Committee on CME Accreditation Accreditation Decision Report ACCREDITED PROVIDER DECISION DATE
Check Box for Recommendations Suggestions Deficiencies Best Practice 2014 ACCME Criteria for Adopted by Illinois State Medical Society with the Addition of ISMS Policy on Cultural Competence Provider: Accreditation Decision Date: 1. 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. 2. The provider incorporates into CME activities the educational needs (knowledge, competence, or performance) that underlie the professional practice gaps of their own learners. 3. The provider generates activities/educational interventions that are designed to change competence, performance, or patient outcomes as described in its mission statement. 5. The provider chooses educational formats for activities/interventions that are appropriate for the setting, objectives, and desired results of the activity. 6. The provider develops activities/educational interventions in the context of desirable physician attributes (e.g., IOM competencies, ACGME Competencies). 7. The provider develops activities/educational interventions independent of commercial interests (SCS 1, 2 and 6). SCS 1 SCS 2 SCS 6 8. The provider appropriately manages commercial support (if applicable, SCS 3). 9. The provider maintains a separation of promotion from education (SCS 4). 10. The provider actively promotes improvements in health care and NOT proprietary interests of a commercial interest (SCS 5). 11. The provider analyzes changes in learners (competence, performance, or patient outcomes) achieved as a result of the overall program s activities/educational interventions. 12. The provider gathers data or information and conducts a program-based analysis on the degree to which the CME mission of the provider has been met through the conduct of CME activities/educational interventions. 13. The provider identifies, plans and implements the needed or desired changes in the overall program (e.g., planners, teachers, infrastructure, methods, resources, facilities, interventions) that are required to improve on ability to meet the CME mission. 16. The provider operates in a manner that integrates CME into the process for improving professional practice. 17. The provider utilizes non-education strategies to enhance change as an adjunct to its activities/educational interventions (e.g., reminders, patient feedback). 18. The provider identifies factors outside the provider s control that impact on patient outcomes. 19. The provider implements educational strategies to remove, overcome or address barriers to physician change. 20. The provider builds bridges with other stakeholders through collaboration and cooperation. 21. The provider participates within an institutional or system framework for quality improvement. 22. The provider is positioned to influence the scope and content of activities/educational interventions. Accreditation Statement Policy Physician Participation Policy Activity Documentation Policy ISMS Cultural Competency Policy AMA PRA Statement Policy 0 S 0 S Accreditation Decision Accreditation Term Progress Report {select} {select} {select} 2
with Accreditation Criteria and Policies Criterion 1: 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. 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. The provider does not have 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. Criterion 2: The provider incorporates into CME activities the educational needs (knowledge, competence, or performance) that underlie the professional practice gaps of their own learners. The provider incorporates into CME activities the educational needs (knowledge, competence, or performance) that underlie the professional practice gaps of their own learners. The provider does not incorporate into CME activities the educational needs (knowledge, competence, or performance) that underlie the professional practice gaps of their own learners. 3
Criterion 3: The provider generates activities/educational interventions that are designed to change competence, performance, or patient outcomes as described in its mission statement. The provider generates activities/educational interventions that are designed to change competence, performance, or patient outcomes as described in its mission statement. The provider does not generate activities/educational interventions that are designed to change competence, performance, or patient outcomes as described in its mission statement. Criterion 5: The provider chooses educational formats for activities/interventions that are appropriate for the setting, objectives, and desired results of the activity. Not applicable The provider chooses educational formats for activities/interventions that are appropriate for the setting, objectives, and desired results of the activity. The provider does not choose educational formats for activities/interventions that are appropriate for the setting, objectives, and desired results of the activity. Criterion 5 is not applicable to initial applicants. 4
Criterion 6: The provider develops activities/educational interventions in the context of desirable physician attributes (e.g., IOM competencies, ACGME Competencies). Not applicable The provider develops activities/educational interventions in the context of desirable physician attributes (e.g., IOM competencies, ACGME competencies). The provider does not develop activities/educational interventions in the context of desirable physician attributes (e.g., IOM competencies, ACGME competencies). Criterion 6 is not applicable to initial applicants. Criterion 7: SCS 1 SCS 2 SCS 6 The provider develops activities/educational interventions independent of commercial interests (SCS 1, 2 and 6). The provider develops activities/educational interventions independent of commercial interests (SCS 1, 2, and 6). The provider does not develop activities/educational interventions independent of commercial interests (SCS 1, 2, and 6). 5
Criterion 8: The provider appropriately manages commercial support, if applicable (SCS 3). The provider demonstrates appropriate management of commercial support. (SCS3). The provider does not demonstrate appropriate management of commercial support (SCS3). Criterion 9: The provider maintains a separation of promotion from education (SCS 4). The provider maintains a separation of promotion from education (SCS 4). The provider does not maintain a separation of promotion from education (SCS 4). 6
Criterion 10: The provider actively promotes improvements in health care and NOT proprietary interests of a commercial interest. (SCS 5). The provider demonstrates that the content and format of educational activities is without commercial bias. (SCS5). The provider does not demonstrate that the content and format of educational activities is without commercial bias. (SCS5). Criterion 11 The provider analyzes change in learners (competence, performance, or patient outcomes) achieved as a result of the overall program s activities/educational interventions. The provider analyzes changes in learners (competence, performance, or patient outcomes) achieved as a result of the overall program s activities/educational interventions. The provider does not analyze changes in learners (competence, performance, or patient outcomes) achieved as a result of the overall program s activities/educational interventions. 7
