COMMITTEE ON CONTINUING EDUCATION

APPLICATION FOR MSSNY

ACCREDITATION OR REACCREDITATION

MEDICAL SOCIETY OF THE STATE OF NEW YORK

99 WASHINGTON AVENUE, SUITE 408 ALBANY, NEW YORK 12210

PHONE: (518) 465-8085 FAX: (518) 465-0976

e-mail: jwise@mssny.org

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TABLE OF CONTENTS

Overview & Background Information...........................................................................................................................3

Developing your Self Study for Reaccreditation

Data Sources used in the Accreditation Process

Expectations about Materials

Missing or Incomplete Information

Schedule of Submission of Application Materials and Timeline……………………………………………………..………………….…...4

Accreditation timeline: Initial vs. Reaccreditation

Requirements for Assembling and Submitting CME Activity Lists …….…………………………………………………………………...5

Requirements for Assembling and Submitting Performance in Practice Materials…………………………………………….6-11

How to Prepare Activity Files for Review

How to Set Up your Activity Files

Options for Preparing Activity Files for Review

Option 1: Labeled Evidence of Performance-In-Practice

How to Set up an Activity File Using MSSNY Labels

Option 2: Structured Abstract

How to Set up an Activity File Using the Structured Abstract

Demonstrate Compliance with RSS

Assemble an Activity File

Enclose the CME Product

Completion of MSSNY’s Self-Study Report…………………………................................................................................12-13

Submit Materials to MSSNY

MSSNY’s Accreditation Interview...............................................................................................................................14

MSSNY’s Decision Making Process.............................................................................................................................15

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READ ALL INSTRUCTIONS BEFORE BEGINNING EACH PART OF THE ACCREDITATION PROCESS.

OVERVIEW AND BACKGROUND INFORMATION

DEVELOPING YOUR SELF-STUDY FOR REACCREDITATION

The self-study process provides an opportunity for the accredited provider to reflect on its program of CME. Depending

on the size and scope of your CME program, it is your decision which individuals to involve in the process.

DATA SOURCES USED IN THE REACCREDITATION PROCESS

Demonstration the CME Program is compliant with MSSNY’s accreditation requirements are conducted through three

primary sources of data:

� Self-Study Report

Providers describe the planning and practice(s) related to MSSNY Criteria & Policies as narrative descriptions,

attachments and examples of the implementation of the CME practices described.

� Accreditation Interview

Providers have an opportunity to further describe the practices presented in the Self-Study & activity files, and

provide clarification as needed, in conversation with a survey team who are CME colleagues.

� Performance-in-Practice Review

Documentation review is done to verify CME activities are in compliance with MSSNY Criteria & Policies.

MSSNY will select activities from the current accreditation term for evidence of performance-in-practice for

review. This is a key component because the activity file must verify what is written in the Self Study and

described in the Interview.

EXPECTATIONS ABOUT MATERIALS

Materials submitted to MSSNY, in any format, must not contain any untrue statements, omit any necessary material

facts or be misleading, must fairly present the organization and are the property of the organization.

Materials submitted for accreditation must not include individually identifiable health information, in accordance with

the Health Insurance Portability & Accountability Act (HIPAA).

MISSING OR INCOMPLETE INFORMATION

Providers meeting all deadlines and submission requirements of the reaccreditation process will receive an

accreditation decision from MSSNY. Please note, if MSSNY is unable to render a decision due to missing or incomplete

information, MSSNY reserves the right to request additional information, the expenses for which will be borne by the

provider.

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SCHEDULE OF SUBMISSION OF APPLICATION MATERIALS AND TIMELINE

Date Milestone

12 months prior to

accreditation

expiration date

MSSNY emails notification to Provider which includes:

(a) Application for Reaccreditation Manual

(b) Activity file template

(c) Performance in practice labels

(d) Accreditation Timeline and Provider Milestones

11 months prior to

accreditation

expiration date

Provider deadline for submission of confirmation of Intent to Apply for

Reaccreditation.

����

9 months prior to

accreditation

expiration date

Provider Deadline

For submission of: ( a ) CME Activity List/PARS entries

( b ) Reaccreditation fee, if not paid

( c ) Submission of date preferences

(if not received, MSSNY will decide date)

8 months prior to

accreditation

expiration date

MSSNY informs Provider which Activity Files will be reviewed

����

7 months prior to

accreditation

expiration date

Provider Deadline

For receipt of completed Self Study Reports and Activity Files

MSSNY confirms survey date and time with Providers

3-4 months prior to

accreditation

expiration date

Survey Occurs

The month

accreditation is due to

expire.

