Massachusetts Medical Society: Accreditation Requirements

Accreditation Requirements

ACCME/MMS Accreditation Requirements 

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The Massachusetts Medical Society (MMS) Guidelines

The MMS issues procedural guidelines and policies that supplement the ACCME’s Criteria and Standard for Integrity and Independence in Accredited Continuing Education. Accredited providers must adhere to the MMS procedural guidelines that are relevant to their organizations, as well as to the Accreditation Criteria and Standard for Integrity and Independence in Accredited Continuing Education.

Accreditation Statement

The accreditation statement must appear on all CME activity materials and brochures distributed by accredited organizations, except that the accreditation statement does not need to be included on initial, save-the-date type activity announcements. Such announcements contain only general, preliminary information about the activity such as the date, location, and title. If more specific information is included, such as faculty and objectives, the accreditation statement must be included.

The MMS accreditation statement is as follows:

  • For Directly Provided Activities: “The (name of accredited provider) is accredited by the Massachusetts Medical Society to provide continuing medical education for physicians.”
  • For Jointly Provided Activities: “This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Massachusetts Medical Society through the joint providership of (name of accredited provider) and (name of non-accredited provider). The (name of accredited provider) is accredited by the Massachusetts Medical Society to provide continuing medical education for physicians.”

There is no "co-providership" accreditation statement. If two or more accredited providers are working in collaboration on a CME activity, one provider must take responsibility for the compliance of that activity. Co-provided CME activities should use the directly provided activity statement, naming the one accredited provider that is responsible for the activity. The MMS has no policy regarding specific ways in which providers may acknowledge the involvement of other accredited providers in their CME activities.

CME Content: Definition and Examples

Continuing medical education consists of educational activities which serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession. The content of CME is that body of knowledge and skills generally recognized and accepted by the profession as within the basic medical sciences, the discipline of clinical medicine, and the provision of health care to the public.

CME Clinical Content Validation

Accredited providers are responsible for validating the clinical content of CME activities that they provide. Specifically:

  1. All the recommendations involving clinical medicine in a CME activity must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.
  2. All scientific research referred to, reported, or used in CME in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection and analysis.
  3. Providers are not eligible for MMS accreditation or reaccreditation if they present activities that promote recommendations, treatment, or manners of practicing medicine that are not within the definition of CME, or known to have risks or dangers that outweigh the benefits or known to be ineffective in the treatment of patients. An organization whose program of CME is devoted to advocacy of unscientific modalities of diagnosis or therapy is not eligible to apply for MMS accreditation.

Content Validity of Enduring Materials

Providers that produce enduring materials must review each enduring material at least once every three years or more frequently if indicated by new scientific developments. So, while providers can review and re-release an enduring material every three years (or more frequently), the enduring material cannot be offered as an accredited activity for more than three years without some review on the part of the provider to ensure that the content is still up-to-date and accurate. That review date must be included on the enduring material, along with the original release date and a termination date.

CME Content and the American Medical Association Physicians’ Recognition Award

All CME educational activities developed and presented by a provider accredited by the MMS system and associated with AMA PRA Category 1 CreditTM must be developed and presented in compliance with all MMS accreditation requirements - in addition to all the requirements of the AMA PRA program. All activities so designated for, or awarded, credit will be subject to review by the MMS accreditation process as verification of fulfillment of the MMS accreditation requirements.

AMA Credit Designation Statement

“AMA PRA Category 1 CreditTM” is a trademark of the American Medical Association. Accredited providers are required to use “AMA PRA Category 1 CreditTM” whenever the complete phrase is first used in any publication, and periodically through the publication. This standard language along with the AMA Credit Designation Statement, benefits both providers and physicians by clearly communicating the provider’s privilege to award AMA PRA Category 1 CreditTM on behalf of the AMA.

Providers may never publish or announce that “AMA PRA credit has been applied for.”

AMA Credit Designation Statement

The following credit designation statements must be included on all promotional materials advertising AMA PRA Category 1 CreditTM CME activities.

(REQUIRED – AMA CREDIT DESIGNATION STATEMENT)
The [name of accredited CME provider] designates this [learning format]* for a maximum of [number of credits] AMA PRA Category 1 Credit(s)TM. Physicians should claim only credit commensurate with the extent of their participation in the activity.

Note: the AMA PRA reference must be in italics and must include the trademark symbol.

(REQUIRED – ACCREDITATION STATEMENT)
The [name of accredited CME provider] is accredited by the Massachusetts Medical Society to provide continuing medical education for physicians.

(And, When Appropriate for Massachusetts Providers - Risk Management Study)
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 criteria for risk management study.

(And, When Appropriate - For Joint Providership)
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Massachusetts Medical Society through the joint providership of (name of accredited provider) and (name of non-accredited provider). The (name of accredited provider) is accredited by the Massachusetts Medical Society to provide continuing medical education for physicians.”

The learning format listed in the Credit Designation Statement must be one of the following AMA approved learning formats:

  1. Live activity
  2. Enduring material
  3. Journal-based CME activity
  4. Test-item writing activity
  5. Manuscript review activity
  6. PI CME activity
  7. Internet point-of-care activity
  8. Other

Records Retention

Specific CME activity records must be maintained by all accredited providers. Records retention requirements relate to the following two topics: Physician Participation and Activity Documentation.

  • Physician Participation: An accredited provider must have mechanisms in place to record and, when authorized by the participating physician, verify participation for six years from the date of the CME activity. The accredited provider is free to choose whatever registration method works best for their organization and learners. The MMS does not require sign-in sheets.
  • Activity Documentation: An accredited provider is required to retain activity files/records of CME activity planning and presentation during the current accreditation term or for the last twelve months, whichever is longer. Maintenance of this documentation enables the provider to, at the time of reaccreditation; show MMS how the activities it provided during its current term of accreditation were compliant with all MMS accreditation requirements including the ACCME Standards for Integrity and Independence in Accredited Continuing Education.

