Procedures are outlined for lodging a complaint against nurse anesthesia programs and against the COA in the Accreditation Policies and Procedures manual. The procedures are consistent with the accreditation agency recognition requirements of both the U.S. Department of Education and the Council for Higher Education Accreditation. Some important aspects of these procedures are outlined below. Please refer to the manual for the complete policy Complaints Against Nurse Anesthesia Programs.
The COA considers complaints against nurse anesthesia programs related to noncompliance with the Standards or policies and/or procedures. The COA should be contacted after exhausting any and all internal procedures available to the complainant within the institution. The complaint must contain sufficient information explaining how the program is violating a Standard or COA policy and/or procedure and must contain supporting documentation if available. The COA will not accept electronic protected health information.
A written statement that the complaint can be released to the program must be signed by the complainant and provided to the COA. If (for valid reasons) the complainant requests confidentiality, the COA Executive Director or designee will remove all identifying information from the complaint and the letter containing the complaint will be paraphrased. Anonymous complaints will not be considered unless a complaint suggests an imminent threat of harm to the program administrator, students, staff, patients, or others.
The COA will evaluate a complaint to determine if internal procedures within the nurse anesthesia program have been exhausted. The complaint will then be evaluated to determine if it relates to noncompliance with accreditation Standards or the COA’s policies and/or procedures. If the complaint relates to these areas, then the COA will investigate the complaint in a timely manner. The program and appropriate institutional officials will be notified when a valid complaint against a program is received by the COA. If necessary, the COA will refer a complainant to appropriate federal, state, and/or other agencies if the complaint does not relate to the Council’s Standards.
The COA can take a variety of actions based on its investigation, including:
- Take no action and dismiss the complaint,
- Conduct a supplemental onsite review,
- Defer consideration until the next routinely scheduled onsite review, or
- Make a decision affecting the current accreditation status of the program
(see Decisions for Accreditation).
The COA will notify the program administrator, other appropriate institutional personnel, and the complainant of its decision within 30 days of the time the decision is made.