Note: This process applies only to
complaints regarding providers of Continuing Medical Education; it does not
cover providers of health care.
A. Complaint Status and Statute of Limitation
- Complaints are written notifications to the Massachusetts
Medical Society (MMS) by a third party which claim that an MMS
accredited Provider ("Provider") is not in compliance with MMS
Rules (defined herein as MMS Policies, ACCME Standards for
Commercial SupportSM, Essential Areas and Elements and
accreditation criteria required by the MMS) with regard to one or
more of its activities ("Complaint").
- To receive status as a Complaint, the written Complaint must
identify the accredited Provider, identify the CME
activity in question if applicable, and confirm the name, US Postal
Service address and contact information of the person making the
submission ("Complainant"). The MMS will send a letter of
acknowledgement to the Complainant confirming that the Complaint
has been received and will be reviewed.
- A Complaint may refer to a) single activities/series, or b) the
Provider's entire program of continuing medical education
(CME).
- The statute of limitation of the length of time during which an
accredited Provider must be accountable for any Complaint by the
MMS is twelve (12) months from the date a live activity is ended,
or in the case of a series, twelve (12) months from the date of the
session which is in question. Providers are accountable for
an Enduring Material during the period of time it is being offered
for AMA PRA Category 1 Credit™ CME, and twelve (12) months
thereafter.
- MMS may initiate a Complaint against an accredited
Provider.
B. Procedure for Complaint Review and Provider
Response
- MMS will review the Complaint to determine whether it relates
to the manner in which the Provider complies with the MMS's
Rules.
- If the Complaint does not relate to the Provider's compliance
with MMS Rules, the Complainant will be advised of MMS's position
and the Complaint process will be closed.
- If the MMS determines that the Complaint relates to the
Provider's compliance with MMS Rules, then MMS will send a letter
which identifies the alleged non-compliance to the Provider
("Notice of Complaint"). The Notice of Complaint from MMS may
include a request for documents or data from the Provider.
MMS will attach a redacted copy of the Complaint to the Notice of
Complaint. The identity of the Complainant will be deleted
from the Complaint. To the extent feasible, MMS will not
disclose the identity of the Complainant during the Complaint
process, but the identity of a Complainant may be evident due to
the circumstances of the Complaint, and the Complainant's identity
may be revealed in a legal proceeding.
- The Provider shall either admit the allegations of the
Complaint or provide a written rebuttal and any information
requested by the MMS within forty-five (45) days of receipt of the
Notice of Complaint. The Provider's failure to provide
information requested by the MMS within the forty-five (45) day
time limit may contribute to a finding of non-compliance. The
Provider will be informed in writing that a change of status to Non
Accreditation may occur if the Provider has failed to respond to
the request for information in the manner stipulated by the
MMS.
C. MMS Findings and Decisions
- Subject to the Complaint, the Provider will be found in
Compliance or Not in Compliance for that activity. The
completed process and the findings will be kept confidential by
MMS, with the exception of MMS's response to a lawful subpoena or
other legal process; provided, however, that MMS reserves the right
to make public the non-compliance issue without naming the Provider
which was in non-compliance.
- The Provider will be notified of the finding.
If the finding is Not in Compliance, the non-compliance will be
described in a Notice of Non-Compliance to the
Provider.
- If an activity is found to be in Non-Compliance with the ACCME
Standards for Commercial Support 1 (Independence), Standard
for Commercial Support 5 (Content and Format without Commercial
Bias), or the Content Validation Value Statements, the accredited
provider is required to provide corrective information to the
learners, faculty, and planners. The provider will submit to
the MMS a report describing the action that was taken and the
information that was transmitted. Providers will determine
how to communicate the corrective information and are under no
obligation to communicate that the activity was found in
Non-compliance with MMS requirements.
- In addition, the MMS may also take the following actions in
response to a finding of non-compliance:
- MMS may require the Provider to submit documentation of
corrective action within thirty (30) days of receipt of the Notice
of Non-Compliance.
- MMS may require the Provider to submit a Monitoring Progress
Report at a time determined by the MMS.
- MMS may change the Provider's accreditation status to Probation
or Non-Accreditation; and
- If the Provider fails to convert Non-Compliance to Compliance
via documentation of corrective action, monitoring progress report,
or other remedial measures, MMS reserves the right to change the
Provider's accreditation status to Probation or
Non-Accreditation.
- If a Provider is found Not in Compliance, documents related to
the Complaint review (such as the Complaint, Notice of Complaint,
Provider's response, documentation of corrective action, or
monitoring progress report) will be placed in the Provider's file
and made available to the survey team and MMS Committee on
Accreditation Review as part of the MMS reaccreditation
process.
- After a decision has been made, the Complainant will receive a
Letter of Acknowledgement indicating the Complaint has been
reviewed, appropriate steps taken as necessary, and the matter
is closed.
- At any point in the Complaint process, the MMS reserves the
right to require an immediate full or focused accreditation survey,
including a full or focused self-study report and interview.
- When asked for "documentation of corrective action", the
Provider will be asked to provide documentation of corrective
action to the MMS within thirty (30) days of receipt of the Notice
of Non-Compliance, and will be notified that failure to correct the
deficiencies may result in an immediate resurvey which may affect
the Provider's accreditation status.
- If the Monitoring Progress Report adequately describes and
documents Compliance, it will be accepted. If the Monitoring
Progress Report does not adequately describe and/or document
Compliance, it will NOT be accepted.
- Regarding Request for Information or Response: Change of
status to Probation may automatically occur at forty-five (45) days
from the time the Provider receives a request for
information/response from the MMS, if the Provider has failed to
provide a response or provide the requested information.
- Regarding Documentation of Corrective Action: Change of
status to Probation may automatically occur at fifteen (15) days
after the due date for the notice set by the MMS, if the Provider
has failed to submit the required documentation of corrective
action.
- Regarding Monitoring Progress Report: Change of status to
Probation may automatically occur at thirty (30) days after the due
date for the Monitoring Progress Report set by the MMS, if the
Provider has failed to submit the required Monitoring Progress
Report.
Each instance of a failure by a Provider to respond
as described in paragraphs 7-9 shall be considered a "failure to submit."
- Change of status to Non-Accreditation may occur at thirty (30)
days from the date a Provider was placed on Probation for failure
to submit information or a response, documentation of corrective
action, or a Monitoring Progress Report if the Provider has still
failed to submit the required information and/or
documentation. Change of status to Probation or
Non-Accreditation for "failure to submit" does not require MMS
Committee on Accreditation Review action.
- MMS will send a notice to the Provider of a change of status in
a manner that confirms receipt (e.g., email, USPS certified mail,
FEDEX-type courier).
- Except for an automatic change in status due to a Provider's
"failure to submit", a Provider's compliance must be reviewed by
the MMS's Committee on Accreditation Review to either a) change the
Provider's accreditation status to Probation or Non-Accreditation
or b) proceed with a full or focused accreditation survey,
including a full or focused self-study report and interview.
Complaints may be submitted to:
Nancy Marotta
Manager, Recognized Accreditor Program
Massachusetts Medical Society
860 Winter Street
Waltham, MA 02451
(781) 434-7906
(781) 642-1246 (Fax)
nmarotta@mms.org
