Criteria 1-6 Examples of Compliance and Non- Compliance David Pieper, PhD Assistant Dean for CME Wayne State University School of Medicine

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 non- synchronous 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.

A. Compliant B. Non-Compliant 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.

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

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 Mission Statement ACCME

ACCME Accreditation Criteria Criterion 1 Criterion 2 Criterion 3 Criterion 4 This criterion has been eliminated effective February Criterion 4 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 Criterion 14 Criterion 15 This criterion has been eliminated effective February Criterion 15

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 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