Welcome to the September edition of AOE Compliance Connection, AOE’s monthly newsletter! We are excited to share our monthly ACCME, ACPE and ANCC board updates along with news from the world of CME.
We thoroughly enjoy what we do at AOE. We are committed to excellence no matter the task – everything from compliance management to program benchmarking. We come alongside clients just like you, and help them navigate the ever-changing waters of CME compliance to ultimately facilitate their success. This newsletter is just one of the many educational resources we make available to support achievement of success, compliance and peace of mind.
Enjoy this month’s edition of AOE Compliance Connection! Please visit www.aoeconsulting.com for even more information, including a library of guidelines and weekly compliance tips.
Accreditation Board Bulletin
ACCME
If your organization has gone through initial accreditation or reaccreditation recently, or if you are in the middle of the process now, you may be familiar with the ACCME Performance-In-Practice Structured Abstract. This tool will be particularly valuable to organizations embarking on initial accreditation or reaccreditation in the future.
The Performance-in-Practice Structured Abstract allows CME providers to verify their compliance with evidence of performance-in-practice and is intended to simplify the collection of required information. While this tool was introduced in 2014, its use for submitting performance-in-practice data associated with an initial accreditation or reaccreditation was optional. Starting with the November 2017 Cohort, the ACCME now requires that CME providers use the Performance-In-Practice Structured Abstract when submitting their performance-in-practice evidence for each of the selected activities during the accreditation process.
The Performance-In-Practice Structured Abstract documents required information into specific fields. There are four sections to the Structured Abstract:
- Demographic Information: Details about the CME provider and the CME activity for which evidence is being submitted.
- Activity Information: Details about the planning of the CME activity, specifically addressing Criteria 2 3, 5 and 6.
- Standards for Commercial Support – Independence: Information about the provider’s process for identifying and resolving conflicts of interest as well as management of commercial support, Criteria 7 and 8.
- Bookmarks: A list of required documentation that must be attached and bookmarked with the completed form.
The ACCME provides a tutorial and tools, to assist and guide the use of the Structured Abstract. The completed abstract, inclusive of the required bookmarks, meets the ACCME’s expectations for performance-in-practice documentation specific to each activity.
ACPE
The Standards for CPE were released in 2008, and by the end of 2015, every accredited provider had been reviewed by these original standards. The ACPE reviewed compliance rates and provider feedback, noting that three of the standards had less than 50% compliance: Standards 2, 5 and 12.
The ACPE Board approved the recommended changes/clarifications recommended by the Commission, and effective January 2018, the following changes will be made to the ACPE Standards:
- There will now be 11 Standards instead of 12.
- Standards 1 and 12 will be combined into a new Standard 1: “Achievement of Mission and Goals of the CPE Program.”
- This new standard will be divided into three parts:
- Develop a mission (who you serve and why)
- Develop a strategic plan and/or goals (the “how”)
- Develop an evaluation plan
- This new standard will be divided into three parts:
- Standard 2 will now be called “Gap Analysis” (previously “Needs Assessment”)
- The intent of this standard is the same, but the emphasis is on identifying the gap and the root of the identified gap, along with information on how the gap came to be.
Also beginning January 2018, providers will be able to use an attestation statement for adherence to the Standards of Commercial Support (SCS) in lieu of including each policy in the self-assessment report.
With the debut of the changes in Standards also came reminders about the most recent updates: Standard 11’s shift from a checklist of evaluation components to an overall “broad picture” of the process and success of activity evaluations, and Standard 5’s prohibition of corporate logos for ACPE-defined commercial interests.
The complete updated Standards, Evaluation Rubric, Policies, and Procedures may be found by clicking here.
ANCC
ANCC accredited providers may develop content within their continuing nursing education (CNE) activities to meet the ANCC pharmacotherapeutic contact hour requirement for Clinical Nurse Specialists (CNS) and Nurse Practitioners (NP). To meet certification requirements, CNS’s and NP’s must participate in CNE activities that cover multiple educational areas, among which, are required contact hours in the area of pharmacotherapeutics. When ANCC accredited providers develop content to meet the ANCC pharmacotherapeutic contact hour requirements, specific items must be implemented, as detailed below:
- The content planned and developed must explicitly speak to pharmacotherapeutics. This includes but is not limited to drug specific information, safe prescribing practices, safe medication administration, prescribing methodologies, new regulations or similar content.
