Self Study
Prologue
Behind this tab labeled Self Study Prologue, please provide the following:
1) Demographic Information
Attach a completed “Demographic Information for Applying for Accreditation” form.
2) Self Study Prologue – Narrative only
Provide a narrative description of the following:
1) Brief History of the Program
2) Leadership and Structure of the CME Program
3) Structure and Process that your organization used to complete the Self Study
4) Strengths of CME Program
5) Practices your organization has identified as meeting the ememplary
compliance criteron for specific Element(s) and a brief explanation to link the
practice(s) to the specific exemplary compliance criterion
Behind this tab labeled Essential Area 1 (Purpose & Mission), please provide the
following:
3) Essential Area 1 (Purpose & Mission) – Narrative and Attachments
Element 1.1 Mission
Describe/explain the various components of your CME mission.
Attach CME Mission Statement
Purpose & Mission
Essential Area 1
Element 1.2 Parent Organization
Describe your organization’s relationship to your parent organization.
Provide the documentation that best demonstrates compliance with Element
1.2 (review the decision making criteria for compliance language). Include
any of the following that may be appropriate:
1) Your parent organization’s mission statement,
2) Support from your parent with respect to financial, facility or human
resources,
3) Documentation that your organization’s CME mission statement is
reviewed and approved by the governing body of your parent organization
on a regular basis.
Behind this tab labeled Essential Area 2 (Education Planning & Activity Evaluation), please provide the
following:
4) Essential Area 2 (Educational Planning & Activity Evaluation) – Narrative and Attachments
Element 2.1 Planning Process
Describe your planning process(es) specifically addressing the linkage of identified educational
needs to desired results.
Attach documentation of your planning process(es) and the steps that demonstrate how the
identified educational needs are linked with desired results for a specific CME activity.
Element 2.2 Needs Assessment
Describe how needs assesment data is used in planning your CME activities.
Attach a copy of each method you use to collect needs assessmenty data.
Attach documentation demonstrating use of needs assessment data in the planning of a
specific CME Activity.
Element 2.3 Purpose and Objectives
Describe how the purpose and/or objectives for your CME activities are made known to
participants before participating in the activity.
For one specific activity attach promotional material for the activity highlighting the
Ed Plan & Activity Eval
purpose/objectives and the appropriate accreditation statement.
Essential Area 2
Element 2.4 Activity Evaluation
Describe how your CME activities are evaluated in terms of meeting the identified educational
need.
For one specific activity, attach an evaluation instrument and a summarized data set from a
specific activity.
Behind this tab labeled Essential Area 2 (Overall Program Evaluation), please provide
the following:
4e) Essential Area 2 (Overall Program Evaluation) – Narrative and Attachments
Element 2.5 – Program Evaluation
Describe how your organization evaluates the effectiveness of its overall CME
Program.
Attach evidence of the use of a mechanism(s) for evaluating the effectiveness
of the overall CME Program, as well as evidence that improvements were
made as a result of this process.
Overall Program Eval
Essential Area 2
Behind this tab labeled Essential Area 3 (Administration), please provide the following:
5) Essential Area 3 (Administration) – Narrative and Attachments
Element 3.1 - Organizational Framework
Describe your organization’s structure, process(es), and system(s) that allow your CME
program to operate effectively
Attach an organizational chart.
Complete the attached CME Program income and expense statement* for
o The past year (for initial accreditation); or
o Each year of the accreditation term (for reaccreditation).
Attach an income and expense statement for a specific CME activity.
*[NOTE: The income and expense statements provided for BOTH the CME Program and the specific
CME activity must include:
1) Income from commercial support, advertising and exhibit fees, tuition and registration fees, internal
budget allocations and any other sources as separate line items when they represent ≥20% of total
income.
2) Staff salaries, meeting costs, honoraria, faculty travel expenses and any other items as separate
line items when they represent ≥20% of total expense.]
Element 3.2 - Business and Management Practices
Attest (written statement) to your organization’s compliance with business/management
policies.
