In January 2008, the ACCME released an updated RSS toolkit. In the memo attached to the toolkit, Dr. Kopelow emphasized the importance of developing RSS activities that support learning and change, as well as improvements in professional practice. He stated that RSS make up 40% of all certified CME in the US and this type of activity must be based on the professional practice gaps of the learners.
The ACCME expanded the requirements for RSS activities in 2008. Monitoring data for each series must continue to be gathered to demonstrate compliance with Criteria 2-11, and providers are now required to list each series within their RSS program on the summary report form that accompanies the Self Study for Accreditation document. Files for series listed on the summary report may be called for review by the ACCME during the accreditation process to demonstrate performance-in-practice.
The ACCME defined its expectation for RSS in terms of meeting Criterion 2 (gap analysis). Dr. Kopelow states, “Professional practice gaps can be those of individuals; however, it is more likely that in an institutional setting the gaps will be those of the healthcare team, or system, in which the learners practice. Providers must deduce the educational need that underlies the professional practice gaps.” He went on to provide questions that will assist providers in assessing the gaps, including the following:

• Why is it that the professionals have this gap?

• Is it because they do not ‘know’? Is it because they do not have an appropriate strategy in place to address the problem?

• Is it that they know what to do, but that they have not, or cannot, implement it?

Accordingly, then, RSS activities must be developed to make a change in clinical competence (strategy), performance or patient outcomes (Criterion 3), and they must be designed to allow for measurement of the changes (Criterion 11) in the series based on the designation outlined in the planning process (e.g., changes in competence and/or performance in practice and/or patient outcomes). Measurement of change can be determined either at the system or healthcare team level, the individual learner level, or within the community of professionals. The ACCME will review the monitoring data to ensure RSS are practice based learning opportunities that impact changes and improvements.
RSS offers opportunities for integrating CME into the process for improving professional practice, development of non-educational strategies to enhance change, collaboration in education, an opportunity to bridge identified barriers to change and to impact the scope and content of education offered within and beyond the organization in which CME is provided. (Criteria 16-22).

SP&A-Recommended Strategies for Demonstrating Your RSS Monitoring System

As mentioned previously, the monitoring requirements have not changed. They are provided as a reminder.  Providers that produce RSS are required to:

• Implement monitoring systems that demonstrate their RSS meet the ACCME’s Updated Criteria

• Provide evidence (e.g., reports) of their monitoring system(s) that meet the following expectations:

1. The ACCME expects that all series and all sessions within a series will meet ACCME’s Updated Criteria and be in compliance with ACCME Policies.  Providers’ monitoring systems must incorporate, measure, and document compliance with Criteria 2 - 11 and applicable ACCME Policies.
2. The provider must collect data and information from all series as a part of its monitoring system. However, data on each criterion and policy need not be collected from every series. For example, a CME provider may monitor Series A for meeting Criterion 2 and Series B for meeting Criterion.
3. Monitoring data may be derived from either (1) a sample of a provider’s sessions or (2) from all sessions. However, if sampling is used, it must be applied consistently for 10% to 25% of the sessions within each series across the whole accreditation term.
4. A provider must analyze the data and information and determine if the RSS has met ACCME’s Criteria 2 - 11 and the applicable ACCME Policies.
5. A provider must also analyze the data and information for Criteria 16 - 22 (only if the your organization intends to demonstrate it is a Level 3 provider). A provider would indicate that an RSS has met a criterion or is in compliance with an ACCME Policy if its monitoring system indicates performance—as outlined in the criterion or policy—is achieved in 100% of the sample.
6. The provider will report whether or not it has met Criteria 2-10 and is in compliance with the applicable ACCME Policies within the self study report.

If monitoring system data indicate that performance within the sampled series or sessions did not meet any one of Criterion 2 - 10 or an applicable ACCME Policy, then the provider must:

• Identify the problem and describe it within the chapter on Criterion 13

• Describe the implemented improvements within the chapter on Criterion 14

• Describe the impact of the implemented improvements in the chapter on Criterion 15

You may access the most recent documents and formats related to managing RSS programs at www.passinassociates.com/downloads/rss1.doc and www.passinassociates.com/downloads/rss2.pdf.