MSSNY’s Subcommittee on Surveys Meeting

Within 4 weeks.

Provider receives Accreditation Decision from MSSNY

ACCREDITATION TIMELINE: INITIAL VS. REACCREDITATION

Reaccreditation applicant: See grid above for reaccreditation timeline.

Initial Applicant: The timeline for an initial applicant to complete the accreditation process is dependent upon the

dates that materials are submitted to the MSSNY. Once a pre-application is approved by MSSNY, an organization has

six (6) months to submit a Self Study Report for initial accreditation. MSSNY’s accreditation process requires a 3-

month window between the submission of a Self Study Report for initial accreditation and date of the interview.

Based on the date of the survey, all applicants will receive a decision from MSSNY at a Committee on Education

meeting which meets in March, June, September or December. Within a month of the Committee meeting at which

the applicant receives a decision, MSSNY will notify the provider of its findings in writing.

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REQUIREMENTS FOR ASSEMBLING AND SUBMITTING CME ACTIVITY LISTS

Review the Accreditation Timeline & Provider Milestones included with your Self-study to determine when you are to

submit your Activity List. These instructions will guide you in preparing the Activity List:

1. The list of activities must be submitted using MSSNY’s template spreadsheet only.

2. TO BE INCLUDED ON THE ACTIVITY LIST:

• List all activities beginning the month after your last accreditation decision through December 31, 2013.

3. HOW TO LIST YOUR ACTIVITIES:

• List your activities chronologically by month & year within each activity type. For example: list all 2011 activities:

courses, then enduring materials, then RSS, etc. Do the same for each year of the term.

• Activities offered on multiple dates at various locations to different audiences, even with the same title &

content, must be listed for each date & location offered.

• Include Regularly Scheduled Series as a single activity, using the date of the 1st

session.

4. HOW TO COMPLETE THE ACTIVITY LIST SPREADSHEET:

Column A: List the title of the activity.

Column B: List date the activity occurred in “MM/DD/YYYY” format.

If activity is multi-day, only provide the beginning date of the activity.

If activity is enduring material, only provide release date or most recent review date.

Column C: List the activity’s location in “City, ST” format. For enduring materials, list your home / state.

Column D: Indicate directly or jointly provided only.

Column E: List the type of activity using the drop-down box to choose: Course, RSS, Internet Activity Live, Enduring Material,

Internet Activity Enduring Material, Journal-based CME, Manuscript Review, Test Item Writing, Committee Learning, Performance

Improvement, Internet Searching & Learning, or Learning from Teaching.

Column F: List the number of maximum number of credits available for the activity.

Column G: List # of MD’s learners. If attendance is incomplete at time of submission, use TBD.

Column H: List # of non-MD’s learners. If attendance is incomplete at time of submission, use TBD.

Column I: Indicate whether activity received commercial support. Answer only Yes or No.

Column J: List amount received: all financial or in-kind support from a commercial entity. For future activities,

estimate what you expect to receive. Advertising & exhibit income is not commercial support.

Column K: List the number of commercial supporters of the activity. (If not yet presented, estimate).

Column l: Indicate if activity was designed to change competence. Yes or No ONLY.

Column M: Indicate if change in competence was measured. Yes or No ONLY.

Column N: Indicate if activity was designed to change performance. Yes or No ONLY.

Column O: Indicate if change in performance was measured. Yes or No ONLY.

Column P: Indicate if activity was designed to change patient outcomes. Yes or No ONLY.

Column Q: Indicate if change in patient outcomes was measured. Yes or No ONLY.

IMPORTANT:

• Do not alter the spreadsheet format, leave blank cells in columns A-I or add blank rows or columns;

• Do not send spreadsheet as a “zip file”. Submission should be one worksheet attached as one file.

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REQUIREMENTS FOR ASSEMBLY & SENDING PERFORMANCE-IN-PRACTICE ACTIVITY FILES

PERFORMANCE IN PRACTICE is the review of activity files which show how you plan & implement your activities in

accordance with the CME criteria. MSSNY reviews Activity Lists and requests files be submitted. Files are reviewed for

evidence of planning & implementation of CME in accordance with accreditation criteria

• Activities are selected from across the accreditation term & types of activities produced.

