Decision Committee & Appeals Panel Operating Procedure

Field	Value
Document ID	CHSPS-ACC-108
Title	Decision Committee & Appeals Panel Operating Procedure
Edition	2026.1
Status	Published Procedure - effective August 19, 2026
Owner	Accreditation Governance
Supersedes	New document
Next review	No later than August 2028, or earlier upon material change
Publication authority	CHSPS controlled-document publication authority

Operating principle

Technical review, final decision and appeal are separate functions. The purpose of this procedure is to make the composition, conflict controls, quorum, record, voting, notice and appeal mechanics visible before any applicant relies on them.

1. Purpose and scope

1.1 This procedure shall govern the Accreditation Decision Committee, reconsideration routing that requires committee action, and every Appeals Panel convened for a CHSPS accreditation matter.

1.2 Technical reviewers develop findings and recommendations but shall not issue the final accreditation decision on the same file.

1.3 Applicant-support, education, membership, sponsorship, sales or other revenue functions shall not direct a committee or panel outcome.

2. Decision Committee composition and appointment

2.1 The Accreditation Decision Committee consists of five voting positions. A decision meeting shall include at least four conflict-free eligible voting members with collective competence appropriate to the accreditation pathway and the decision before them.

2.2 Standing committee composition shall include perspectives sufficient to evaluate technical conformity, due process and public-interest implications; no single employer, commercial interest or applicant category shall control the committee.

2.3 Members shall be appointed through documented authority and shall complete role orientation, confidentiality obligations and conflict-of-interest disclosures before service.

2.4 A person who provided paid applicant-specific consulting, served on the technical review team, or has another disqualifying interest in the matter shall not vote on that matter.

2.5 A conflict-free substitute may be appointed when recusals or absence would otherwise prevent quorum; substitute appointment and qualification shall be recorded.

3. Quorum, agenda and record closure

3.1 Quorum for an accreditation decision is four conflict-free eligible voting members of the five-position Accreditation Decision Committee. If recusals, vacancies or absence reduce eligible participation below four, the matter shall be deferred or a qualified conflict-free substitute shall be appointed under documented authority. Conflict requirements shall not be waived merely to achieve quorum or a target timeline.

3.2 The committee shall receive a case packet that identifies the applicable standards and edition, scope, material evidence, unresolved findings, applicant responses, reviewer rationale and any procedural issues requiring attention.

3.3 The case packet shall exclude sponsorship, membership, education-purchase and other commercial information not relevant to conformity or due process.

3.4 The record shall be treated as closed for decision when the required technical review and applicant response opportunities are complete. New material evidence after closure shall be handled through a documented reopening, reconsideration or remand rather than informal ex parte submission.

4. Conflict screening and recusal

4.1 Each assigned member shall complete case-specific conflict screening before receiving deliberative materials.

4.2 Potential conflicts shall be resolved before deliberation. Recusals, substitutions and the basis for a non-recusal decision shall be documented.

4.3 A recused member shall not participate in deliberation, vote counting or drafting of the decision rationale for the affected case.

4.4 If quorum cannot be achieved without a conflicted member, the matter shall be rescheduled or reassigned; conflict requirements shall not be waived merely to meet a target timeline.

5. Deliberation and voting

5.1 The chair shall confirm quorum, applicable standards, conflict status and the decision options before substantive deliberation.

5.2 Deliberation shall address whether the record supports conformity and the disposition of material findings under the published decision vocabulary.

5.3 The committee may request clarification of the existing record, but it shall not create or apply an unpublished substantive requirement.

5.4 A final decision requires a majority vote of eligible members present. Abstentions shall not be used to avoid a known conflict and shall be recorded.

5.5 When the vote does not produce a valid majority, the case shall be deferred for additional deliberation or reassignment; the chair shall not manufacture a casting vote unless that authority is expressly established in the governing charter.

5.6 Available initial outcomes are Accredited, Accredited - Compliance Report Required, Deferred and Denied, as defined in CHSPS-ACC-101.

