535.