Simple Tips for Navigating Reaccreditatio

nRebecca Daniel, MD

and Kathy Collins

DisclosuresThe following planners/presenters have no relevant financial relationships to disclose:

Rebecca Daniel, MDCME Director, St. Joseph Mercy Health System – Ann Arbor

Kathy CollinsCME Specialist, Office of CME, Michigan State University College of Human Medicine – East Lansing

Speakers below provided us permission to use their

slidesThe following planners/presenters have no relevant financial relationships to disclose:

• Sandy C. DeebaCME Manager, Oklahoma State Medical Association, Oklahoma City, Oklahoma• Casey Harrison, MBADirector, Continuing Medical Education, Texas Medical Association, Austin, Texas• Debbie Platek, MSCAssistant Director, Education, Accreditation and Licensure, Illinois State Medical Society, Chicago, Illinois• Melissa Carter, M.A.Senior Vice President of Education & Membership, Florida Medical Association, Tallahassee, Florida• Dion A. Richetti, DCVice President for Accreditation and Recognition, ACCME, Chicago, Illinois• Frank C. Berry, CCMEPDirector, Division of Continuing Professional Development, MedChi, The Maryland State Medical Society, Baltimore, Maryland

Objectives

• Identify strategies to make reaccreditation simple and streamlined

• Identify & coordinate your team to approach reaccreditation process

• Formulate overall plan to approach reaccreditation

• Organize materials for activity file reviews & self-study documentation

Equivalency

The ACCME’s 2008 Markers of Equivalency are1. Equivalency of Rules2. Equivalency of Process3. Equivalency of Interpretation4. Equivalency of Accreditation Outcome5. Equivalency of Evolution/Process Improvement

Equivalency(WHAT, WHY, WHO?)

What-Markers of EquivalencyWho-Created by a collaboration:

o Recognized Accreditors & ACCME’s Advisory Committee on Equivalency(state medical society leaders).

Why-Purpose: ensure equivalency of accreditation decision-making across the national system, and streamline and strengthen the recognition process.

The Markers, create a system where:ACCME = Recognized Accreditors of the State

Medical Societies

Tips for Reaccreditationo Time Managemento Materials and Documentationo Your Processo Your Self Studyo The Interviewo Communicationso Education and Training

Time Managemento Start Early

• Establish a timeline for self-study-adhere to it!• Contact the Accreditor • Review Accreditor requirements

http://www.msms.org/Education/CMEFormsLibrary.aspx

• Read the guidance documents as soon as they are available

• Once activity files identified-compile documentation• Respond to Accreditor regarding intent to pursue

accreditation• Ensure all activities are entered into PARS

Time ManagementEstablish dates for survey/interview and methodo Phone teleconferenceo Site visito Reverse site visit

Use your calendar o Enter deadlines with action plans and responsible

members of the staffo Make sure to account for vacation time, maternity, etc

How can you put these into practice within your organization?

Materials & Documentation1. Develop Strategy2. Who will be involved?3. Compiling the evidence of performance in practice

(Criteria labels or structured abstract)4. Writing the Self Study Report

*Store documentation in manner you would for accreditation• Keep activity Check list in each file• Keep central copies of files-files are all labeled• Ensure all disclosures include spouse /partner• Ensure correct definition of commercial interest• Update all of your accreditation and designation

statements-but don’t alter previous documents

Materials & Documentation

Keep a file for evidence of Commendation Criteria

o Prior to beginning your Self-Study, pick your top 2 CME activities

o Collect materials for C16-C22 in a folder or document in a spreadsheet throughout the accreditation period.

o Only include the necessary documentation in your performance in practice file.

How can you apply these tips to your organization?

Your ProcessInvolve the whole teamo Don’t just use the CME director, chair or staff person for

interviewso Prep those involved and make sure they have a copy of

the activity filesDivide taskso Assign coordinator(s) portion(s) of the

self-study/performance in practice filesInvolve other staff o CME Committee members to draft content for the self-

study report or review the material

Your ProcessEngage an outside reviewer to:

1) Review for completeness2) Mock questions/use questions as per criterion/survey tool

o Reviewer shouldn’t be involved in planning activities

o Assess potential conflict of interesto National or State experience-consider both

o What are some ways you could integrate these tips into what your organization

does?

Your Self StudyTell your CME story • Describe your CME example activities so

that someone outside of your institution would understand• Answer all the questions in the Accreditors

outline or application.• Select a commercially-supported activity as

an example, if available

Your Self Studyo Connect your narrative (Self-Study Report)

and your evidence o Choose your best examples with that meet

compliance o Provide reviewers with context for your

evidence of performance-in-practice. o Your evidence of performance-in-practice

should also bring to light changes, improvements, or discrepancies in your performance which can then be explained in the Self-Study Report.

Your Self-StudyRead the self-study instructions x 3o Page numbering, table of contents, examples

with commendation, not utilizing blank formsReview the surveyor’s documentation formso Performance in practice labels, etc. evidence in

your activity fileBe both thorough and minimalistico Submit only what is needed o Do your best to minimize paperwork while

ensuring that every area has been addressedBe concise and specific when describing your processes

Your Self Study

o Proofread, Proofread, Proofread! o Outside of CME department review for error

before submissiono Review should not be done by only one persono CME Chairo members of your Committeeo Confirm number of copies and upload to USB or

CD for submission and a final copy for your program

o How will you approach your organization’s self study report?

The Interview• Designate who and their role-invite the right

people• Communicate roles to each person involved• Each person involved has read through the

Self-Study Report• Copies of the Performance-in-Practice files on

hand and that at least one person is familiar with these• CME Committee Chair and Committee review

carefully your Self-Study

The InterviewConduct a Mock Survey• 1-6 months before your actual site survey

Present yourself in the best light—• Know examples of the great things your

organization does. This is of particular importance for showing compliance with the engagement criteria

What strategies will you use for your organization’s interview?

Communicationso Communicate with your accreditoro Ask questions o Upfront with your accreditor/concern about the

accreditation process, its’ better not to guess at the meaning.

o Submit on time ( If you need extra time, submit it in writing to get approval by your Accreditor)

What steps will you take to ensure that you effectively communicate with your

Accreditor?

Education and Trainingo Contact MSMS for Self-Study Training-in person or via

phone, MSMS can provide helpful tips, tools and guidance to the process of Reaccreditation. Check with Brenda Marenich for dates and time available

o http://www.msms.org/Education/EducationResources/CMEResources.aspx

o Throughout your accreditation term participate in continuing education. • MSMS annual CME meeting• ACCME • Alliance • AHME

o Keep your staff and committee members trained

What educational opportunities are available to you and your organization?

ACCME Criterion