Annual Year-End Reporting

MMS accredited providers are required to provide the ACCME with data about their CME activities and overall CME program using ACCME’s Program and Activity Reporting System (PARS) in order to maintain their accreditation status. The purpose of the Annual Report is to confirm contact information for the accredited provider, and to compile an aggregate of the size and scope of the CME enterprise, e.g., the number and type of activities planned and executed, the number of CME credits awarded,, the number of physician and non-physician learners taught, the amount of commercial support received, and the total income of the enterprise. Accumulated data received from all ACCME and state medical society accredited providers is published annually at www.accme.org as a service to accredited providers, other members of the CME community, and the public.

Providers who fail to complete the report by the published due date are subject to a change of their accreditation status to probation. Notification that the Annual Report has not been submitted by the published due date may be sent to the accredited provider’s President and/or Chief Executive Officer. Providers that do not complete the report by the deadline may be subject to a decision of non- accreditation.

Payment of Fees

MMS accredited providers are accountable for timely submission of fees that are required either to attain or maintain accreditation.

Joint Providership

The MMS defines joint providership as the providership of a CME activity by one accredited and one non-accredited organization. Therefore, MMS accredited providers that plan and present one or more activities with non- accredited providers are engaging in “joint providership.”

The accredited provider must take responsibility for a CME activity when it is presented in cooperation with a non-accredited organization and must use the appropriate accreditation statement.

The MMS maintains no policy that requires or precludes accredited providers from charging a joint providership fee.

Informing the Learner

The accredited provider must inform the learner of the joint providership relationship through the use of the appropriate accreditation statement. All printed materials for jointly provided activities must carry the appropriate accreditation statement.

“This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Massachusetts Medical Society through the joint providership of (name of accredited provider) and (name of non-accredited provider). The (name of accredited provider) is accredited by the Massachusetts Medical Society to provide continuing medical education for physicians.”

Compliance and Noncompliance Issues

The MMS expects all CME activities to be in compliance with the accreditation requirements. In cases of joint providership, it is the MMS- accredited provider’s responsibility to be able to demonstrate through written documentation this compliance to the MMS. Materials submitted that demonstrate compliance may be from either the MMS- accredited provider’s files or those of the non-accredited provider.

Providers on Probation

If a provider is placed on Probation, it may not jointly provide CME activities with non-accredited providers, with the exception of those activities that were contracted prior to the Probation decision. A provider that is placed on Probation must inform the MMS of all existing joint providership relationships, and must notify its current contracted joint providers of its probationary status.

Self-Monitoring

Most MMS accredited providers are evaluated for re-accreditation every four or six years. Once you have achieved accreditation, MMS expects that during your accreditation term, your organization will take an active role in ensuring that it is continuously meeting the expectations of MMS in its purview of CME.

Following are specific actions that you can do to assist your organization in keeping informed about the Accreditation Requirements:

  • Ensure your email address is current with MMS to receive notifications on changes in continuing medical education (CME) or important accreditation requirements.
  • Access the MMS accreditation webpage for most recent accreditation information.
  • Participate in MMS’ educational opportunities including Quarterly Provider Webinars and the Annual Accreditation Conference to help increase your organization’s understanding of the MMS accreditation process and its requirements.
  • Contact the MMS with any questions you may have about your organization’s compliance with the Accreditation Requirements.

Organizational or Personnel Changes

Contact Information
To keep providers aware of important policy updates as well as information specific to their individual accreditation, MMS requires accredited providers to promptly inform MMS of any personnel or organizational changes. These types of changes include changes of address or phone number or email address, and changes to the individual to whom providers would like MMS to send correspondence (“primary contact”).

Changes may be submitted to Nancy Marotta via email at nmarotta@mms.org.

Corporate Change
If an MMS accredited provider undergoes a corporate change, (i.e., from a merger or acquisition), the MMS must be notified of the change as soon as possible.

Note: MMS accreditation is awarded to organizations that demonstrate compliance with Accreditation Requirements. For this reason, an organization cannot become an accredited provider by purchasing or merging with an organization that is already accredited. Transference of accreditation is not permitted without prior MMS approval.

Similarly, if an accredited provider undergoes significant organizational change, for example, becoming partially owned by an ineligible company or losing its 501(c) IRS tax status, the MMS considers the provider to be significantly different than the organization which was accredited. Therefore, the MMS will expect the provider to cease offering AMA PRA Category 1 CreditTM as an MMS accredited provider. The MMS will set a date of non-accreditation for these providers.

The MMS will withdraw a provider’s accreditation if the provider is dissolved, or ceases to exist, as a result of a merger, acquisition or dissolution.

When two or more MMS accredited providers merge, the MMS will consider that all but one of the accredited providers will cease to exist as an entity. The name of the remaining provider may be changed to reflect or include the name(s) of the former provider(s). The remaining provider must assume responsibility for unfinished CME activities and/or unexpired enduring materials of the provider(s) with which it merged, and must maintain activity registration records for six years for the provider(s) with which it merged.

New providers created through corporate change must submit a Pre-application and/or Self-Study Report per the direction of MMS as a first step towards initial MMS accreditation.

Additionally, if MMS receives a complaint about an accredited provider, and the complaint relates to the provider’s implementation of one or more MMS Accreditation Requirements, MMS may ask the provider to respond to the complaint according to MMS’ Procedure for Handling Complaints/Inquiries. The length of time during which an accredited provider must be accountable for any complaints/inquiries received by the MMS is limited to twelve months from the date of the activity, or in the case of a Regularly Scheduled Series (RSS), twelve months from the date of the activity which is in question.

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