• You may also provide an additional activity of your choosing if the sample selected by MSSNY does not capture

best practices or accurately reflect your CME program. Contact MSSNY for details.

HOW TO PREPARE ACTIVITY FILES FOR REVIEW

• Review the Accreditation Timeline and Provider Milestones to determine when to submit activity files.

• If, after reviewing the list of selected activities, an error such as incorrect activity date or format is noted, please

notify MSSNY via email and the selection will be updated.

• Do not send an entire working file. Send only material demonstrating how accreditation criteria is met.

THERE ARE 2 OPTIONS FOR PREPARING ACTIVITY FILES FOR REVIEW:

Note: Providers must choose one of the two following options for submitting evidence of performance-in-practice to

MSSNY. The option that is chosen must be used for all activities selected for review.

OPTION 1: LABELED EVIDENCE OF PERFORMANCE-IN-PRACTICE

• The label template is provided & is pre-formatted to print on Avery Standard File Folder Labels #5266

• Once materials are chosen, use labels to show compliance with each criterion. Example: Label #1: Verification the

activity is developed from a professional practice gap connected to your own learners. Label the page that

specifically shows how you identified practice gaps for your learners. BE VERY SPECIFIC.

• Once you have labeled evidence, highlight demonstration of compliance. DO NOT ATTACH LABELS RANDOMLY!

Labels should identify exactly what you want MSSNY to use to determine compliance.

• If multiple Criteria/Policies are addressed in one document, affix multiple labels to that document as long as

labels do not cover the evidence of compliance.

• If you include strings of email or meeting minutes as evidence, highlight items relevant to the labels.

• IMPORTANT: Labels are for activity files only – do not use in the self study

• IMPORTANT: Labels should make very clear where compliance was achieved – you do not want the surveyors to

assume what you mean or that you are noncompliant.

HOW TO SET UP AN ACTIVITY FILE USING MSSNY LABELS

Set up the following dividers and include the suggested items to show compliance for all CME criteria:

Divider: Planning

Completed application forms and/or meeting minutes which document:

• identification of professional gap,

• need that underlies the gap,

• design of content to change need,

• measurable objectives,

• format appropriate for setting/objective/results

• planned in context of desirable physician attribute

• examples of non-educational strategies,

• factors outside provider control: impact patient

outcomes

• strategies to remove, overcome or address barriers to

physician change

• collaboration and cooperation

Faculty and presenter lists

Activity content (powerpoints, slides, screen shots for internet activities, etc)

Brochure or flyer or agenda with times

Strategic planning/Meeting minutes: must be detailed about planning & approval process to be applicable

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Divider: Disclosure

All Relevant Financial Relationship (RFR) forms for anyone with the potential to control the content (planners,

presenters, moderators, authors etc).

Documentation of management of refusal to complete an RFR

Documentation of management of conflict/bias

Documents that show disclosure of all RFR or lack thereof.

Divider: Commercial Support

All commercial agreements signed by all parties

Documentation of disbursement of funds – copies of checks, payment vouchers, account ledgers etc

Final budget showing all revenue and expenses

Brochure or flyer showing disclosure of all commercial support

Blank sheet with labels if commercial support is not accepted

Divider: Evaluation

Compiled or summary of evaluation data

Analysis/measurement of evaluation data

For RSS: monitoring data which shows compliance with CME criteria

Divider: Policy

Honoraria policy

Conflict of interest policy

Divider: Enduring Material Product

Enduring material product (CD, DVD, manual etc)

OPTION 2: STRUCTURED ABSTRACT The Performance-in-Practice Structured Abstract has been provided with your reaccreditation information. Using

the Structured Abstract, you will complete text-limited fields, tables, and attach evidence that verifies the activity

meets the reaccreditation requirements.

HOW TO USE THE ACCME PERFORMANCE-IN-PRACTICE STRUCTURED ABSTRACT

The ACCME Structured Abstract is a tool CME providers may use to verify performance-in-practice during the

accreditation process. The goal with the abstract is to simplify, clarify and be explicit about the information that

MSSNY is looking for as performance-in-practice evidence.

The Performance-in-Practice Structured Abstract is a Microsoft Word-based fill-out form that enables you to insert

information into specific fields in the document. In addition to filling out this information, you will need to include

attachments when submitting materials for your performance-in-practice review.

