Markers of Equivalency

As part of its commitment to continuous improvement, the ACCME released an updated set of recognition requirements in 2008.  The Markers of Equivalency were developed by the ACCME in collaboration with Recognized Accreditors and the ACCME’s Advisory Committee on Equivalency, a group composed of state medical society leaders from across the country.  The purpose of the Markers is to ensure the equivalency of accreditation decision-making across the national system, and streamline and strengthen the recognition process.

The ACCME’s 2008 Markers of Equivalency  are:

1. Equivalency of Rules

The Recognized Accreditor must:

1.1  Use the ACCME’s Accreditation Requirements1 that are applicable at the time (“accreditation requirements”) as the basis for each accreditation decision.

1.2  Incorporate all the formats of CME activities2 into the accreditation review process consistent with national standards established by the ACCME.

2.   Equivalency of Process

Regarding the development of accreditation decisions, the Recognized Accreditor must,

2.1.  Implement a mechanism to communicate to its accredited providers and prospective applicants all applicable “accreditation requirements” and processes.

2.2. Implement an accreditation process that requires providers to describe and verify compliance in all applicable “accreditation requirements.”

2.3.  Implement an accreditation process that makes accreditation decisions using data and information,

a.  descriptive of compliance in each applicable “accreditation requirement.”

b.  from a provider’s self study report and a provider’s performance in practice and an interview with representatives of the provider.

c. from all the types of CME activities offered by the provider.

d. from all years of a provider’s term of accreditation.

2.4. Utilize its accreditation decision-making body to verify and adopt accreditation findings and outcomes before communicating findings and outcomes to the provider.

2.5. Report to the Provider in writing the Provider’s compliance or non compliance,

a.  with each applicable “accreditation requirement.”

b.  of an accreditation decision being made that is consistent with national standards established by the ACCME.3

Regarding the operations of an accreditation system, the Recognized Accreditor must,

2.6.  Implement procedures to resolve conflicts of interest within the accreditation decision-making process consistent with national standards established by the ACCME.4

2.7.  Maintain accurate accreditation records that are updated in a timely fashion by,

a.  making an accreditation decision or granting an extension before a provider’s term expires.   If an extension is granted the extension must be consistent with national standards established by the ACCME.5

b.  making all accreditation decisions by conducting a provider’s survey interview consistent with national standards established by the ACCME.6

c. updating the provider’s accreditation information through the ACCME's national reporting system and submitting a compliance grid reflecting accreditation and progress report decisions consistent with national standards established by the ACCME.7

2.8.  Communicate in writing to the provider and the ACCME the new accreditation expiration date when an extension was granted.

2.9.  Implement mechanism(s) to collect, store, and retrieve the following documents and information used in administering the accreditation process for each provider (Documents and information that must be maintained for each provider should be retained by the accreditor for the provider's current term of accreditation). 

a. Completed self study report/application from the provider that the accreditor reviewed in the process for making the most recent accreditation decision on the provider.

b. One complete activity file that was reviewed in the process for making the most recent accreditation decision on the provider.

c. All completed surveyor forms (e.g., surveyor report form, documentation review forms, activity review forms, etc.) used in the process for making the most recent accreditation decision on the provider.

d. Correspondence between the accrediting body and the provider during the accreditation process (from notification to decision) and throughout the provider’s term of accreditation.

e. Written actions taken by the accreditation body which outline the term and status awarded to the provider.

f. Follow-up reports (e.g., progress reports) generated by the CME provider, if required.

2.10. Ensure that Annual Report data and the Annual Fee from each accredited provider, consistent with national standards established by the ACCME, is submitted via the national reporting system in keeping with ACCME-designated expectations and deadlines.8

2.11. Have, and use when necessary, written policy and procedure on Reconsideration and Appeals on adverse accreditation decisions.

2.12. Have, and use when necessary, written policy and procedure on Complaints and Inquiries on its accredited providers.

3.   Equivalency of Interpretation

The Recognized Accreditor must:

3.1. Base its compliance findings and decisions solely on the integration of data collected from the three sources during the accreditation process.

3.2. Develop compliance findings for each accreditation requirement that are,

a.  Supported by data and information from three sources.

b.  Consistent with national standards established by the ACCME.9

c.  Appropriate to the performance of the provider.

