What is in this article?:
- Understanding and Acting On ACCME Criterion 21â€”the Quality Framework
- Documenting Compliance with Criterion 21 in Activity Files
To comply with's Criterion 21, which requires that a CME provider participate in an institutional or system framework, providers must bake a commitment to that framework into everything from your organization’s mission statement to every activity that you plan, implement, and evaluate. Here’s how.
Documenting Compliance with Criterion 21 in Activity Files
Criterion 21 is system-based, and there are no performance-in-practice labels for “Engagement with the Environment” criteria. Nevertheless, it is prudent to demonstrate how your organization adheres to your quality frameworks. To demonstrate compliance, the following examples are a good place to start:
• Conduct periodic strategic planning sessions with your CME team and clinical experts to clearly identify emerging quality and patient safety issues in your core areas of education; keep notes on the issues you identify so that you can ensure those issues are incorporated into activities planned in the next year. This will show that you incorporate key quality and patient safety issues into your CME program and document the process.
• If you have a chief quality officer who is responsible for ensuring that identified quality and safety issues are infused into your activities, be sure to document the CQO’s input into staff meetings, planning sessions, etc.
• Your planning activity notes should incorporate up-to-date biographical information on course directors, board members, and committee members. Their appointments with other organizations, especially those that may be involved in standard setting, guidelines development, and similar processes bring valuable insight into the planning process.
• Where and when applicable, keep minutes from meetings where activity planning and content incorporates or addresses current standards of care and associated guidelines.
• Track activity evaluation results where competence, performance, and/or patient outcomes data can be compared to baselines, standards, or guidelines.
• Maintain activity file notes on collaborative partners, especially those who are associated with standard setting for the professional practice areas.
• Maintain a database of your outreach efforts to quality departments, committees, and organizations.
• Make sure that your activity file captures the standards, best practices, and/or guidelines that were current during the planning and implementation phases of the activity.
As you can see, demonstrating compliance with the quality framework and its impact on your CME program is not something that you back into. It starts with your CME mission, progresses through the fiber of every activity you plan, and is based on an organization-wide commitment to using your program of CME to improve quality of care and patient safety as a primary commitment.
Steven Passin is the president and CEO and Judy Sweetnam is a senior associate and director of training for Steve Passin & Associates, Newtown Square, Penn. You may reach Steve at email@example.com and Judy at firstname.lastname@example.org.