Accreditation FAQs

Accreditation Criteria

Where can I find examples of Compliance and Non-Compliance of the Accreditation Criteria?  

http://www.accme.org/examples-compliance-and-noncompliance


What is a Regularly Scheduled Series (RSS)?

A regularly scheduled series (RSS) is a CME activity that is planned as a series with multiple, ongoing sessions, e.g., offered weekly, monthly, or quarterly; and is primarily planned by and presented to the accredited organization’s professional staff.  The RSS should be entered once into PARS with the date of the first session of the series. The number of hours of instruction, number of AMA PRA Category 1 credits, and number of learners should be aggregated for all sessions in the series.  

For more detailed information about RSS visit: http://www.accme.org/education-and-support/video/tutorials/resources-planning-and-monitoring-regularly-scheduled-series


How are Regularly Scheduled Series (RSS) reported in PARS?

http://www.accme.org/ask-accme/how-do-i-report-information-about-regularly-scheduled-series-rss-pars 


What are some sources to help identify practice gaps -- Criterion 2? 

http://www.massmed.org/Continuing-Education-and-Events/CME-Accreditation-for-Institutions/Resources-for-Identifying-Practice-Gaps 


Where can I find a sample of a disclosure form?

Please refer to this link for other sample forms and documents: MMS-CME Accreditation for Institutions - http://www.massmed.org/Continuing-Education-and-Events/CME-Accreditation-for-Institutions/CME-Accreditation-for-Institutions

What are methods/mechanisms to resolve a conflict of interest?

http://www.accme.org/sites/default/files/null/SCS%20Toolkit%202_344_Identifying_and_Resolving_COI_20120207.pdf


What are some examples of language to make disclosure to learners? 

  1. The following individuals  have disclosed relevant financial relationship with commercial interests: The name of the individual, the name of the commercial interest(s), the nature of the relationship the person has with each commercial interest.
    1. Use statement #1 if relevant financial relationship exists for faculty or others.
  2. None of the individuals in a position to control the content of the CME activity have any relevant financial relationships to disclose.
    1. Use statement # 2 when all parties including faculty, moderators, planners  . . .  etc., have no relevant financial relationships to disclose.
  3. None of the planners and/or members of the CME committee have any relevant financial relationships to disclose.
    1. Statement # 3 could be used in combination with #1 if the planners/CME committee have nothing to disclose but the faculty/speakers/ moderator/others have relevant financial relationships to disclose.


Are electronic signatures on disclosure forms acceptable?

Yes


What is the difference between relevant relationships and significant relationships?

http://www.accme.org/ask-accme/what-difference-between-significant-financial-relationships-and-relevant-financial


Examples of program analysis for Criterion 12

  • Title of activity, activity format, date, location, joint provider (if applicable), participation data (by physicians and other learners)
  • Whether activity was designed to change competence, performance, and/or patient outcomes and if changes in competence, performance, and or patients outcomes were measure
  • Reported knowledge and strategies gained that learners did not have before participating.

The following chart shows the changes measured for all activities offered in 2011. 

FAQs Chart 1 
Table 1

Activity Evaluation

The above data shows that the majority of our activities succeeded in changing our learners’ competence.  Further analysis of evaluation data related to competence, revealed that respondents learned at least one relevant strategy to their practice that they did not have before participating in our activities- see table 2.  Some of the knowledge and strategies reported by participants include cognitive and behavioral changes and cultural awareness. 

FAQs Chart 2
Table 2

Although we are on the right track impacting our learners’ knowledge and competence, we are challenged by the limited effect our CME activities are having on physicians’ performance or patient outcomes.  Only eight percent of learners indicated that our activities will impact their performance, while one percent reported improvements in patient-related outcomes - see table 1. 
For 2012, our CME leadership, planners and educational design experts will convene to discuss ways to tackle this challenge.  Representatives from our audience will be invited to provide more in depth input about our activities.  It is also important to note that the reported data represent a very small fraction of our learners.  Despite multiple attempts to engage learners, only 12% of surveyed learners completed post activity evaluations - another challenge to address for 2012.


How should the Credit Designation and Accreditation Statements be listed on activity materials? 

http://www.massmed.org/Continuing-Education-and-Events/CME-Accreditation-for-Institutions/Designation/Accreditation-Statements 



Licensing Board Regulations

What qualifies for Risk Management (RM)? And how should it be listed on promotional materials?