4.   Equivalency of Accreditation Outcome

The Recognized Accreditor must:

4.1.  Translate accreditation findings into accreditation outcomes (accreditation term; accreditation status, progress reports) that are,

a.  Appropriate for the accreditation findings.

b. Consistent with national standards established by the ACCME.10

4.2.  Require the demonstration of improved performance (a progress report) for each finding of Noncompliance within a timeframe, consistent with national standards established by the ACCME.11

4.3.  Require that a progress report contain both a review of a provider’s performance in practice and descriptions of procedures and practices, in order to determine if the provider has improved.

4.4.  Hold a provider accountable, through second progress reports or a change in accreditation status (Probation or Non Accreditation), when a provider fails to demonstrate improved performance within a timeframe and in a manner, consistent with national standards established by the ACCME.12

5.   Equivalency of Evolution/Process Improvement

The Recognized Accreditor must:

5.1. Integrate new accreditation requirements and new national standards established by the ACCME into its accreditation processes and/or the CME programs of its providers.  

5.2. Provide access to training for accreditation staff, surveyors and decision makers to ensure that these individuals attain and maintain adequate knowledge and competence in the accreditation of CME providers in a manner that supports equivalency in the national accreditation system.

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1 ACCME’s Essential Areas, Elements, Updated Accreditation Criteria and Policies (including 2004 Standards for Commercial Support) as noted in following links: ACCME’s Essential Areas, Elements, and Criteria and ACCME Policies.

2 Current Formats of CME activities include: Course, Committee Learning, Enduring Material, Internet Activity-Live, Internet Activity-Enduring Material, Internet Searching and Learning, Journal-based CME, Learning from Teaching, Manuscript Review, Performance Improvement, Regularly Scheduled Series and Test Item Writing

3 Accreditors must inform provider of accreditation decision within 4 weeks of decision.

4 Individuals with conflicts of interest must recuse themselves from the decision-making process.

5 Extensions may not exceed 8 months.

6 Accreditation decisions must be made within 6 months of conducting a provider’s survey interview.

7 Accreditor must update provider’s accreditation information and submit a compliance grid within 4 weeks of making an accreditation or progress report decision.

8 Accreditors must facilitate the annual reporting process of its providers which will result in the collection, review and submission of data for all providers through the ACCME’s national reporting system by the designated due date.  Accreditors must facilitate the annual fee collection for all providers that will result in submission to the ACCME by the designated due date.  Failure to comply will result in change of status to Probation for either the Recognized Accreditor or accredited provider, based on the circumstances.

9 Accreditors must give an accreditation compliance finding of either “Compliance” (provider meets criteria for compliance) or “Non-Compliance” (provider does not meet criteria for compliance) for each criterion and applicable policies. 

10 Accreditation decisions must be one of five options; Provisional Accreditation with a two-year term (Initial applicant in compliance with C1-3, 7-12); Accreditation with a four-year term; Accreditation with Commendation with a six-year term (provider in compliance with C1-22); Probation, provider receives a four year term with a maximum of two years on Probation.  Nonaccreditation, the provider’s accreditation is terminated or in the case of an initial applicant, accreditation is not awarded. An initial applicant that receives one or more noncompliance findings required for Provisional Accreditation automatically receives a decision of Nonaccreditation.  If a provider is found in compliance with (a) Criteria 1-15, and (b) all but one of Criteria 16-22 and the policies measured during the accreditation process, then that provider is eligible to submit a progress report to be considered for a change in status to Accreditation with Commendation.

11 A Noncompliance finding in C1-13 must result in an expectation of the demonstration of improvement by the provider.  This improvement must be demonstrated via a progress report and/or focused survey and/or a full survey. If a provider fails to demonstrate compliance, a change in status to Probation must result. 

12 Repeated failure to demonstrate compliance with all Criteria will result in a change in status. Providers on Probation must demonstrate that all Noncompliance findings have been converted to Compliance within not more than two years or the Accreditor must change the provider’s status to Nonaccreditation. 

13 Recognized Accreditors are expected to participate in educational opportunities offered by the ACCME throughout the year in support of equivalency.

 

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