2006 ACCREDITATION CRITERIA

What everyone needs to know about CME credits for educational

programs

SO WHAT?

• ACCME: Accreditation Council on CME• ACCME sanctions our CME program • New expectations for CME providers• Criteria have been developed• To maintain accreditation we must keep to

the spirit and word of the criteria

WHO CARES?

• ACCME requires adoption of new criteria• CME Office is under a mandate to accept• The Health System benefits with

improved competence and performance of the physicians and health professionals

• Physicians benefit by improved job satisfaction

• Patients have better outcomes

WHAT’S IN IT FOR ME?

• Educational programs developed to improve real problems

• Educational programs designed to correct the root cause of the identified gap

• Educational programs targeted to the correct audience

• Educational programs that demonstrate improved patient care

• More efficient use of time and effort• Better patient outcomes

CRITERION 2

• Professional practice gaps are identified• Educational interventions and activities are

designed based on educational needs• Educational needs may require

interventions that improve:– Knowledge– Competence– Performance

CRITERION 2 (continued)

• Definition of a practice gap– Current practice or outcome– Achievable practice or outcome– Requires benchmarking

• The provider working with the learner group determines using deduction– Is lack of knowledge the cause?– Is an effective strategy the cause?– Is poor performance the cause?

CRITERION 2 (continued)

• What is an example of a professional knowledge gap?– Management of hospitalized patients blood glucose (Knowledge

alone is unacceptable must affect patient outcome)

• What is an example of a professional strategy gap?– Anticoagulation safety initiative (Competence)

• What is an example of a professional performance gap?– Hand washing and hospital acquired infections (What they

actually do in practice)

CRITERION 2 (continued)

• What constitutes professional practice?– Clinical– Patient care – Research– Administrative

CRITERION 2 (continued)

• What is considered non-compliance?– No evidence of gap analysis between current

performance and desired performance– Courses designed to help learners pass board

examinations because they are not linked to a gap in physician knowledge

– Statistical data alone does not does not prove the provider identified knowledge, competence or performance was the root cause

– The educational activities have to be linked to the gap – Literature and evaluations alone are unacceptable

SUMMARY CRITERION 2

• Data gathering• Analyze trended data• Compare with benchmarks• Deduce cause of gap• Develop educational activity• Examine trended data after the

intervention

CRITERION 3

• Educational design• Designed to change behavior

– Competence– Performance– Patient outcomes

• Activities/educational interventions• Mission statement contains goals

CRITERION 3 (continued)

• Implementation Criterion 2– Everything is based on practice gap

• Planning of CME must attempt to change– Competence– Performance– Patient outcomes

• Knowledge alone is unacceptable– Convert to change in competence,

performance or patient outcomes

CRITERION 3 (continued)

• Educational design for changing competence– Case based scenario learning with ARS

• Educational design to change performance– Surgical skills lab with improved patient outcomes

• Educational design to change patient outcomes– Gap analysis results in improved patient outcomes

CRITERION 3 (continued)

• What is considered non-compliance?– Activities must be designed to change

behaviors• Competence, performance or patient outcomes

– Activities and programs that were designed only to change knowledge• Competence, performance or patient outcomes

CRITERION 4

• Content matches learners current or potential scope of professional activities

• What do the learners actually do in their practice

• Educational activities and interventions are congruent with learners practice

CRITERION 4 (continued)

• Align content with the learners scope of practice– Psychiatrists don’t require training on the Da

Vinci robot• Match scope of practice

– Development of clinical guidelines is appropriate

• Don’t forget RSSs must be data driven

CRITERION 5

• Educational format is appropriate– Consider setting– Consider objectives – Consider desired results

• Activities and and interventions– Didactic– Small group– Interactive– Hands on skill labs

CRITERION 5 (continued)

• Formats are based on participant feedback or nature of content

• Utilize a variety of formats

CRITERION 6

• Desirable physician attributes– IOM competencies– ACGME competencies

• Develop activities in terms of competencies– Medical knowledge– Specialty specific

• Consider individual and programmatic level

CRITERION 6 (continued)

• Activities may be based on– Medical knowledge– Evidence based practice– Quality improvement– Patient centered care– Interpersonal and communication skills

CRITERION 6 (continued)

• What is considered non-compliance?– RSS must have gap analysis– Desirable physician attributes are included in

self study and selected activities– Must have evidence this was considered in

planning process

CRITERION 6 (continued)