ACCME Criteria Review: Program Analysis

Whether you are an accredited provider such as i3 Health or you are an educational partner working with an accredited provider, it's still important to understand the criteria that underly continuing medical education (CME) activities. This is part of a periodic series of posts looking at what each criterion means in general and what it might mean for you.

The criterion I'm going to focus on in today's post follows the criterion that used to be called C1 and is now known simply as "Mission." If you haven't been following this series, you may want to start by reviewing that criterion here. Hopefully you'll see how today's criterion logically follows from that one.

Program Analysis (formerly Criterion 12) states:

The provider gathers data or information and conducts a program-based analysis on the degree to which the CME mission of the provider has been met through the conduct of CME activities/educational interventions. (ACCME, 2020)

In order for a program to be accredited, it must have some system to determine whether or not the mission statement is being met. This is, therefore, unique to each program because each program's mission statement is unique to that organization. But there is a unifying feature to all accredited program analyses because all mission statements must contain the desired results of the program.

As a refresher, Mission (formerly Criterion 1) states:

The provider has a CME mission statement that includes expected results articulated in terms of changes in competence, performance, or patient outcomes that will be the result of the program. (ACCME, 2020)

This means that the Program Analysis, at a minimum, needs to measure changes in competence, performance, or patient outcomes.

Many programs include an evaluation component at every single activity. Those evaluations measure the impact of that activity, but they do not measure the program, at least not on their own. One way a provider can evaluate their program is to aggregate the data from all of these activity-level evaluations to create a picture of the program as a whole. This is useful for programs that cover a wide variety of topics.

Programs that are smaller or more focused may be able to use other datasets to look for signs of change in competence, performance, or patient outcomes. Health care systems could data mine their electronic health records (EHRs). Follow-up surveys could be sent to learners or activity planners.

A key thing to note is that the criterion doesn't state that the mission statement must be met. The analysis needs to be done to determine how well the mission statement is being met. Maybe your program is doing great, and that's what your analysis will show. But maybe it's not. And that's okay. This means that you're identifying deficiencies in your program. You can't improve your program if you don't first analyze it.

But program improvement? Well, that's the next criterion, so that's a post for another day.

I hope that you're seeing the logic in how the ACCME has reorganized their criteria. First, your program needs a mission statement. Then you need to analyze your program to determine if you're meeting that mission statement. And next you'll figure out how to improve based on your analysis. I'll write about that in the next installment in this series.

Accreditation Council for Continuing Medical Education (2020). Accreditation Criteria. Available at: https://www.accme.org/accreditation-rules/accreditation-criteria

Image credit: Tasch Michael. Licensed under CC BY-SA 4.0