Guide to the KMA Accreditation Process
Overview of the Accreditation Process
Phases: The accreditation process involves four phases: data collection, data review and
analysis, decision, and feedback to the provider.
Data Collection: The process uses multiple data sources. The following data sources will be
used to make a determination about accreditation of the CME Program:
1. A Self Study Report
2. Survey

Organizational Review (Your organization and personnel in it)

Documentation Review (Documentation of compliance for actual activities)

Activity Review, if appropriate, (Observation of an Activity)
Data Topics: KMA collects, reviews, and analyzes data for three Essential Areas:
1. Purpose and Mission
2. Educational Planning and Evaluation
3. Administration
Purpose and Mission describes why the organization is providing CME. Educational Planning
and Evaluation explain how the organization provides CME activities and how well the
organization is accomplishing its purpose and providing CME activities.
Administration defines what organizational resources are provided and the protocol used by the
CME unit.
Within each Essential Area are required Elements for which measurement Criteria have been
established. The Elements are descriptors of performance in the Essential Area. The Criteria
describe the levels of performance and accomplishment for each Element.
Data Review and Analysis, Decision-Making and Feedback: The completed Self Study,
along with the surveyors’ report, will be reviewed by the CME Committee. The CME Committee
is responsible for integrating the collected data and information so they can formulate a
recommendation to the ACCME. The ACCME is responsible for making a final decision on
accreditation. Within two weeks of the Committee meeting, at which your Self Study is
considered, you will receive a report which will include an accreditation decision and specific
information on the strengths and weaknesses of your CME Program discovered throughout the
data-gathering and decision-making processes.
Summary: To make accreditation decisions, the KMA will review the data collected from the
multiple sources for the three Essential Areas to determine if the provider’s performance in
practice is in compliance with CME requirements.
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Guide to the KMA Accreditation Process
2
Resources for Accreditation
The following resources are available on the KMA Web site (www.kyma.org) to assist you in the
completion of the accreditation process:
1. Accreditation Package
2. Resources

