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Framework for Establishing Substantial Equivalency
A Framework for Establishing Substantial Equivalency Between Continuing Medical Education Accreditation Organizations

The Accreditation Council for Continuing Medical Education (ACCME) and the Committee on the Accreditation of Continuing Medical Education of the Association of Canadian Medical Colleges (CACME/ACCME) offer this document to facilitate discussion among and between those who are concerned with the effectiveness of CME accreditation and who are interested in finding ways to improve the efficiency of the overall system. It is not the policy of the ACCME or of the CACME/ACMC.

Accreditation in continuing medical education (CME) has an important role in the domain of quality assurance in medical education. Among other purposes, CME accreditation is meant to: · Promote, develop, and encourage the development of principles, policies, and standards for continuing medical education , · Assist in improving quality of CME and accessibility of CME , and · Ensure the availability of CME activities that are appropriate. [and which] must be developed in a manner which will ensure quality educational content and relevance.

In some jurisdictions, a system accredits local institutions and organizations according to developed standards, and is responsible for assuring compliance with these standards1. In others, a process connects existing and emerging accreditation systems and can act as a clearing-house for CME accreditation and credits2. And there are some jurisdictions in which a system accredits individual CME activities3.

Regardless of the organizational approach to decision making, reasonable uniformity in the principles and outcomes of CME accreditation would be valuable so physicians, who participate in CME presented by an accredited provider or as individually accredited activities, wherever available, could obtain credits for different local, national and international organizations that require CME for maintenance of status purposes. In addition, physicians attending CME activities, and organizations that value accredited CME, wherever offered, could be assured educational programs are of good and predictable quality.

A range exists in the possible degrees of uniformity among systems. In some situations, one organization could establish a precise and explicit set of expectations about how another organization must operate in order to function the same as that organization. A review and decision-making process could be used to decide if the two systems are identical.

An alternative is substantial equivalency. This is a relationship that exists when accrediters deem their systems to be based on a set of agreed upon shared principles and values and are carried through and operationalized accordingly. In substantial equivalency, a significant amount of commonality would be expected, however some differences would also be expected and accepted.

The Fundamental Elements of a System for Recognizing Substantial Equivalency

The following is a set of values and criteria, which form the basis for an accrediter's recognition that another accrediter is operating a system that is substantially equivalent to its own.

The Values Supporting Equivalence in CME and Life Long Learning

The accrediter would be considered substantially equivalent if it supports and recognizes continuing medical education and life-long learning that,
· Enhances physician performance and thereby improves the healthcare of people,
· Is based on data describing physicians' educational needs with a commitment to education that helps them meet the health care needs of their patients and communities,
· Has its effectiveness assessed as it relates to physician performance or health status improvements, and
· Is developed with the control for the content, quality and scientific integrity being the responsibility of the provider.
And it should be apparent that the accrediter values the following aspects of an accreditation process:
· That other accreditation systems are equal partners in an international system.
· That equivalency can exist among CME providers and activities accredited within different systems.
· Fairness, validity, innovation, and consistency in accreditation practices.
· Reasonable standards and criteria for CME providers.
· Accountability, responsiveness, and leadership of accrediters.
· Promotion of continuous quality improvement of the accreditation systems as well as the education systems they support.
· Collaboration and partnership between and among accrediters, and between accrediters and providers.
The Criteria to Determine Substantial Equivalency

The accrediter would be considered substantially equivalent if,
1. As the basis for accreditation activities, there is an explicit set of performance requirements that requires providers to:
a. Use educational needs data as the basis for educational planning,
b. Measure the effectiveness of their CME activities,
c. Ensure that the content of CME activities meets accepted standards of scientific integrity
and is consistent with common and/or local practice, and
d. Ensure that activities are free of commercial bias and beyond the control of persons or organizations with commercial interests.
2. Accreditation decision-making is implemented and based on data and information relevant
to the explicit performance requirements (as in 1a-d).
3. A mechanism is in place, which allows for collection, storage and retrieval of the data and information necessary for the administration and evaluation of the accreditation process.

An Option for Maintenance of Equivalency

Once substantial equivalency has been identified, there should be a system in place to ensure that it is maintained. A maintenance of equivalency process could include the following elements.
· A periodic review of standards and procedures that the equivalent accrediter uses in accreditation.
· An opportunity to review the performance of the equivalent accrediter system in operation.
· Assistance to other systems in maintaining substantial equivalency by providing information, resources and counsel.
· The communication of information descriptive of system or process changes to the equivalent accrediter, in a timely fashion.
· At a mutually agreed upon interval, and through a process of self-study and reflection, the equivalent accrediter will provide information about its continuing substantial equivalency.
· It is appropriate for all expenses associated with this review process to be borne by the accrediter seeking recognition as being substantially equivalent.

Addendum: Definitions

Continuing medical education (CME): In its broadest sense, CME can include any learning activity undertaken by a physician to enhance his/her knowledge, skills or attitude. In the context of this document, CME will usually refer to pre-planned group learning activities.
CME provider: An institution or organization that develops, presents and evaluates a CME activity.
Accredit: To give official authorization to or approval of a CME provider to plan and implement CME activities deemed to meet defined education standards. Alternately, to approve CME activity according to defined education standards. ac·cred·it: Pronunciation: &-'kre-d&t,
Function: transitive verb, Etymology: Latin accreditus, past participle of accredere to give credence to, from ad- + credere to believe -- more at CREED Date: 1535; a: to give official authorization to or approval of: 1 : to provide with credentials; especially : to send (an envoy) with letters of authorization 2 : to recognize or vouch for as conforming with a standard 3 : to recognize (an educational institution) as maintaining standards that qualify the graduates for admission to higher or more specialized institutions or for professional practice; b: to consider or recognize as outstanding; c: attribute, credit. from Merriam- Websters College Dictionary available at Accreditation: The organized and duly performed process of accrediting CME providers on individual and /or CME activities Accrediter: An institution or organization that accredits CME providers and/or CME activities. Substantial equivalency: A relationship that exists when two accrediters deem their accreditation systems to be based on a set of shared principles and values and are carried through and operationalized accordingly.
Commercial bias: When one product, device or service is favored over another in a manner that is perceived to, or intended to, advance its commercial interest. As it relates to the control, use, or deployment of products, devices or services by physicians in the care of their patients, it is prohibited in certified CME.
Commercial interest: A fiduciary or agency relationship to a firm with a proprietary or pecuniary interest in a product, device or service that physicians control, use, deploy or manage in the care of patients Footnotes
1 Constitution and Bylaws, Accreditation Council for Continuing Medical Education (ACCME) of the United States, 1982.
2 EACCME ®, European Accreditation Council for Continuing Medical Education, Purpose and Procedure, available at
3 CME Information Booklet, American Academy of Family Physicians, available at
4 Status is variously meant to include licensure, membership, credentials, privileges, and certification.