STEP-BY-STEP GUIDE

D E M O G R A P H I C I N F O R M A T I O N

The first section of the structured abstract asks the provider to include information about its organization and

about the CME activity for which evidence is being submitted.

1. ACCME Provider ID: NA

2. Provider Name: Enter the name of your organization.

3. Activity Title: Enter the the title of the activity you are describing in the structured abstract.

4. Activity Date: Enter the start date for the activity.

5. Activity Type: Select the type of activity from the drop down list on the abstract.

6. Providership: Select either Direct or Joint Providership

7. Commercial Support Received: Indicate “Yes” or “No” if commercial support was received.

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A C T I V I T Y I N F O R M A T I O N

In the 2nd

section, you enter information about the planning of the CME activity, specifically related to professional

practice gaps and educational needs (C 2), what the activity was designed to change in learners or patient

outcomes (C 3), and which physician competencies (C 5) the activity addressed. The information expected is

described on the abstract, including word limits.

8. Criterion 2: Briefly state the professional practice gap(s) that this activity was based on.

9. Criterion 2: Enter the educational needs that you determined to be the cause of the professional practice

gap(s): - is there a knowledge need (i.e., “Learners need to understand…”), and/or

- a competence need (i.e., “Learners need a new/better strategy…”), and/or

- a performance need (i.e., “Learners need to do something differently…”).

It is expected that every CME activity address educational need(s) that underlie professional practice gap(s) of

your learners. However, multiple activities can address the same gap(s) & need(s).

10. Criterion 3: What change(s) in learners or patient outcomes was the activity designed to change? Are you

intending to change their competence (approach/strategies), performance, (what they do in practice),

and/or patient outcomes (the impact on patient care).

11. Criterion 5: Briefly explain why the educational format is appropriate for the activity.

12. Criterion 6: Select desirable physician attributes (i.e., competencies) the activity addresses. If none of the

choices apply, use the Other Competency(ies) option to provide your response. Providers are required to

choose at least one competency listed—or specify an “Other Competency”—for each CME activity.

S T A N D A R D S F O R C O M M E R C I A L S U P P O R T – I N D E P E N D E N C E

The next section relates specifically to the provider’s processes for identifying and resolving conflicts of interest (C

7—Standard 2 of ACCME Standards for Commercial Support).

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13. Please complete one row for each individual in control of content for the activity, as directed. If the

financial relationship of the individual (including their spouse or partner’s financial relationships) does not

constitute a relevant financial relationship with an ACCME-defined commercial interest, you do not need to

complete the fields for “name of the commercial interest” and “nature of relationship.” If you already have

the information required for this table electronically, you may include it along with the material required by

Attachment 2 (see the “Attachments” section below) and do not need to fill out the fields in this table.

If the activity was commercially supported, you need to complete the next table on the abstract to describe the

provider’s management of commercial support (Criterion 8—ACCME Standards for Commercial Support 3.4-3.6).

14. Complete one row for each ACCME-defined commercial interest that provided commercial support for the

activity, specifying the name of the commercial interest and the dollar amount of monetary support

received. Put an X in the checkbox if the activity received in-kind support. If you already have the

information required by this table electronically, you may include it along with the material required by

Attachment 8 (see the “Attachments” section below) and do not need to fill out the fields in this table.

DO NOT LIST EXHIBITORS OR ADVERTISERS HERE.

A T T A C H M E N T S

The last section is a list of attachments you are asked to include with the completed form. Attachments 1-6 must be

included for all CME activities. Attachments 7-9 are included only if there was commercial support.

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HOW TO SET UP AN ACTIVITY FILE USING THE ABSTRACT

Set up the following dividers and include the suggested items to show compliance for all CME criteria:

Attachment 1:

Agenda, brochure, program book, or announcement that shows the topics/content the activity addressed.

Application or minutes which demonstrate compliance.

Attachment 2:

All Relevant Financial Relationship (RFR) forms for anyone with the potential to control the content (planners,

presenters, moderators, authors etc) as listed on the abstract (#13 above).

Documentation of management of refusal to complete an RFR

Attachment 3:

For all individuals in control of content, show how your mechanism(s) to resolve conflicts of interest were

implemented prior to the start of the activity.

