OUTLINE FOR THE SELF-STUDY REPORT FOR ACCME REACCREDITATION

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OUTLINE FOR THE SELF-STUDY REPORT FOR ACCME REACCREDITATION FOR NOVEMBER 2017 AND MARCH 2018 COHORTS (UPDATED TO INCLUDE OPTION OF SUBMITTING EVIDENCE FOR THE NEW MENU OF CRITERIA FOR ACCREDITATION

1 OUTLINE FOR THE SELF-STUDY REPORT FOR ACCME REACCREDITATION FOR NOVEMBER 2017 AND MARCH 2018 COHORTS (UPDATED TO INCLUDE OPTION OF SUBMITTING EVIDENCE FOR THE NEW MENU OF CRITERIA FOR ACCREDITATION WITH COMMENDATION) I) Self-Study Report Prologue A) Enter a brief narrative (maximum 250 words) that tells the history of your continuing medical education(cme)program. B) Attach an organizational chart that showstheleadershipandorganizationalstructureofyourcme Program. II) Purpose and Mission (Criterion 1) Enter yourcmemissionstatementwiththeexpectedresultsofyourcmeprogram,articulatedin termsofchangesincompetence,performance,orpatientoutcomeshighlighted.(c1) III) Educational Activities (Criteria 2-7 and Policies) ThenextsetofitemsisdesignedtogatherinformationonyourincorporationoftheACCME srequirementsintoyourprogram ofcontinuingmedicaleducation. A) Pick two of your CME activities as examples. Using these examples, within the context of your organization sprocessesandmechanisms,describeallofthestepsyouwentthroughtocreatethese educationalactivitiesanddemonstrate: 1. Theprofessionalpracticegapthattheactivitieswereaddressing (C2) 2. Theeducationalneed(s)thatyoudeterminedwereunderlyingthegap(s)foryourlearners (C2) 3. Whatcompetenceorperformanceorpatientoutcometheactivitywasdesignedto change. 4. Yourexplanationofwhytheformatoftheactivityyouchosewasappropriateforthe setting,objectivesanddesiredresultsoftheactivity 5. Thedesirablephysicianattribute(s)youassociatedwiththeactivity (C6) (C3) (C5) ACCME OutlinefortheSelfStudyReportforACCMEReaccreditation:November2017andMarch2018 Page1of9 009_

2 6. i.adescriptionofyourplanningprocessthatisindependentofthecontrolofany ACCMEdefinedcommercialinterestandthemechanismsimplementedtoensurethat you,astheaccreditedprovider,retaincompletecontrolofthecmecontent.relateyour descriptiontoeachelementofscs1(af). ii.theuseofemployeesofaccmedefinedcommercialinterestsasfacultyandplanners ofaccreditedcmeisprohibited,exceptinthespecificsituationspermittedbytheaccme thatmaintainindependenceasspecifiedontheaccmewebsite( to:1)reportingaboutresearchanddiscovery;2)demonstratingtheoperationalaspectsof theuseofadevice;and,3)controllingcontentthatisnotrelatedtotheproductlinesof thecommercialinterest.aprovidermustdemonstratethatitcomplieswithaccme requirementstoensureindependenceinthesespecificsituations.withoutsuchevidence, thispracticewillresultinnoncompliancewithc7(scs1.1).(see roleemployeesaccmedefinedcommercialformoreinformationonthistopic.) If your organization is involved in these rare circumstances, please: a.) DescribethefactorsyouconsiderindetermininganappropriateroleofanACCME definedcommercialinterestemployeeinplanningand/orpresentingaccredited CME;and b.) Describethemechanismsimplementedto ensure independence in these situations. 7. Themechanism(s)yourorganizationusedtoa)identifyandb)resolveconflictsofinterest foreveryoneinapositiontocontroleducationalcontent(i.e.,teachers,authors,planners, reviewers,andotherswhocontrolledcontent.) 8. Yourorganization sprocess(es)andmechanism(s)fordisclosuretothelearnersofrelevant financialrelationshipsofallpersonsinapositiontocontroleducationalcontent. 9. Yourorganization sprocess(es)andmechanism(s)fordisclosuretothelearnersofthe sourceofsupportfromcommercialinterests,including inkind support. (C7 SCS1) (C7 SCS2) (C7 SCS ) B) YoumayfeelthatthetwoexamplesinSectionIII(A)donotprovideyouwithadequateopportunity tosufficientlydescribehowyouapplytheaccme srequirementsinthedevelopmentofyourcme activities.pleasefeelfree,insectioniii(b),toprovideotherexamplesanddescriptionsthatprovide DIFFERENTinformationorDIFFERENTstrategiesthatwerenotavailableinthetwoexampleschosen insectioniii(a), above.thisisespeciallyimportantforadescriptionofyourimplementationofthe ACCME Standards for Commercial Support: Standards to Ensure Independence in CME Activities SM. Recording and verifying physician participation A) Describethemechanismyourorganizationusestorecordandverifyphysicianparticipation forsix yearsfromthedateofyourcmeactivities. B) UsingtheinformationfromoneoftheexampleactivitiesinSectionIII(A) or (B),above,showthe informationorreportsyourmechanismcanproduceforanindividualparticipant. OutlinefortheSelfStudyReportforACCMEReaccreditation RevisedDecember _2016_12 Page2of9

