Goodbye To The Essentials?

When the new executive director and secretary of the Accreditation Council for Continuing Medical Education (ACCME) says he wants to have dialog with accredited CME sponsors, take him at his word: Murray Kopelow, MD, logged thousands of miles this spring to get face-to-face, literally, with CME directors and coordinators around the country. Medical Meetings caught up with him at the end of May in Lake Success, NY, where he met with the committee on continuing medical education of the Medical Society of the State of New York (MSSNY). The purpose of his peregrinations: To present CME providers with a framework for changing the accreditation process, and to hear their views before moving on to the design stage.

Will CME providers really be saying goodbye to the seven Essentials, those guidelines for the process of producing continuing education for physicians? For those who can demonstrate their competency in a different way, the answer may be "yes," according to Kopelow. In his talk before the MSSNY CME committee, and in a draft document first published last December and since revised, he put forth several proposals that will begin having an impact on CME providers in 1997. The bottom line for educators and meeting planners:

* There will be at least four different ways to achieve accreditation, and CME providers will be able to choose the method that best fits their organizations. These four methods include demonstrating administrative excellence, teaching excellence, improvement in physician behavior, and improvement in patient care.

* There will be different levels of accreditation, and CME providers will be expected to seek accreditation in areas of special competence.

* Among the areas of special competence will be something called proctoring of nonaccredited sponsors. This will replace current rules regarding joint sponsorship-rules that are considered onerous by many CME organizations.

* The accreditation process itself will become one of "organizational self-study" rather than a procedural audit, and the ACCME will attempt to achieve its goal of continuous quality monitoring in a way that is neither punitive nor burdensome.

* The Standards for Commercial Support will remain in place-although it may come to pass that commercial supporters receive some kind of accreditation designating them as legitimate providers of educational grants.

Why Change Now? "In 1992 we set some strategic imperatives," says Kopelow. "We said that accountability, management, and changes in accreditation were important to us. We surveyed our sponsors, and found that we are perceived as being too process-oriented; that sponsors see maintaining accreditation as a burden, financial and otherwise; and that joint sponsorship has become a sticky area."

Yet another finding of the ACCME's survey was that the organization is perceived as not listening to its members. "I am the manifestation of the correction of this problem," says Kopelow. "I'm here to listen and respond, not to tell CME sponsors 'This is how it's going to be.'"

In fact, it appears that at least two of the proposals developed in December 1995 are not going to fly. The first is a proposed requirement that accredited providers offer some minimum number of CME activities per year; the second, a proposal that the ACCME accredit individual CME activities, as does the American Academy of Family Physicians.

The other reason for changing the accreditation process is that the environment in which CME is developed and presented is so different from what it was four years ago as to be unrecognizable. Managed care organizations and communications technology, including the development of self-study programs on the World Wide Web, have seen to that.

Who Shall Be Eligible? A fundamental challenge facing the ACCME is the touchy area of eligibility criteria. Under the present system, university medical schools, large and small medical associations, for-profit communications companies, and 50-bed community hospitals are all capable, at least in theory, of achieving the same accreditation status. "Is it elitist to say that there should be eligibility criteria, or is this just a way of saying that accreditation is a big step?" asks Kopelow. "By 1997 it will cost $3,850 to become accredited, and $900 a year to maintain accreditation."

The ACCME is proposing three eligibility requirements. The first is an ethical one-that the organization seeking accreditation demonstrate a commitment to physician education. "Is a for-profit CME provider committed to physician education? Is a hospital? We need to understand this," says Kopelow. The second is that the organization be able to demonstrate that it is a credible entity. "We accredit groups with 75 members whose office is the current president's basement and whose records travel around in a single file cabinet," says Kopelow. "Should we stop accrediting them?" The third requirement is that the organization be willing to abide by ACCME policies.

A Menu Of Accreditation Options Once an organization has passed the eligibility hurdles, the ACCME is proposing four possible standards by which CME sponsors may be judged. Under this concept, says Kopelow, a provider will be able to say, don't look at our paperwork, look at

1. Organizational structure: "You'll be able to say 'This is our structure, and our structure makes our organization a credible CME provider.'"

2. Organizational activities: "Look at what we do; we know how to teach, and this makes us a credible CME provider."

3. Learner outcomes: "Look at what the physicians who participated in our CME activity learned."

4. Patient outcomes: "Look at how patients cared for by physicians in my CME activities got better quicker and at lower cost."

Beyond these standards, CME sponsors will be asked to identify any of six specific domains within which they want to provide education (one, more than one, or as many as all six):

1. Synchronous learning (e.g., meetings),

2. Enduring materials (e.g., textbooks),

3. Self-study, print (e.g., workbooks),

4. Self-study, multimedia (e.g., courses on CD-ROM or on the World Wide Web),

5. Proctoring of non-accredited sponsors (e.g., joint sponsorship), and

6. Personalized education programs.

For each of these domains, CME sponsors will be expected to demonstrate that their programs have certain attributes, that these attributes meet certain operational criteria, and that each of these criteria meet specified ACCME standards. Consider personalized education programs: An attribute of such programs is that they have a program evaluation process. The criteria for program evaluation are that there be both internal and external reviews of the program. The ACCME standard is providing evidence that these internal and external reviews actually occur.

In working with CME sponsors on their performance in these educational domains, Kopelow believes the ACCME will need to act as a kind of mentor. "Our role should be to say 'Here's where you are, here's where you want to be. What will it take to get you where you want to be?'" he says. To this end, he adds, the accreditation and re-accreditation processes will be a kind of institutional self-study. "If this were the accreditation process, wouldn't it be immensely valuable to your organization?" he asks. He adds that the ACCME still needs to simplify record-keeping for CME sponsors. "We need something like Quicken [a financial software program]: You fill in data as you go along, and once a year you push F5 and that creates your report to us."

Commercial Support For all changes proposed in the way CME sponsors are accredited, Kopelow makes it clear that the Standards for Commercial Support will not be among the changes. "The Standards for Commercial Support were created-in good faith-to deal with conflict-of-interest issues," he says. "We created it for the express purpose of keeping the Food & Drug Administration (FDA) at arm's length. The Task Force on Industry/Provider Collaboration created the concepts, and the ACCME accepted them. They are problematical, they are bureaucratic, paper-trail-oriented, but they are the rules we live by.

"Disclosure is not meant to insult; it is something necessary. If I'm speaking about asthma products, and I get $700,000 a year for my research from one asthma product manufacturer, you need to know that."

Our Right To Be Various The ultimate purpose of altering the process of accreditation is to build enough flexibility into the system to make it workable for all. In this matter, Kopelow, who was a pediatrician based in Manitoba before coming to the ACCME's Chicago headquarters, gives a glimpse of his Canadian heritage:

"The ACCME's goals are to come up with standards that are flexible, physician-centered, efficient, effective, and meaningful. In presenting these goals, I have learned something about this country. In the United States, it is our responsibility and our right to be various. I'm supposed to come up with a standard, but nobody wants to meet it! If we provide one guideline, one definition, one opinion-it's not going to work."

And so, for those organizations comfortable with the present Essentials and Standards, the option to achieve accreditation in that way will remain. State sponsors will be measured by their ability to meet the Essentials and Standards as brought to bear on their particular community's needs.

"The old and new could co-exist," says Kopelow. "Maybe some of you don't have to change the way you work. But it is clear that we need to get some flexibility into the system."