Instructions for Conducting the Self
Study

Essential
Criteria

Self Study Report Outline

Survey Guide

Sample Self Study Questions

Surveyor Report Form

Documentation Review Form

Activity Review Form

Glossary

Accreditation Compendium
Areas,
Elements
and
The KMA staff is available to answer questions about accreditation and the Self Study. Staff
may be reached at the KMA office.
Initial Accreditation Timeline
Calendar (you
add months)
Maximum
Time
to
Completion
(Months)*
Function
6
Pre-application downloaded from CME Web site by potential
applicant
1
Pre-application submitted by applying organization to KMA. KMA
decision on pre-application forwarded to applicant along with an
Initial Self Study Package for KMA Accreditation, if eligible.
6
Initial Self Study Report returned to the KMA, along with payment
and preferences for survey dates.
3
Self Study Report reviewed by staff and an On-Site Survey is
scheduled. On-Site Survey conducted.
3
KMA integrates and reviews data and survey report, and makes a
final decision on accreditation.
1
Provider notified of accreditation status.
*This timeline is the maximum time for the completion and review of an Initial Self Study Report for CME
Accreditation. The actual time is dependent on the applying organization and the timing of the KMA CME
meetings.
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Instructions for Conducting a Self Study for Accreditation
Purpose of the Self Study
The organizational Self Study is fundamental to the generation of descriptive information and
assessment of the CME Program and to the program’s plans for future improvement. The Self
Study Report will form the foundation for the KMA Accreditation process.
The goals of the Self Study are to provide an opportunity for the provider to:
 Assess its commitment to and role in providing continuing medical education,
 Analyze its current practices,
 Identify areas for improvement,
 Determine its future direction, and
 Effectively present the results to the KMA for accreditation purposes.
During the Self Study, the CME program is encouraged to assemble and/or seek information
from stakeholders (administration, faculty, attendees and other appropriate constituents) to:
 Collect and analyze data collected about what, why and how the CME program and its
products and services are utilized,
 Assess how well they are performing, and
 Identify changes made and improvements planned to enhance its work.
This process is most effective if the participants represent those involved in the organization’s
entire CME program.
The KMA uses the Self Study Report, in addition to other data, to evaluate the provider’s ability
to fulfill its educational mission effectively and comply with the Essential Areas, Elements, and
Policies.
Administration of the Self Study
The organization and planning for a Self Study requires time and effort from many constituents
involved in the provider’s continuing medical education program. Appropriate leadership and
broad involvement of constituents are two important factors to a successfully planned and
implemented Self Study.
Leadership - The Provider should identify an individual who is responsible for the organization
and completion of the Self Study. That individual should have a formal connection with the CME
Program and be able to facilitate the collection of needed data and support for the effort. The
individual would be responsible for the preparation of the final Report about the program to the
KMA.
Constituent Involvement - Every constituency that has a connection with the CME Program
should be involved in the Self Study, possibly through a Self Study Task Force or Team. The
constituencies include, but are not limited to, the CME staff, faculty, administration, participants,
and others such as librarians, quality improvement staff, or other partners that are relevant to
the venue of the program.
Completing the Self Study Report
The Self Study Report is intended to address two major components of accreditation: (1) a
documentation of the CME Program’s compliance with the Essential Area Elements and
Policies and (2) an outline of the plans for improvement of the Program.
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Compliance with the Essential Areas – The CME provider should review the past and current
performance of the program in meeting the Criteria for each Element in all three Essential
Areas. Evidence should be presented in the Self Study Report of current compliance. Where
appropriate, the provider should identify areas of exemplary compliance. If the provider
identifies an area that is less than compliant with an Element, the Report should note the
deficiency and outline a plan to improve the deficiency.
Plans for Improvement – In addition to outlining improvement plans for identified problems in
the Essential Areas, the provider should review the practice of CME and the environment in
which the provider practices to determine what improvements the overall CME Program should
make. Those improvements could be in the context of the Program itself, the way CME is
practiced or should be practiced by providers, or in reference to the changes in the health care
environment that the Program functions.
These plans for improvement will reflect the vision and values of the Program and provide a
frame of reference for the improvement process for the program.
The applications should be mailed to:
CME Department
Kentucky Medical Association
4965 US Hwy 42, Ste 2000
Louisville, KY 40222
Accreditation Fees
Accreditation fees are listed under KMA Accreditation Fees. Your organization must make
payment of its accreditation fee prior to the initial survey stated deadline. In addition, you are
responsible for the expenses of the site survey and for the survey team if an on-site visit, or
activity review, is necessary. Those expenses will be paid by the KMA and billed to your
organization for reimbursement after the survey.
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Initial Self Study Report Format and Outline
The Self Study Report should reflect an analysis of the CME Program of your organization and
its compliance with the Essential Areas, Elements, and Policies. If you believe your organization
is in exemplary compliance with any Element, please use the Report to describe and provide
evidence of your exemplary performance. If you find your organization is less than compliant
with an Element, please use the Program Summary section of the Report to describe your plans
for addressing improvements.
Instructions for completing/compiling the Self Study Report:
1) Provide a narrative and the required attachments for each item of the outline as
indicated.
2) Type the report with at least 1” margins (top, bottom and sides), using an 11 point type or
larger.
3) Number the pages of the Self Study Report consecutively including attachments. The
name (or abbreviation) of your organization must appear with the page number on each
page. (Note: if the report is not numbered it will not be accepted and will be returned to
