The ACCME has a rigorous, multilevel process for making accreditation and reaccreditation decisions. These decisions are made three times a year. Accreditation decisions are determined through a review by two ACCME committees: first, the Accreditation Review Committee, and second, the Decision Committee of the Board of Directors. All accreditation decisions are then ratified by the ACCME’s Board of Directors. Throughout the process, ACCME staff members provide support and guidance to committee members.
This multitiered process provides the checks and balances necessary to ensure fair and accurate decisions. In addition, the ACCME uses a criterion-referenced decision-making system to ensure fairness, consistency, and accuracy. Members of the Accreditation Review Committee, Decision Committee, and Board of Directors must disclose conflicts of interest related to the accreditation decision-making process and recuse themselves if necessary.
Please refer to the ACCME Public and Confidential Information about the Accredited Providers policy to understand what information the ACCME shares from the accreditation decision-making process.
The Accreditation Review Committee's Role in Decision-Making: The surveyors’ reports (Surveyor Report Form and Documentation Review Form) and the CME providers’ materials are forwarded to the Accreditation Review Committee. Each ARC reviewer is assigned approximately five CME providers per accreditation cycle. The reviewer checks the materials to make sure they are complete and then determines whether or not the provider has complied with each of the accreditation criteria.
An ACCME staff person is assigned to each reviewer to provide support and to monitor the review process. The staff reviews the surveyors’ observations and the reviewer’s findings for validity and congruity, addressing any differences that are found between the two data sets, and ensuring that the accreditation recommendations are valid and supported by the data.
The Accreditation Review Committee meets three times a year. Each meeting lasts two days and is held at the ACCME’s offices. In addition to the ARC members, about 10 ACCME staff members, including the executive staff, attend the meetings to provide support and monitor the process. At the beginning of each meeting, prior to discussions of individual CME provider practices, members engage in exercises to come to consensus about new or unusual compliance issues regarding the providers under review.
Members present their findings for the CME providers they have reviewed, and then explain their recommendations. All the providers’ materials are in the meeting room, available for the members to review. ARC members are not allowed to discuss hearsay information. They must make their decisions based only on the data gathered during the accreditation process. The entire committee asks questions and discusses the compliance issues until they arrive at a consensus and recommend an accreditation decision. The ACCME implements quality-control measures to make sure that ARC members determine the correct compliance and noncompliance findings for each criterion, and to ensure that their decisions are consistent and impartial. The ACCME produces color-coded grids showing the compliance and noncompliance findings for each criterion and the final accreditation decision for each CME provider in the cohort, so that the ACCME staff, ARC members, and Board members can compare accreditation decisions, making sure that providers that have similar findings receive the same accreditation status.
About the Accreditation Review Committee: ARC members are CME professionals who have in-depth knowledge concerning the philosophy and process of CME, the ACCME, and accreditation requirements. Some ARC members have served as surveyors; some have experience with a CME program accredited by the ACCME or an ACCME Recognized CME Accreditor.
The ARC comprises up to 30 members. Of these, at least 21 are nominated by the ACCME’s member organizations and elected by the ACCME Board of Directors. The remaining members are nominated by the ACCME’s CEO and elected by the Board. The initial term is two years; members may serve for a maximum of six years.
New ARC members are trained by ACCME staff. They attend their first meeting as observers; at their second meeting they are assigned one review, which they do under the supervision of a staff person. At their third meeting, they begin doing reviews on their own.
The Decision Committee's Role in Decision-Making: After the ARC completes its work, the Board of Directors’ Decision Committee reviews the materials, which include narrative descriptions of noncompliance findings and justifications for the accreditation decisions. The ARC chair informs the committee about any compliance issues that required new interpretations. The Decision Committee compares the compliance grid for the provider cohort under review with grids from previous cohorts to make sure that decision-making has been consistent. The committee then makes accreditation decision recommendations to the full Board.
The Board of Directors' Role in Decision-Making: As the last step in the accreditation decision-making process, the ACCME’s Board of Directors ratifies the decisions. All accreditation decisions must be ratified by the ACCME Board of Directors; through this ratification, the Board of Directors ensures that the accreditation process was conducted according to the ACCME’s published policies and procedures.
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