6. Written decision and notice

6.1 Every decision shall identify the program/scope, governing standard edition, outcome, effective date where applicable, material findings or follow-up conditions, and a rationale sufficient to understand the basis of the decision.

6.2 An adverse or conditional decision shall identify the available reconsideration and appeal routes and the applicable filing period.

6.3 Decision notices shall be issued through an authorized CHSPS communication channel and retained with the accreditation record.

6.4 public verification publication shall occur only after the final status is eligible for publication under CHSPS-ACC-101 and the mark/claims rules.

7. Reconsideration routing

7.1 A timely reconsideration request shall identify the conclusion challenged, the reason for the challenge and the evidence already in the record that the requester believes was misunderstood or incorrectly evaluated.

7.2 A reconsideration that can be resolved by correcting an administrative or transcription error may be handled through the correction route defined by policy. After a final accreditation decision, any substantive reconsideration shall be routed to the Accreditation Decision Committee or an expressly authorized conflict-free substitute decision body and shall be decided under the same quorum, conflict-screening and record requirements that govern the original decision.

7.3 Before a final decision, factual or technical clarification may be handled within the technical-review function under the applicable review procedure. After a final decision, no technical reviewer, original decision participant with a disqualifying conflict, or other person shall decide substantive reconsideration merely by defending their own earlier finding, recommendation or action.

7.4 The written reconsideration outcome shall state what was reviewed, the disposition and any change to the original decision or finding.

7.5 A timely reconsideration tolls the appeal filing period; the appeal period runs from the written reconsideration outcome.

8. Appeals Panel formation and independence

8.1 An appeal shall be heard by a panel of at least three conflict-free members who did not participate in the underlying technical review, original decision or substantive reconsideration of the appealed matter.

8.2 Panelists shall be selected for competence in accreditation due process and the subject matter reasonably necessary to understand the record.

8.3 The appellant shall be notified of panel composition sufficiently in advance to raise a documented conflict challenge. A challenged panelist shall not decide their own challenge.

8.4 The Appeals Panel shall receive the complete appeal record, including the decision, relevant review record, timely appeal submission and the CHSPS response to the asserted procedural grounds.

8.5 The panel shall not conduct a new merits review merely because it would have weighed technical evidence differently; it shall apply the published grounds and remedies for appeal.

9. Appeal hearing and outcome

9.1 The panel may decide on the written record or conduct a remote or in-person hearing when oral clarification would materially assist due process.

9.2 If a hearing is held, both the appellant and CHSPS shall receive a reasonable and balanced opportunity to address the accepted appeal grounds.

9.3 The panel may uphold the decision, vacate it, remand specified issues, or require independent re-review within the remedies authorized by CHSPS-ACC-102.

9.4 The written appeal outcome shall state the accepted grounds, material reasoning, disposition and any required next action.

9.5 The appeal outcome is final within the CHSPS accreditation process unless the governing policy expressly provides another route.

10. Confidentiality, minutes and records

10.1 Committee and panel deliberations, nonpublic applicant evidence and individual voting positions shall be treated as confidential except to the extent publication or disclosure is authorized by controlled policy or law.

10.2 Minutes or a decision record shall document attendance, quorum, recusals, motions or decision disposition, vote result and required follow-up without creating unnecessary disclosure of confidential deliberation.

10.3 Case packets, conflict attestations, minutes, decision notices, appeal records and panel outcomes shall be retained under CHSPS-ACC-104.

10.4 Material procedural deviations shall be documented and evaluated for corrective action, including independent re-review when the deviation could have affected the outcome.

11. Calibration and quality oversight

11.1 Decision and appeal participants shall receive periodic calibration on decision vocabulary, due-process boundaries, conflicts, confidentiality and material changes to the standards or procedures.

11.2 CHSPS shall periodically review decision consistency, remand/reversal patterns, timeliness and procedural deviations as quality indicators.

11.3 Quality monitoring shall not be used to pressure a committee toward a target approval, denial or appeal-success rate.