Initial Accreditation

Self-Study Report

The self-study report is an opportunity for you to tell the “story” of your CME program to the ACCME and provide background and information on how your organization accomplishes its CME mission. Initial applicants are asked to provide descriptions, attachments, and examples to give the reader an understanding of CME practice(s) related to the ACCME Accreditation Criteria, Standards for Integrity and Independence, and applicable policies. Descriptions are narrative explanations. Attachments are specific documents. Examples are demonstrations of the implementation of the practices described that may include narrative and/or attachments. The self-study process provides an opportunity for the initial applicant to:

• assess its commitment to and role in providing continuing medical education,
• analyze its current practices and their success in helping the applicant meet its educational mission.

The ACCME provides specific instructions about what to include in the self-study report. The time available to complete the self-study report depends on the timing of the approval of eligibility and the next available cohort. Initial applicants may request a different cohort if they need additional time to conduct a thorough self-analysis of their CME program. ACCME encourages you to use this time effectively to develop a report that clearly describes and documents your educational enterprise. You must demonstrate compliance with ACCME’s Core Accreditation Criteria, the Standards for Integrity and Independence in Accredited Continuing Education, and applicable policies to receive an outcome of Provisional Accreditation with a two-year accreditation term. If any of the Core Accreditation Criteria, Standards for Integrity and Independence in Accredited Continuing Education, and policies are found to be in Noncompliance, the accreditation outcome will be Non-Accreditation.

Please be advised that the ACCME has no relationship with, and does not endorse, any vendor providing accreditation compliance advice or products to CME providers. The ACCME has neither approved nor disapproved the advice or products of any such vendors.

Conducting a self-study requires time and effort from many constituents involved in your CME program. Appropriate leadership of the self-study effort and broad involvement of administration, faculty, attendees and other stakeholders are important to a successfully planned and implemented self-study.

Once your self-study report is complete, you will submit it to the ACCME. ACCME staff will review the self-study report for completeness and contact you with any questions. Note that ACCME conducts its affairs in English, and requires that all self-study reports be submitted in English.

The self-study report outline includes the questions initial applicants will be asked to complete. All information and materials must be submitted in the ACCME’s Program and Activity Reporting System (PARS), https://pars.accme.org.

Performance In-Practice Review

Initial applicants are asked to verify that their CME activities are in compliance with ACCME accreditation requirements through the documentation review process. The initial applicant will present evidence to the ACCME for documentation review from at least two recently completed educational activities.

Actions required for this process:

• Select at least two CME activities, completed within the last 24 months, for performance-in-practice review
• Enter data into the ACCME’s Program and Activity Reporting System (PARS) (pars.accme.org) for the activities it selects for performance-in-practice review
• Submit evidence of performance-in-practice for each of the selected activities using the ACCME’s Performance-in-Practice Structured Abstract

The activities selected for performance-in-practice review may be conducted in joint providership with an accredited ACCME provider, or they may be offered by initial applicants without CME credit. In all cases, the evidence of performance-in-practice presented from these activities will be an important data source upon which the initial accreditation findings and decision will be based.

Following the structured abstract, initial applicants will provide the information requested with narrative explanations and statements, in tables, and include documents and evidence to verify that the activity meets the ACCME’s requirements. Initial applicants are expected to provide performance-in-practice evidence that demonstrates compliance with all Core Accreditatin Criteria, the Standards for Integrity and Independence in Accredited Continuing Education, and applicable policies. 

Accreditation Interview

Initial applicants are presented with the opportunity to further describe the practices presented in the self-study report and activity files, and provide clarification as needed, in conversation with a team of volunteer surveyors, who are colleagues from the CME community, trained by the ACCME.

You will be required to submit the written self-study report and evidence of performance-in-practice, along with payment of the Initial Accreditation Fee before participating in the accreditation interview. Once all required information and payment have been received, the ACCME will schedule your accreditation interview. 

Timeline

The process for Initial Accreditation takes 8-10 months.