34th Annual Alliance HospitalHealth Care System Member Section Meeting

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34th Annual AllianceHospital/Health Care System
Member Section Meeting

• Regularly Scheduled Series

Elizabeth Mullikin, MS January 28, 2009
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RSS Defined

• ACCME defines Regularly Scheduled Series as
• series that occur on an ongoing basis (i.e.
  weekly, monthly, or quarterly)
• primarily planned by and presented to the
  providers professional staff

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RSS Examples

• Grand rounds
• Tumor boards
• Morbidity / mortality conferences
• Journal clubs
• Case conferences
• RSS are NOT repeated or road show activities

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ACCME RSS Policy

• 2003

• Providers that offer RSS must DESCRIBE and VERIFY
  that they have a SYSTEM IN PLACE TO MONITOR these
  RSS compliance with ACCME Criteria, SCS, and
  Accreditation Policies.
• The monitoring system must
• Be based on real performance data
• Result in improvements
• Ensure LOAs are in place

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ACCME RSS Policy

• The Provider is required to make available and
  accessible to the learners some form of an
  information management system (examples include
  paper, web or LAN-based systems through which
  data and information on a learners participation
  can be recorded and retrieved). The critical data
  and information elements include learner
  identifier, name/topic of activity, date of
  activity, hours of credit designated or actually
  claimed. (NOTE The ACCME limits the providers
  responsibility in this regard to access,
  availability and retrieval. Learners are free to
  chose not to use this available and accessible
  system.)

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What does it mean? UW Interpretation
DESCRIBE

• Put it in writing
• Written policy to codify the process
• Thorough discussion of process in the self- study
  report
• Walk through how you will do it
• Create a flowchart

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What does it mean? UW Interpretation
VERIFY

• That you can do what you described you would do
  and that your system is being implemented
• Show that you have documents to support
  Compliance with ACCME Criteria and Policies
• Design and utilize a planning kit / application
  for Credit
• Create and utilize checklists and templates
• Set up a process to audit documentation

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What does it mean? UW Interpretation
MONITOR COMPLIANCE

• Monitor that all ACCME Policies and Criteria are
  being followed as you have described
• Review and approve/deny planning kits
• Audit RSS files, checklists, and supporting
  documentation
• Track compliance status of each RSS
• Spot check RSS through onsite visits
• Meet with RSS planners
• Pearl
• Hold back on issuance of credit certificates
  until all required documents are submitted

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What does it mean? UW Interpretation

• THE MONITORING SYSTEM MUST
• BE BASED ON REAL PERFORMANCE DATA
• A checklist is not good enough
• Supporting documentation must come with it to
  show evidence of performance!
• Ensure LOAs are in place
• Every time funds are used to support the CME
  activity

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What does it mean? UW Interpretation

• THE MONITORING SYSTEM MUST
• RESULT IN IMPROVEMENTS WHEN CALLED ON FOR
  COMPLIANCE DATA (CHECK)
• If an RSS is found to be not in compliance in a
  certain area, implement an improvement, document
  the improvement being made, and evaluate the
  impact of the improvement
• Provide written feedback to the planners that
  summarizes improvements required
• Follow-through and document that improvements
  were actually made

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What does it mean? UW Interpretation

• THE MONITORING SYSTEM MUST
• ENSURE LOAS ARE IN PLACE
• Every time funds are used to support the CME
  activity
• LOAs are signed and filed (check SCS for more
  info)

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What does it mean? UW Interpretation

• Provider must document
• Learner identifier
• Name and topic of activity
• Date of activity
• Amount of credit earned
• Learners must have access to this information

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ACCME RSS Toolkit
2005 Revised 2008

• Tools to help providers reflect on organization
  and delivery of RSS
• Clarifies ACCME expectations for monitoring RSS
  compliance
• Provides examples of 3 organizations monitoring
  systems and reports

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ACCME RSS Toolkit

• Tools to help providers reflect on organization
  and delivery of RSS
• How do you organize the RSS? e.g. one session
  one activity or one series one activity
• What procedures are used to plan the RSS? e.g.
  yearly planning meeting
• How do you implement the RSS?e.g. who is
  responsible?

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ACCME RSS Toolkit

• Clarifies ACCME expectations for monitoring RSS
  compliance
• ALL series and ALL sessions within a series will
  meet ACCMEs Updated Criteria and be in
  compliance with ACCME Policies
• The provider must collect data and information
  from ALL series as a part of its monitoring
  system, however data on each Criterion and Policy
  need not be collected from every series
• Monitoring data may be derived from all sessions
  or a sample (applied consistently for 10-25 of
  sessions within each series across the whole
  accreditation term)
• Provider must analyze the data and information
  and determine if the RSS has met ACCME Criteria
  and applicable ACCME Policies

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ACCME RSS Toolkit

• RSS is considered in compliance if its monitoring
  system indicates performance is achieved in 100
  of the sample
• If the RSS did not meet one of the Criteria or
  applicable ACCME Policy, then the provider must
  include in the self study
• Description of the identified problem
• Description of implemented improvements
• Description of the impact of the implemented
  improvements

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ACCME RSS Toolkit

• Provides examples of 3 organizations monitoring
  systems and reports
• Includes a description of the monitoring system
• Examples of tools used

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UW RSS Monitoring System in a Nutshell

• Has a written RSS Policy
• Has a flowchart to visually depict the planning
  and compliance process
• Requires RSS planners to attend a bi-annual
  workshop
• Utilizes a planning document, checklists, and
  templates to aid RSS planners with fulfilling
  requirements and documentation
• Requires RSS planners to submit a checklist and
  documentation for every session within a series
• Audits RSS files (checklists and documentation)
  for compliance
• Tracks compliance of all ACCME Criteria and
  Policies
• Provides feedback to RSS planners regarding
  performance
• Implements improvements
• Documents improvements
• Holds back credit if improvements are not met
• Tracks learner participation in a database and
  makes this information available to learners
• And last but not least

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UW RSS Monitoring System in a Nutshell

• and possibly most important

A staff person dedicated to implementing RSS
policy and procedure, training RSS planners,
monitoring and improving all RSS
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RSS Planning and Implementation Flowchart
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RSS Checklist
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RSS Compliance Tracking(per session in each
series)
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Self Study Monitoring Report
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• Thank You!!