CME Provider Webinar July 27, 2017 2 3 p.m. Welcome & Introductions All phone lines will be muted, please press the raise your hand button or use the typed question feature if you have a question or comment. Questions/comments are welcomed! 2 1
ACCME MOC Webinars Go to http://www.accme.org/events to register! 3 It s Essential 2017 SAVE THE DATE! It s Essential November 29 Sheraton Madison Hotel 4 2
Webinar Archive https://www.wisconsinmedicalsociety.org/resources/continuing-medical-education/ 5 New Menu of Criteria for Accreditation with Commendation 6 3
1. True or False? Providers pursuing Accreditation with Commendation using the Menu of New Criteria must achieve compliance with at least one criterion from each of the five menu categories? 7 Achieving Accreditation with Commendation Any 7 Criteria 1 from Achieves Outcomes 8 Total Criteria 8 4
2. True or False? An organization can achieve Accreditation with Commendation using criteria from both the current Commendation Criteria (C16-22) and the Menu of New Criteria (C23-38). 9 Society Implementation Timeline Decisions between December 2018 to May 2019 can choose Option A or Option B: Option A: Includes seven criteria (Criteria 16-22) that demonstrate engagement with the health care environment. Option B: Provides a menu of 16 criteria (Criteria 23-38) from which providers must select and present evidence for eight criteria (including at least one from Achieves Outcomes ). Decisions after May 2019 must use Option B. 10 5
3. True or False? For those criteria in the Menu of Commendation Criteria that require submission of evidence at review, there is a sliding scale for the evidence that must be submitted that is based on the number of activities the provider reports in PARS during its accreditation term. 11 Supporting Information The rationale for the criterion s inclusion. The critical elements required to demonstrate compliance. The standard for measuring compliance. 12 6
The Standards Attestations: Providers will need to attest to meeting the criterion in 10% of activities during the accreditation term this percentage is the same for all providers. Submitting evidence at review: Providers will need to submit evidence to show how they met the criterion. The number of activities is based on the number of activities reported during the current term. Examples and descriptions: For the program-based criteria, providers will need to demonstrate compliance with examples or descriptions submitted as part of the self-study report. 13 Program Size Indicated by the number of CME activities your program has offered in the current accreditation term: Small Medium Large Extra Large <39 40-100 101-250 >250 14 7
Calculating Your Program Size 1. Login to PARS 2. Click on the Activities Tab 3. On the left sidebar, click Download All Activities 15 Remember It s Optional As with the existing commendation criteria 16-22, compliance with the new commendation criteria is optional and is required to achieve Accreditation. But: Providers are required to address in self study report for reaccreditation. Even if not seeking Commendation, can help spark ideas and excel CME program. Sometimes providers are doing more than they realize to meet these optional criteria, so do your best to address these criteria in your Self-Study report. 16 8
Achieves Outcomes Only one of the five categories that is mandatory (at least one criterion). Designed to reward providers that engage their learners in a measurement that shows that they are improving. 17 Criterion 36: The provider demonstrates improvement in the performance of learners Rationale Critical Elements The Standard Research has shown that accredited CME can be an effective tool for improving individuals and groups performance in practice. This criterion recognizes providers that can demonstrate the impact of their CME program on the performance of individual learners or groups. Measures performance changes of learners AND Demonstrates improvements in the performance of learners Demonstrate that in at least 10% of activities the majority of learners performance improved. 18 9
Demonstrating Compliance 1. Attest: Include attestation statement that indicates that the Critical Elements for Criterion 36 have been met in at least 10% of the CME activities (but no less than two) during the accreditation term. 2. Submit a description(s) of the method(s) used to evaluate learner performance. 3. Submit evidence based on size of your CME program, (small: 2; medium: 4; large: 6; extra large: 8). For each example include the following information: Activity title Activity date Activity type Mechanism to determine change in performance of learners Number of learners that participated in the activity Number of learners that participated in the evaluation Number of learners that improved their performance 19 What Constitutes Performance Change? Measured changes in a learner s or learners' behavior, for example: Higher patient communication ratings Fewer coding errors Greater participation in team meetings More appropriate prescribing, etc. Providers can set their own specific goals/targets for the performance improvement and can also choose the most appropriate mechanisms to measure performance change, and how much change in learners is acceptable. Should be consequential in relation to the objectives. 20 10
