CME Accreditation

CME ACCREDITATION SERVICES

The Institute for Medical Quality (IMQ)/California Medical Association (CMA) has been designated by the nationally recognized accrediting agency for continuing medical education, the Accreditation Council for Continuing Medical Education (ACCME), as California’s intrastate accrediting agency.

IMQ, on behalf of CMA, accredits California-based hospitals, ambulatory care clinics, specialty societies, health plans, and other health care organizations on a voluntary basis to offer AMA PRA Category 1 Credit(s)^TM.

Physicians who attend CME courses offered by IMQ/CMA accredited providers meet the Medical Board of California’s Division of Licensure requirements for physician licensure and the California Medical Association’s Certification in Continuing Medical Education.

WHO NEEDS THE SERVICES

The Institute for Medical Quality/California Medical Association assesses the CME programs of hospitals, clinics, and other health care organizations to determine compliance with the IMQ/CMA Accreditation Standards for Continuing Medical Education. Organizations which are accredited by IMQ/CMA are widely recognized by physicians and other health care professionals as offering high-quality continuing medical education.

BENEFITS OF BECOMING AN ACCREDITED PROVIDER Welcome to the world of CME! The ultimate goal of continuing medical education is optimum patient care. The physician’s concern for this outcome is expressed through a process of lifelong learning – from experience, professional relationships, reading, independent study and participation in organized educational activities. Planned CME activities developed in accordance with accreditation criteria enhance the physician’s professional growth.

By a becoming an accredited CME provider, your hospital/organization can: - Improve patient care in your organization and community - Offer your physicians a convenient way to get their required CME credits - Provide name recognition for your organization by inviting non-affiliated physicians to your educational activities - Develop your own cost-effective CME activities, independent of joint sponsors

SERVICES WE OFFER

CONSULTATION:

IMQ offers its Continuing Medical Education Consultation Program to both hospitals and organizations wishing to establish or improve their continuing medical education program.

For the full consultation information, please click here.

EDUCATION:

IMQ/CMA offers a number of written communications, as well as in person workshops, to accredited providers and those seeking accreditation. The Annual CME Provider Conference, which takes place every May, provides an excellent opportunity for networking and learning. This conference offers new and experienced CME professionals plenary sessions on state and national trends affecting physician education, discussion groups on state accreditation standards and their implementation in hospital, clinic, and other health-related settings, and workshops on program planning skills and considerations.

CME ACCREDITATION PROCESS Overview The Institute for Medical Quality (IMQ)/California Medical Association (CMA) has been designated by the ACCME as California’s intrastate accrediting agency. The IMQ/CMA CME Accreditation Program accredits organizations as providers of Category 1 CME, but does not accredit individual activities. The IMQ/CMA CME Accreditation Program has transitioned from the prior accreditation standards (called the Accreditation Areas and their Elements) to the 2006 Accreditation Criteria. All applicants, whether initial or reaccreditation, are now surveyed under the 2006 Accreditation Criteria. Both initial and reaccreditation applicants for CME Accreditation are required to submit an application for accreditation and demonstrated evidence of their performance in practice, as well as undergo an accreditation survey. These three sources (the application, evidence of performance and the survey) comprise the data that are used in rendering the accreditation decision. For more information on the accreditation requirements, please download and review our latest standards manual by clicking here.

Reaccreditation Application Process

♦ Overview

All currently accredited providers have been placed into “accreditation groups,” or cohorts, to facilitate the accreditation process. All accredited providers in each group have the same deadlines and will be reviewed within a similar time frame.

♦ Reaccreditation Process

Several months prior to each group’s accreditation expiration date, IMQ will notify each organization of its upcoming expiration by sending the CME coordinator and CME chair on record a letter with instructions for completing the application as well as all deadlines. This letter is also sent out via e-mail.

First the accredited provider must submit both the Demographic Information Form and their List of Activities from their accreditation period. This due date is specified in the notification letter.

IMQ will then select up to fifteen activity files for review. The provider should submit two copies of each selected activity files, two complete copies of the accreditation application, and the appropriate accreditation fee

by the due date.

The survey includes an interview with the accredited provider and review of submitted documentation. After the survey, the surveyor submits to IMQ a Surveyor Report Form as well as Document Review Forms for each selected activity file. These documents are submitted to the CME Committee for review at the accreditation group’s specified committee meeting date. The CME Committee will review all of the documentation from the surveyor and render an accreditation decision.

♦ Reaccreditation Decision

The IMQ/CMA CME Committee reviews the surveyor’s findings for each reaccreditation applicant and typically renders one of the following decisions: • Continued Accreditation requires compliance with Compliance with Criteria 1 to15 and all accreditation policies and generates a 4 year accreditation term. • Accreditation with Commendation requires compliance with Criteria 1 to 22 and all accreditation policies and generates a 6 year accreditation term. The continued accreditation level may include a requirement for an interim report to monitor any areas of non-compliance found during survey. Please see the accreditation standards manual for more details by clicking here.