3 IV) Regarding your Program of CME, your Educational Activities, and the ACCME Standards for Commercial Support: Standards to Ensure Independence in CME Activities (Criteria 8-9) A) Describeyourprocess(es)forthereceiptanddisbursementofcommercialsupport(bothfundsand inkindsupport).(c8scs3.1) orenterhere, We do not accept commercial support for any of our directly or jointly provided CME activities. B) Describe what policy, procedure or communications you employ to ensure that all commercial supportisgivenwithyourorganization sfullknowledgeandapproval.(c8scs3.3) orenterhere, We do not accept commercial support for any of our directly or jointly provided CME activities. C) Attach your written policies and procedures governing honoraria for planners, teachers, and/or authors orenterhere, We do not provide honoraria in any form to planners, teachers, and/or authors. (C8SCS3.73.8) D) Attachyourwrittenpoliciesandproceduresgoverningreimbursementofexpensesforplanners, teachers,and/orauthors orenterhere, We do not provide reimbursement of expenses in any form to planners, teachers, and/or authors. (C8SCS3.73.8) E) Describewhatpolicy,procedure,orcommunicationsyouemploytoensurethatnodirectpayment from an ACCMEdefined commercial interest is given to the directorof an activity, any planning committeemembers,teachersorauthors,jointprovider,oranyothersinvolvedinanactivity.(c8 SCS3.3;3.9) F) Describethepractices,orprocedures,orpoliciesyouhaveimplementedtoensurethatsocialevents, ormeals,atcommerciallysupportedcmeactivitiescannotcompetewithortakeprecedenceover educationalevents.(c8scs3.11) orenterhere, We do not accept commercial support for any of our directly or jointly provided CME activities or enterhere, We do not provide social events or meals for any of our directly or jointly provided and commercially supported CME activities. G) Doyouorganizecommercial exhibitsinassociationwithanyofyourcmeactivities?if No, write in this section, We do not organize commercial exhibits in association with any of our CME activities. Ifyes,describehowyourorganizationensuresthatarrangementsforcommercialexhibits donot(1)influenceplanningorinterferewiththepresentationand(2)arenotaconditionofthe provisionofcommercialsupportforcmeactivities.(c9scs4.1) H) DoyouarrangeforadvertisementsinassociationwithanyofyourCMEactivities?If No, writein thissection, We do not arrange for advertisements in association with any of our CME activities. If yes, describe how your organization ensures that advertisements or other productpromotion materials are kept separate from the education.in your description, distinguish between your processesrelatedtoadvertisementsand/orproductpromotionineachofthefollowingtypesofcme activities:(1)printmaterials,(2)computerbasedmaterials,(3)audioandvideorecordings,and(4) facetoface.(c9scs4.2,4.4) OutlinefortheSelfStudyReportforACCMEReaccreditation RevisedDecember _2016_12 Page3of9