Attach the Table of Contents from your organization’s Human Resources and Financial
Policies or Procedures Manual. (This is not your CME department’s policies.)
Element 3.3 Disclosure and Commercial Support Standards
Describe how your organization’s activity planning process ensures that planning decisions
are made free of the control of a commercial interest.
Describe and attach documentation of the mechanism your organization uses to ensure that
everyone in a position to control educational content has disclosed to your organization
relevant financial relationships with commercial interests.
Describe the mechanism(s) you use to identify conflicts of interest prior to an activity.
Describe the mechanism(s) you use to resolve conflicts of interest prior to an activity.
Describe how you manage commercial support (funds and in-kind support), including your
decision making process(e) to receive and disburse support.
Describe your process for payments of honoraria and reimbursement of expenses to
planners, teachers or authors.
Describe how you manage commercial promotion associated with each type of CME activity
that you provide in fulfillment of the elements of SCS Standard 4.
Describe how enduring materials are distributed to learners (if applicable).
Describe and explain the mechanism(s) your organization uses to ensure that the content of
CME activities promotes improvements or quality in healthcare.
Describe and explain the mechanism(s) your organization uses to ensure that the content of
CME activities gives a balanced view of therapeutic options.
Describe your organization’s process(es) and mechanism(s) for disclosure to the learners of
relevant financial relationships and the source of support from commercial interests.
Attachments:
Attach an example of the mechanism(s) your organization uses to collect the disclosure
information of relevant financial relationships of everyone in a position to control education
Essential Area 3
Administration
content.
Attach an example of a written agreement documenting terms, conditions and purposes of
commercial support that you have used, or would use, to fulfill relevant elements of SCS
Standard 3.
Attach your written policies and procedures governing honoraria and reimbursement of
expenses for planners, teachers and/or authors.
Attach examples that verify the disclosure of relevant financial relationships to learners.
Attach examples of the disclosure of the source of support from commercial interests to the
learners.
Attach examples of the disclosure of the source of support from commercial interests to the
learners.
NSMA Policies
Behind this tab labeled NSMA policies, please provide the following:
6) NSMA Policies* - Narrative and Attachments
Describe the mechanism your organization uses to verify physician participation in your
CME activities.
Describe how your organization is in compliance with NSMA’s Definition of CME*
Describe how your organization is in compliance with NSMA’s content validity value
statements.*
Attach a list of the URL(s) for all of your Internet CME activities for assessment of
compliance with NSMA’s Internet CME policy (if applicable).
Submit two copies of a Journal CME activity for assessment of compliance with NSMA’s
Journal CME policy (if applicable).
Submit two copies of each type of enduring material produced for assessment of
compliance with NSMA’s Enduring Materials policy (if applicable).
* For exact language of policies, please see NSMA Policies at
http://www.nsmadocs.org/education.asp)
Behind this tab labeled Program Summary (Self Assessment and Improvement Plans,),
please provide the following:
7) Program Summary (Self Assessment and Improvement Plans) – Narrative only
Describe you CME Program’s Areas for Improvements and Specific Plans for
Addressing Improvements.
Describe your CME Program’s Future Goals.
Self Assess Improve Plan
Program Summary
Behind this tab labeled CME Activities, please provide the following:
8) CME Activities – Attachments only
For initial accreditation
Attach a complete “Summary of CME Activities” (a copy is attached; an electronic
version is available in the Documents and Forms section of
http://www.nsmadocs.org/education.asp.)
Attach a list of the CME activities presented prior to applying for accreditation (a
copy is attached; an electronic version is available in the Documents and Forms
section of http://www.nsmadocs.org/education.asp.
For reaccreditation
Attach a complete “Summary of CME Activities” (a copy is attached; an electronic
version is available in the Documents and Forms section of
http://www.nsmadocs.org/education.asp) presented during your organization’s
current period of accreditation.
Attach a list of all the CME activities that the CME Program has presented during
its current period of accreditation (a copy is attached; an electronic version is
CME Activities
available in the Documents and Forms section of
http://www.nsmadocs.org/education.asp.