It's been two weeks since our Accreditation Council for CME on-site survey, and although we won't get the official notice on our accreditation status for several months, I feel good about our chances for re-accreditation and about the new system of accreditation. What a surprise! I certainly wasn't at this point when the process started.
I've written this article for several reasons: to help lessen other providers' anxiety about re-accreditation under the new system based on our experiences, to offer some practical tips on how to approach the re-accreditation process, and to share what I learned is the real benefit of the's new system of accreditation. But first, some background.
The Endocrine Society, in Bethesda, Md., is a specialty society of almost 10,000 physicians and researchers working in the field of endocrinology (i.e., hormones). Our educational programs include an annual meeting and smaller conferences and symposia. We also produce enduring materials, including Web-based programs. We have been accredited by the ACCME since 1975 and this was my third re-accreditation review.
I'd Rather Be at the Dentist
When I received notice from the ACCME in February of our re-accreditation, my initial response was the same as if it were an appointment reminder from my dentist — something I must do but truly dread. Although I'd completed two previous re-accreditation applications and feel fairly well-versed in the ACCME requirements, this would involve the “new system” and an on-site meeting with the ACCME surveyors, as we had not had a visit in the past 10 years. As I quickly read through the materials in the notification package, my anxiety continued to grow. It was apparent that the self-study report was going to be a lot of work.
I got off to a good start. I promptly sent off the required acknowledgement to the ACCME that we had received the package and would be submitting a re-accreditation application. I also sent a memorandum to our CME advisory committee, executive office, and other governing committees notifying them of the survey and providing them with a copy of the self-study report outline so they could understand the process. I created a timeline for drafting and reviewing the material and established our target mail date for sending the application package to the ACCME (early August). I even discussed the file review I wanted to complete for all activity files within the review period with my staff, as well as a checklist we would revise and use for each file. It was the end of February, and I'd lined everything up to organize and work on the study. I put the re-accreditation folder on a prominent corner of my desk and then immediately got caught up in preparing for our annual meeting and other projects.
Fast-forward to June. The self-study folder is buried somewhere on my desk, and even though I've thought about it and reminded everyone about it on a regular basis, we haven't started. My initial timeline is a sore reminder of just how behind we are on preparing the materials. I haven't written a single sentence, and as I leave for the annual meeting, the albatross is getting heavier, and my anxiety level is growing. I know when I return I have to start preparing the self-study, and time is not on my side.
I actually started working on the application on June 28 — two months behind my original timetable, and I wasn't even sure how to start. I began by creating a document that followed the self-study report outline provided by the ACCME, and expanded this to include the sample self-study questions on the Essential Areas also included in the ACCME package. I started writing a narrative for each section and answering the questions. It became very obvious that one major difference in the two systems was the writing required. This was nothing like what I had done for the previous re-accreditation applications. I spent hours completing the various sections. Some were easy — such as writing a brief history of the program. Others were more thought-provoking and really required not only a hard look at both the good and bad of the program but plans for the future.
The self-study went through numerous reviews and revisions and involved both members and staff. Once in final form, we incorporated our supporting examples and mailed the required four copies to the ACCME on August 8 (just four days after the original target mail date). What a relief!! Phase one was complete — now we had to finish the extensive file review and wait to hear something.
In mid-August the ACCME confirmed October 18 as the date for the site survey and identified the two surveyors. In mid-September we received the list of activity files that should be available for review at the survey. In late September I was contacted by the lead surveyor to discuss the upcoming survey.
“It became very obvious that one major difference in the two systems was the writing required…. I spent hours.”
In addition to receiving an agenda for the meeting, I was assured that the surveyors were meeting with us for clarification of the self-study and to gain a better understanding of our CME program. Internally, we identified the team that would attend the meeting, including our executive director and the chair of our CME advisory committee, and discussed final preparations.
The Big Day
Finally, the BIG DAY arrived. To say I was nervous would be an understatement. When the surveyors arrived, the lead surveyor outlined the process we would follow during the meeting and quickly explained the role of the survey team in gathering additional information that would supplement the self-study report.
