• Policies & Procedures

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  • Essential Area 1

    Purpose and Mission

    The Morehouse School of Medicine and CME missions serve to guide the CME program along its intended path, protect against manipulation of the program into education situations, or otherwise adverse situations, not endorsed by the policies.

    The most important reason for any health care organization to establish a CME program is the desire to enhance high quality medical care. The physician must be involved as a participant and student in the active process of learning.

    In order to apply the guidelines of the MSM and CME missions, the planning and CME committees consider the following criteria:

    • What does this program expect to accomplish? (Purpose)
    • What will be the focus of our topics? (Content Areas)
    • For whom will the educational activity be intended? (Target Audience)
    • What type of activities will be provided? ( Activities)
    • What are the expected outcomes of the program? ( Results)

    The Mission Statement is reviewed and revised regularly by the CME Committee and approved by the Academic Policy Council.

    Essential Areas 2.2 and 2.2

    Educational Planning/ Needs Assessment

    1. Needs Assessment documentation is the first step in the planning process.
    2. A learning needs survey is conducted periodically to identify educational needs perceived by the faculty and the area physicians as well as to evaluate performance of the continuing medical education component of the medical school. The data is then summarized and used in the planning of the educational activities.
    3. Identified needs from multiple sources are used to initiate and support the planning process.
    4. Community physicians are surveyed to determine learning needs and to determine the best vehicle for meeting those needs.
    5. Each source of need requires a supporting document to use in setting methodology, design, objectives, and evaluation of the CME activity.

    Essential Area 2.3

    Planning Objective

    1. The objectives are developed for each CME activity based upon the identified needs.
    2. The target Audience is identified and stated in all learning materials.
    3. Background requirements of the prospective participants are listed when necessary for the respective activity.
    4. Learning outcomes in terms of knowledge, skills, and/or attitudes are indicated and communicated to the learner.
    5. The purpose or objectives of the activity describe learning outcomes in terms of physician performance or patient health and are consistently communicated the learner.

    Essential Area 2

    Planning and Design


    1. The selection and organization of content, and decisions about educational formats are based upon the most effective and efficient methods of meeting the stated objectives of the CME activity.
    2. The types of learning methods are selected based on the subject target audience as indicated in the planning process.
    3. The activity faculty is selected by the physician planning group based upon expertise in the field, and the resources available to fulfill objectives defined for the activity. The CME committee or its designated planning group reviews curriculum vitae.
    4. Proposed learning aids such as the syllabus, are reviewed by the Planning Committee and the OCME prior to the activity.
    5. The activities always include Q/A ranging from 10-30 minutes usually after each presentation and/or session.
    6. Promotional brochures or flyers are mailed to the target audience, and posted as appropriate.
    7. Enduring materials for self-directed learning are developed through the MSM Office of CME.


    1. All expenditures and revenue are documented in the activity.

    MSM Process for Payments of Honoraria

    MSM requires that MSM faculty not be paid honoraria for participation (speaker or planning member) in the MSM CME activities.

    Guest faculty are usually paid a modest honorarium ranging from $500 to $3,000. The honorarium is intended to show appreciation for participation in MSM CME activities. Honoraria must comply with the Standards for Commercial Support of the ACCME and not influence the choice of speaker or the content of the presentation.

    The amount paid will vary depending on the activity and the requirements. Considerations for determining the honorarium include the speaker’s expertise and reputation, the number and length of presentations, preparation and travel-time.   In compliance with the ACCME Standards for Commercial Support no honoraria or reimbursement will be paid directly by the commercial supporter(s) to a speaker.

    Essential Area 3


    1. All educational activities are evaluated for effectiveness in meeting identified educational needs, as measured by satisfaction, knowledge, or skills. When applicable, educational activities are evaluated for effectiveness in meeting identified educational needs, as measured by practice application and/or health status improvement.
    2. The overall CME program is evaluated regularly by the CME committee with review of MSM’s mission and activities of the previous fiscal year. Annual review of the CME program is included in the annual needs survey by feedback from the community physicians. Improvements are made in the CME program by incorporating suggestions of the CME committee into the operating policies of the Office of CME.
    3. Outcomes in physician behavior which influence the health of the population are measured when applicable by repeated surveys or statistical review of morbidity data.


    Joint Sponsorship - a CME activity that is planned implemented and evaluated by MSM, the accredited provider and a non-accredited entity.

    Co-Sponsorship - a CME activity presented by two or more ACCME accredited providers.  Only one accredited provider can take responsibility, thus awarding the credit and maintaining compliance with ACCME.

