CE Basics: Preparing for Reaccreditation

By Rebecca DeVivo, MPH, MSW, and Brian S. Thompson, MBA

Competency 5.2
Execute CE activities and the overall CE program in compliance with applicable accreditation and/or regulatory policies and requirements by utilizing materials from the implementation of CE activities/interventions and the administration of the overall CE program to demonstrate compliance with applicable accreditation and/or regulatory policies and requirements.

The CME Self-Study Prep Workshop panel, held during the 2016 Alliance Annual Conference, got into the nitty-gritty of preparing for the self-study process and included planning timelines, tips for writing a self-study, tools for developing activity files, and how to prepare for the interview.

What follows are takeaways, distilled from that session, which may assist you during your next reaccreditation. It is important to note the following reflects personal opinions and not prescriptive answers for any accreditor.

Starting the self-study process
Organize a meeting with staff who will be involved with writing the self-study and organizing the activity. Review goals and create a timeline with this group to ensure that everyone is operating from a shared expectation and that the right materials come together in a timely fashion.

When creating your timeline, it’s best to start at the end (when the self-study is due) and work backward. Include time for internal and external reviews and outline milestones from your accrediting body. It’s important to consider and work around key dates like conferences, committee meetings, boards meetings and other activities that staff are involved with. Accounting for these events in advance can prevent delays and manage expectations.

To organize your timeline, section it out:
January: Due to Accrediting Organization: Complete “Confirmation of Intent to Apply”
March: Due to Staff: Submit sections I & II of Self-Study
April: Due to Staff: Have five completed files ready for review
August: External Review: Send draft copy to external stakeholders
October: Due to Staff: Initial senior staff/committee review of draft self-study

Who writes the self-study?
There was healthy debate on the subject of whether a self-study should be written by one person or multiple people, and it’s clear that it will vary by organization. Either way, it is recommended to designate a lead writer from the beginning; this will help ensure there is a consistent voice throughout the entire self-study and uniformity with activity files.

Should it be written all at once or in sections?
This too will vary by organization, but most panelists felt it’s better to write the self-study in sections as opposed to trying to write it all at once. One advantage of writing in sections is that it may help to eliminate writing fatigue, and the self-study is organized in a way that easily allows for it to be written in sections. Also, it’s easier to create a timeline around sectional authoring.

How long should a self-study be?
The biggest misconception is that a self-study has to be long and drawn out. This is not true — and more isn’t necessarily better. Panelists recommend keeping a self-study to the point, without including extra “fluff”: reviewers don’t give extra credit. When writing a self-study:

  • Highlight key areas;
  • Be clean (you don’t need pictures and callouts);
  • Follow the accreditor’s instructions. For example, the ACCME requires providers to include page numbers and your ID number on each page.

Also, create the table of contents last; this will save you a lot of time and frustration.

Selecting sample activities
As long as the activities demonstrate your planning process, there is no magical answer as to activities to include. ACCME reviewers are looking to “check the boxes” and your goal is to make it as easy and clear to them as possible. Most presenters felt that the sample activities are an opportunity to highlight aspects of their organization that might not come out elsewhere, such as team-based training or certification programs. Most panelists chose two different types of activities (e.g., a live course and an enduring material, or one activity with commercial support, one without). It was recommended to stay away from complicated activities or activities that are hard to explain in written form.

Who reviews the self-study before it is sent to the accrediting body?
The panel agreed that it’s best to have a self-study reviewed by people who are not involved with the planning and implementation of the education activities/interventions. In addition, it’s a good idea to ask colleagues from other organizations to review the material before it’s finalized; this way, there is a combination of reviewers who understand the organization and reviewers who understand the accreditation system.

If this group can understand what’s been written, it’s a good indication that you’ve told the story well. Continuing Education in the Health Professions is a friendly environment where people are often willing to help; use this to your advantage and be willing to help them in return.

Lastly, while opinions vary, you’ll need to decide if you want committee members or volunteer leaders (if applicable) to read the self-study. You know your stakeholders best; trust your judgment.

Who should construct the activity files?
Similar to the self-study, designate someone to lead this portion. An appointed leader will help to ensure that the activity files are consistent with formatting and organization, which enhances readability for surveyors.

Organizing activity files
Make the files easy to follow. Include documentation that is required and leave out unnecessary paperwork; less is more. Highlight what you want the surveyor to notice; this can be done using an actual highlighter or include written narration. If you have an activity that includes commercial support, carefully review LOAs for signatures and proper dates, and verify the dollar amounts equal what you’ve reported. Be forthcoming about inconsistencies and document them.

Including organizational policies
Keep an eye out for little things in your policies, such as “Last Review Date,” “Updated Last…” and correct definitions. As providers, we should be reviewing our policies and documents annually to ensure we are current and relevant to the environment. This doesn’t mean you have to update anything during the annual review, but performing and documenting a regular review demonstrates that you are continuously monitoring what you’re doing and provides an opportunity to make changes as needed.

If you make any updates, record changes by listing “last update, xx/xx” on the document.

Lastly, if you include accreditor-specific definitions within any of your policies and documents, make sure these definitions are up to date. For example, if you list the ACCME definition of a commercial entity on your disclosure form, ensure you are using the correct definition, as provider definitions change over time.

Preparing for the interview
The recommended way to prepare for an interview is to meet internally with your stakeholders that will participate in the interview; review the self-study and a couple of the activity files together. Ask your own questions about weak areas; now is the time to review, reconsider and plan for similar questions from your surveyors. It’s also the time to determine who will take the lead and be the main “voice” during the interview. Just like the survey materials were authored with a lead voice, having a main speaker during the interview helps to eliminate confusion, especially if the interview is conducted via conference call. Two notes:

  • You aren’t required to include volunteers in the interview. While some panelists felt that including volunteers can help, others believed that it can be risky to include an unknown element if the volunteers don’t know the self-study well. There are no “extra points” for including volunteers.
  • The length of the interview when it is completed is no indication of how well it went. It could take 20 minutes; it could take 90 minutes. Don’t read too much into it.

Keep in mind, surveyors aren’t interviewing you to put you on the spot, they are interviewing you to make sure they have all the facts in order when they submit your self-study and activity files with their report. In many cases, this is an opportunity to provide additional information that will ultimately help you.

Disclaimer: The information included in this article is from the perspective of the panelists, and in no way represents the position of the ACCME or any other accrediting body. Please contact your accrediting organization for any specific questions you may have.


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