No one seemed to see it coming when, just after Labor Day, the Accreditation Council for Continuing Medical Education dropped a bomb on the CME provider community in the form of 22 new accreditation criteria. “The ACCME has been talking about it for a long time, but no one knew what form it would take, when it would come, or what direction it would go in,” says Jann Balmer, PhD, director of CME with the University of Virginia School of Medicine, Charlottesville. “Now we know.”

To achieve Level 1 (provisional) or Level 2 (full) accreditation under the new criteria, which go into effect in November 2008, CME providers will have to revamp their mission statements to focus on education that improves physician competence, performance, or patient outcomes. They also need to design educational interventions that can live up to those mission statements, and to continually improve their CME programs. To meet Level 3 (accreditation with commendation) requirements, they also have to integrate CME into practice improvement, address barriers to physician change, and participate in quality improvement — all of which asks providers to take on components of the healthcare system that traditionally have been outside the purview of CME. (For a full listing of the 22 criteria, along with supporting documents and FAQs, go to accme.org.)

Once the shock of those 22 criteria virtually thudding into their in-boxes began to wear off, most CME providers seemed to approve of the new accreditation requirements — at least in principle. Robert Addleton, EdD, director of education, Medical Association of Georgia, Atlanta, speaks for many when he says, “The ‘quality movement’ has been active in healthcare since the late 1980s. This document is the first time that CME has been identified as an integral partner in that movement. The success metric is being shifted from numbers of activities, attendance, and the paper trail to the impact on physician learning and even patient outcomes. How refreshing.”

Why then, as providers talked about the new criteria at the National Task Force on CME Provider/Industry Collaboration conference in Baltimore a month after the documents were released, were so many saying things like, “It's time for me to start thinking about my second career as a Wal-Mart greeter,” and even contemplating which nonessential organ to schedule for removal so they can be out on medical leave when the ACCME surveyor next comes to their office?

The Gray Zone

As is often the case with ACCME's newly released documents, the criteria for accreditation contain a number of gray areas. For many providers, the lack of specificity, coupled with the November 2008 deadline for implementation, are causing great angst. Byron Roseman, MD, director of medical education with Lowell General Hospital in Lowell, Mass., for example, finds criterion 19 (“The provider implements educational strategies to remove, overcome, or address barriers to physician change”) to be too vague to implement. And he doesn't see any difference between criteria 20 and 21, which state, respectively, “The provider builds bridges with other stakeholders through collaboration and cooperation,” and “The provider participates within an institutional or system framework for quality improvement.”

“A two-year implementation is not a long time for 22 criteria, and the anxiety comes from much of this not being clearly defined yet,” says Balmer. She points out: “On a good day, there are things that would take a good two years to get your head and hands and program around.” Because her organization is coming up for reaccreditation in 2009, she says, “I don't have the luxury of waiting. I'm going to give it my best guess and hope I'm right. Even if I don't have the GPS points laid out, I know I have to go north, and I'm going to ask everyone I run into along the way if they know a better route.”

The ACCME has stated that it doesn't expect full compliance with all 22 of the new criteria until 2012, but that it does want providers to show progress as of the November 2008 cycle. (See the list of FAQs at accme.org for more details about ACCME expectations.) But providers still have many questions, including how much of their program needs to be compliant to get a passing grade for reaccreditation.

Kurt Boyce, president, Global Education Group, Rutherford, N.J., on the other hand, says he has no problem with the document's ambiguity. “As for clarity, I suppose the criteria can be perfectly clear to any two CME professionals, but they may not agree on exactly what any particular criterion means. Thus, we will have a situation much like what we find today: Different groups developing different methods to comply. This is as it should be. In the past, ACCME has been very receptive to this diversity. Also, it is important to note that ACCME is concerned with a provider's process as well as its results. This allows for trial and error.”

Is It Worth It?

Even for providers in hospitals, who already have the potential to be in the quality improvement loop, the criteria can look like a whole new pile of work. Says Roseman, who is no fan of the new criteria, “The added burden, expense, and frustration may cause some providers to leave the industry.” And he may be right. It's particularly daunting for those who are already strapped by limited resources, small staffs, and shrinking grant dollars.

That's the case for this CME manager with a hospital in the Midwest, who asked to remain anonymous. “After looking at the new criteria, I said to myself, ‘We have met the enemy, and he is us.’” She says she just can't face the idea of revamping her system to align with the new criteria.

“We just finished reworking our whole process, and we received exemplary [accreditation] in every area. We have everything up to speed and we are doing everything we can with the resources we're given. We just don't have the resources to go into every physician's charts and track what happens after an educational intervention. The way the new criteria line things up, we could go from exemplary [accreditation] to provisional in the blink of an eye. I am ready to turn in my retirement papers — sometimes you come to a place in your life where it's just not worth it.” She adds that she can see some of the smaller institutions giving up on CME altogether because they lack the resources to implement the new criteria.

On the other hand, Linda Caples, continuing medical education coordinator with Waukesha Memorial Hospital, Waukesha, Wis., says that while she initially questioned whether she had the resources to make it all work, she found that her hospital, like many, already has quality improvement initiatives and is tracking physician performance improvement — just not in the CME office. As she attempts to get CME into the loop of quality improvement, she says her goal is “to find a system of communication that's not going to burden everyone involved. There is a team in place already. I don't have to do the chart reviews, I don't have to get the articles, I don't have to send them out, and I don't have to do the [post-activity] review. I do have to draft the evaluation and close the loop, but once that is established, we should be good.”