Decisions
Upon completing the initial, reaccreditation or progress report process, your organization will receive an individualized ACCME decision. The decision is ACCME’s formal notification to you of the accreditation status and term that your organization has been assigned. Your decision also summarizes ACCME’s findings related to your compliance with the accreditation requirements.
Your ACCME decision will note all findings of compliance and will also include standard language that describes all findings of noncompliance.
CME providers that receive a decision of Probation or Nonaccreditation are entitled to participate in the ACCME’s Reconsideration and Appeals process.
The ACCME compiles data on compliance with each of its criteria and policies and analyzes this information to assess providers’ educational needs and develop strategies for improving the accreditation process.
Compliance Findings
For each applicable accreditation requirement, an accredited provider receives one of the following compliance findings:
| Compliance | The CME provider fulfilled the ACCME’s requirements for the Core Accreditation Criteria, Standards for Integrity and Independence, and/or the policies. |
| Noncompliance | The CME provider did not fulfill the ACCME’s requirements for the Core Accreditation Criteria, Standards for Integrity and Independence, and/or the policies. |
Steps in the Process
The Decision Making Process
ACCME’s 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 and Decision Committees 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 typically assigned approximately two to 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, standards, and policies.
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. Members present their findings for the CME providers they have reviewed, and then explain their recommendations. The committee has access to the materials submitted by the provider at any time during the meeting. 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.
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; for subsequent meetings they begin doing reviews on their own, working collaboratively with ACCME staff.
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 compliance data for the provider cohort to longitudinal compliance data from previous cohorts to make sure that decision-making has been consistent.
Progress Reports
During the accreditation review process, organizations found to be in noncompliance with:
a) Core Accreditation Criteria
b) Applicable Standards of Integrity and Independence in Accredited Continuing Education
c) and potentially with applicable Accreditation Policies
may be required to demonstrate compliance through the progress report process. The ACCME will notify providers whether they are required to submit a progress report via their decision report.
Learn more about progress reports here.
Guide to Your Decision
The ACCME has a rigorous, multilevel process for making accreditation and reaccreditation decisions, which are made three times a year. The “Guide to Your ACCME Decision” under Explore Resources can help providers understand their ACCME decision.