the provider.)
4) Include a Table of Contents listing the page number of each section of the Self Study
Report Outline.
5) Use the tabs that are provided for each section of the outline to assist with the
organization of the Report (instructions have been repeated on the tabs for your
convenience).
6) Separate each section/required attachment within the tabs of the Report with colored
sheets.
7) Place the Self-Study Report and all the attachments, excluding copies of enduring
materials, in a two-inch, three-ring binder or some other mechanism of binding, e.g.,
tape-binding. (Note: If the report is larger than two inches it will not be accepted and will
be returned to the provider.)
8) Submit four copies to KMA, as described.
9) Be sure to keep a separate copy for your use during the survey.
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Outline/Sections for the Self Study Report:
1) Demographic Information
Complete the attached “Demographic Information for Applying for Accreditation” form.
2) Self Study Report Prologue –Narrative only
a) Brief History of the CME Program
b) Leadership of the CME Program
c) Current and Projected Practice of CME
d) Review of Health Care Environment in which CME Program Operates
e) Self Study Structure and Process (i.e. Membership/Leadership)
3) Essential Area 1 (Purpose and Mission) – Narrative and Attachments
a) Element 1.1 - Mission
i)
Specifically describe and explain the components of your CME mission (i.e.,
purpose, content areas, target audience, types of activities and expected results).
ii) Attach CME mission statement.
b) Element 1.2 - Parent Organization
iii) Describe your organization’s relationship to your parent organization.
iv) Provide the documentation that best demonstrates compliance with Element 1.2
(review the decision making criteria for compliance language). Include any of the
following that may be appropriate:
(1) Your parent organization’s mission statement,
(2) Support from your parent with respect to financial, facility or human resources,
and/or
(3) Documentation that your organization’s CME mission statement is reviewed and
approved by the governing body of your parent organization on a regular basis.
4) Essential Area 2 (Educational Planning and Evaluation) – Narrative and Attachments
a) Element 2.1 - Planning Processes
i)
Describe your planning process(es) specifically addressing the linkage of identified
educational needs to desired results.
ii) Attach documentation of your planning process(es) and the steps that demonstrate
how the identified educational needs are linked with desired results for a specific
CME activity.
b) Element 2.2 - Needs Assessment
i)
Describe how needs assessment data is used in planning your CME activities.
ii) Attach documentation demonstrating use of needs assessment data in the planning
of a specific CME activity.
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c) Element 2.3 - Purpose and Objectives
i)
Describe how the purpose and/or objectives for your CME activities are made known
to participants before participating in the activity.
ii) Attach promotional material for each type of activity
purpose/objectives and the appropriate accreditation statement.
highlighting
the
d) Element 2.4 - Activity Evaluation
i)
Describe how your CME activities are evaluated in terms of meeting the identified
educational need.
ii) For each type of activity, attach an evaluation instrument and a summarized data
set from a specific activity.
iii) If your organization produces Regularly Scheduled Conferences (RSCs),1
please also demonstrate compliance with KMA ‘s policies on regularly scheduled
activities by:
(1) Describing and verifying the use of a system to monitor RSCs compliance with
the KMA’s Elements and Policies, including the Standards for Commercial
Support,
(2) Attaching aggregated or summary performance data and information collected by
your system. Summary data will be sufficient,
(3) Describing and attaching evidence of improvements made as a result of the
monitoring system for RSCs, and
(4) Describe how your organization provides access and availability for physician
learners to a mechanism to record their participation in the activity.
e) Element 2.5 – Program Evaluation
i)
Describe how your organization evaluates the effectiveness of its overall CME
Program.
ii) Attach evidence of the use of a mechanism(s) for evaluating the effectiveness of the
overall CME Program, as well as evidence that improvements were made as a result
of this process.
1
Regularly Scheduled Conferences (RSCs) are defined as daily, weekly or monthly, quarterly CME activities
of accredited providers that are primarily planned by and presented to the provider’s professional staff.
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5) Essential Area 3 (Administration) – Narrative and Attachments
a) Element 3.1 Organizational Framework
i)
Describe your organization’s structure, process(es), and system(s) that allow your
CME Program to operate effectively.
ii) Attach an organizational chart.
b) Element 3.2 – Business and Management Practices
i)
Attest
(written
statement)
business/management policies.
to
your
organization’s
compliance
with
iii)
ii)
If your CME Program receives annual audited financial statements,
please include a copy of these statements for the past year.
iii) If your CME Program does not receive annual audited financial statements, please
attach an income and expense statement* for your CME program for the past year.
iv) Attach an income and expense statement* for a specific CME activity.
*Your income and expense statement must reflect:
Significant sources of income: Include income from commercial support,
advertising and exhibit fees, tuition and registration fees, internal budget
allocations, and any other source that represents > 20% of total income.
Significant expenses: Include staff salaries, meeting costs, honoraria, faculty
travel expenses, and any other item that represents > 20% of your total expense.
v) Attach the Table of Contents from your organization’s Human Resources and
Financial Policies or Procedures Manual. (This is not your CME department’s
policies.)
c) Element 3.3 – Standards for Commercial Support
i)
Describe how your organization’s activity planning process ensures that planning
decisions are made free of the control of a commercial interest.
ii) Describe and attach documentation of the mechanism your organization uses to
ensure that everyone in a position to control educational content has disclosed to
your organization relevant financial relationships with commercial interests.
iii) Describe the mechanism(s) you use to identify and resolve conflicts of interest prior
to an activity. (see KMA Accreditation Policies & Guidelines - Including Conflict of
Interest Guidelines)
iv) Describe your process for payments to planners, teachers or authors. (See Policies:
Reimbursement/Honoraria Guidelines)
v) Describe how you manage commercial promotion associated with each type of CME
activity that you provide in fulfillment of the elements of SCS Standard 4.