The continued accreditation level may include a requirement for an interim report to monitor any areas of non-compliance found during survey. Please see the accreditation standards manual for more details by clicking here. ♦ Accreditation Materials All of the accreditation documents, such as the written application for accreditation, are based on ACCME accreditation materials. ♦ Late Submission of Materials Accredited providers are expected to meet specified deadlines. It is the organization’s responsibility to submit the Demographic Information Form, List of Activities, two complete copies of each selected activity files, two complete copies of the accreditation application and the appropriate accreditation fee by the due dates outlined in their notification for reaccreditation. ♦ Extensions Requests for extensions for either the accreditation application due dates or the actual accreditation period will not be granted at this time. ♦ Reconsideration and Appeal of Adverse Decisions An adverse accreditation decision is a decision by the IMQ/CMA CME Committee to deny provisional accreditation, withdraw a current provider’s accreditation or place the provider on probation. The organization has the right to request reconsideration in accordance with the procedure outlined in the IMQ/CMA CME Policy & Procedure on the Reconsideration and Appeal of Adverse Decisions. This policy can be found in the accreditation standards manual by clicking here. ♦ Confidentiality of Information Throughout either the initial or reaccreditation process, IMQ/CMA collects data related to a provider’s compliance with Accreditation Requirements. IMQ/CMA will maintain this information as confidential, except as required for IMQ/CMA accreditation or ACCME recognition purposes, or as may be required by legal process, or as otherwise authorized by the CME provider to which it relates.

Initial Application Process ♦ Overview Initial applicants for CME Accreditation are assessed from the perspective of the organization’s readiness to achieve compliance with all accreditation requirements (i.e., the 2006 Accreditation Criteria and accreditation policies). Initial applicants are required to plan, implement and evaluate at least two to four CME activities within the 24-month period prior to the initial accreditation survey. A track record of four activities is preferred. Please note that the applicant is encouraged to work with an accredited provider but it is not required. An initial applicant is only eligible for provisional accreditation with an accreditation period of two years and is not guaranteed accreditation. For initial applicants, the accreditation process can take up to eighteen months, but is typically between 6 and 8 months.

Eligibility for IMQ/CMA CME Accreditation

Only certain organizations are eligible for IMQ/CMA CME Accreditation. The following criteria must be met. The organization must, • Be located in California. • Have a California-based physician audience. • Be developing and/or presenting a program of CME for physicians on a regular and recurring basis. • Not be a commercial interest.(See ACCME definition for more information) • Not be developing and/or presenting a program of CME that is, in the judgment of the IMQ/CMA, devoted to advocacy on unscientific modalities of diagnosis or therapy. • Present activities that have “valid” content. Specifically, the organization must be presenting activities that promote recommendations, treatment or manners of practicing medicine that are within the definition of CME. Providers are not eligible for accreditation if they present activities that promote treatments that are known to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients.

The IMQ/CMA accredits the following types of institutions: • Hospitals/Health Care Delivery Systems • Non Profit Physician Membership Organization • Non Profit (Other) • Consortium/Network/Alliance • Insurance Company/Managed Care Company • Voluntary Health Association • Government or Military • Publishing/Education Company

♦ Process The first step in the application process is the submission of a letter of intent to IMQ/CMA. This letter of intent should include a description of the organization’s eligibility for accreditation as explained above. Then the organization will be sent a pre-application form to complete, which will be assessed by IMQ to determine if the organization is eligible of accreditation. The pre-application must be completed and returned to IMQ within 60 days. IMQ will notify the organization once a decision has been made regarding eligibility to continue with the initial accreditation process. Once an organization is deemed eligible, it will be assigned to the appropriate accreditation “group,” as described in the reaccreditation process. Each group has specific deadlines for application materials, a timeframe for the accreditation survey and an approximate date of accreditation decision by the CME Committee. At this point, the provisional accreditation process parallels the process for those providers applying for continued accreditation (please see above for the accreditation process). The first items the organization is required to submit are the Demographic Information Form and List of Activities, which will consist of the organization’s “track record.” ♦ Accreditation Decision The IMQ/CMA CME Committee reviews the surveyor’s findings for each accreditation applicant. An initial applicant is only eligible for provisional accreditation with an accreditation period of two years and is not guaranteed accreditation. Provisional accreditation requires compliance with the 2006 Accreditation Criteria 1 to 3 and 7 to 12 and all accreditation policies.

OUR SURVEYORS

IMQ/CMA CME accreditation surveys are conducted by physicians who have been actively involved in CME. All surveyors are well-versed in CME principles and the accreditation requirements. IMQ is currently looking for surveyors. If you are interested, please do not hesitate to contact us.

CME Standards Manual

Both accredited providers and those thinking about becoming accredited should obtain IMQ/CMA’s standards manual, 2011 IMQ/CMA CME Accreditation Standards: A Guide to Continuing Medical Education in California, for assistance in developing and maintaining an effective continuing medical education program. The Standards Manual is available in PDF format and was most recently updated in November 2011. This Manual is updated annually at the time of the annual CME Provider Conference.

