Important Notes and Instructions for Completing the CME Application
The Accreditation Council for Continuing Medical Education (ACCME) has a rigorous policy for accrediting CME activities. As an approved provider, DUCOM is required to maintain strict compliance with the ACCME standards and guidelines. Requirements are outlined in the ACCME Standards for Commercial Support.
It is the responsibility of the Office of Continuing Medical Education (OCME) to ensure that all of DUCOM’s CME activities are in compliance. Failure to comply with the standards not only jeopardizes continued accreditation for individual programs, but also puts the institution in jeopardy of losing its accreditation status as a CME provider. Due to the severity of the sanctions, the OCME is committed to ensuring that CME activities meet ACCME standards and compliance requirements.
The planning process of the activity is an important factor. It is necessary to show 1) that multiple individuals and resources were included in the planning of the activity, 2) there was an established process for deciding what activity(s) will be offered and 3) the activity(s) offered resulted from a formalized needs assessment process. The planning committee is encouraged to use the Activity Development Worksheet for identifying the performance gaps and submit the worksheet as one sample of documentation on the planning process.
Sample Planning Documentation (PDF)
The method of determining educational needs must be specified and documented. Programs must be designed to meet specific educational objectives. The needs assessment must identify 1) the performance or quality gap of the target group in terms of knowledge, competence, performance or patient outcomes and 2) the desired outcome (desired behavior or level at which the target audience should perform).
Explain how the educational needs were determined and document the resources and references used (i.e., QI data, chart audits, physician surveys, clinical guidelines, ABMS-MOI, IOM competence guidelines, etc.). Then identify the learning objectives that will help close the performance gap. Use the Activity Development Worksheet to work through the needs development process. Submit the worksheet as part of the planning process documentation.
Needs Assessment Guidelines (PDF)
Steps to consider:
- What is the current performance or quality gap demonstrated by the target group?
- Is this a gap in knowledge, competence, performance or patient outcomes?
- What methods were used to determine the professional practice performance gaps? (clinical guidelines, JCAHO requirements, HEDIS data, chart audits, quality improvement/risk management data, public health statistics, insurance data, epidemiological data, etc.)
- Review the OCME website for needs assessment and evidence-based medicine resources.
- Identify the desired outcomes and the level at which the target audience will perform after the activity.
- Identify the learning objectives that will help close the performance gaps and accomplish the desired outcomes. Refer to application guidelines for help developing objectives.
All CME activities must be evaluated. Evaluations provide critical feedback for improving the quality of CME activities, planning future activities, assessing the educational impact and measuring changes in practice habits and attitudes.See the evaluation template below.
Application Deadlines – (Submit complete applications with all attachments. Incomplete applications will be returned)
Applications for regularly scheduled series (RSSs) are due June 18th for the upcoming fiscal year. Applications for all other activities should be submitted 6 to 9 months before the activity, but prior to the printing of all marketing materials no less than 90 days prior to the activity. OCME cannot review an application if the marketing material was distributed prior to OCME’s review and approval or the application was submitted less than 90 days before the event. It takes approximately 4 weeks for the CME committee to review applications. Once the application has been approved, the activity director will be notified.
The Disclosure of Relationships and Declaration Form must be completed and submitted with the CME application for each of the planning committee members, activity director, moderator and speakers. The Disclosure of Relationships and Declaration Form can be completed online, or a PDF can be downloaded and filled out.
The form must be updated annually or more often if relationships change. Disclosure of Relationships and Declaration Forms for all faculty must be submitted no later than 8 weeks prior to the start date of the activity. All conflicts of interest must be identified and resolved prior to the presentation. If a speaker refuses or fails to submit the Disclosure of Relationships Form, that individual may not participate in the CME activity.
Speakers – Provide speaker with speaker guidelines. S/he must be independent of and not employed by a commercial entity, disclose commercial relationships prior to the presentation, assist in the resolution of conflicts of interest, use generic names, deliver an evidence-based, scientifically valid presentation, and clearly identify unlabeled and investigational application of treatments.
Activity Directors are responsible for ensuring that speakers submit the Disclosure of Relationships and Declaration Form well in advance of the activity; confirm there is no conflict of interest or that potential conflicts have been resolved; acknowledge commercial relationships and methods used to resolve conflicts of interest to the audience; and ensure that programs are independent and free from commercial bias.
