Simple Tips for Navigating Reaccreditation
Simple Tips for
Navigating
Reaccreditation
Rebecca Daniel, MD
and
Kathy Collins
Disclosures
The following planners/presenters have no relevant
financial relationships to disclose:
Rebecca Daniel, MD
CME Director, St. Joseph Mercy Health System – Ann
Arbor
Kathy Collins
CME Specialist, Office of CME, Michigan State
University College of Human Medicine – East Lansing
Speakers below provided us permission to use their slides
The following planners/presenters have no relevant financial relationships to
disclose:
•
Sandy C. Deeba
CME Manager, Oklahoma State Medical Association, Oklahoma City, Oklahoma
•
Casey Harrison, MBA
Director, Continuing Medical Education, Texas Medical Association, Austin, Texas
•
Debbie Platek, MSC
Assistant 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, DC
Vice President for Accreditation and Recognition, ACCME, Chicago, Illinois
•
Frank C. Berry, CCMEP
Director, 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 are
1. Equivalency of Rules
2. Equivalency of Process
3. Equivalency of Interpretation
4. Equivalency of Accreditation Outcome
5. Equivalency of Evolution/Process Improvement
Equivalency(WHAT, WHY,
WHO?)
What-Markers of Equivalency
Who-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 Reaccreditation
o
Time Management
o
Materials and Documentation
o
Your Process
o
Your Self Study
o
The Interview
o
Communications
o
Education and Training
Time Management
o
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 Management
Establish dates for survey/interview and method
o
Phone teleconference
o
Site visit
o
Reverse site visit
Use your calendar
o
Enter deadlines with action plans and responsible
members of the staff
o
Make sure to account for vacation time, maternity,
etc
How can you put these into practice within your
organization?
Materials & Documentation
1.
Develop Strategy
2.
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 Process
Involve the whole team
o
Don’t just use the CME director, chair or staff person for
interviews
o
Prep those involved and make sure they have a copy of the
activity files
Divide tasks
o
Assign coordinator(s) portion(s) of the self-
study/performance in practice files
Involve other staff
o
CME Committee members to draft content for the self-study
report or review the material
Your Process
Engage an outside reviewer to
:
1) Review for completeness
2) Mock questions/use questions as per
criterion/survey tool
o
Reviewer shouldn’t be involved in planning
activities
o
Assess potential conflict of interest
o
National or State experience-consider both
o
What are some ways you could integrate these
tips into what your organization does?
Your Self Study
Tell 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 Study
o
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-Study
Read the self-study instructions
x 3
o
Page numbering, table of contents, examples
with commendation, not utilizing blank forms
Review the surveyor’s documentation forms
o
Performance in practice labels, etc. evidence in
your activity file
Be both thorough and minimalistic
o
Submit only what is needed
o
Do your best to minimize paperwork while
ensuring that every area has been addressed
Be concise and specific when describing your
processes
Your Self Study
o
Proofread, Proofread, Proofread!
o
Outside of CME department review for error
before submission
o
Review should not be done by only one person
o
CME Chair
o
members of your Committee
o
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 Interview
Conduct 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?
Communications
o
Communicate with your accreditor
o
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 Training
o
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/CME
Resources.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
Tips and strategies to simplify the reaccreditation process, identify team coordination approaches, and organize documentation. Learn about equivalency markers and how to streamline decision-making. Discover valuable insights for approaching reaccreditation efficiently and effectively.
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Presentation Transcript
Simple Tips for Navigating Reaccreditation Rebecca Daniel, MD and Kathy Collins
Disclosures The following planners/presenters have no relevant financial relationships to disclose: Rebecca Daniel, MD CME Director, St. Joseph Mercy Health System Ann Arbor Kathy Collins CME Specialist, Office of CME, Michigan State University College of Human Medicine East Lansing
Speakers below provided us permission to use their slides The following planners/presenters have no relevant financial relationships to disclose: Sandy C. Deeba CME Manager, Oklahoma State Medical Association, Oklahoma City, Oklahoma Casey Harrison, MBA Director, Continuing Medical Education, Texas Medical Association, Austin, Texas Debbie Platek, MSC Assistant 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, DC Vice President for Accreditation and Recognition, ACCME, Chicago, Illinois Frank C. Berry, CCMEP Director, 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 are 1. Equivalency of Rules 2. Equivalency of Process 3. Equivalency of Interpretation 4. Equivalency of Accreditation Outcome 5. Equivalency of Evolution/Process Improvement
Equivalency(WHAT, WHY, WHO?) What-Markers of Equivalency Who-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 Reaccreditation o Time Management o Materials and Documentation o Your Process o Your Self Study o The Interview o Communications o Education and Training
Time Management o 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 Management Establish dates for survey/interview and method o Phone teleconference o Site visit o Reverse site visit Use your calendar o Enter deadlines with action plans and responsible members of the staff o Make sure to account for vacation time, maternity, etc How can you put these into practice within your organization?
Materials & Documentation 1. Develop Strategy 2. 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 Process Involve the whole team o Don t just use the CME director, chair or staff person for interviews o Prep those involved and make sure they have a copy of the activity files Divide tasks o Assign coordinator(s) portion(s) of the self- study/performance in practice files Involve other staff o CME Committee members to draft content for the self-study report or review the material
Your Process Engage an outside reviewer to: 1) Review for completeness 2) Mock questions/use questions as per criterion/survey tool o Reviewer shouldn t be involved in planning activities o Assess potential conflict of interest o National or State experience-consider both o What are some ways you could integrate these tips into what your organization does?
Your Self Study Tell 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 Study o 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-Study Read the self-study instructions x 3 o Page numbering, table of contents, examples with commendation, not utilizing blank forms Review the surveyor s documentation forms o Performance in practice labels, etc. evidence in your activity file Be both thorough and minimalistic o Submit only what is needed o Do your best to minimize paperwork while ensuring that every area has been addressed Be concise and specific when describing your processes
Your Self Study o Proofread, Proofread, Proofread! o Outside of CME department review for error before submission o Review should not be done by only one person o CME Chair o members of your Committee o 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 Interview Conduct 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?
Communications o Communicate with your accreditor o 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 Training o 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/CME Resources.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?