Updates to the Standards Manual are posted on the website periodically. To ensure that you have the most current program information it is advisable to check our website frequently.

In the 2009 edition, the new Cultural and Linguistic Standards were added as was a clarification to the expectations of the monitoring system for Regularly Scheduled Series

• • The new Cultural and Linguistic Standards (New Cultural and Linguistic Proficiency Policy Conforming with AB 1195 Guidelines) can be found on page 12.
• • Clarification to the expectations of the monitoring system for Regularly Scheduled Series can be found on page 20.

Please note that this manual also was updated on March 31 with new IMQ/CMA Program Policies, including:

• • Length of Accreditation Periods to Correspond with Levels of Accreditation
• • Initial Applicants for CME Accreditation
• • Applying for Reaccreditation
• • Handling Providers with Organizational Change
• • Incomplete Applications
• • Policy for Complaints and Inquiries about Accredited Providers
• • Policy on Definitions of Organization Types for CME Accreditation

Accredited providers also should obtain the American Medical Association’s recently revised version of its Physician Recognition Award (PRA) booklet, The Physicians Recognition Award and Credit System. The booklet can be accessed online.

CME Accreditation Application Materials

In September 2006, the national CME-accrediting body, the Accreditation Council for Continuing Medical Education (ACCME), introduced new Accreditation Criteria. All new applicants and IMQ/CMA accredited providers whose accreditation term expires on or after November 01, 2008, will be surveyed using the Updated Accreditation Criteria. Materials Needed for the Accreditation Application

Stage One:

• • Common Questions on the DIF and LOA
• • Demographic Information Form
• • List of Activities Template
• • Instructions for Submitting the CME Activity List
• • Sample List of Activities

Stage Two:

• • IMQ/CMA Guide to the Accreditation Process
• • Application for CME Accreditation [Note: This application currently applies to organizations applying for Accreditation/Reaccreditation through September 2012 and may be changed thereafter; contact IMQ for additional information if your application deadline is after this date.]
• •
• • Instructions for Preparing the Activity Files for Submission and Review
• • Label Template for: Activity Content; Evidence of Compliance with Criteria 2-11; Evidence of Appropriate Use of Accreditation Statement
• • Label Template for: Evidence of Appropriate Use of: AMA PRA Credit Designation Statement
• • Label Template for: Evidence of Compliance with: AB 1195 (CLC)

The Organization’s Steps in Accreditation Process

• • Submit Demographic Information Form; potential survey dates; and list of activities by due date
• • Receive notification from IMQ of the CME activities selected for review
• • Participate in one of the mandatory conference calls to discuss the new application and processes
• • Submit fee for reaccreditation; two copies of the written application, with attachments; and one complete copy of each selected CME activity files by the due date
• • Receive notification from IMQ of the assigned CME Surveyor Work with CME Surveyor to secure a date for the CME accreditation survey
• • Participate in the CME accreditation survey, which will include an interview, discussion of the application and a review of activity files
• • Receive notification of accreditation decision, generally 2-3 weeks after committee meeting, which meets every other month

Assembly Bill 1195 – Continuing Education: Cultural and Linguistic Competency

Resources IMQ maintains a comprehensive list of resources to assist providers in integrating cultural and linguistic competency elements into CME activities.

About the Assembly Bill On October 4, 2005, Governor Arnold Schwarzenegger signed Assembly Bill 1195 (AB 1195) into law. (AB 1195) California Business and Professions Code. Ch. 5, Article 10, 2190.1 (2005) went into effect July 2006. The law mandates that the CME accrediting agencies (the ACCME and IMQ/CMA) must develop standards for compliance.

On and after July 1, 2006, all continuing medical education courses must contain curriculum that includes cultural and linguistic competency in the practice of medicine. California-based providers planning courses within the State of California must comply with (AB 1195) California Business and Professions Code. Ch. 5, Article 10, § 2190.1 (2005).

Expectations IMQ/CMA expects that accredited providers will make a good-faith effort to comply with Assembly Bill 1195. When developing CME activities, it is important to assess the need for cultural and linguistic competency issues as suitable to each educational subject. Not all issues will apply to all CME activities. IMQ/CMA does expect, however, some evidence that the provider has made an effort to incorporate appropriate cultural and linguistic competency topics into the educational content of CME activities.

Providers will be asked on the accreditation/reaccreditation application about their process to comply with this law. In addition, IMQ/CMA surveyors will expect to see in the program planning documentation evidence of the provider’s efforts to address cultural and linguistic competency issues in CME activities.

Carol Havens, MD, the former Chair of the IMQ/CMA Committee on Continuing Medical Education, discussed the new accreditation standards and policies generated by Assembly Bill 1195 and the committee’s expectations for provider compliance. Please contact IMQ if you would like a copy of Dr. Haven’s presentation in Portable Document Format (PDF).

In addition, the California Endowment commissioned a report on linguistic competency.

CONTACT US Please click here for a list of IMQ CME Program Staff. Our staff have extensive health administration experience and interact regularly with California and national Continuing Medical Education providers.