EMORY UNIVERSITY SCHOOL OF MEDICINE
OFFICE OF CONTINUING MEDICAL EDUCATION
REGULARLY SCHEDULED SERIES MONITORING SYSTEM
1. GOAL:
In accordance with ACCME Policy 2003-A-08, the following Monitoring System is
implemented to guide Emory Medical School faculty and staff in the planning and
execution of regularly scheduled conferences (RSS). This System will be used to track
compliance and recommend improvements when necessary.
2. POLICIES:
2.1 In support of ACCME Criterion 2, RSS directors will be required to implement and
participate in an annual activity planning process that will identify the professional
practice gaps of its target audience; determine the educational needs that may result from
the deficiency; and link these to desired results.
(Supporting document: Course Activity Planning and Approval Form)
2.2 In support of ACCME Criterion 3, RSS directors will identify and link needs with
gaps in professional practice or standard of care. These can be identified from sources
including faculty consensus, past evaluation data, hospital QI analyses and reviewing
media and societal trends. Educational interventions should be developed that will
impact learner knowledge and competence .
(Supporting document: Course Activity Planning and Approval Form)
2.3 In support of ACCME Criterion 4, the RSS should be designed for a clearly defined
target audience and session topics should reflect the level and scope of their practice.
(Supporting document: Course Activity Planning and Approval Form)
2.4 In support of ACCME Criterion 5, at a minimum, the global objectives of the RSS
will be communicated to the participant prior to the beginning of the session. These
objectives should dictate the type of format used to present the RSS, i.e. journal review,
morbidity/mortality data review, lectures, case review, etc.
(Supporting document: Flyer, email, and/or Sign-in Sheet)
2.5 RSSs will be evaluated on a consistent, ongoing basis. The evaluation tools will be
summarized on an annual basis to measure the RSS effectiveness in achieving the desired
results of changing learner behavior in terms of knowledge and competence. Where
available and appropriate, hospital data and chart audits can be utilized to measure
changes in patient health outcomes.
(Supporting document: Sample Evaluation Form)
2.6 Each RSS will have a dedicated person in the clinical department to coordinate all
activities associated with the RSS to ensure appropriate compliance.
2.6 ACCME Criterion 7 and 8 require that sessions of the RSS be planned and
implemented free of commercial influence. To meet this requirement, (prior to the start
of the activity), each speaker, whether Emory or external, must complete a Conflict of
Interest Declaration form. Any financial relationships relevant to the session must be
reviewed by the RSS coordinator and, if necessary, steps implemented to resolve any
conflicts. Several options for conflict resolution are available. See options listed on the
course approval form or call the CME Office for assistance. All solutions to conflicts
should be documented and available for review if requested.
An announcement to the audience, whether written or verbal, must be made regarding
any relationships the RSS speaker might have with the products or devices discussed in
the presentation. In additions, if the RSS or specific session is financially supported by a
pharmaceutical or device company, a Letter of Agreement outlining the terms and
conditions of the support, must be signed by the CME Program Director and the
company. This support must also be announced to the audience and can be done via the
RSS Sign In Sheet.
(Supporting document: Financial Relationship Disclosure form, Sign-in Sheet, Letter
of Agreement)
2.7 In support of ACCME Criterion 9, RSS activities will keep exhibits and exhibitors
separate from the educational session. RSS planners must adhere to the School’s
Industry Relations Policy.
2.8 In accordance with ACCME Policy 94-A-28, the accreditation statement will be
present on printed materials regarding the RSS when appropriate.
2.9 RSSs will be evaluated periodically by the OCME RSS coordinator for level of
compliance with these policies and procedures. Problems with compliance will be
examined and a plan of action implemented. The RSS will be placed on provisional
approval status. If compliance issues continue, the CME certification will be
withdrawn. The RSS will have the right to reapply for full approval status during the
next RSS period.
2.10 The OCME will record and maintain evidence of the participant’s involvement in
the RSS. This information will be readily accessible to the participant via distribution of
attendance certificates and maintenance of the information in a management database.
3. PROCEDURES:
3.1. Each RSS must have a dedicated coordinator assigned to ensure compliance with all
policies and procedures associated with the RSS. This person will be responsible for file
maintenance, record-keeping, and communications with the OCME RSS coordinator.
3.2. Annually, the Course Activity Planning and Approval Form (CAF) must be
completed, signed and submitted to the Office of Continuing Medical Education
(OCME). All appropriate documentation must be included. The CAF will be reviewed
by the Program Manager and approved by the Executive Director. Notification of
provisional or full approval status will be made within 60 days. An incomplete CAF
will be returned without approval.
3.3. A signed Conflict of Interest Declaration Disclosure Statement from each presenter
(Emory and non-Emory faculty) must be obtained. This document must be kept in the
RSS file. Information given on this form must be written on the RSS Sign-In Sheet. An
additional step may involve a resolution of any suspected conflict of interest stemming
from a speaker’s financial relationship with a company. If a conflict is identified, the RSS
director must take action to resolve it. Actions might include slide review for commercial
bias and inappropriate commercial references or a revision of the focus of the speaker’s
presentation. If a resolution cannot be reached, it is the responsibility of the RSS director
to cancel the speaker’s appearance. All actions should be documented and available for
review upon request.
3.4 Speakers that are financially supported by a pharmaceutical or device company, i.e.
have an honorarium and/or expenses paid by a company, must have a completed and
signed Letter of Agreement in place. This form must be signed by the RSS course
director, the company representative, and the OCME program manager. Under no
circumstances are companies allowed to pay travel expenses or honorarium directly to the
speakers when CME credit is being offered. Those funds should be made payable to
Emory University.
3.5 The Sign-In Sheet must be completed and available at each RSS session. The RSS
coordinator is responsible for keeping these on file. At the end of the RSS period, the
sign-in sheets should be summarized. A typed Roster of Participants, complete with first
and last name, last 4 digits of social security number and total number of credit hours
earned by each participant, must be submitted to the CME Office within 90 days of the
end of the RSS period.
3.5.1 This Roster should be verified and signed by the RSS course director. It will
be kept on file in the CME Office.
3.5.2 The certificates of attendance will be mailed to the RSS coordinator within
30 days of receipt. The certificates should be distributed at the next session of the RSS.
3.6. Written announcements regarding the RSS must include Emory’s accreditation
statement: The Emory University School of Medicine is accredited by the ACCME
to provide continuing medical education for physicians.
3.7 The RSS coordinator will complete the RSS Summary Sheet for each RSS session
and submit it on a quarterly basis to the OCME RSS coordinator. This Sheet will be used
to monitor each RSS’s level of compliance with the procedures above.
3.7.1 On a routine basis, the OCME RSS coordinator will also visit the RSS
coordinator and/or RSS. During these visits, the RSS coordinator will be asked to
produce the RSS file. The OCME RSS coordinator will verify that all documents listed
above are in the file. Any problems with the RSS file and recommendations for
improvement will be noted on the RSS Summary Sheet.
3.7.2 Consistent problems with documentation or failure to comply with
improvement recommendations will result in the RSS being placed on provisional status.
The RSS course director will be notified regarding the problem areas. If further
improvements are not made, the Executive Director of OCME will notify the chairperson
of the department.
3.7.3 Continued compliance issues will result in the withdrawal of CME
certification and CME credit will not be awarded to participants.
Updated 12/2010; 2/2012