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The Mission Criterion says, "expected results articulated in terms of changes in competence, performance, or patient outcomes that will be the result of the program." What definition of "competence" is ACCME using? Does it mean knowledge and skill, or does it mean the application of knowledge or skill in practice? If the later is true, how does it differ from performance?

In the ACCME context, we are using Miller's (1990) definition of competence as "knowing how" to do something. Knowledge, in the presence of experience and judgment, is translated into ability (competence) - which has not yet been put into practice. It is what a professional would do in practice, if given the opportunity. The skills, abilities and strategies one implements in practice is performance.

See Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990; 65(9 Suppl):S63-7.


This is an ACCME adaptation of an Agency for Healthcare Research and Quality (AHRQ) definition of a gap in the quality of patient care where the gap is "the difference between health care processes or outcomes observed in practice, and those potentially achievable on the basis of current professional knowledge."

The ACCME does not want to limit the scope of CME providers' or learners' educational projects. Part or all of some professionals' practices include important non-clinical, non-patient care elements which are still considered relevant to continuing medical education.

When there is a gap between what the professional is doing or accomplishing compared to what is "achievable on the basis of current professional knowledge," there is a professional practice gap.

See Kaveh G. et al, Technical Review, Number 9 , Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies Volume 1- Series Overview and Methodology, Publication No. 04-0051-1 Agency for Healthcare Research and Quality , U.S. Department of Health and Human Services Contract No. 290-02-0017, August 2004.

The Educational Needs Criterion requires that the educational needs that underlie the professional practice gaps of learners be incorporated into the CME activities. However, the CME provider does not have to collect that needs data. There are many sources of needs data that relate to professional practice gaps. Determining if that data is relevant to the actual learners is a task for the CME provider. Links to Examples of Compliance and Noncompliance, along with Frequently Asked Questions are provided on the criterion page linked above.


Please be aware that confidential patient information that is cropped out of images in PDF or PowerPoint files may still remain part of the file. Even though cropped information and portions of images are hidden from view, they may still be visible online, including on search engines. While this issue is not new, it’s important to remember to make sure that appropriate steps are taken to ensure that any image or information included in accredited CME is compliant with the Health Insurance Portability and Accountability Act (HIPAA).

Below are instructions that you can use if you receive files before use in your program, or you can share these with your faculty to help to ensure that images in CME presentations are HIPAA-compliant.

Problem: After you crop an image within PowerPoint or any other Microsoft Office product, the cropped areas remain part of the file, hidden from view. To help prevent other people from viewing the parts of the image and information that you have removed, you need to take additional steps.

Solution: There are two ways to avoid retaining the sensitive portion of a cropped image within PowerPoint or any other Microsoft Office product and within PDFs that are created from Microsoft Office files:

  • Use a different program: Crop and save the image outside of PowerPoint or other Microsoft Office product, and only insert the image into the presentation after you have saved the cropped image via another program. You can use a program such as Paint or Gimp. Paint is free and part of the default Microsoft Windows installation. Gimp is a free open source image manipulation program that is available for Windows or MAC.


  • Use the compress function: Crop the image within PowerPoint or other Microsoft Office product. Then, compress the image, being careful to select the “Delete cropped areas of pictures” check box to ensure that the sensitive content can no longer be accessed. More details are shown below:
  1. Select the picture or pictures from which you want to delete cropped areas.
  2. Click Picture Tools > Format, and in the Adjust group, click Compress Pictures. A dialog box appears showing compression options.



If you don't see the Picture Tools and Format tabs, make sure that you've selected a picture. You might have to double-click the picture to select it and open the Format tab. Also, if your screen size is reduced, you might only see the Compress Pictures icon.

Source: Crop a picture in Office—Microsoft Office support page


No. The ACCME does not require post-tests for any type of CME activity.


Accredited providers are required to understand the issues with knowledge or competence or performance that underlie a professional practice gap. 

The first definition that’s important for the ACCME to share is that our use of competence is in the educational measurement term. Competence is about ability. Competence is what you would do if you could do it. It’s descriptive of strategy. Competence is knowledge put into action; put into action by the learner.

You put competence into action. You put it into practice — that’s performance. Performance implies in practice.

Outcome, patient outcome, research outcome, executive outcome, administrative outcome — those are the consequences in the system, in your stakeholder, in the place of application of your performance. You measure those to determine the impact of the educational intervention.

Does it matter if you call it performance and we call it competence or vice-versa? No. It doesn’t matter. What we want you to do is to understand those differences so that you know that measuring in practice is different than asking people what they would do if they could. Those are two different things. We call one performance, we call one competence. What we want you to do is decide what it is you want to measure as a result of the educational activity. Do you want to measure their strategy, what they would do if they could? Do you want to measure them in practice? Do you want to measure the consequences of their actual performance in practice? And you measure that. And you can call it what you want: competence, performance or outcome. That’s not what’s important. It’s that you recognize that there are differences between them.