LSMS CME Accreditation Program • Downloadable Forms

Physicians have always understood that they made a commitment to a "lifetime of learning" when they chose to enter the medical profession. The American Medical Association (AMA) recognized the need for formal educational activities and in 1968 the AMA House of Delegates established the Physician’s Recognition Award (PRA) to encourage physicians’ continuance of their medical education as well as to reward those who had already completed such programs. The AMA adopted the following definition of continuing medical education:

"Continuing medical education consists of educational activities which serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession. The content of CME is that body of knowledge and skills generally recognized and accepted by the profession as within the basic medical sciences, the discipline of clinical medicine, and the provision of health care to the public."

The AMA Committee for the Accreditation of Continuing Medical Education (CACME) and the Liaison Committee on Continuing Medical Education (LCCME) were assigned the responsibilities of determining which CME programs were accredited prior to 1981. In 1981 the Accreditation Council for Continuing Medical Education (ACCME) was established, consisting of seven sponsoring organizations. The ACCME is charged with accrediting interstate providers of CME in the United States and recognizing state medical societies to accredit intrastate providers of CME.

There are 2 methods of accreditation. The ACCME is the body that accredits the following institutions for the provision of CME:

State medical societies,
Liaison Committee for Medical Education (LCME)- accredited schools of medicine,
National physician membership organizations,
National specialty medical societies,
Certain other eligible institutions and organizations, as determined by the ACCME in collaboration with the applicable state accrediting body, whose program of CME serve physician learners, more than 30% of whom are from beyond the home or contiguous state(s) of the provider.

Such organizations are accredited as interstate providers directly by the ACCME.

Organizations that do not qualify as interstate providers should seek accreditation from their state medical society. State medical societies were responsible for accreditation activities in their respective states prior to the establishment of the ACCME and so were empowered to continue accrediting intrastate providers. To maintain uniform standards for intrastate and interstate CME accredited organizations, it was necessary to have both methods of accreditation under the umbrella of the ACCME. The Committee for Review and Recognition (CRR) of the ACCME was established to "recognize" state medical societies to accredit intrastate providers, which involves periodic evaluation by the CRR.

Both interstate and intrastate providers of CME are judged by the same criteria. These criteria are the Essentials Areas and Elements. CME credits conferred by an accredited program are transferable across state lines since all programs use the same, or similar, standards. However, intrastate providers must document that 70% or more of the total physician learner hours awarded by the CME Program were awarded to physicians that practice in the respective state or the contiguous states.

Accreditation Process Decisions Fees Requirements Downloadable Forms

LSMS CME ACCREDITATION PROGRAM

The Louisiana State Medical Society’s accreditation of intrastate providers is accomplished through its Continuing Medical Education Accreditation Program (CMEAP). This program is overseen by the LSMS Committee on CME Accreditation, one of the standing committees of the Society. The accreditation process hinges on the Essentials Areas and Elements - ten criteria or standards by which providers of continuing medical education must adhere. The Essentials Areas and Elements as adopted by ACCME are endorsed by the LSMS. These three Essentials Areas include:

Essential Area 1 – Purpose and Mission
Essential Area 2 – Educational Planning
Essential Area 3 – Evaluation and Improvement

The CMEAP accredits different types of organizations; hospitals, professional societies, consortiums, and other healthcare-related organizations. The criteria used to accredit all organizations are identical. To apply for CME provider status applicants are screened for appropriateness using the following criteria:

Applicant must have a CME track record
Applicant must have a formal CME committee, with a majority of membership of physicians licensed by the Louisiana State Board of Medical Examiners
Applicant must be appropriate for intrastate provider status
Applicant may not be an internal department of an institution
Applicant may be a hospital, medical specialty organization, consortium, or managed care organization
Applicant (providing it is a free standing facility) may apply for separate accreditation even if it is a part of a larger organization that is already accredited.

Overview Decisions Fees Requirements Downloadable Forms

Accreditation Process

The accreditation process is essentially a four-step process as follows:

[1] The first step involves the submission of an application by the prospective CME provider to the LSMS. If an applicant will be sponsoring activities that will draw an audience of which 30% or more practice outside Louisiana or the contiguous states, or appears to more appropriately be an interstate candidate, it will be referred to the ACCME. Each applicant will be evaluated as to how well it meets the Essentials Areas and Elements. The application form should be completed by both the physician in charge of the organization’s CME committee and the person who is in charge of the day-to-day operation of the program.

[2] The application is reviewed by both the LSMS Director of Education and LSMS CME Coordinator for completeness and appropriateness. If the application is incomplete or inappropriate it is returned to the applicant for possible clarification or refinement. The applicant may resubmit the application within 60 days without incurring another application fee.