We then had a productive and extremely useful discussion of our CME program. At times it was a brainstorming session with very open dialogue about what we were doing and how we envisioned our program would change and grow. We discussed outcomes-based evaluation processes and the challenges faced by specialty societies in measuring outcomes, the use of scanning technology to process activity evaluations, and the impact and success of Web-based educational initiatives. There were specific questions about information in the self-study, and we had the opportunity to clarify our procedures. I was also able to have all of the staff involved with our CME program attend the meeting as observers — an incredibly valuable training opportunity for them.
As the day progressed, I thought, “Wow, we've really got our act together,” and then the surveyors started the activity file review. I will condense the next harrowing moments into one recommendation that we have immediately implemented. The activity files need to be clearly organized with the educational components in one section and the logistical components in separate sections. For the most part, we had everything the surveyors needed to see — it just wasn't easy to find.
The meeting ended with a summary period where we talked about changes that could be made to strengthen our program. As noted above, documentation and file organization should not be minimized. The files should be easy to review and should make prominent the areas the surveyors must see as part of their file review. The ACCME makes available the surveyor's checklist, which can be used as an internal file review checklist.
When the surveyors left, we all felt as if we had been through an incredibly valuable process. I completed the ACCME evaluation form that had been sent about two days before the survey, and realized that overall the entire process was positive and constructive.
Lastly, I had known that the ACCME thought there would be benefits for accredited providers under the new system having heard Murray Kopelow, MD, executive director of the ACCME, speak on the topic several times. I just didn't get it — until now.
“At times it was a brainstorming session with very open dialogue about what we were doing and how we envisioned our program would change and grow.”
The Power of Reflection
Preparing the self-study report forces you to really think about and reflect on your CME program. With all the demands on our time, who really gets the opportunity to stop and think about what you're doing and how you're doing it? Where is your CME program going? What are you trying to accomplish? Does your mission statement really support these goals? Does your organization support the CME program? Do you have competition? Are you really meeting the educational needs of your audience? You will think about and answer all of these questions. Taking a hard, introspective look at your CME program and ways it can be improved is a much better use of time and resources than completing forms, as was done under the old system.
The process was also an incredible training opportunity for staff — especially those new to the area of CME. Our CME staff now understands why we document an activity the way we do and the importance of an easy-to-follow activity-filing system. We've already revised our checklists and activity file structure. We also have instituted procedures to make sure all of the documentation gets in a file — including e-mail messages. The use of e-mail to communicate with planning committees and activitycontinues to grow, yet we were not systematically filing hard copies of those messages in the activity files. Any and all communication needs to be documented, including notes of phone conversations.
Overall, by going through the process, I've gone from being a skeptic about the new system to being an advocate. It was a lot of work and effort by both members and staff, but I know our CME program and the educational activities designed for our members will benefit.
Note: At press time, Johnson was “on pins and needles” waiting to hear from the ACCME about The Endocrine Society's accreditation status.
Wanda Johnson, CMP, is currently director, CME services, with The Endocrine Society. A nine-year veteran of the society, she began her career there as a long-term temp. In a previous life, Johnson spent more than 10 years working in the banking field; her last position was vice president of the First Women's Bank in Rockville, Md. She holds a second full-time job as a wife and mother of two children. In her free time, she is an avid reader and — as you can probably tell — an aspiring writer.
New System Survival Tips
The report is a detailed summary of all facets of a CME program. Depending on the complexity of your program, it will take a significant amount of time to write and edit the report and compile the examples. Do not minimize your efforts here — the better written and prepared your report is, the easier it will be for the surveyors to understand how you manage the program. I spent a solid month focused on writing and preparing the report with the clock quickly ticking — not the best way to do this! Here are some more tips:
Be reasonable in your timeline for completing the application, considering your other tasks. I created a tense situation early in the process by developing an unrealistic timeline given my workload. It would have been better if I'd divided the report into sections and identified target dates for the sections rather than focus on the completing the entire report by a specific date.
Use the resources provided in the application package. Read everything carefully and follow the guidelines, which will walk you through the process. Once I got started, 98 percent of what I needed had been provided.
Don't be afraid to ask questions of the ACCME staff. It's better to get correct information than guess. I spoke with a couple of CME colleagues who had been through the process with the new system and walked away with misinformation. When I called, the ACCME staff was both friendly and detailed in the clarification. I also found the ACCME Web site (www.accme.org) to be very helpful.