4 V) Regarding the Content of your Continuing Medical Education Activities (Criterion 10 and Policy on Content Validation) A) ItisanexpectationoftheACCMEthat, ThecontentofCMEactivitiesdoesnotpromotetheproprietaryinterestsofanycommercial interests.(i.e.,thereisnotcommercialbias) CMEactivitiesgiveabalancedviewoftherapeuticoptions. (C10SCS5.1) (C10SCS5.2) Describe howyourcmeactivitiesandyourprogramofcontinuingmedicaleducationensurethat thesetwoexpectationsarefulfilled(e.g.,planning,procedures,policy,monitoring). B) ItisanexpectationoftheACCMEthat, ThecontentofCMEactivitiesisincompliancewiththeACCME scontentvalidityvalue statements* (PolicyonContentValidation) *ACCME s Policy on Content Validation:AlltherecommendationsinvolvingclinicalmedicineinaCMEactivitymustbebasedonevidencethatisacceptedwithintheprofession ofmedicineasadequatejustificationfortheirindicationsandcontraindicationsinthecareofpatients.allscientificresearchreferredto,reportedorusedincmeinsupportor justificationofapatientcarerecommendationmustconformtothegenerallyacceptedstandardsofexperimentaldesign,datacollectionandanalysis.providersarenoteligible foraccmeaccreditationorreaccreditationiftheypresentactivitiesthatpromoterecommendations,treatmentormannersofpracticingmedicinethatarenotwithinthe definitionofcme,orknowntohaverisksordangersthatoutweighthebenefitsorknowntobeineffectiveinthetreatmentofpatients. Describe howyourcmeactivitiesandyourprogramofcontinuingmedicaleducationensurethatthis expectationisfulfilled(e.g.,planning,procedures,policy,monitoring). VI) Evaluation and Improvement (Criteria 11-13) A) Basedondataandinformationfromyourprogram sactivities/educationalinterventions,provide your analysis of changes achieved in your learners competence, performance, or in patient outcomes.(c11) B) Basedondataandinformationgathered,provide yourprogrambasedanalysisonthedegreeto whichtheexpectedresultscomponentofyourcmemissionhasbeenmetthroughtheconductof yourcmeactivities/educationalinterventions.(c12) C) Describe the needed or desired changes in the overall program (e.g., planners, teachers, infrastructure,methods,resources,facilities,interventions)requiredtoimproveonyourabilityto meetyourcmemissionthathavebeenidentified,planned,andimplemented.(c13) OutlinefortheSelfStudyReportforACCMEReaccreditation RevisedDecember _2016_12 Page4of9

5 ACCREDITATION WITH COMMENDATION The following pages of this outline include the instructions for submitting evidence to demonstrate compliance with the ACCME s Criteria for Accreditation with Commendation. Providers receiving accreditationdecisionsthroughnovember2019maychooseoptionaoroptionb. Option A includes seven criteria (Criteria 1622) that demonstrate engagement with the healthcare environment. Option Bprovidesamenuof16criteria(Criteria2338)fromwhichprovidersmustselectandpresent evidenceforeightcriteria(includingatleastonefrom AchievesOutcomes ). NOTE: IfyourorganizationintendstoseekAccreditationwithCommendation,youhavetheoptionof demonstratingcompliancewitheitheroptiona(criteria1622)oroptionb(menuofcriteria2338). Please choose Option A or Option B and describe/demonstrate your compliance with the applicable criteria(ormenuofcriteria). VII) Option A: Engagement with the Environment (Criteria 16-22) (IfyourorganizationchoosesOptionA youmustdescribe/demonstratecompliancewithallofcriteria 1622.) A) DescribehowyourorganizationintegratesCMEintotheprocessforimprovingprofessionalpractice. Includeexamplesofexplicitorganizationalpracticesthathavebeenimplemented.(C16) B) Describehowyourorganizationutilizesnoneducationstrategiestoenhancechangeasanadjunct toitseducationalactivities.includeinyourdescriptionanexplanationofhowthenoneducation strategieswereconnectedtoeitheranindividualactivityorgroupofactivities.includeexamplesof noneducationstrategiesthathavebeenimplemented.(c17) C) Describehowyourorganizationidentifiesfactorsoutsideofitscontrolthatwillhaveanimpacton patientoutcomes.includeexamplesoffactorsoutsideofyourorganization scontrolthatwillhave animpactonpatientoutcomes.(c18) D) Describe how your organization implements educational strategies to remove, overcome, or addressbarrierstophysicianchange.includeexamplesofeducationalstrategiesthathavebeen implementedtoremove,overcome,oraddressbarrierstophysicianchange.(c19) E) Describehowyourorganizationisengagedincollaborativeorcooperativerelationshipswithother stakeholders.includeexamplesofcollaborationandcooperationwithotherstakeholders.(c20) F) Describe how your organization or CME unit participates within an institutional or system frameworkforqualityimprovement.includeexamplesofyourorganization/cmeunitparticipating withinaninstitutionalorsystemframeworkforqualityimprovement.(c21) G) Describehowyourorganizationhaspositioneditselftoinfluencethescopeandcontentof activities/educationalinterventions.includeexamplesofhowyourorganizationispositionedto influencethescopeandcontentofactivities/educationalinterventions.(c22) OutlinefortheSelfStudyReportforACCMEReaccreditation RevisedDecember _2016_12 Page5of9

