Transcript Criteria 1-6 Examples of Compliance and NonCompliance David Pieper, PhD Assistant Dean for CME Wayne State University School of Medicine [email protected].

Criteria 1-6
Examples of Compliance and NonCompliance
David Pieper, PhD
Assistant Dean for CME
Wayne State University School of Medicine
[email protected]
Criteria 1: Mission Statement
The provider has a CME mission statement that
includes expected results articulated in terms of
changes in competence, performance, or patient
outcomes that will be the result of the program.
WSU Mission Statement (Old Criteria)
559 Words
Wayne State University School of Medicine is committed to excellence in education and research and to the translation of new knowledge into excellence of
patient care. Its commitment to the education of physicians extends from undergraduate education through residency and fellowship training to education for
the practicing physician.
PURPOSE: The Goal of the School's CME program is to plan and deliver high quality education activities for practicing physicians in order to reinforce their
past learning and to disseminate new concepts and practices in medicine which may improve patient care for all medical specialties.
In accordance with the educational affiliation agreement between Wayne State University and the Detroit Medical Center, the School is the accredited
sponsor for all CME activities of the Detroit Medical Center and its constituent institutions.
TARGET AUDIENCE: The audiences to be reached by its program of CME are:
Physicians in all medical specialties and sub-specialties
Faculty of the school and medical staffs of DMC hospitals
Physicians practicing in metropolitan Detroit, throughout the State of Michigan or wherever practicing in the US or internationally.
Physicians-in-training
Other health care professionals from Wayne State University, the DMC hospitals and the community
TYPES OF ACTIVITIES: The educational activities provided within the program shall use whatever educational methods are appropriate and may include
lectures, laboratories, discussion groups, and enduring materials such as, films, video tapes, monographs, computer programs and web based programs.
The types of activities may include live courses, live regularly schedules seminars, live internet conferences, and enduring materials such as nonsynchronous internet courses and journal CME. Whenever it may promote the educational objectives of the School, any of the above types of activities may
be Jointly Sponsored with other institutions or groups which may or may not themselves be accredited to provide CME.
CONTENT AREAS: The content areas of CME activities sponsored by the Wayne State University School of Medicine include primary care, and specialty
and sub-specialty topics in all fields of medicine. The scope of sponsored activities includes the basic medical sciences, clinical medical sciences and the
provision of health care to the public.
The Division shall promote excellence in teaching by facilitating the training of its faculty of the School and affiliates in the methods and techniques of
medical teaching. It shall promote research into how physicians learn, how to plan and deliver educational materials to meet their needs.
The Division of Continuing Medical Education expects the general academic quality of each CME activity to be relevant to the level of medical practice of
the target audience, that the educational process activities will be of appropriate quality, and that the activities will be applicable to the professional
development needs of physicians and health professionals in the community. The Division insures that all CME activities comply with the accreditation
requirements as established by the ACCME.
EXPECTED RESULTS: As a result of participation in Wayne State University Continuing Medical Education programs, practicing clinicians will improve
patient care competency, maintain specialty board certification and cultivate lifelong learning. These objectives will be achieved in a setting which is
evidence-based, culturally sensitive and free of commercial bias. The CME office is committed to the practice of continuing program improvement. The
office will actively explore new educational technologies, develop collaborative relationships, and seek to build the capacity to evaluate patient care
outcomes.
Mission Statement (71 Words)
To develop and implement creative, ethical, and evidence-based
educational opportunities for life-long learning that are designed
to increase competence, enhance practice performance,
promote patient safety, and/or improve patient outcomes in the
populations served by the healthcare providers we
educate. Learners are expected to gain competence in their
approach to clinical problem solving, apply newly acquired
strategies in their practice, and change their performance in
order to provide evidence-based and patient-centered care.
A. Compliant
B. Non-Compliant
Mission Statement
 Can accredited providers include components in their
CME mission statements in addition to the expected
results described in Criterion 1?
 ACCME: Yes. Accredited providers can choose to
include components in their CME mission statements in
addition to those specified in Criterion 1. However, during
the accreditation process, providers’ mission statements
will be evaluated only to ensure that the mission
statement includes “expected results articulated in terms
of changes in competence, performance, or patient
outcomes that will be the result of the program”.
CME Mission Statement
The purpose of the Office of Continuing Medical Education (CME) is to certify learning activities for physicians in order to improve the practice of medicine. This
includes patient care, research, medical education, and administration. In addition, the office tracks credits for physicians who attend CME-certified activities and
provides consultation on educational processes and accreditation issues. The content areas include a range of clinical, research, medical teaching, and leadership
skills that are based on identified needs of practitioners. This includes all segments of contemporary, primary, and specialty practice.
MSU is a world-class institution of higher learning. The target audience of the CME office includes: the broad community of health care professionals, including
primary and specialty physicians locally, regionally, nationally, and internationally.
Those target audiences include:

Clinicians, researchers, medical educators, and medical administrative leaders at MSU

Physicians from our six community campuses throughout the state

Physicians and other health professionals in the United States who participate in national activities jointly sponsored by our educational partners and framed in
the context of the IOM and ACGME competencies

International physicians and health professionals who attend national conferences and/or take advantage of our Web-based learning resources
The CME office sponsors a wide range of educational activities:

Regularly Scheduled Series (RSS)

Live activities

Enduring materials (online learning, monographs, CD-ROMs)

Test item writing

Journal-based CME
The expected results of the CME program are to provide activities that:

Incorporate the educational needs that underlie the professional practice gaps of our learners, and which match the current or potential scope of professional
activities independent of commercial interests

Improve patient outcomes through early adoption of new standards and enhanced clinical skills

Foster the continuing educational development of physicians and health professionals to enhance their competence and performance

Improve the quality of the educational process through consultation and documented compliance with accreditation standards/criteria

Expand the use of technology in the documentation of physician participation

Enhance physician’s professional competence through integrating the use of technological advances, health care information, and research findings based on
valid content with the ultimate goal of improved patient outcomes in clinical and professional practices
MSU
CME Mission Statement
Our mission is to assist physicians and health
care professionals in their commitment to lifelong
learning by providing evidence-based medical
education to enhance their ability to provide
excellent patient care, health maintenance and
improved patient outcomes. We understand that
change is constant and that new knowledge will
guide the educational needs of healthcare
professionals in the future.
A. Compliant
B. Non-Compliant
UM
Mission Statement
The expected outcome of County
Medical Society’s CME program
will be measurable and lead to
continuous improvement in
patient care, quality
measurements, and physician
development and satisfaction.
A. Compliant
B. Non-Compliant
ACCME
ACCME Accreditation Criteria
 Criterion 1
 Criterion 2
 Criterion 3
 Criterion 4 This criterion has been eliminated effective February 2014.
 Criterion 5
 Criterion 6
 Criterion 7
 Criterion 8
 Criterion 9
 Criterion 10
 Criterion 11
 Criterion 12
 Criterion 13
 Criterion 14 This criterion has been eliminated effective February 2014.
 Criterion 15 This criterion has been eliminated effective February 2014.
Planning Criteria
 C2: The provider incorporates into CME activities the educational needs
(knowledge, competence, or performance) that underlie the professional
practice gaps of their own learners.
 C3: The provider generates activities/educational interventions that are
designed to change competence, performance, or patient outcomes as
described in its mission statement.
 C4: This criterion has been eliminated effective February 2014.
 C5: The provider chooses educational formats for activities/interventions that
are appropriate for the setting, objectives, and desired results of the activity.
 C6: The provider develops activities/educational interventions in the context of
desirable physician attributes [eg, Institute of Medicine (IOM) competencies,
Accreditation Council for Graduate Medical Education (ACGME)
Competencies].
C2: Gap Analysis for Symposium
“The field of transplant surgery is constantly
evolving at a rapid pace and the healthcare team
needs to keep pace. Annual updates on the latest
surgical techniques, patient selection and
treatment for post-transplant care are needed.”
A. Compliant
B. Non-Compliant
C2: Gap Analysis for Tumor Board
Gaps are based on suboptimal care given to an
individual case (usually a child with cancer). The