- The presenter of the content must be an expert in the area of pharmacology. The presenter does not have to be a nurse.
- As a best practice, the provider should define the number of pharmacotherapeutic contact hours, when creating the content for an educational activity. Typically, pharmacotherapeutic contact hours are calculated at the time the speaker develops the content for the planned CNE activity.
- A content review may be conducted on the CNE activities/programs containing pharmacotherapeutic content, to determine the suitable amount of pharmacotherapeutic contact hours.
The previous list of requirements should be executed for all pharmacotherapeutic content. Additionally, the ANCC accredited provider should include the number of contact hours in the area of pharmacotherapeutics on all program materials, audience generation materials and documentation of awarded contact hours to ensure learners are aware of the opportunity to be awarded these contact hours toward their recertification. If you have any additional questions related to pharmacotherapeutic contact hours, please reach out to AOE for further clarification.
CME in the News: MOC Board Announcement
Currently, there are three specialty boards that collaborate with the ACCME when it comes to CME for MOC credit: the American Board of Internal Medicine (ABIM), the American Board of Pediatrics (ABP) and the American Board of Anesthesiologists (ABA). The ACCME has hinted for months about new potential partnerships, and earlier this month, a fourth board was announced: the American Board of Pathology (ABP). As of now, the timeline for this collaboration has not been released.
Providers and learners benefit from these board collaborations. Learners experience a more stream-lined process and CME providers no longer have to submit MOC applications to the certifying boards and can, instead, use PARS to register and report these activities. As part of this process, providers attest to compliance with board requirements, agree to collect the required individual participant completion data, and meet other requirements.
Later this week, the ACCME will host an MOC-specific webinar: “CME for MOC: Ask your questions” to engage and address providers working through the MOC process. Get more information and register by clicking here.
AOE in the Spotlight: Managing Enduring Activities
In our April 2017 newsletter, we shared some practical tips and best practices for day-to-day management of your CME program. This month we’d like to share some ideas for effective management of enduring activities.
- Tracker: Develop a tracker for enduring activities to ensure that the following information is organized in a central location: activity launch and expiration date, date to pull and summarize evaluation data, annual review date and updates, if applicable, etc. Having this key information in one location makes compliance management of enduring activities straightforward and helps preclude any oversights.
- Organizing Activity Files: Per the ACCME, enduring activities can endure for three years. The activity must be reported to PARS each year the activity is offered to learners. One recommendation is to create an activity file for each year the activity endures. This can help ensure that if the activity is selected for audit, the information is already organized and can be easily pulled for Performance-in-Practice.
- Checklist: Since enduring activities have some additional requirements, it is a best practice to create a checklist to ensure that items such as the following aren’t overlooked:
- Clear instructions provided to learner for how to successfully complete the activity
- Assessment of learner with a minimum, established performance level
- Minimum performance level communicated to learner
- Mechanism to determine credit designation
- Annual Review: While it is not required to review enduring activities each year, it is a best practice that helps ensure the activity information, including gap(s)/need(s), is still up-to-date and relevant for learners. Create a form for members of your CME or Education Committee to utilize and set a date each year for annual review of existing enduring activities.
These are just a few best practices we’ve collected. We know that providers of different sizes and circumstances have their own best practices. We hope that what we’ve shared helps prompt new ideas for improving your CME program’s management of enduring activities.
- “CME for MOC: Ask Your Questions” Webinar
September 20, 2017, Online
Read More >> - ACPE Fall 2017 Continuing Education Administrator Workshop
September 25-26, 2017, Chicago, IL
Read More >> - Quality and Innovation Summit (QIS)
September 25-27, 2017, Park City, UT
Read More >> - Getting Started with Joint Accreditation
October 17, 2017, Chicago, IL
Read More >> - MAACME 7th Annual Conference
November 16, 2017, Hunt Valley, MD
Read More >> - Professional Nurse Educators Group Conference
November 9-12, 2017, Pittsburgh, PA
Read More >>