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 ACCME Self Studies
The self study process is an opportunity to take a thorough look at the CME program within your organization. There have been many changes mandated by the ACCME over the past few years and today the self study is written largely as a thesis, with many attachments that demonstrate compliance for each essential element and policy.
Steve Passin & Associates can assist your organization
in the following ways for a self- study report:
Audit of your CME Program and Strategic Planning
To begin the self assessment process, it is helpful to ascertain exactly how well the CME Program complies or doesn't comply with ACCME Essential Areas and policies. SP&A conducts an audit of your program and provides you with a detailed report of findings that will become a roadmap to the self-study and provide suggestions for improvements. Once that is complete, SP&A works with providers to examine the new system of accreditation and its criteria, to help the provider determine whether they aspire to attain Level 2 or Level 3 accreditation, and then to map out a strategy and tactics to achieve those levels.
Formation of the Stakeholders' Task Force
The stakeholders' task force is beneficial in guiding the self study process. The task force, recommended by the ACCME, is typically comprised of those people in and surrounding your organization that have a "stake" in the effectiveness of your CME Program. Stakeholders might be the Dean or Vice President, a faculty member, a learner, a key partner organization (if you joint sponsor), the president of your parent organization (if applicable), and representatives from your staff and CME Advisory Board or Committee. This group is helpful in identifying future goals for the organization, as well as a means to identify areas for improvement. It is not mandatory to have a Stakeholders Task Force, but it is a good way to gather objective input from those with a stake in your CME program.
Development of Exemplary Evaluation Tools
SP&A performs an analysis of your current methods of evaluating your CME activities and makes suggestions for upgrading those processes in order to meet requirements for exemplary compliance. Suggested tools might include pre-evaluation, post-activity evaluations, and outcomes measurements. However, development of well-written learning objectives is key to measuring outcomes, and SP&A offers training and support for applying Kirkpatrick’s levels of evaluation to the linkage of identified needs, and desired results. SP&A staff and contracted experts in evaluation mechanisms are available to assist the provider in building skill levels in evaluation and/or performing more complex evaluation mechanisms.
Production of the Self Study Report
The preparation and management of the self study process is greatly enhanced by the expertise of a seasoned consultant. SP&A has supervised the preparation of many self study reports and can provide the structural, strategic and tactical direction that is necessary for a successful result.
Files Review
As required by the ACCME, a review of specific activity files is conducted during the self study process. This is the method the ACCME uses to determine if your intentions match your performance-in-practice. In order to ensure full compliance, or exemplary compliance, SP&A will review selected files of different types of activities and advise you of our findings. This audit provides an overview of the compliance findings, according to the ACCME review form and SP&A's suggestions to ensure activity files meet all ACCME requirements. If desired, files can be organized using our checklists that are prepared in accordance with the ACCME Documentation Review.
Policy and Procedures Manual Update
A Policy & Procedure manual is a mechanism to assure that well-conceived policies and operational formats are standardized throughout your CME Program as well as with any joint sponsors involved the CME Program. In order to ensure your CME Policy and Procedure manual is up-to-date, SP&A reviews your policies and their operational processes and recommends appropriate changes. If you do not have a manual, SP&A will design one for you. The manual becomes a key resource in training for staff.
Mock Survey
To prepare your CME team for the onsite or video survey, SP&A conducts a mock survey that recreates the environment of the actual survey. An experienced former senior ACCME surveyor conducts the survey. All mock survey outcomes are kept confidential, of course, and a full debriefing is held to make final preparations for the actual ACCME survey.
Survey
For re-accreditation, the video survey is the most common way to conduct a survey. The survey lasts 90 minutes and is an effective way to present yourself and your organization. SP&A assists providers in last minute preparation of the provider’s survey team, organizing the video session, providing training on optimal visual effectiveness, and supervising the process from behind the scenes. Providers also have a choice of requesting an in-person onsite visit when that option enhances the ability to more fully present their CME Program. SP&A has years of experience in organizing these surveys for their clients for optimal impact.
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