Council on Accreditation for Respiratory Therapy Education Complaint Policy
Objectives
The purpose of this policy is to provide a mechanism to ensure that issues and concerns expressed by third parties are addressed appropriately and in a timely manner. The objectives of the complaints policy are:
- to maintain the integrity and credibility of the accreditation process;
- to ensure a fair and open process for stakeholders to identify concerns and questions regarding a program’s conformity with the requirements for accreditation;
- to provide a mechanism for accountability of the accrediting body to the public.
Premises and criteria
Program reviewers and members of CoARTE, as well as CSRT staff, are required to maintain the confidentiality of all information regarding the program and the assessment. If an outside party (third party) has reason to believe that an accredited program may not be in conformity with one or more of the requirements for accreditation, the party may submit a formal complaint to CoARTE. The complaint must describe a specific concern or concerns about the program and/or identify one or more accreditation requirement(s) that is/are not being met. The complaint must include evidence to support the stated concern(s).
In order for such a concern to be considered by CoARTE, a signed and dated written letter must be sent to CoARTE secretariat, along with any available supporting documentation. CoARTE will then consider the complaint in light of CoARTE Terms of Reference and Rules of Procedure, and/or CoARTE Accreditation Manual. If there are no violations of these documents, CoARTE will avow jurisdiction, and refer the issue back to the complainant.
Complaint process
Step 1
Before submitting a complaint to CoARTE, the third party must show evidence that they have attempted to resolve the complaint directly with program/institution officials by following the due process or grievance procedures provided by the program/institution. If the third party is unable to resolve the complaint with program/institution officials or believes that the concerns have not been properly addressed, he or she may submit a complaint of non-conformity in writing to CoARTE.
Step 2
The letter of complaint must include:
- a description of the nature of the complaint and the related accreditation policies or procedures that the complainant believes are not being met by the program. The complainant must provide supporting data for the charge.
- a demonstration that the complainant has made reasonable efforts to resolve the complaint, or alternatively that such efforts would be unavailing; includes verification and documentation (e.g., copies of grievance processes, communications verifying completion of processes, etc.) if the complaint is from a student or faculty/ instructional staff member at that institution, that the complainant exhausted all relevant institutional grievance and review mechanisms before submitting a complaint to CoARTE; and
- a signed covering letter including the complainant’s name, address, and telephone contact information and the complainant's relationship to the program in order for CoARTE secretariat to verify and communicate with the source of the complaint. All complaints must be submitted to CoARTE Chair, at the Canadian Society of Respiratory Therapists, 102-1785 Alta Vista Drive, Ottawa, ON K1G 3Y6. Complaints will not be accepted by e-mail or facsimile.
Step 3
Upon receipt of a written complaint, the accreditation secretariat forwards the submission to CoARTE for a decision within 14 calendar days as to whether action should be taken on the complaint. CoARTE’s decision is based on whether the complaint is relevant and within the scope of accreditation. If the issue(s) is/are not relevant or within the scope of accreditation, the complaint is not pursued.
Step 4
If CoARTE decides that the issue is relevant, CoARTE informs the program in question, within 14 calendar days of its decision, that a third party complaint has been received but does not disclose the name(s) of the complainant(s). CoARTE requests a response from the program within 30 calendar days. If the program’s next submission for reaccreditation is due within the next 6 months, CoARTE requests the program to include its response in the submission for reaccreditation.
Complaints that do not meet all of the above requirements will be returned to the complainant with an explanation. Complaints meeting the above requirements are transmitted by CoARTE Accreditation Manager to CoARTE Complaints Committee for consideration. Forms or letters submitted without signature or the required supporting material will not be considered.
