142 East Ontario Street, Chicago, IL 60611-2864
ph 312 202 8000  800 621 1773
Guidelines for Correction of Deficiencies
Each program cited by the PTRC for one or more deficiencies must file a Corrective Action Plan listing the
steps that the program will take to correct those deficiencies. The citation of deficiencies, and the corrective
action process, can work as aids to programs in focusing resources in specific areas in a process of continuous
improvement. Although the perception of sanctions is inevitable, that is not the primary intent. The process
described below provides a guide to programs, OPTIs, and the specialty colleges in utilizing deficiencies for
improvement in program quality. Your feedback on this process is valuable – please direct your comments to
[email protected]
Corrective Action responses are tracked and are reported to the PTRC. If a program does not file a
Corrective Action Plan the program may be cited for an additional deficiency. If you have any concerns
about how to file this plan properly, please contact your OPTI officer or staff in the AOA Division of
Postdoctoral Training.
Time Line

PTRC Notification: The Division of Postdoctoral Training will send notification of Program and
Trainee Review Council (PTRC) actions within 15 days of each meeting. The notification letter will
include the deficiencies as recommended by the specialty college and approved by the PTRC.

Corrective Action Plan: The program will file a plan for the correction of those deficiencies with
their OPTI within 45 days of receipt of the PTRC letter. The Corrective Action Plan should cite
each deficiency and the plan for correcting that deficiency. The plan needs to be verifiable, i.e. what
documentation can the program submit that will verify that the deficiency is corrected.

OPTI Action: The OPTI GMEC (Graduate Medical Education Committees) will review the
Corrective Action Plan within 30 days of receipt. If the plan is accepted, the OPTI will forward the
plan with approval to the PTRC in care of the AOA Division of Postdoctoral Training. If the plan is
not accepted, the OPTI will notify the AOA of the status of the plan. Transmission through
FileWorks is encouraged if available to your institution through your OPTI.

Specialty College Action:
o
o
o
On receipt of the plan, the AOA will send an electronic copy to the specialty college and will
track the corrective action. The EEC (education and evaluating committee) of the Specialty
College must review the Corrective Action Plan within 45 days.
If the EEC accepts the action plan, they will send an Acknowledgement Resolution to the
AOA, which will notify the program that the action plan is accepted. A copy of this
notification will be included in the site review materials for the next on site review for that
program
If the EEC does not approve the action plan, they will submit a Denial Resolution with an
explanatory statement to the PTRC for formal action.
(see page 2 over)
AOA Corrective Action Plans Memo (Rev. 04/2013)
Page 2
What if one or more deficiencies were cited in error?
Rules for reconsiderations by PTRC allow programs to ask for a review of deficiencies that are cited as Error
in Fact. Submit such requests as a separate section in your action plan. State the deficiency and attach
documentation of evidence that the deficiency did not in fact exist at the time of site review. Error in Fact
will not apply where documentation or other information could have been presented to the inspector but was
not, or where the deficiency was corrected after the site review took place.
What if my program was cited for a deficiency that is now corrected?
If your program was cited for a deficiency that was corrected after the site review you can highlight this as
“Correction Implemented” in a separate section of your action plan. Please attach supporting
documentation as evidence that the plan for correction of the deficiency was implemented.
What if I file a Corrective Action Plan and there is no response from AOA or from the specialty college?
AOA also tracks compliance on corrective action plans by each of the specialty colleges and files follow up
actions with the colleges. Reports on specialty college compliance are also reported PTRC. No program will
be cited for failure of the specialty college to respond.
What is the Next Step? Programs will implement the approved corrective action plan according to the
guidelines below.
Guidelines for Implementation of Corrective Action
Policy Change: The AOA Board of Trustees approved a significant change in the Implementation Phase of
the Corrective Action process. OPTIs will now monitor and assist with the Implementation phase, and will
communicate their processes to member institutions. Please direct questions to your OPTI office or the
AOA Division of Postdoctoral Training at [email protected]. The current process is described
below for information purposes and documents submitted under this process will be reviewed.
Programs should submit documentation as Evidence of Implementation of the Corrective Action for
correction of deficiencies to their OPTI.

Specialty College Acceptance of the Corrective Action: Within fifteen (15) days of the specialty
college acceptance of the action plan, the AOA will send a written acknowledgment of the plan to
the program director.

Documentation of Implementation: Within six (6) months to nine (9) months of receipt of the
acknowledgment above, the program will file documentation of Evidence of Implementation of the
Corrective Action with their OPTI. The OPTI will review the documentation and, if approved
forward a confirmation of this approval to the AOA (actual evidence does not need to be forwarded
only confirmation of approval by OPTI). If documentation is not approved as satisfying the
deficiency, the OPTI will advise the AOA of the status of the correction plan.

Specialty College Action: No specialty college action is required. If the specialty college education
and evaluating committee wants to review the Evidence of Implementation the AOA will forward a
copy on request to the specialty coordinator.