Vanderbilt University School of Medicine
DIVISION OF CONTINUING MEDICAL EDUCATION
Policy Statement – Non-Compliant CME Regularly Scheduled Series
1.
Purpose
The purpose of this policy is to explain the procedures for addressing non-compliance issues related to CMERegularly Scheduled Series.
2. Definitions
a. Regularly Scheduled Series (RSS) are typically weekly or monthly CME activities that are planned by and
presented to Vanderbilt University School of Medicine faculty. RSS include, but are not limited to, grand
rounds, tumor boards, journal clubs, M&M conferences, case conferences, and user group meetings.
b. Non-compliance means that requirements set forth by one or more of the following organizations have
not been fully met during the planning and/or implementation of a live course: the Accreditation Council of
Continuing Medical Education (ACCME), Vanderbilt University Medical Center (VUMC), Vanderbilt Division
of Continuing Medical Education (VCME).
c. Annual Review refers to both the procedure and form used to measure the adherence of Regularly
Scheduled Series to ACCME, VUMC, and VCME requirements. The items comprising the Annual Review
should be submitted to VCME no later than the date provided by the CME Office.
d. Course Director refers to the full-time Vanderbilt faculty member who is ultimately responsible for the
educational content of the Regularly Scheduled Series.
e. CME Associate refers to the Vanderbilt staff member who is responsible for administering a CME-certified
Regularly Scheduled Series.
3.
Compliance
A Regularly Scheduled Series is found to be in compliance when all ACCME, VUMC, and VCME requirements
have been satisfactorily met. Measurement of compliance is made on as as-needed basis and at least once per
via the Annual Review of an Approved CME Regularly Scheduled Series form.
4.
Non-compliance
A Regularly Scheduled Series is found to be non-compliant when at least one ACCME, VUMC, or VCME
requirement has not been satisfactorily met. Items that may be measured for compliance include, but are not
limited to:
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disclosure of financial relationships
sign-in sheets
letters of agreement (if commercial support is obtained)
financial summaries (if commercial support obtained)
evaluation
attendance
scheduling (applies to grand rounds only)
5.
Results of non-compliance
Depending on the severity or frequency of the deficiency, non-compliance may result in a warning from VCME,
probation, or suspension of credit. See chart below for details.
Results of non-compliance
Area of non-compliance
Warning
Probation
Suspension
DFR forms for course directors,
planners, and moderators not
updated by 12 month deadline
or deadline given on Annual
Review form
NA
NA
Credit will be suspended for
the next upcoming quarter
Complete quarterly schedules
not submitted by deadline
1x late within a 12 month
period = notification sent to
course director, CME
associate, and chief/chair
2x late within 12 month
period = notification sent to
course director, CME
associate, and chief/chair
3x late within 12 month
period = suspend credit for
the next upcoming quarter
Complete quarterly evaluation
summaries, or notice that no
evaluations received, not
submitted by deadline
1x late within a 12 month
period = notification sent to
course director, CME
associate, and chief/chair
2x late within 12 month
period = notification sent to
course director, CME
associate, and chief/chair
3x late within 12 month
period = suspend credit for
the next upcoming quarter
Complete quarterly attendance
summaries not submitted by
deadline
1x late within a 12 month
period = notification sent to
course director, CME
associate, and chief/chair
2x late within 12 month
period = notification sent to
course director, CME
associate, and chief/chair
3x late within 12 month
period = suspend credit for
the next upcoming quarter
DFR forms for each new session speaker/presentation topic (Grand Rounds and Guest Lecture Series only)
Presenter does not submit
form to department or division
1 to 4 weeks prior to
presentation
DFR forms not submitted to
VCME due to administrative
(course director or CME
associate) error
If presenter does not submit form prior to the activity start
date, the course director must disqualify him/her from
speaking.
1x late within a 12 month
period = notification sent to
course director, CME
associate, and chief/chair
2x late within 12 month
period = notification sent to
course director, CME
associate, and chief/chair
If course director does not
disqualify the speaker,
chief/chair will be notified
and credit will be immediately
pulled for the remainder of
the quarter.
3x late within 12 month
period = suspend credit for
the next upcoming quarter
If a financial relationship is disclosed on the DFR form, then the presentation must be reviewed
(Grand Rounds and Guest Lecture Series only)
If course director does not
disqualify the speaker,
chief/chair will be notified
and credit will be immediately
pulled for the remainder of
the quarter.
Presenter does not submit
presentation to department or
division 1 to 4 weeks prior to
presentation
If presenter does not submit his/her presentation prior to the
activity start date the course director must disqualify him/her
from speaking.
Presentation not obtained or
review form not submitted to
VCME due to administrative
(course director or CME
associate) error
1x late within a 12 month
period = notification sent to
course director, CME
associate, and chief/chair
2x late within 12 month
period = notification sent to
course director, CME
associate, and chief/chair
3x late within 12 month
period = suspend credit for
the next upcoming quarter
Sign-in sheets or recruitment
materials contain incorrect
verbiage
1x within a 12 month period =
notification sent to course
director, CME associate, and
chief/chair
2x within a 12 month period =
notification sent to course
director, CME associate, and
chief/chair
3x incorrect or omission of
verbiage within a 12 month
period = suspend credit for
the next upcoming quarter
It is expected that during the period of suspension the responsible department or division will take steps to
prevent future infractions.