Commercial Support must be in the form of an educational grant, made payable to the provider (DUCOM) or approved designee. The grant must be preceded by the Letter of Agreement, which has been signed by the commercial supporter and the assistant dean of CME. If the commercial supporter intends to cover the cost of refreshments for a grand rounds event, the department makes all arrangements then reimburses the departmental account when grant funds are received. A representative of the commercial supporter (i.e., marketing representative) cannot make independent arrangements to supply refreshments for a CME accredited event or “drop by” with food/beverage.
Refer to the Commercial Support Dos and Don’ts (PDF) for details.
Marketing Materials must be pre-approved by the OCME. Allow 1 week for review of flyers, 4 weeks for brochures. Accreditation Statement (directly vs. jointly sponsored) and Disclosure Statement must appear on marketing materials.
Sample flyer for jointly sponsored activities (PDF)
Sample flyer for directly sponsored activities (PDF)
Definition of Terms
Continuing Medical Education (CME)
“Continuing medical education consists of educational activities that serve to maintain, develop or increase the knowledge, skills, professional performance and relationships a physician uses to provide services for patients, the public or the profession. The content of CME is that body of knowledge and skills generally recognized and accepted by the profession as within the basic medical sciences, the discipline of clinical medicine and the provision of health care to the public.”
Patient Care or Patient-Centered Care: compassionate, appropriate, and effective in the treatment of health problems and the promotion of health.
Medical Knowledge: established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care.
Practice-Based Learning and Improvement: investigation and evaluation of patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.
Interpersonal and Communication Skills: effective information exchange and teaming with patients, their families and other health professionals.
Professionalism: a commitment to professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population.
Systems-Based Practice: demonstrates an awareness of and responsiveness to the larger system of health care and the ability to utilize system resources to provide optimal care.
Professional Practice Gap
The difference between health care processes or outcomes observed in practice and those potentially achievable on the basis of current professional knowledge. When there is a gap between what the professional is doing or accomplishing compared to what is “achievable on the basis of current professional knowledge,” there is a professional practice gap.
Acquaintance with facts, truths, and principles of medicine. Demonstrates knowledge about established and evolving biomedical, clinical and cognate sciences and their application in patient care.
Knowing how to do something. Knowledge, in the presence of experience and judgment, is translated into ability (competence), which is not yet put into practice. It is what a professional would do in practice, if given the opportunity.
The appropriate application of skills and techniques. Demonstrates the best evidence and practices compared to peers and national benchmarks.
Promote outcomes that are compassionate, appropriate, and effective in the treatment of health problems and the promotion of health.
OCME Office of Continuing Medical Education
NCQA National Committee for Quality Assurance
JCAHO Joint Commission on Accreditation of Healthcare
HEDIS Health Plan Employer Data and Information Set
Data Submission Form (PDF) – check off sheet to be used when forwarding materials to OCME.
Audience Disclosure Announcements (PDF) – announcements which must be made to the audience.
Verification and Resolution Form (PDF) – form completed by the activity director and used to document and report the review of relationships and resolution of conflicts of interest. Form is forwarded to OCME with the Disclosure of Relationships and Declaration Form.
Disclosure of Relationships and Declaration Form (PDF) – All individuals who have an opportunity to influence content of the CME activity (planning committee members, activity director, moderators, speakers, etc.) are required to disclose his/her commercial relationships and methods used to resolve potential conflicts of interest to the audience prior to the start of the activity.
Evaluation Form (PDF) – form used to collect feedback on CME activity. Data must be summarized and forwarded to OCME.
Honoraria Policy (PDF) – each provider is required to have and adhere to an established policy for the payment of honoraria
Guidelines for Individuals Planning and/or Presenting at CME Activities (PDF) – outlines expectations and requirements. Include these guidelines with the letter to the speaker (see below).
Letter of Agreement or LOA (Word file) – contract between CME provider and commercial supporter of CME activity. Must be signed by the commercial supporter and assistant dean of CME.
Exhibitor Contract (Word file) – contract between CME provider and commercial supporters who wish to exhibit at activity. Must be signed by the commercial supporter and assistant dean of CME.
Regularly Scheduled Series (RSSs) – grand round/M&M/case conference/tumor board/journal club.
Policy and Procedures on Disclosure, Resolution of Conflicts of Interest and Content Validation (PDF) – conflicts of interest must be resolved prior to the CME activity. The individual’s commercial relationship(s) and method used to resolve the conflict must be announced to the audience prior to presentation.
Speaker Letter (Word file) – letter to speaker, which outlines obligations and expectations.
Activity Development Worksheet for Program Planning and Needs Assessment (PDF) – planning committee uses worksheet to develop the needs assessment.
Learning Objectives (PDF) - objectives must be measureable.