6 VIII) Option B: Menu of New Criteria for Commendation (Select Eight from Criteria 23-38) (IfyourorganizationchoosesOptionB,youmustdemonstratecompliancewithanysevencriteriafrom anycategory plusonecriterionfromtheachievesoutcomescategory foratotalofeightcriteria. Pleasedonotincludedescriptions/evidenceformorethaneightcriteria.) CATEGORY: Promotes Team-Based Education (C23)Ifyourorganizationengagesmembersofinterprofessionalteamsintheplanninganddeliveryof interprofessionalcontinuingeducation,please: A) Attest: Includethefollowingstatement,withthenameofyourorganizationandtheindividual responsibleforyourcmeprogram. On behalf of [organization name], I attest that our organization has met the Critical Elements for Criterion 23 in at least 10% of the CME activities (but no less than two activities)duringtheaccreditationterm.[individualname,title] B) Submit evidenceforthenumberofactivitiesthatmatchthesizeofyourcmeprogram,asstated inthestandard(small:2;medium:4;large:6;extralarge:8) 1. Foreachexampleactivityyoupresent,pleaseprovidethename/date/typeoftheactivityand describetheprofessionsoftheplannersandfaculty,aswellasabriefdescriptionofwhatthe activitywasdesignedtochangeintermsofthecompetenceorperformanceofthehealthcare team(maximum250wordsperexample). (C24)Ifyourorganizationengagespatient/publicrepresentativesintheplanninganddeliveryofCME, please: A) Attest:Includethefollowingstatement,withthenameofyourorganizationandtheindividual responsibleforthecmeprogram. On behalf of [organization name], I attest that our organization has met the Critical ElementsforCriterion24inatleast10%oftheCMEactivities(butnolessthantwo)during theaccreditationterm.[individualname,title] B) Submit evidenceforthenumberofactivitiesthatmatchthesizeofyourcmeprogram,asstated inthestandard(small:2;medium:4;large:6;extralarge:8): Foreachexampleactivityyoupresent,pleaseprovidethename/date/typeoftheactivityand describeinwhatwaytheplannersandpresentersoftheactivityrepresentthepatientorpublic, alongwiththeroletheyplayedintheplanning/presentationofyourcmeactivity(maximum250 wordsperexample). (C25)Ifyourorganizationengageshealthprofessions studentsintheplanninganddeliveryofcme, please: A) Attest: Includethefollowingstatement,withthenameofyourorganizationandtheindividual responsibleforthecmeprogram: On behalf of [organization name], I attest that our organization has met the Critical ElementsforCriterion25inatleast10%oftheCMEactivities(butnolessthantwo)during theaccreditationterm.[individualname,title] 1 ProgramSizebyActivitiesperTerm:S(small):<39;M(medium):40100;L(large):101250;XL(extralarge):>250 OutlinefortheSelfStudyReportforACCMEReaccreditation RevisedDecember _2016_12 Page6of9

