In 2002, the ACCME adopted special policy for Regularly Scheduled Series in healthcare institutions, in academic medical centers. Regularly Scheduled Series are what people call grand rounds. They’re the education by the physicians of the center, for the physicians of the center. There are several series in most institutions, usually representing clinical care areas or medical specialties. And they’re repeated a number of times in different sessions throughout the year. The ACCME adopted policy to make the demonstration of compliance and record keeping for those types of activities simpler for the institutions. So, instead of us looking at these things as thousands of sessions and thousands of activities — they might have thousands of sessions but they might only be five or six activities, internal medicine, emergency, critical care — each of those would be a separate activity.
ACCME asks that you know about the compliance of those activities by sampling the individual sessions across each of those activity types, so that you will have a sample of compliance information for you about those sets of activities. So, for example, you could check 25 percent of the sessions in internal medicine to ensure that disclosure occurred. You could look at 25 percent of the emergency department rounds to ensure that they were based on professional practice gaps. And we would ask you to collate that information for each of those series and say: This is what I know about this series, this is what we know about that series, this is what we know about the other series and together, taken all together, this is what we know about the compliance of our institution in Regularly Scheduled Series across the year. You have to sit and look at the data that you aggregate across all of the series and look at it and see how your compliance stands up to the national standard.
For those institutions that are found out of compliance with Regularly Scheduled Series, it is most commonly because the providers do not have a data set that crosses all of the series and covers all of the elements of the ACCME requirements. And the providers do not sit down and analyze those data as part of their compliance with Criterion 11. They don’t integrate those data into their analysis and synthesis of the extent to which programs change competence, performance or patient outcomes. And they don’t integrate that information into Criterion12 — the extent to which you meet your mission.
So, if I’ve got a single message for you, it is: get data from every series, get data for all of our Criteria, 1 through 10 across those series, and then for Criteria 11 and 12, aggregate that information and come to a conclusion, come to a new level of knowledge about your compliance with those Regularly Scheduled Series in order to design change or to keep going on the course that you’re on.