gap is what the activity director perceives as the
less than desirable treatment or outcome and what
could be changed to improve current or future
patients with similar conditions and situations.
A. Compliant
B. Non-Compliant
C2: Gap Analysis
Course is designed to assist learners to pass the
Internal Medicine Certification Examination
A. Compliant
B. Non-Compliant
The provider designs courses to assist learners to
pass board review courses. However they do not
provide evidence of how the board requirements are
either a gap in physicians’ professional practice or are
linked to or derived from a gap.
C2: Gap Analysis
Practice gaps are based on National data
regarding patient safety and medical ethics.
A. Compliant
B. Non-Compliant
The provider described in its self-study report a
process to identify professional practice gaps by
referencing national data regarding patient safety
and medical ethics. However, the provider did not
link the professional practice gaps to their learners
C2: Gap Analysis
Practice gaps are based on post-activity surveys
and requests from physicians.
A. Compliant
B. Non-Compliant
The provider does not identify professional
practice gaps. It identifies educational needs
through post-activity surveys and requests from
physicians, institutions, and healthcare
professional groups.
C3: Designed to change competence,
performance or patient outcomes
“After participating in this ‘Train the Trainer’ activity,
our staff – who serves as faculty for all regularly
scheduled series – will know the benefits of
giving feedback during educational events.”
A. Compliant
B. Non-Compliant
C3: Designed to change competence,
performance or patient outcomes
“After participating in this ‘Train the Trainer’ activity,
our staff – who serves as faculty for all regularly
scheduled series – will know how to implement
effective strategies for giving feedback during
educational events.”
A. Compliant
B. Non-Compliant
C3: Designed to change competence,
performance or patient outcomes (OB GR)
Need for improved care of patients in any disease or
condition related to OB/GYN. Some topics selected based
on low percent of patients meeting quality improvement
guidelines. Need to give participants new abilities and
strategies for treating patients.
A. Compliant
B. Non-Compliant
C3: Knowledge vs Higher Level Outcomes
Majority of activities should assess Competence, Performance or
Patient Outcomes
ACCME Example of Noncompliance:
“The provider describes in its self-study report and presents evidence
that its activities were solely designed to change knowledge.”
The ACCME affirms that “knowledge” is acceptable content for
accredited CME. With respect to Criteria 3 and 11, even if the
preponderance of a provider’s activities is focused solely on changing
knowledge, the provider must still show how these activities contribute
to the overall program’s efforts to change learners’ competence, or
performance or
C5: Appropriate Format
“The upcoming ‘Train the Trainer’ activity, will use
case scenarios and role playing to achieve the
goal of teaching our faculty effective strategies for
giving feedback during educational events.”
A. Compliant
B. Non-Compliant
C6: Desirable Physician Attributes
At each CME Planning Committee meeting,
included in the materials is a copy of the ACGME
Competencies. One member is assigned the
responsibility of mapping the activities discussed
to a competency and challenging any activities
that don’t have a clear alignment. The members
rotate this responsibility from meeting to meeting.
A. Compliant
B. Non-Compliant
Summary: RSS Monitoring
ACCME Example of Noncompliance:
“The provider did not demonstrate that it collected and
analyzed data and information to assess the
compliance of its program of regularly scheduled
series (RSS) for Criteria xx .”
Summary
Planning CME Activities
 Use a CME Application Form
 Include request for information on C2-C13
 For RSS require a Recertification Form
 Include request for information on C2-C13]
 Request examples from individual sessions