    1. A commercial interest cannot take the role of non-accredited partner in a joint/co-sponsorship relationship.
    2. Jointly/co-sponsored activities must be consistent with MSM CME’s mission and purpose statements.
    3. MSM CME or its designee, must review and approve all materials associated with the activity prior to their release; once these materials have been reviewed and approved by MSM CME, no further changes can be made.
    4. Any and all funds solicited on behalf of a CME activity must either (a) be received by MSM, or (b) be delivered to the joint/co-sponsor with MSM CME’s written authorization.
    5. The responsibilities and role of the joint/co-sponsor will be clearly delineated in a letter of approval between the joint/co-sponsor and MSM CME.  MSM CME has the right to withdraw from any activity if the joint/co-sponsor fails to meet its obligations as described in the letter of approval or fails to comply with MSM CME policies and procedures.
    6. All activity expenses are the responsibility of the organization seeking joint sponsorship. Evidence of a proposed neutral budget. The joint/co-sponsor shall submit a projected budget for each CME activity to MSM CME for review and approval.  MSM CME will review the projected budget to ensure that adequate resources have been devoted to the development of an activity consistent with meeting the activity’s objectives.  MSM will withdraw from an activity if resources are inadequate for the development of a high quality educational product or activity.
    7. At MSM CME’s discretion and with written authorization, the joint/co-sponsor may solicit funds under the direction of MSM CME but may not make any representations or commitments to commercial supporters as to educational content, choice of speakers, learning objectives, marketing, and/or evaluation.
    8. All potential joint/co-sponsorship relationships will be examined on their individual merits.  Although all CME activities joint/co-sponsored with MSM CME must comply with this policy, MSM CME reserves the right to refuse to enter into a joint/co-sponsorship agreement for any reason whatsoever, regardless of that organization’s willingness to comply with this policy.
    9. MSM CME will charge fees for its services.  These fees and the terms for its payment will be mutually agreed upon and delineated in an exhibit to the aforementioned letter of approval between MSM CME and the joint/co-sponsor:
      • Administrative Fee reflects: (a) oversight and involvement in the planning process by members of MSM CME’s staff and/or consultants that represent MSM CME; (b) expertise in the rules and responsibilities of providers, joint/co-sponsors, and commercial supporters of continuing medical education activities as derived from the ACCME and AMA; and (c) fees required to maintain full accreditation
      • AContent reviewer fee represents fees to be paid by MSM CME to selected content reviewers.  These fees will be negotiated between MSM CME and the content reviewer(s) and will be submitted as a line item to the joint/co-sponsor for inclusion in the projected budget for the CME activity.
      • ACertificate fee represents the costs to MSM CME associated with the awarding of credit and the maintenance of six years of detailed records of participation in CME activities certified by MSM.  Certificate fees will be established with each joint sponsor applicant.
      • AHonoraria for a MSM clinician serving as Activity Medical Director, Activity Co-Director, author, speaker, moderator, steering committee chair, etc. will be separately negotiated between the joint/co-sponsor and the individual faculty member (e.g., MSM CME does not enter into these negotiations).

    Regularly Scheduled Series

    1. Regularly Scheduled Series (RSS) such as grand rounds, MMA boards and cancer conferences are approved on the basis of common needs and goals for each session for a one year period.
    2. The CME Application is to be submitted to the OCME no later than June I before the next fiscal year. The application should have an attached listing of topics, objectives and speakers for at least the first three months of the year.
    3. Additional schedules and documentation for each series are due at least by the 15th of the month for the following month.  This is required for accurate documentation and promotion of the session s on the CME activity Calendar
    4. Within 30 days of the session date, follow up documentation of the evaluation summary, attendance record, and evidence of disclosure having taken place are required in the Office of CME.
    5. Regularly scheduled conferences must be at least 60minutes in length for 1 category 1 credit.

    Evaluation /improvement

    • Series are audited regularly for compliance with the ACCME essential and Elements Policies, including the Standards for Commercial Support.
    • Performance data is collected and shared with the series course director and the designated coordinator, with emphasis on improvement in results.
    • A plan for improvement is developed and implemented for each series.
    • ACCME Letters of Agreement must be in the Office of CME prior to the session whenever funds are contributed in support of CME.

    Attendance and Record Keeping

    A. Credit for attendance will be granted when the following conditions apply:

    1. Sign-in on the appropriate attendance form.
    2. Multi-day conferences require sign in once at the beginning of the conference and initials daily.
    3. For multi-hour conferences, each physician indicates the number of credits claimed.
    4. Each physician should claim only those credits actually spent in the educational activity.

    B. Record keeping for participation in CME activities:

    1. Computerized transcripts are available for a nominal fee.
    2. Records of attendance are maintained in a database for 6 years.
    3. A Certificate of Attendance or Credit is awarded to participants.
    4. The certificate indicates the maximum number of credits designated for Category 1, the title of the program, start date, end date and the name of the participant with the number of credits claimed.
    5. The signature of the Director of CME appears on the certificate.

    Required Documentation for the CME Activity File

    Before the Activity

    1. *Completed application for CME sponsorship
    2. *Documentation of Need
    3. *Objectives
    4. *Topics  and speakers with the time frames
    5. *Curriculum vitae of all course presenters
    6. *Proposed Budget
    7. Full disclosure declaration for each speaker
    8. *Brochure, flyer, or other promotional material (DRAFT)
    9. Speaker confirmation form and confirmation letter ( if applicable)
    10. Planning notes and related correspondence
    11. Letter(s) of Agreement for Commercial Support ( if applicable)

    After the CME Activity

    1. Actual promotional flyer/brochure and final program
    2. Disclosure Forms
    3. Sign in form /Attendance record
    4. Evaluation Summary
    5. Handout materials
    6. Complete budget/Accounting
    7. Participant CME fees and other fees per budget

    *Required prior to CME committee consideration

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