vi) Describe how enduring materials are distributed to learners.
vii) Describe and explain the mechanism(s) your organization uses to ensure that the
content of CME activities promotes improvements or quality in healthcare.
viii) Describe and explain the mechanism(s) your organization uses to ensure that the
content of CME activities gives a balanced view of therapeutic options.
ix) Describe your organization’s process(es) and mechanism(s) for disclosure to the
learners of relevant financial relationships and the source of support from
commercial interests.
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Attachments:
x) Attach an example of a written agreement documenting terms, conditions and
purposes of commercial support that you have used, or would use, to fulfill relevant
elements of SCS Standard 3. (See Sample Written Agreement for Commercial Support – under
Documents and Forms.)
xi) Attach examples that verify the disclosure of relevant financial relationships to
learners.
xii) Attach examples of the disclosure of the source of support from commercial interests
to the learners. (See Sample 1st Letter to Faculty Initiating Disclosure with Disclosure Form and
Definitions.)
6) KMA Policies* – Narrative and Attachments
a) Describe the mechanism your organization uses to verify physician participation in your
CME activities.
b) Provide documentation that verifies your organization is in compliance with KMA’s Definition
of CME.
c) Provide documentation that verifies your organization is in compliance with KMA’s content
validity value statements. (See KMA Accreditation Policies and Guidelines – Including Conflict of Interest
and Reimbursement/Honoraria Guidelines.)
d) Attach a list of the URL(s) for all of your Internet CME activities for assessment of
compliance with KMA’s policy on Internet CME with user ID and passwords for KMA to use.
e) Submit two copies of a Journal CME activity for assessment of compliance with KMA’s
policy on Journal CME.
f)
Submit two copies of each type of enduring material produced for assessment of
compliance with KMA’s policy on Enduring Materials.
7) Program Summary (Self Assessment and Improvement Plans)
a) Describe your CME Program’s Strengths and reasons you believe you may be in
Exemplary Compliance with any Element(s).
b) Describe your CME Program’s Areas for Improvements and Specific Plans for
Addressing Improvements.
c) Describe your CME Program’s Future Direction.
8) Activity Attachments
a) Attach a complete “Summary of CME Activities” and a list of the CME activities presented
prior to applying for re-accreditation.
(*For exact language of policies, please see KMA Accreditation Policies and Guidelines – Including
Conflict of Interest and Reimbursement/Honoraria Guidelines.)
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Demographic Information for Applying for Accreditation
THE DEMOGRAPHIC INFORMATION FORM SHOULD BE THE FIRST TWO PAGES OF YOUR SELF STUDY REPORT
Name of organization as it should appear on accreditation certificate:
Check if Initial Applicant
Chief executive officer of organization:
Name:
Title:
Address:
Telephone number:
(
)
-
Fax number:
(
)
-
e-mail address:
Individual responsible for CME unit and for the material contained within this self-study:
Name:
Signature:
Date:
Title:
Address:
Telephone number:
(
)
-
Fax number:
(
)
-
e-mail address:
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Contact person for self-study/survey:
Check here
if the contact person is same as individual responsible for CME unit.
Name:
Title:
Address:
(
Telephone number:
)
-
Fax number:
(
)
-
e-mail address:
Does your organization have a parent organization?*
1.2 is applicable for completing this application.
Yes
No. If yes, please note that Element
*A “parent” is an organization, a higher body, which owns or is affiliated with the accredited CME provider
that has control or subsidizes the budget, board, or other areas of the CME Unit. A hospital would not be
considered the “parent of the CME unit” because it is the hospital that is accredited. However, if that
accredited hospital were a part of a health system, the system MAY be considered the parent of the
hospital.
Type of organization
Please indicate what classification most accurately describes your organization.
Non-Profit (physician member organization)
Non-Profit (other)
Hospital/Health Care Delivery System
School of Medicine
Government/Military
Other: (please specify)
The CME program
does receive commercial support
does not receive commercial support
does participate in Joint Sponsorship
does not participate in Joint Sponsorship
does produce Enduring Material
does not produce Enduring Material
does produce Internet CME
does not produce Internet CME
Current accreditation status
Accredited by (List)
Not accredited
Years of accreditation
2 years
4 years
6 years
Accreditation status
full
provisional
probation
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Summary of Continuing Medical Education Activities
The summarized data in this table should reflect the number of activities your program has presented
prior to applying for accreditation, as defined below. A copy of the summary and list of the CME
activities presented prior to applying for accreditation must be included in the self-study report.
Number of
Activities
Type of Activity
Physician
participants
Hours of instruction
Non-physician
participants
Jointly
Directly
Jointly
Directly
Jointly
Directly
Jointly
Directly
Sponsored
Sponsored
Sponsored
Sponsored
Sponsored
Sponsored
Sponsored
Sponsored
Live
Courses
Regularly scheduled
Internet
Enduring Materials
Internet
Other
Journal CME
Subtotals
Totals
Definitions
Course:
A live activity, sometimes multiple-hour and sometimes multiple day, that is planned on a one-by-one basis and
designated for credit as a single activity. (Examples: annual meeting, conference, seminar)
Regularly scheduled:
Daily, weekly or monthly CME activities that are primarily planned by and presented to the accredited organization’s
professional staff and are designated for credit as one activity. Examples include weekly Grand Rounds of the
Department of Pediatrics and Morbidity and Mortality Conferences. Count all sessions in a series together – as one
activity, indicating the total hours for the entire series and the total number of physician registrants for all the sessions
taken together. (Example: Internal Medicine Grand Rounds is one activity that meets weekly, made up of 52 hours of
instruction; if 20 physicians participated in each session, total physician participants would be 1,040 for that activity.)
Internet:
Activities offered live or in an enduring materials format, via the internet
Other:
Activities other than internet that are considered enduring materials. (Examples include audio, video, monographs)
Journal:
An activity that requires reading a journal article, a learner-directed phase, evaluation and documentation of
completion of the activity to the provider.
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