Welcome to the November edition of AOE Compliance Connection, AOE’s monthly newsletter! As the end of the year quickly approaches, we are prepared to help you and your team end the year well! In this month’s newsletter, we feature end-of-year tips and best practices, along with board updates from the ACCME, ACPE and ANCC. We are passionate about helping you achieve compliance and success in all your CME/CE endeavors.
Visit www.aoeconsulting.com for additional information, weekly compliance tips, guideline updates and more! We hope you enjoy this month’s edition of AOE Compliance Connection!
Accreditation Board Bulletin
ACCME
To be compliant with ACCME criteria and standards, a provider must be able to show that everyone in a position to control the content of a CME activity has disclosed all relevant financial relationships with any commercial interest to the provider. Did you know that disclosure about relevant financial relationships can be collected verbally? Per ACCME policy, when disclosure is collected verbally, providers need to provide the ACCME with documentation that verbal disclosure did occur. As such, a representative of the provider who was present at the time of verbal disclosure must attest, in writing:
- That the verbal disclosure did occur.
- Itemize the content of the disclosed information to include: the name of the individual, the name of the commercial interest(s), the nature of the relationship with each commercial interest; or that there was nothing to disclose.
While verbal disclosure collection is not as common as the use of a traditional disclosure form, providers may choose the best mechanism to meet the needs of their organization, provided they are demonstrating compliance to the ACCME. To review provider examples of compliance and noncompliance with verbal disclosure, click here.
ACPE
The ACCME’s definition of “joint providership” is referred to frequently in CME discussions, and is commonly known.
But what does the ACPE say about joint providership? Does it have different requirements for this type of activity?
According to the ACPE Policies and Procedures Manual, it’s all about collaboration: “ACPE accredited providers that collaborate on content development with ACPE and/or non-ACPE accredited providers are engaging in joint providership.”
ACPE expects all jointly provided CPE activities to comply with the Accreditation Standards for Continuing Pharmacy Education. As a reminder: The responsibility of demonstrating this compliance falls on the provider, and must be demonstrated through written documentation.
Here are a few more specific guidelines about ACPE Joint Providership:
- The accredited provider is required to collaborate with the joint provider(s) in all stages of development of the activity: planning, development, promotion, delivery, evaluation and revision.
- Agreements should be developed regarding the joint providership that very clearly define the functional relationships between groups, including deadlines and recourses in case one or more groups don’t meet their expected requirements.
- These agreements should clearly document the ACPE-accredited provider’s responsibility to comply with ACPE standards. (The ACPE notes: “Non ACPE-accredited organizations cannot assume responsibility for compliance with ACPE standards; therefore, this responsibility must be explicit in the agreement.”)
- As with the ACCME, commercial interests cannot be joint providers.
For more information about joint providership according to the ACPE, please see page 18 of their Policies and Procedure Manual located here.
ANCC
As with any organization, ANCC accredited providers may experience changes within their program. Although many adjustments may not be significant, there are certain times when accredited providers must notify the ANCC of these updates.
Within seven business days, the ANCC must be notified of the occurrence or discovery of any of the following:
- Changes/events that make the organization ineligible for accreditation or reaccreditation; or prevent the organization from meeting the Accreditation Program requirements
- There is a change in the commercial interest status of the organization
Within thirty days, the Lead Nurse Planner (or designee) must notify the Accreditation Program office of any change within the organization that affects accreditation, or the information submitted in the accreditation application materials. This includes but is not limited to the following:
- The organization has changes to information submitted in the application, such as change of address, name, or ownership
- The organization rescinds, or does not wish to submit the self-study documentation following the application
- The organization has a role change with the Lead Nurse Planner and/or Nurse Planner(s)
- The Lead Nurse Planner and/or Nurse Planner(s) nursing license becomes suspended, lapsed, revoked, or terminated
When an organization finds that there has been a significant change or event warranting notification, the notice may be sent via email, certified mail, or common carrier. The method selected must allow for a confirmation from the ANCC (e.g. email receipt or signature confirmation).
ANCC Contact Information:
American Nurses Credentialing Center
ATTN: Accreditation Program Office
8515 Georgia Ave., Suite 400
Silver Spring, MD 20910
Accreditation@ana.org
CME in the News: PARS Updates
All eyes are on the ACCME right now, as registration for their 2018 annual meeting just opened (details here) and they released significant updates to PARS, their Program and Activity Reporting System, that will affect all ACCME-accredited providers.
ACCME-accredited providers were sent an email the last week of October that describe how the changes affect you and your organization. (If you did not receive an email, reach out to the ACCME directly by emailing info@accme.org).
The changes include:
- A password reset: Providers will need to reset their passwords by clicking on the “Can’t login or forgot your password” option. There may be a short delay the first time you log in with new credentials.
- A streamlined login process: Entering organizational IDs will not be required for login, and users who function as a contact for multiple providers will be able to access them through a single login.
- Unchanged functionality: The processes to edit information, enter and upload files and data, or register activities for MOC or REMS has not been changed. No data or information will need to be re-uploaded.
- Accreditation process updates: For ACCME-accredited providers, the accreditation process will now take place online, instead of via email or hard copies. Providers can view their accreditation history and reaccreditation instructions online. (For state-accredited providers, the process has not been changed at all.)
- Joint accreditation: The PARS changes now include an option to report activities through one system, Joint Accreditation PARS (JA-PARS). This can be used to report information about all activities (beginning with the 2018 reporting year).
The ACCME has made multiple resources available about these updates, depending on what various providers may need:
CME End-of-Year Preparation
While it’s easy to let the end-of-year slide by and postpone thinking about the new year until it has arrived, a few simple steps can set your CME program up for a smooth, successful transition into 2018. Below are a few best practices for closing out the year.
Mission Statement Review: The end of the year is an excellent time to conduct a quick review of your CME program mission statement to ensure it is up-to-date and accurate. It’s also important to evaluate whether your CME program mission statement has been met within the last year.
CME/Education Committee Structure Review: If your CME program relies on the support of a CME or Education Committee, the end of the year is a great time to evaluate whether the current structure and processes are working. Are responsibilities clearly defined? Are your members engaged? Is the frequency of meetings appropriate?
Review of Key CME Policies and Procedures: It is important to conduct a full audit of your CME policies and procedures on an annual basis. While the end of the year may not be the optimal time to conduct the full review, it can be a great time to take a look at a few key policies and procedures. Do a quick audit to ensure key policies are up-to-date with accreditation board criteria and that they’re being implemented consistently and effectively.
Initial Review of Annual Report Data: While you may have a few more activities before the end of the year officially closes, November and December are a great time to do an initial audit of your 2017 data in preparation for annual reporting.
Start, Stop, Continue: One final tip is to gather your CME team and do a quick “start, stop, continue” exercise. Start: Consider some simple process changes your team wants to start doing in 2018. Maybe you want to start a weekly touch-base to discuss upcoming activities. Stop: What do you really need to stop doing? Is manual data entry slowing down your program? What inefficiencies is your program facing? Continue: What should your program continue doing? What is working well?
These are just a few year-end best practices. We hope that you and your CME program have a wonderful end-of-year!
- “CME for MOC: Ask Your Questions” Webinar
November 15, 2017, Online
Read More >> - ANCC PTAP Introductory Workshop
November 16-17, Silver Spring, MD
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 >> - Self-Study for ACCME Accreditation Webinar
December 8, 2017, Online
Read More >> - Alliance 2018 Annual Conference
January 20-23, 2018, Orlando, FL
Read More >>