For an activity to be eligible for RM study, the content must include instruction in medical malpractice prevention such as risk identification, patient safety, and loss prevention. In addition, it may include courses in medical ethics, quality assurance, medical-legal issues, patient relations, non-economic aspects of practice management, or courses designed to reduce the likelihood of medical malpractice through means other than increasing the licensee’s medical education and technical competence. Risk management study also includes review of the Board of Registration in Medicine’s Patient Care Assessment regulations (234 CMR 3.01-3.16) and participation on designated peer review committees dealing with quality assurance. Content in Pain Management, End of Life Care, and Electronic Health Records is also eligible for risk management study.


What language should be used to designate activities that are eligible for Risk Management Study?

You may use the following:

This activity meets the criteria of the Massachusetts Board of Registration in Medicine for risk management study. OR [number of credits] meet the criteria of the Massachusetts Board of Registration in Medicine's for risk management study.  


Accreditation Survey

How should the Self-Study be organized?

  • Requirements for Organizing and Formatting Your Self-Study Report
    • The Self-Study Report must be formatted as indicated to facilitate the review of your CME program: The cover of each of the two Self-Study Report binders should clearly identify your organization by name. Use the full name of your organization as it is known to the MMS (no acronyms or abbreviations).
  1. Each page in the binder, including the attachments, must be consecutively numbered.  
  2. The Self-Study Report must be organized using divider tabs as specified by the MMS.  
  3. Narrative, attachments, and examples must be provided as indicated in the MMS Self-Study Report Outline.
  4. The Self-Study Report must be typed with at least 1” margins (top, bottom and sides), using 11 point type or larger; double-sided printing is acceptable and encouraged.
  5. Pertinent excerpts must be photocopied on standard paper for inclusion in the binder. Do not use plastic sleeves for single pages or for multi-page documents (i.e. brochures, handouts, etc.).
  6. The Self-Study Report must be submitted in a three-ring binder. The rings may not be more than 1½ inches in diameter, and the materials may not be more than 1 ½ inches in thickness.
  7. Two hard copies of the Self-Study Report must be submitted to the MMS. Keep a separate duplicate copy for your reference at any time during the accreditation process, but especially at the time of the accreditation interview.  
  8. One electronic copy of the Self-Study Report in its entirety must be submitted to the MMS (in addition to the two binders), as a single PDF file on a USB flash drive, bookmarked according to the seven sections of the MMS Self-Study Report Outline.
  • Regarding Self-Study Report Divider Tabs  
    • The Self-Study Report must be organized using divider tabs to separate the content of the report in the seven sections of the MMS Self-Study Report Outline. For the purpose of printing tabs, the titles of the sections have been abbreviated as follows:

I) General Information

II) Prologue

III) Purpose and Mission (C1)

IV) Educational Activities (C2-7 and Policies)

V) CME Program and Educational Activities (C8-9)

VI) Content of Educational Activities (C10 and Content Validation)

VII) Evaluation and Improvement (C11-13)

VIII) Engagement with the Environment (C16-22)


What will the Survey Interview entail?

The survey interview provides an opportunity for your organization to discuss your CME program and your organization’s policies and practices to ensure compliance with Accreditation Criteria, including the Standards for Commercial Support and Accreditation Policies. The surveyors will seek clarification about any questions they may have regarding the self-study information materials you submitted to the MMS. The surveyors may request or collect information in support of your compliance that was not included in the self-study report or in the evidence of performance-in-practice submitted for selected activities.  Interviews typically average 90 minutes in length and can be held at the accredited provider’s site, MMS headquarters, or via conference call.  


What is the deadline for submitting annual accreditation and other fees? 

All fees are due to MMS within 60 days of the date of the invoice. 


Reporting in PARS  

What is the deadline for submitting to Program and Activity Reporting System (PARS)?

The deadline to submit your previous year’s activities into PARS is March 15th unless otherwise indicated.  PARS Annual Report late fees will apply - http://www.massmed.org/Continuing-Education-and-Events/CME-Accreditation-for-Institutions/Accreditation-Fees-for-MMS-State-Accredited-Providers

How to do a “batch upload” of activities into PARS.  

http://www.accme.org/education-and-support/video/tutorials/pars-tab-delimited-upload-process-tutorial


Other

Sample Director of Medical Education Job Description


Sample CME Coordinator Job Description


Writing learning/activity objectives:

http://www.massmed.org/Continuing-Education-and-Events/Joint-Providership/Writing-Activity-Objectives



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