Documentation of management of conflict/bias

Conflict of Interest Policy

Attachment 4:

For each individual in control of the content of the activity, provide the documents that show disclosure

information that was provided to learners about the relevant financial relationships (or absence thereof).

Attachment 5:

Attach the data or information describing the changes in your learners’ competence (i.e., strategies), performance,

or patient outcomes that were generated from the activity. (Compiled or summary of evaluation data and

Analysis/measurement of evaluation data)

For RSS: monitoring data which shows compliance with CME criteria

Attachment 6:

Example of the accreditation statement for this activity, as it was provided to learners.

Attachment 7:

Final Income and Expense statement that details that receipt and expenditure of all commercial support.

Documentation of disbursement of funds – copies of checks, payment vouchers, account ledgers etc

Honoraria Policy

Attachment 8:

Each executed commercial support agreement(s) for the activity signed by all parties.

Attachment 9:

Documentation commercial support disclosure information as was provided to learners of the activity.

NOTE: Blank forms and checklists alone do not verify performance in practice. Activity files must prove what you

describe in the self study & the interview. If you describe it, the files must verify that process.

IF YOU DO NOT HAVE EVIDENCE OF COMPLIANCE BECAUSE:

(1) the activity date precedes your organization’s implementation of the Criterion; or

(2) the Criterion is not applicable to the activity; or

(3) unable to find or was not completed

• If using labels, place label on a sheet of paper and explain why there is no evidence.

• If using the abstract, place a sheet of paper and explain why there is no evidence.

o “No evidence because date of the activity preceded implementation of the Updated Criteria”;

o “No commercial support accepted”;

o “No evidence found”

BE VERY CAREFUL WITH N/A. Required criteria should NEVER be listed as “not applicable”.

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Assemble an Activity File

1. Labeled evidence for each activity must be submitted in an 8 ½” by 11” manila file folder

2. Each file folder should be no more than ½” thick

3. Affix label on the front of folder that specifies:

• Full Name of organization (no acronym)

• Activity title as it appears on the CME Activity List;

• Activity date and location;

• Type of Activity (Course, RSS, Internet Activity Live, Internet Activity Enduring Material, Enduring Material, Journal CME, Journal-

based Manuscript Review, Test Item Writing, Committee Learning, PI, Learning from Teaching, Internet Searching & Learning);

• Directly or jointly sponsored activity;

• If commercial support was accepted

The Medical Society of the State of New York

2013 Annual Meeting

January 1, 2013

Albany, New York

Course

Directly Provided

Commercial Support accepted.

IMPORTANT:

☺ The name, date and location on your label should be the same as it appears on your activity list. Any variation

must be explained to MSSNY prior to submission of the materials.

☺ Activity files should be easy to navigate. Use colored paper, tabs, or pagination to organize.

☺ Do not paper clip materials together. Use of staples or binder clips is preferred.

☺☺☺☺ DO NOT SUBMIT ACTIVITY FILES IN BINDERS, PLASTIC SHEETS OR ANYTHING EXCEPT A FILE FOLDER

ENCLOSE THE CME PRODUCT (ENDURING MATERIALS [EM])

• If an EM is chosen from the activity list, submit the CME product (actual CD, URL and password, etc) in its

entirety for each EM activity selected in addition to the evidence for these activities

• If using performance–in-practice labels, affix to the hard copy to show compliance with the applicable criteria.

In the product, you may also highlight or provide written directions to ensure you are showing where you are

meeting the policy requirements.

• For Internet activities, provide a direct link to online activities or URL and a username & password. If an

Internet activity selected is no longer available online, submit the activity saved to CD/drive or provide access

on an archived Web site. If surveyors have difficulty accessing the activities or finding the required

information, you will be expected to clarify this evidence at the interview. Active URLs, logins, and passwords

must be made available for the duration of your accreditation review. Include screen shots of webpages that

include accreditation requirements.

Demonstrate compliance with RSS:

A regularly scheduled series (RSS) is an activity presented as a series of sessions which occur on an ongoing basis

(weekly, monthly, or quarterly) & are primarily planned by, and presented to, the provider’s own professional

staff. Examples: Grand Rounds, Tumor Boards & M&M Conferences. Providers producing RSS must ensure they

are designed & implemented in compliance with MSSNY’s requirements – just like any other activity type.

