42 tips on surviving ACCME review
Whether your next reaccreditation review will be under the Accreditation Council for CME's current Essentials, the updated criteria, or a combination of both — the experience can be stressful, painful, and scary. But, by taking control and being proactive, the process becomes much more manageable, says Ron Murray, PhD, University of Virginia School of Medicine, Charlottesville; and Julie White, MS, administrative director, CME, Boston University School of Medicine. Here are the tips they offered during a session they led at the Alliance for CME annual conference, held in January in Phoenix.
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At the top of their list was this advice: start early, which means at least two years out, said Murray.
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Go to an “Understanding ACCME Accreditation” workshop (check ACCME's Web site, accme.org, for info.
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Explore all the documentation on the ACCME's Web site — accme.org — including the surveyors' report.
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Talk to other providers about how the process worked for them. “I've been amazed at how much information competitors will freely share at conferences like the Alliance's,” said Murray. “Some post all their documentation on their Web sites.”
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Consider bringing in a CME consultant to help you.
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Create a master timeline that works back from the due date of the self-study. As Murray said, “By the time ACCME reminds you, it's too late.” Also, create a master checklist, and revise your timeline as needed, he said. “You might find something you thought would take three months only took three weeks,” or vice versa.
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Choose members of your reaccreditation work group early, appoint a leader, and determine everyone's roles, based on their interests and strengths.
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Involve key faculty and course directors in a way that works best for your CME office. “Roles can vary from data-gathering to brainstorming,” said White.
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Consider holding a staff retreat to iron out all the details. “Hold it away from the office, so there aren't distractions, and try to keep it structured and fun,” said White. For the fun factor, she says she made up T-shirts that said “6 in 2006,” referring to their aim to achieve six-year accreditation with commendation. “Even though no one actually wore them, we hung them up in our offices as reminders.” Try to come up with a slogan that can keep the motivation going. Murray suggested that even if you can't do a retreat, hold a meeting with the core staff to explain their roles. “If it's just you, hold up a mirror and give tasks to yourself,” he said.
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Give every member a notebook to keep on his or her desk to jot down ideas that might be useful in the process.
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Have regular progress meetings with whoever's in charge of each piece of the project, but be sure to still give them ownership over their particular area. “We give each person an Element,” said White.
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If possible, have someone not involved in the project provide relief on mundane details to give your staff a break.
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Develop a consistent filing system so all team members are using the same method. Create a checklist for each file and keep it in the front of the file. Review all your files now and correct all deficiencies. Remember, any file can be up for review.
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Use color coding for each file heading. “It sounds simplistic, but you'd be amazed at how this makes life easier,“ said Murray.
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Make sure all your files for joint- and co-sponsored events have all the necessary documentation, including the files your joint or co-sponsors prepare for you.
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Ensure your financial records are up to date.
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Keep job descriptions up to date, and have staff write their own bios.
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Store the work, including files and samples, in a central location. Back up your data at every step in the process. “There's nothing worse than losing your data,” Murray said.
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Read through the instructions several times before writing anything, and don't be afraid to call ACCME with any questions, even the ones you think are dumb. Have everyone in the office also read through the instructions.
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Gain a thorough knowledge of the Essential Areas and the new accreditation criteria, and brainstorm about the ways your program fulfills each aspect.
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Analyze where you were at your last reaccreditation, and outline the improvements you've made in your program since then. You can review your accomplishments Essential by Essential or Element by Element for inclusion in the written self-study, White said.
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Showcase your accomplishments in your self-study. “This is your chance to shine,“ White said.
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On the other hand, be honest. Don't try to hide your deficiencies. “The reaccreditation process lets you show improvement,” said Murray. “Take advantage of that. Do a gap analysis, then show how you plan to get from where you are to where you want to be.”
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Review all your activity types (grand rounds, conferences, DVDs, podcasts, etc.) Don't forget to make copies of all the components of online activities, including pre- and post-activity tests, before you take them down from your site.
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Break the process down into manageable pieces for you and your team members. Write the self-study one Essential Area at a time. Complete one Element per day, or week, or month — whatever schedule works best for you.
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Use clean forms and samples of your work — no coffee stains, crumpled papers, or mess.
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Design a visually appealing cover and spine.
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Make things easy for surveyors to find. Make sure all Elements are included, and highlight target areas. Place labels on all the files ACCME has selected for review so they can find what they need.
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Don't number the pages until the process is complete. “Surveyors don't want to be referred to page 12 when there is no page 12,” said Murray. Recheck the page numbers and the attachments. Use two-inch, three-ring binders and plastic sleeves for files and samples for a cleaner presentation.
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Check the assembly of your notebooks — you don't want to have any upside-down pages.
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Proofread — and proof again. Have someone who hasn't seen it before read the final draft to get a fresh perspective.
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Make extra copies of your self-study notebook. With some fine-tuning, it can be used for applying for accreditation with the American Nurses Credentialing Center and the Accreditation Council for Pharmacy Education.
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Ship your self-study via a trackable vendor. You don't want it to get lost.
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If possible, opt for a site visit for your interview. “It's a good opportunity to get the staff and faculty involved, and you can show the surveyor things you can't ship off. You also get more time with the surveyor that way,” said White.
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Prepare for the site visit by re-reading the notebook, and let the CME committee know what to expect.
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Clean your office before the site visit, and display any awards you have won.
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Give surveyors a nice space to work in, preferably one with its own computer and Internet access so they don't have to sit at someone else's desk. Offer refreshments and be hospitable.
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Take the surveyor — and your team — to lunch.
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Be prepared to wait. ACCME board meetings, where cases are reviewed, are held only in March, July, and November.
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Evaluate the survey process with your team to determine what went well and what didn't, and how you can improve for next time.
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Celebrate! And celebrate even more if you get accreditation with commendation.
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Don't forget that while all this is important, you have a life outside of CME. Put your family first.
Accreditation Council for CME staffers gave the inside scoop on the review process during a session at the Alliance for CME annual conference, held in January in Phoenix. Here are their suggestions.
Every accreditation decision is based on three sources of data: the self-study report, the review of performance in practice, and the survey interview. For the evidence of performance in practice, the CME provider submits a list of all activities undertaken, and the ACCME selects 15 activities to review, for which the provider must submit files, said Heidi Richgruber, assistant manager, accreditation services, ACCME. “If we pick one you really wish we hadn't, let us know and we can add one you'd rather have, so you'll have 16 instead of 15.” She added that if there's a piece of documentation that's not available, put a sticker on a blank sheet and note that it's not available, and why, and what you've done since to prevent that problem from happening again.
When preparing your notebooks, don't stuff the two-inch binders with extraneous stuff, said David Baldwin MPA, manager, accreditation services, ACCME. “We want everything to fit within those two inches,” he said. “Just put in what's best about your program. We don't need the hotel contracts and every faculty member's CV.” Use the labels the ACCME provides on its Web site, and include the checklist and source data. Package them all together in an 8 ½ by 11-inch folder, and make it easy to navigate, he added. “Some like to use the document review form as a cover sheet. It's not necessary, but it can be useful,” he added.
The provider gets to choose the interview format, which could be an on-site visit, a trip to the ACCME offices, or via videoconferencing. Each survey team includes at least one very experienced surveyor, Baldwin said. “It used to be anticipated that it would be an adversarial experience. But we orient our survey teams to be your advocates. They're there to make sure a complete picture of your program goes forward. If they're not seeing what we're looking for, we ask surveyors to look for what we need — it may be in the wrong place.”