7 B) Submit evidenceforthenumberofactivitiesthatmatchthesizeofyourcmeprogram,asstated inthestandard(small:2;medium:4;large:6;extralarge:8). Foreachexampleactivityyoupresent,pleaseprovidethename/date/typeoftheactivityand describethehealthprofessions studentsinvolvedintheactivity,includingtheirprofessionand levelofstudy(e.g.undergraduatemedicalstudents,nursepractitionerstudents,residentsin generalsurgery)andhowtheyparticipatedasbothplannersandfacultyoftheactivity(maximum 250wordsperexampleactivity). CATEGORY: Addresses Public Health Priorities (C26) Ifyourorganizationadvancestheuseofhealthandpracticedataforhealthcareimprovement, please submit evidenceforthenumberofactivitiesthatmatchthesizeofyourcmeprogram,as statedinthestandard(small:2;medium:4;large:6;extralarge:8). A) Describe how your organization incorporates health and practice data into your educational programthroughteachingaboutthecollection,analysis,orsynthesisofhealth/practicedataand howyourorganizationuseshealth/practicedatatoteachabouthealthcareimprovement. B) Submit evidenceforthenumberofactivitiesthatmatchthesizeofyourcmeprogram,asstated inthestandard(small:2;medium:4;large:6;extralarge:8). For each activity you present, please provide the name/date/type of the activity and for each activity, describe how the activity taught learners about collection, analysis or synthesis of health/practicedataandhowtheactivityusedhealth/practicedatatoteachabouthealthcare improvement(maximum250wordsperactivitydescription). (C27) Ifyourorganizationaddressesfactorsbeyondclinicalcarethataffectthehealthofpopulations, please: A) Attest: Includethefollowingstatement,withthenameofyourorganizationandtheindividual responsibleforthecmeprogram: On behalf of [organization name], I attest that our organization has met the Critical Elements for Criterion 27 in at least 10% of the CME activities (but no less than two) reportedduringtheaccreditationterm.[individualname,title] B) Submit evidenceforthenumberofactivitiesthatmatchthesizeofyourcmeprogram,asstated inthestandard(small:2;medium:4;large:6;extralarge:8). Foreachexampleactivityyoupresent,pleaseprovidethename/date/typeoftheactivityand describethestrategyorstrategiesusedtoachieveimprovementsinpopulationhealth(maximum 250wordsperexample). (C28) Ifyourorganizationcollaborateswithotherorganizationstomoreeffectivelyaddresspopulation healthissues,pleasedescribefourcollaborationswithotherorganizationsduringthecurrentterm of accreditation and show how these collaborations augmented your organization s ability to addresspopulationhealthissues(maximum250wordspercollaboration). OutlinefortheSelfStudyReportforACCMEReaccreditation RevisedDecember _2016_12 Page7of9

8 CATEGORY: Enhances Skills (C29) If your organization designs CME to optimize communication skills of learners, please submit evidenceforthenumberofactivitiesthatmatchthesizeofyourcmeprogram,asstatedinthe Standard(small:2;medium:4;large:6;extralarge:8). Foreachexampleactivityyoupresent,pleaseprovidethename/date/typeoftheactivityand describetheelementsoftheactivitythatweredesignedtoimprovecommunicationsskills.in addition,pleasedescribetheevaluationofcommunicationsskillsusedforlearnersinthisactivity (maximum 250 words per example). For each activity, attach an example of the formative feedbackprovidedtoalearneraboutcommunicationskills(thismaybeawrittendescriptionif thefeedbackwasprovidedverbally). (C30) IfyourorganizationdesignsCMEtooptimizetechnicalandproceduralskillsoflearners,please submit evidenceforthenumberofactivitiesthatmatchthesizeofyourcmeprogram,asstated inthestandard(small:2;medium:4;large:6;extralarge:8). For each example activity you present, please provide the name/date/type of the activity. Describetheelementsoftheactivitythataddressedtechnicalorproceduralskillsandhowyou evaluatedtheobservedtechnicalorproceduralskillsofthelearners(maximum250wordsper example).foreachactivity,attach an exampleoftheformativefeedbackprovidedtoalearner abouttechnicalorproceduralskills.thismaybeawrittendescriptionifthefeedbackwasprovided verbally. (C31) Ifyourorganizationcreatesindividualizedlearningplansforlearners,pleasesubmit evidence of repeatedengagementandfeedbackforthenumberoflearnersthatmatchesthesizeofyourcme program,asstatedinthestandard(small:25;medium:75;large:125;extralarge:200). Pleaseprovide a descriptionofthetypesofindividualizedlearningplansthatyouhaveoffered (maximum250words). (C32) IfyourorganizationutilizessupportstrategiestoenhancechangeasanadjuncttoitsCME,please: A) Attest: Includethefollowingstatement,withthenameofyourorganizationandtheindividual responsibleforthecmeprogram: On behalf of [organization name], I attest that our organization has met the Critical ElementsforCriterion32inatleast10%oftheCMEactivities(butnolessthantwo)during theaccreditationterm.[individualname,title] B) Submit evidenceforthenumberofactivitiesthatmatchthesizeofyourcmeprogram,asstated inthestandard(small:2;medium:4;large:6;extralarge:8). Foreachexampleactivityyoupresent,pleaseprovidethename/date/typeoftheactivityand describe thesupportstrategy(ies)thatwereadjunctivetothisactivity.provideyouranalysisof the effectiveness of the support strategy(ies) and describe planned or implemented improvements(maximum250wordsperexample). OutlinefortheSelfStudyReportforACCMEReaccreditation RevisedDecember _2016_12 Page8of9