Criterion 12: The provider gathers data or information and conducts a program-based analysis on the degree to which the CME mission of the provider has been met through the conduct of CME activities/educational interventions. The provider gathers data or information and conducts a program-based analysis on the degree to which the CME mission of the provider has been met through the conduct of CME activities/educational interventions. The provider does not gather data or information to conduct a program-based analysis on the degree to which the CME mission of the provider has been met through the conduct of CME activities/educational interventions. Criterion 13: The provider identifies, plans and implements the needed or desired changes in the overall program (e.g., planners, teachers, infrastructure, methods, resources, facilities, interventions) that are required to improve on ability to meet the CME mission. Not applicable The provider identifies, plans and implements the needed or desired changes in the overall program (e.g., planners, teachers, infrastructure, methods, resources, facilities, interventions) that are required to improve on ability to meet the CME mission. The provider does not identify, plan and implement the needed or desired changes in the overall program (e.g., planners, teachers, infrastructure, methods, resources, facilities, interventions) that are required to improve on ability to meet the CME mission. Criterion 13 is not applicable to initial applicants. 8
with Criteria for Accreditation with Commendation Criterion 16: The provider operates in a manner that integrates CME into the process for improving professional practice. The provider operates in a manner that integrates CME into the process for improving professional practice. Based on the evidence reviewed, the provider does not operate in a manner that integrates CME into the process for improving professional practice. The provider did not submit evidence for review by the ISMS site surveyors or Committee on CME Accreditation to demonstrate compliance with this Criterion. Criterion 17: The provider utilizes non-education strategies to enhance change as an adjunct to its activities/educational interventions (e.g., reminders, patient feedback). The provider utilizes non-education strategies to enhance change as an adjunct to its activities/educational interventions (e.g., reminders, patient feedback). Based on the evidence reviewed, the provider does not utilize non-education strategies to enhance change as an adjunct to its activities/educational interventions (e.g., reminders, patient feedback). The provider did not submit evidence for review by the ISMS site surveyors or Committee on CME Accreditation to demonstrate compliance with this Criterion. 9
Criterion 18: The provider identifies factors outside the provider s control that impact on patient outcomes. The provider identifies factors outside the provider s control that impact on patient outcomes. Based on the evidence reviewed, the provider does not identify factors outside the provider s control that impact on patient outcomes. The provider did not submit evidence for review by the ISMS site surveyors or Committee on CME Accreditation to demonstrate compliance with this Criterion. Criterion 19: The provider implements educational strategies to remove, overcome or address barriers to physician change. The provider implements educational strategies to remove, overcome or address barriers to physician change. Based on the evidence reviewed, the provider does not implement educational strategies to remove, overcome or address barriers to physician change. The provider did not submit evidence for review by the ISMS site surveyors or Committee on CME Accreditation to demonstrate compliance with this Criterion. 10
Criterion 20: The provider builds bridges with other stakeholders through collaboration and cooperation. The provider builds bridges with other stakeholders through collaboration and cooperation. Based on the evidence reviewed, the provider does not build bridges with other stakeholders through collaboration and cooperation. The provider did not submit evidence for review by the ISMS site surveyors or Committee on CME Accreditation to demonstrate compliance with this Criterion. Criterion 21: The provider participates with an institutional or system framework for quality improvement. The provider participates within an institutional or system framework for quality improvement. Based on the evidence reviewed, the provider does not participate within an institutional or system framework for quality improvement. The provider did not submit evidence for review by the ISMS site surveyors or Committee on CME Accreditation to demonstrate compliance with this Criterion. 11
Criterion 22: The provider is positioned to influence the scope and content of activities/educational interventions. The provider is positioned to influence the scope and content of activities/educational interventions. Based on the evidence reviewed, the provider is not positioned to influence the scope and content of activities/educational interventions. The provider did not submit evidence for review by the ISMS site surveyors or Committee on CME Accreditation to demonstrate compliance with this Criterion. 12
Accreditation Statement and ISMS Logo Policy with Accreditation Policies The provider consistently utilizes the appropriate accreditation statement(s) and ISMS logo for its activities. The provider does not consistently utilize the appropriate accreditation statement(s) and ISMS logo for its activities. Physician Participation Policy The provider has mechanisms in place to record and, when authorized, verify participation of a physician for six years from the date of the CME activity. The provider does not have mechanisms in place to record and, when authorized, verify participation of a physician for six years from the date of the CME activity Activity Documentation Policy The provider retains activity records/files for the current accreditation term or for the last twelve months, whichever is longer. The provider does not retain activity records/files for the current accreditation term or for the last twelve months, whichever is longer. 13
with Other Accreditation Policies ISMS Cultural Competence Policy The provider assessed the need for cultural competence as part of its planning processes. The provider assessed the need for cultural competence. Based on the evidence reviewed, cultural competence was not assessed by the provider. AMA PRA Statement Policy The provider correctly displays the AMA PRA statement on its CME activity materials. The provider correctly displayed the AMA PRA statement on its CME activity materials. The provider does not correctly display the AMA PRA statement on its CME activity materials. 14
Overall Best practices cited by Committee on CME Accreditation, if applicable: 15