In addition to either labeled evidence or use of the abstract, for the performance-in-practice review, RSS require

a FOUR-part information set that includes,

1) description of monitoring system used to collect & analyze data regarding the RSS compliance;

2) summary of the RSS monitoring data collected presented in summary or aggregate

3) analysis & compliance conclusions drawn from the data;

4) itemization/description of activity or program improvements needed and implemented;

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Completion of the MSSNY’s Self Study Report

MSSNY has specific requirements for the Self-Study Report content outline, but the process of conducting a self-

study is unique to your organization. The content of the Self Study Report is intended to address:

• Extent to which your organization has met its CME Mission (C1, C12).

• An analysis of factors that support or detract from the CME mission being met. (C11, C12)

• Extent, in context of meeting your CME mission, that your organization produces CME that:

o Incorporates educational needs that underlie professional practice gaps of your learners (C2),

o Is designed to change competence, performance, or patient outcomes (C3),

o Includes formats appropriate for the setting, objectives, and desired results (C5),

o Is in the context of desirable physician attributes (C6),

o Is independent, maintains education separate from promotion, ensures appropriate management of

commercial support & does not promote propriety interest of commercial entity (C7-10)

• How implemented improvements helped your organization better meet its mission. (C13)

• The extent to which your organization is engaged with its environment (C16-C22).

Structure and Format Requirements

1. Include a Table of Contents listing the page numbers of each narrative and attachment. See example:

2. Include the following completed forms behind the “Prologue” Tab:

Demographic Information Form

Updated CME Activity List

3. To separate the content of the Self Study Report, use dividers or tabs for each section of the Self Study

a. Provide required narrative and attachments for each item of the outline behind the tabs.

b. Put attachments behind the appropriate tab. Do not put them all at the end of the report.

c. For the purpose of printing tabs, the titles of the sections have been abbreviated as follows:

I) Prologue

II) Purpose And Mission (C1)

III) Educational Activities (C2-7 and Policies)

IV) CME Program and Educational Activities (C8-9)

V) Content of Educational Activities (C10 and Content Validation)

VI) Evaluation and Improvement (C11-15)

VII) Engagement with the Environment (C16-22)

4. Type with at least 1” margins (top, bottom and sides), using 11 point type or larger. It is acceptable to use

double-sided printing.

5. Pertinent excerpts must be photocopied or scanned on standard paper for inclusion in the binder. Do not use

plastic sleeves for single pages or for multi-page documents (i.e. brochures, handouts, etc).

6. Consecutively number each page in the binder including the attachments. The organization name (or

abbreviation) must appear with the page number on each page. If the report is not numbered, it will not be

accepted and will be returned at your organization’s expense.

7. Place the Self-Study Report and all the attachments in a 1 1/2 inch (ring diameter), 3-ring binder only.

8. Submit three copies in binders to MSSNY. Be sure to keep a separate copy for use during the interview.

EXAMPLE TABLE OF CONTENTS PAGE

V) Regarding the Content of your CME Activities (Criterion 10 and Policy on Content Validation) 58 -61

Description of how CME activities and your program of continuing medical education ensure 58

that these three expectations are fulfilled (e.g., planning, procedures, policy, monitoring). Attachment I 59

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Please pay careful attention to the requirements for organizing and formatting the Self-Study Report.

These requirements facilitate review of your CME program. If they are not fulfilled, then:

1) The reaccreditation process will be suspended, and the provider’s review will be deferred to the next cohort with

new deadlines and milestones established;

2) A fee that is equal to the standard extension fee will be required; and,

3) All self-study materials will be discarded by MSSNY and another complete set will be required by the new

deadline

Submit the Self Study and Activity Files to MSSNY on Time

The following materials must be shipped, using a method that has a reliable electronic, web-enabled delivery

tracking system, for MSSNY’s receipt by the published due date:

• Three copies of the Self-Study Report in binders formatted and organized as specified

• One electronic copy of the Self-Study Report as a single PDF file on a CD-ROM or flash drive

• Three copies of each of your evidence of performance-in-practice for selected activities

• One copy of the CME product(s) for any enduring materials, Internet, or journal-based CME activities

Original documents will not be returned. Retain a duplicate set of materials including the Self-Study Report and

labeled activity files for your own reference during the accreditation process, but especially at the time of the

interview. If the need arises, MSSNY may ask for a second copy of a file or set of files.