9 CATEGORY: Demonstrates Educational Leadership (C33)IfyourorganizationengagesinCMEresearchandscholarship,please: A) Describeatleasttwoscholarlyprojectsyourorganizationcompletedduringtheaccreditation termrelevanttocmeandthedisseminationmethodusedforeachone(e.g.poster,abstract, manuscript)(maximum250wordsforeachproject). B) For each project described above, submit as an attachment, the project itself (e.g. poster, abstract,presentation,manuscript). (C34)IfyourorganizationsupportsthecontinuousprofessionaldevelopmentofitsCMEteam,please describe yourorganization scmeteam,thecpdneedsthatyouidentifiedfortheteamduringthe termofaccreditationandthelearningplanimplementedbasedontheneedsidentified,including theactivitiesexternaltoyourorganizationinwhichthecmeteamparticipated(maximum500 words). (C35) IfyourorganizationdemonstratescreativityandinnovationintheevolutionofitsCMEprogram, pleasepresentfourexamplesofinnovationsimplementedanddescribeeachinnovationandhow it contributed to your organization s ability to meet your mission (maximum 250 words per innovation). CATEGORY: Achieves Outcomes (at least one required) (C36) Ifyourorganizationdemonstratesimprovementintheperformanceoflearners,please: A) Attest: Includethefollowingstatement,withthenameofyourorganizationandtheindividual responsibleforthecmeprogram: Onbehalfof[organizationname],IattestthatourorganizationhasmettheCriticalElementsfor Criterion36inatleast10%oftheCMEactivities(butnolessthantwo)duringtheaccreditation term.[individualname,title] B) Describethemethod(s)usedtoevaluatelearnerperformance(maximum500words). C) Attach data (qualitative or quantitative) that demonstrates improved performance in the majorityoflearners. (C37)IfyourorganizationdemonstrateshealthcarequalityimprovementrelatedtoitsCMEprogram please: A) Describe at least two examples in which your organization collaborated in the process of healthcare quality improvement, along with the improvements that resulted (maximum 500 wordspercollaboration). B) Attach data(qualitativeorquantitative)thedemonstratesthoseimprovements. (C38) If your organization demonstrates the impact of its CME program on patients or their communities,please: A) Describeatleasttwoexamplesofyourorganization scollaborationintheprocessofimproving patient or community health that includes CME, along with the improvements that resulted (maximum500wordspercollaboration). B) Attach data(qualitativeorquantitative)thatdemonstratesthoseimprovements. OutlinefortheSelfStudyReportforACCMEReaccreditation RevisedDecember _2016_12 Page9of9

OUTLINE FOR THE SELF- STUDY REPORT FOR ACCME REACCREDITATION

OUTLINE FOR THE SELF- STUDY REPORT FOR ACCME REACCREDITATION FOR NOVEMBER 2017 AND ALL 2018/2019 COHORTS (UPDATED TO INCLUDE OPTION OF SUBMITTING EVIDENCE FOR THE NEW MENU OF CRITERIA FOR ACCREDITATION