CoARTE decision
Within 30 calendar days of the program’s response, CoARTE informs the program of its decision. CoARTE takes one of the following actions:
- maintains the program’s accreditation status with no further action, if the response provides evidence of continuing conformity with the requirements for accreditation;
- requests additional information if the response provides insufficient evidence of continuing conformity with the requirements for accreditation;
- conducts a site revisit if further evidence from program participants is required to validate the response and demonstrate program conformity with the requirements for accreditation. The site revisit is conducted within 60 calendar days of CoARTE’s decision. A program site revisit is mandatory to validate documented evidence of non-conformity before a decision is made on accreditation status. The institution contact is notified, and a date for the site visit is expeditiously scheduled. The program is responsible for expenses of the site visit. The site visit team is selected from the current roster of CoARTE program reviewers. During the site visit, emphasis is given only to those standards with which the program is allegedly not in conformity. The site visit team submits a written report to CoARTE no later than 30 days following the site visit. As with all other site visits, only the observations of the program reviewers are reported; program reviewers do not make accreditation recommendations. CoARTE forwards the report to the institution contact within 15 days. The program or institution should provide a written response to the chair of CoARTE within 30 days of the date on which the report is postmarked to the institution contact. The purpose of the response is to verify the accuracy of the site visit report. If the site revisit does not provide the required evidence of conformity, CoARTE changes the accreditation status of the program to reflect the program’s conformity level. The decision is communicated to the program in 15 days. If CoARTE withholds/ withdraws accreditation, the institution contact is informed within 15 days of CoARTE decision that accreditation has been withheld/ withdrawn. Notification also includes justification for the decision, and informs the program that it has the right to appeal the decision.
Program appeal
If the program chooses to appeal, CoARTE must receive the appeal within 30 days from the date of the notification letter. With the appeal, the program must submit additional written documentation to justify why accreditation should not be withheld/ withdrawn. CoARTE will evaluate the appeal and take one of the following actions within 30 days:
- Recommends modifications of the program within a specified period of time (except for those areas that are solely within the purview of the institution);
- Places the program on probation;
- Withholds/ withdraws accreditation.
Within 15 days CoARTE notifies the program of its decision.
Confidentiality
The confidentiality of the complaining party is protected by CoARTE unless release of identity has been authorized, or disclosure is required by legal action.
Reply to complainant
CoARTE informs the complainant within 30 calendar days of receipt of the complaint whether the complaint is being investigated, and if not, why not. Within 60 calendar days of CoARTE’s final response to the program following the investigation, CoARTE informs the complainant about the outcome of the investigation (i.e., whether the program is in conformity with the requirements for accreditation that were in question and whether the program is still accredited).
Summary of timelines:
14 days after receiving complaint – CoARTE’s decision whether complaint gives grounds for action;
14 days after decision of action – program is informed about complaint;
30 days – program must respond;
30 days after program’s response – CoARTE decides a course of action;
60 days from this decision - site revisit, if so required;
30 days for site revisit team to submit report to CoARTE;
15 days - CoARTE forwards report to program contact;
30 days from date of postmark – program should respond in writing to the report;
15 days – CoARTE notifies program of its decision;
30 days – program’s appeal in case that CoARTE withholds/ withdraws accreditation;
30 days – appeal’s evaluation and action;
15 days – CoARTE notifies program of its final decision;
30 days from receipt of complaint – CoARTE informs complainant;
60 days from final response to program – CoARTE informs complainant.
Report to CSRT Board of Directors
The CSRT Board of Directors will be informed when a legitimate complaint is received and the process initiated. Brief updates may be provided during the process, and a thorough account of the decision and the remedial course of action, if any, at the end of the process.
CoARTE discretion
CoARTE has the discretion to adjust the time frames for reports when circumstances unduly prejudice those who may be affected by the outcome of the complaints process. For example, CoARTE may extend the time frame if the report falls due over a holiday period; alternatively, CoARTE may shorten the time frame if the students enrolled in the program are close to graduation. CoARTE’s overriding consideration at all times is to promote high quality patient care through the maintenance of educational standards.
Profession of good faith
CoARTE is dedicated to providing a sustained quality of program evaluation and review. Established procedures are followed when complaints are received alleging that CoARTE has not complied with established accreditation practices, including nonconformity with its own policies and procedures, exceeding its scope as defined by the Meaning of Accreditation, the behaviour of its on-site program reviewers, or nonconformity with the CSRT Accreditation Manual and CoARTE Terms of Reference and Rules of Procedures.
No institution or person who, in good faith, makes a complaint against CoARTE, its members, agents, or its staff will be subject to harassment, retaliation, or adverse accreditation decisions by virtue of having lodged the complaint.
|
PRINT