What Data/Information Can be Used to Show Performance Change? The improvement data may emerge from selfreported changes, observed improvements, practice-level data, or other sources. Change can be measured at an individual or group (team) level. Can include all learners, not just physicians. Improvements in knowledge and plans to change performance would not meet the expectation of this criterion. 21 Do You Need to Measure Performance Change in Every Learner? No! For example: If you use a survey or evaluation to measure performance change, with C36, performance change would be calculated based on those learners who respond to the survey. The provider should ensure there are appropriate mechanisms in place to optimize the response rate. 22 11
C36: Compliance Example The provider describes using records from in-hospital resuscitations to determine baseline performance for critical care teams in using an appropriate resuscitation sequence, then revisits the data over time to assess changes in performance following quarterly simulator training sessions. The provider shares evidence that the data showed that the measures improved over time for those code teams who participated in the simulator training activities. 23 Criterion 37: The provider demonstrates healthcare quality improvement Rationale Critical Elements The Standard CME has an essential role in healthcare quality improvement. This criterion recognizes providers that demonstrate that their CME program contributes to improvements in processes of care or system performance. Collaborates in the process of healthcare quality improvement AND Demonstrates improvement in healthcare quality Demonstrate healthcare quality improvement related to the CME program at least twice during the accreditation term. 24 12
Demonstrating Compliance 1. Describe at least two examples in which your organization collaborated in the process of healthcare quality improvement, along with the improvements that resulted. 2. Include data (qualitative or quantitative) that demonstrates those improvements. 25 What is Healthcare Quality Improvement? The ACCME considers it simply: improvements in clinical care processes or systems This can include, for example, quality measures that are validated by outside sources and/or measures that are appropriate and important to the CME provider s own setting. Collaboration is not limited to a single institution. The provider can choose how, and with whom, it collaborates with. 26 13
Sound Familiar? Similar to C21:The provider participates within an institutional or system framework for quality improvement. But for C37, the provider also needs to demonstrate the healthcare quality improvements that resulted. 27 C37: Compliance Example The provider's patient safety committee observes an increase in post-surgical infections and collaborates with hospital leadership, the CME department, nursing education, and operating room technicians to use its weekly surgical case conferences to facilitate training on using checklists to ensure adherence to best practices in post-surgical infection prevention. Following a 3-month education effort, the Chief of Nursing reports that use of the checklist has increased from 86% to 94%. The Manager of Quality reports that readmissions with infected surgical wounds may be declining. 28 14
Criterion 38: The provider demonstrates the impact of the CME program on patients or their communities Rationale Critical Elements The Standard Our shared goal is to improve the health of patients and their families. This criterion recognizes providers that demonstrate that the CME program contributed to improvements in healthrelated outcomes for patients or their communities. Collaborates in the process of improving patient or community health AND Demonstrates improvement in patient or community outcomes Demonstrate improvement in patient or community health in areas related to the CME program at least twice during the accreditation term. 29 Demonstrating Compliance 1. Describe at least two examples of your organization s collaboration in the process of improving patient or community health that includes CME, along with the improvements that resulted. 2. Include data (qualitative or quantitative) that demonstrates those improvements. 30 15
What is Patient or Community Health? Health characteristics or outcomes related to individuals or to groups of individuals within a geographic location, service area, or other grouping. Health and health outcomes can include incidence and/or prevalence of disease, mortality, vaccinations, nutrition, and social determinants. 31 C38: Compliance Example The provider describes collaboration with cultural organizations, faith leaders, and translators to serve as faculty in an initiative to pursue culturally and linguistically appropriate services for its diverse patient population. The provider shows improvement in patient outcomes related to health equity as a result of the initiative, including improved ratings from patient experience surveys for items such as, My doctor showed respect for my culture and beliefs. and My care team made sure that I understood my procedure by offering translation services to answer my questions. 32 16
4. True or False? Providers can use the same CME activity, or activities, to demonstrate compliance for multiple criteria from the Menu of New Commendation Criteria. 33 5. True or False? Although only eight criteria are required, providers can submit evidence for more than eight to further demonstrate the ability to meet compliance standards with the Menu of Commendation Criteria. 34 17
Questions? 35 18