[3] If this review determines that the organization is a candidate for accreditation, a Site Survey is then scheduled with the applicant by the LSMS. The site survey team is usually composed of five persons: two members of the Committee on CME Accreditation, the LSMS Director of Education, the LSMS CME Coordinator, and one outside nonvoting surveyor from an organization already accredited by the LSMS CMEAP. During the site survey the LSMS surveyors will observe the prospective CME provider’s actual CME program in operation, interview the CME staff, review pertinent records and facilities, and meet with the CME committee. The amount of time spent in conducting this survey will vary. However, each site survey will be no more than one-half a day in duration. The site survey team will prepare a report of its evaluation of the program for submission to the LSMS Committee on CME Accreditation.

A "reverse site survey" may be used for organizations applying for the third and subsequent accreditation periods. The organization will send representatives (including the physician Chair and the staff CME coordinator) to a meeting of the LSMS Committee on CME Accreditation. They will be asked to present documentation and information necessary to help the Committee make an accreditation decision.

[4] In the last step of the accreditation process, the full Committee on CME Accreditation votes on the application. This vote is based upon information in the application site survey report. A favorable vote results in the accreditation of the provider who is given a certificate for public display attesting to this distinction.

Each applicant organization will be notified by the Director of Education whether they have been accredited. Applicants will then be asked to evaluate the LSMS on the application and site survey process.

A method of appeal is available if a negative judgement is rendered. (See B-1)

Program Process Fees Requirements Downloadable Forms

Accreditation Decisions

There are four types of accreditation decisions:

PROVISIONAL ACCREDITATION

the standard accreditation for initial applicants
2 years accreditation
may also be given when an accredited organizations program is so altered that it is essentially a new program
may not joint-sponsor

CONTINUED ACCREDITATION

may be awarded to organizations which have passed the Provisional Accreditation period
maximum of four years
may joint sponsor with LSMS CMEAP approved policies and procedures

PROBATIONARY ACCREDITATION

may be given to an accredited program with serious deviations from the Essentials Areas and Elements
may be for one or two years
may not be extended
may not joint sponsor
must precede non-accreditation except for organizations that are on Provisional accreditation
representatives of the organization must appear before the Committee on CME Accreditation during the accreditation period to report on the progress of the program

NON-ACCREDITATION

may be rendered to an initial applicant by the LSMS Committee on CME Accreditation when it is determined that a CME program is not in substantial compliance with the Essentials Areas and Elements
may be rendered to an organization on Probationary Accreditation if it is determined to not be in substantial compliance with the Essentials Areas and Elements

Overview Process Decisions Requirements Downloadable Forms

Fees

There are three general expenses for an organization seeking accreditation of its CME Program. First, there is a pre-application and application fee to be paid to the LSMS at the time of submission of the "Accreditation Application". Second, the applicant must pay the expenses of the individuals that are on the Site Survey Team. Legitimate expenses include travel, as well as food or lodging, if required. Individuals participating in the site survey do not charge honoraria. The applicant organization will be informed, prior to the site survey, of the individuals on the site survey team. At this time the applicant will also be advised of the approximate costs of the site survey. In many cases overnight accommodations are not necessary and the total costs for the site survey are often less than $500. The third expense is the Accreditation Maintenance Fee. This fee is based on accreditation length and is to be paid in advance in one lump sum at the time accreditation is awarded (see the fee schedule on page A-6).

Requirements of Accredited Providers

Strict adherence to the LSMS Essential Areas and Elements
Abide by the Standards for Commercial Support of Continuing Medical Education and the AMA’s ethical opinions on "Gifts to Physicians from Industry" and "Continuing Medical Education".
If required submit a Progress Report by a given date. Reports will not be accepted more than 30 days after this date and the institution will have its accreditation revoked. It may then only apply for provisional accreditation.
Submit the Annual Report by January 31^st each year. Again, reports will not be accepted more than 30 days after this date and the institution will have its accreditation revoked. It may then only apply for provisional accreditation.
Maintain data of participants at CME activities as required by the CMEAP.
Maintain documentation as required by the Essential Areas and Elements and the Standards for Commercial Support.
Notify the LSMS within 30 days if there is a change in either the Medical or Staff Director of the CME program.
Submit other documents as may be required by the LSMS CMEAP by the respective deadlines.
Assure that CME Coordinators and CME Committee members are aware of current CME requirements by attending meetings held by the LSMS, ACCME, Alliance for CME, or other organizations, reading material from LSMS CMEAP, and where available, periodically review the LSMS Web Page. It is mandatory that the CME Coordinator, or a representative, attend at least one of the LSMS CME Coordinator Conferences each calendar year.
Be knowledgeable about the information contained in the latest version of the AMA PRA Information Booklet regarding the AMA’s requirements for designating AMA PRA Category 1 and 2 credits for activities.
If jointly sponsoring activities with a nonaccredited provider, the accredited organization must have a written Joint Sponsorship Policy on file with the LSMS CMEAP which meets the requirements of the LSMS CMEAP Joint Sponsorship Policies.
Submit an application for reaccreditation no less than six months before current accreditation period ends. Organizations that miss this deadline will have their accreditation lapse and will only be considered for provisional accreditation if they reapply.

Downloadable Documents

Fees Policies and Procedures Application Instructions for Application

Binder Labels