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ACCME Criteria Review: Program Improvements

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.

We've looked at a CME program's Mission, and we've looked at using that mission to perform a Program Analysis. Today we'll finish this first set of criteria by looking at Program Improvements (formerly Criterion 13).

This criterion states:

The provider identifies, plans, and implements the needed or desired changes in the overall program (eg, planners, teachers, infrastructure, methods, resources, facilities, interventions) that are required to improve on ability to meet the CME mission.

This criterion feels long when you read it, but that's primarily because it contains a lengthy list of examples. The key part of the criterion is in the first line. Program improvement requires 3 things:

  • 1) Identify
  • 2) Plan
  • 3) Implement

Step 1 should be easy. The Program Analysis criterion means you should have, well, analyzed your program. There is no requirement for that analysis to come up roses. The Program Analysis may reveal changes that need to be made in your program. There also may be things that you may identify that aren't necessary but would be nice.

Example 1: A Needed Change—Patient Outcomes Measurement

Your mission statement includes that changes in patient outcomes will be measured, but in your program analysis, you realize that you aren't collecting data that will allow you to see if there have been changes in patient outcomes. You realize you need to change how data is collected so that you can meet this part of your mission.

Example 2: A Desired Change—A New LMS

You're outgrowing your learning management system (LMS). A new one will provide better support to your staff, your planners, your faculty, and your learners. You can get by with your current LMS, but a new one would make your program better.


Step 2 will require some thought. You've identified the changes that you need to make. Now you need to figure out how to make those changes.

Example 1: A Needed Change—Patient Outcomes Measurement

Why aren't you collecting data on patient outcomes? Is it an access issue? If so, who can help? Or is it that your activities aren't designed to address patient outcomes in the first place? Do you need to change your activities? Or do you need to rethink your mission overall?

Example 2: A Desired Change: A New LMS

What do you need in a new LMS? What's your budget? Whose support do you need to make this purchase?


This is the step that is most frequently missed in this criterion. It's great to identify changes that you plan to make, but if you don't implement them, then you haven't done anything to improve your program. The final step is what completes the program improvement process.

Example 1: A Needed Change—Patient Outcomes Measurement

You collaborate with your research team to data mine your electronic health records (EHR) for patient outcomes and use their expertise to write needs assessments and identify practice gaps for a selection of activities. After each of those activities is concluded, you return to the research team to perform a new analysis of EHR data to measure how much patient outcomes have changed.

Example 2: A Desired Change—A New LMS

Your team compares multiple systems and presents your preferences and recommendations at your annual budget meeting. Due to budget restrictions, you are told that you cannot get a new LMS at this time. You table your plan until the next budget cycle.


The key thing to remember in achieving this criterion is that all 3 steps are required. You'll note from my examples, though, that you may not fully achieve your desired changes. There may be barriers. But if you have begun the implementation process, then you are actively working to improve your program.

This set of criteria may not be directly related to your work if you are not an accredited provider although it is possible that you will receive some requests to support the program analysis and improvement process. But even if that doesn't happen, these 3 criteria do provide a nice guide to how any organization can assess its mission and improve.

Other Posts in This Series CME Mission and Program Improvement Educational Planning and Evaluation Reference

ACCME (2020). Accreditation Criteria. Available at: 

Image credit: Maximilianklein. Licensed under CC BY-SA 4.0

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ACCME Criteria Review: Designed to Change
ACCME Criteria Review: Program Analysis