AOE Compliance Connection – August 2018 Newsletter

Welcome to the August edition of AOE Compliance Connection, AOE’s monthly newsletter.  We aim to equip you with compliance updates and CME news that will contribute to your success.

This month’s newsletter features board updates for each of the three primary boards (ACCME, ANCC, ACPE), a look at QPP/MIPS updates, and some tips for building your organization’s CE/CME team.

In case you missed it last month, AOE published an easy-to-digest summary of the ACCME’s 2017 Annual Report here.  Be sure to glance through it for CME trends and data.

As always, we encourage you to visit www.aoeconsulting.comfor ongoing information, including our weekly compliance tips!

Providers who offer accredited CME not only address gaps in competence, performance and possibly healthcare quality, but also help learners meet specific professional requirements/standards.

For example, this year, learners who are eligible for MIPS (the Merit-based Incentive Payment System) are now allowed to report their participation in CME activities that address quality improvement and/or performance in order to fulfill MIPS Clinical Practice Improvement Activities. These improvement activities can be found on the Quality Payment Program QPP website, listed as “Completion of An Accredited Safety or Quality Improvement Program” under the Patient Safety and Practice Assessment category on the QPP website.

If interested in MIPS-related activity, the ACCME suggests in this published guidethat Providers should follow these three steps:

1. First, identify which of their CME activities might already fall into this category based on content:Does the board require the activity to address a safety or quality gap that is supported by a needs assessment?  Consider the following approaches:
   • Performance measures, registry data, chart audit, clinical data
   • Root cause analysis
   • Self-identified needs of individuals or groups
   • Organizational priorities and strategic plan
   • Patient satisfaction

   Does the board require the activity to have measurable metrics for improvement?  If so, consider crafting objectives that:

   • Improve an outcome of care or a healthcare process
   • Improve patient/population health
   • Address skill/procedure performance
   • Improving teamwork, care coordination, interprofessional team collaborative
2. Second, Providers can choose among the available professional requirements that are most useful to your specific learners.  These include MOC collaborations, MIPS activities, and others.
3. Third and lastly, and to help clinicians as they report their participation, Providers should become familiar with the ACCME Program and Activity Reporting System (PARS)and keep an eye out for QPP  guidance that’s coming soon that will aid learners in the attestation of their participation for 2018.

What key traits should hiring managers consider when looking to build their CE/CME team?  Given the many moving pieces of a successful CE/CME program, there are several important traits to look for before making a hiring decision.

Approach to Organization

With multiple CE/CME activities each at different stages in the planning, implementation and reconciliation cycle, an individual working in CE/CME must be highlyorganized. When reviewing resumes and particularly when conducting interviews, look for examples in which an individual has managed projects or events, organizing both circumstances and/or people for a successful outcome. Most prospective employees will say they are organized, but drill in with scenario-type questions to flesh this out further.  Consider asking a potential candidate to explain a scenario in which he/she had to develop a tool or strategy to stay organized.

Detail-Oriented

CE/CME program and activity management requires an individual who is detail-oriented. Having a team member with acute attention to detail can be the difference between compliance or non-compliance. When interviewing candidates, ask an individual to provide an example of a scenario or project that required attention to detail and why it mattered.

Communication Skills

Individuals working in CE/CME are constantly communicating with various stakeholders across the CE/CME enterprise from planners and faculty to funders (if applicable), learners and others. This requires clear written and verbal communication skills. Whether making a request of faculty with limited time or developing clear narrative for a grant proposal, an individual in CE/CME must have strong communication skills in order to effectively navigate and manage day-to-day CE/CME processes.

Flexibility & Ability to Evolve

The CE/CME enterprise is ever-evolving with the collaboration between stakeholders.  As examples, collaboration among accreditation boards, the ACCME and ABMS member boards as well as CME for Merit-Based Incentive Payment System to the Menu of New Criteria for Accreditation with Commendation, just to name a few. As CE/CME evolves, systems, processes and policies and procedures also need to evolve. This requires individuals who are adaptable to change and who proactively seek to adjust accommodate systemic change(s). When interviewing a potential candidate, ask him/her to describe a situation in which a change required him/her to respond accordingly.

Critical Thinking

Applying accreditation criteria and standards requires individuals who are adept at critical thinking. Often situations are gray and require that an individual think critically about all factors in order to make decisions that protects the integrity of the CE/CME program, based on interpretation and utilization of reference materials. Ask potential candidates to describe a time they had to make a difficult decision, how they went about making the decision and the final outcome.

There are many other skills and traits that make an individual an excellent candidate for working in CE/CME, but those listed above are a solid foundation for the next interview you conduct!

Each board varies in its approach of awarding partial credit.  In the CPE Policies and Procedures, Policy 5.0 deals directlywith awarding credit for both live and enduring activities and states, “Providers may not offer partial credit for CPE activities. Rather, providers should assign a unique Universal Activity Number (UAN) to each CPE activity for which a participant will receive full credit for successful completion or no credit for non-completion.” (Policy 5c).

A common misinterpretation of this policy is that partial credit refers to fractions of credit points (i.e. 1.5 points or 2.75) when actually, this policy refers to learners earning a portion of the activity’s full hours (i.e. a learner requesting 1.0 points for an activity worth 2.0 contact hours because he/she had to leave the event early.)

Regardless of number of contact hours, the ACPE encourages all providers to be conservative in the amount of credit they award for each CPE activity, and to monitor their own internal methods of determining hours by asking learners to document the amount of time they spend in completing the activity.