Materials must be shipped via a method with a reliable electronic, web-enabled delivery tracking system to:

The Medical Society of the State of New York

Continuing Medical Education Office

99 Washington Avenue, Suite 408

Albany, NY 12210

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MSSNY’s Accreditation Interview

The accreditation interview offers the provider the opportunity to discuss its CME program with qualified

surveyors. MSSNY surveyors will be assigned to review the self-study and performance in practice materials you

submit to MSSNY. They will meet with representatives of your CME program to engage in a dialogue about your

organization’s policies and practices that ensure compliance with the Accreditation Criteria, including the

Standards for Commercial Support and Accreditation Policies.

At the interview, the surveyors will seek clarification about any questions they may have regarding the self-study

materials you submitted to MSSNY. You can expect MSSNY surveyors to: 1) conduct their interactions with

providers in a professional manner, 2) be familiar with your materials and MSSNY’s Accreditation Criteria and

Policies, and 3) communicate clearly and effectively with providers without offering consultative advice or

feedback regarding compliance or the expected outcome of the accreditation review.

MSSNY utilizes the face-to-face meeting as its standard accreditation interview format, including meeting at

MSSNY offices, an on-site meeting at your organization’s offices or via televideo. Interviews typically average 2

hours in length.

You will be asked to provide your first and second choice date for the interview. MSSNY will make every effort to

schedule either your first or second choice date, however, that may not always be possible. If not, MSSNY will

offer a new date or ask for additional dates from you. Each organization may request the interview format and

location, however, to ensure validity of the process and based on circumstances and available resources, MSSNY

reserves the right to make all final decisions regarding the interview format, date, time, and/or composition of the

survey team. MSSNY will confirm your assigned surveyor(s) and the interview date and time in advance via email.

Your organization will be asked to confirm receipt of this communication.

Interview Formats

The format for all interviews involves a meeting between the representatives of the accredited provider and the

MSSNY survey team. MSSNY offers the following three interview formats:

Televideo Interviews Your organization must have access to two-way televideo transmission. MSSNY

uses a 384-speed ISDN line; your organization must arrange for bridging service

if your site is IP only.

Face to Face Interviews Representatives from your organization come to MSSNY’s offices in Albany or

Long Island NY.

On-site Interviews On-site interviews are intended to occur at provider administrative offices or

the site of the provider’s CME activities. While the interview time is designed

to take approximately 90 minutes, the survey team may spend up to one-half

day with the provider. In addition to interview time, the survey team spends

time meeting together and completing reports.

On-site interviews may be longer than one-half day if a live CME activity is

reviewed during the visit.

MSSNY may require a provider to have a CME activity reviewed, in accordance

with MSSNY policy. MSSNY policy requires that initial applicants or provisionally

accredited providers must have a CME activity reviewed prior to receiving a

status of “accreditation”. In addition, CME activity reviews can be requested as

part of an accreditation decision or monitoring issue. Providers required to have

an activity reviewed as part of the accreditation process will be prompted by

MSSNY to submit information to facilitate this process.

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MSSNY’s Decision Making Process

Your organization’s compliance findings and the outcome of the accreditation review are determined by MSSNY

based on the data and information collected in the accreditation process. MSSNY will also consider data from

monitoring issues, if such data are applicable to the provider.

The data and information are analyzed and synthesized by the Survey Team. The Survey Team makes

recommendations on findings and status which are forwarded for action to MSSNY’s Subcommittee on Surveys.

Once the recommendations have been accepted by the Subcommittee on Surveys, all accreditation decisions are

ratified by the full MSSNY Committee on Education which meets four times each year (March, June, September and

December). Accreditation decision letters are sent to providers via Fed Ex following the MSSNY Committee on

Education meeting

This multi-tiered system of review provides checks and balances necessary to ensure fair and accurate decisions.

The fairness and accuracy are also enhanced by MSSNY's use of a criterion-referenced decision-making system.

• Each Provider will be notified of the accreditation decision by mail within 4 weeks of the Committee

on Education meeting. Decisions are rendered in March, June, September and December.

• Please do not contact the MSSNY office for results as staff cannot provide any information either

over the phone or via email.

• Please do not contact survey team members as they cannot provide any information on your

accreditation status.

The decision making process assesses providers' compliance with the Accreditation Requirements based on

information collected during the accreditation process. MSSNY will also consider data from Monitoring issues, if

such data is applicable to the provider.