AOE Compliance Connection

AOE’s monthly newsletter that offers accreditation board bulletins for the ACCME, ACPE, and ANCC, along with updates on the Physician Payments Sunshine Act, highlights of AOE services, and information on upcoming activities and educational opportunities.

AOE Compliance Connection – December 2017 Newsletter

Welcome to the December edition of AOE Compliance Connection, AOE’s monthly newsletter!  We are prepared to help you and your team end 2017 well!  In this month’s newsletter edition, we feature best practices for closing out the end of the year, including review your existing structures, processes and procedures.  Also included in this edition of Compliance Connection are board updates from the ACCME, ACPE and ANCC and a peek at international CME.

Visit for additional information, weekly compliance tips, guideline updates and more.  We hope you enjoy this month’s edition of AOE Compliance Connection, and Happy Holidays from all of us at AOE!


Accreditation Board Bulletin


Recently, the ACCME released new accreditation material for the November 2018 and March 2019 cohorts.  The newly released documentation includes references for both initial accreditation applicants as well as reaccreditation applicants.

Initial Accreditation Material:

  • Outline for the Self-Study Report for ACCME Initial Applicants
  • ACCME Performance-in-Practice Structured Abstract for Initial Applicants
  • Guide to the Process for ACCME Initial Accreditation

Reaccreditation Material:

  • Outline for the Self-Study Report for ACCME Reaccreditation
  • ACCME Performance-in-Practice Structured Abstract for Reaccreditation
  • Guide to the Process for ACCME Reaccreditation

To simplify and streamline the initial accreditation and reaccreditation submission process, the ACCME has moved to a fully online system.  ACCME’s Program and Activity Reporting System (PARS) will be used to complete the Self-Study Report Form and to submit Performance-in-Practice evidence for the selected CME activities as well as schedule your reaccreditation interview.  As necessary, you may be asked to upload supporting documentation that helps show your compliance with the ACCME requirements.  Uploaded documents cannot exceed 3 MB per document.

View the newly released accreditation and reaccreditation documentation outlined above here.  Please also be sure to review the ACCME Reaccreditation Timelines and Provider Milestones for the November 2018 and March 2019 cohorts.


The ACPE outlines helpful information in each of their Standards.  Standard 4 deals specifically with CPE Activity Objectives and is useful for providers wanting direction on designing and writing activity objectives.

Standard 4 specifies that: “The provider must develop objectives for each CPE activity that define what the pharmacists and technicians should be able to do at the completion of each CPE activity.”

As providers register activities in the Provider Web Tool (PWT), there is designated room to enter objectives separately for pharmacists and technicians (providers don’t necessarily need to have the same objectives for both types of learners).

The ACPE offers some guidance on objectives, including:

  • Objectives must be both specific and measurable -
  • Objectives must be developed to specifically address the identified educational need (Standard 2)
  • Objectives must be addressed by an active learning activity (Standard 7) and
  • Objectives must be covered by a learning assessment (Standard 9

For more information about the Standards for CPE Objectives and other ACPE Standards, please visit this page.


As ANCC accredited providers prepare for the upcoming accreditation due dates, March 1, 2018 and July 1, 2018, it is beneficial to look more in depth at each criterion.  This month, let’s emphasize: Structural Capacity 2 (SC2).

The main focus of SC2 is accountability of the Lead Nurse Planner (LNP).  As the leader of the production and implementation of the organization’s CNE program, it is the LNP’s responsibility to ensure all Nurse Planners (NP) are aptly oriented and trained to implement and adhere to the ANCC accreditation criteria and standards.  How might LNPs ensure these standards and supply evidence for the Self-Study Report?

Evidence NPs…

Are Oriented/Trained in ANCC Accreditation Criteria:

Orientation and training strategies may include:

  • Workshops
  • Self-learning packets
  • Webinars
  • Monthly calls and/or mentoring
  • Coaching/Guidance

Implement and Adhere to ANCC Accreditation Criteria:

Evaluation of implementation and adherence may include:

  • Monitoring of an NP by a more experienced NP
  • Quality assurance auditing of the documentation and activity planning
  • When planning activities, utilizing the peer review process to discuss the application of accreditation criteria
  • Case studies and small group activities may provide opportunities for assessing adherence
  • Conducting annual competency evaluations

It is crucial that NPs have access to ANCC accreditation resources, but it is not sufficient for the LNP to only provide access to resources.  To ensure compliance the LNP must make certain that NPs understand how to use the resources and that they apply the principles of a high quality educational design with adherence to ANCC accreditation criteria and standards.


CME in the News: International CME

There have been some recent changes in the way that three international associations handle their codes of conduct regarding CME (and other professional development activities).  MedTech Europe, the Advanced Medical Technology Association (AdvaMed), and the Asia Pacific Medical Technology Association (APACMed) plan to introduce in 2018 revised codes that prohibit device manufacturers from making direct payments to clinicians to enable their attendance at professional development activities.  The device manufacturing industry may still support CME through grants given either to health systems/employers or directly to accredited CME providers.

The ACCME stands in support of these recent changes, as they represent closer alignment with industry standards here in the United States.  In response to this announcement, the ACCME has released some direction for CME providers:

As always, organizations that are accredited in the ACCME system may accept financial support for their educational activities from commercial entities (I.e., device manufacturers) under the revised codes and maintain independence from industry by following ACCME's Standard 3: Appropriate Use of Commercial Support.

Standard 3 can be satisfied by an accredited organization following the below criteria when accepting funding from commercial interests:

  • Make all decisions regarding the use of the support, independent of any company or companies;
  • Have a signed written agreement with the company that includes the specific terms and conditions of the support;
  • Use the funds only for the educational activity and to offset the cost of participation to the learners as a whole;
  • Not pay for travel, lodging, honoraria, or personal expenses for any non-teacher or non-author participants of the supported educational activity; and
  • Disclose to all learners the source (and if in-kind, the nature) of the commercial support.

If an international learner receives funding from his or her hospital or other commercial entity not affiliated with the ACCME-accredited organization to participate in the education, the accredited organization is not prohibited from accepting that learner's registration and participation in the education.

The revised codes and existing ACCME requirements can be aligned by ensuring that funds received from companies by organizations accredited in the ACCME system are not used to pay for any travel, lodging, honoraria, or personal expenses for any non-teacher or non-author participants.

To read more from the ACCME-released press release on this topic, click here.


Planning for 2018: Setting Up Your CME Program for Success

Last month we shared some best practices for closing out the end of the year which focused heavily on review of existing structures, processes and procedures.

This month we’d like to share some best practices for looking ahead towards 2018 to ensure your CME program is set-up for success before leaving for the holiday break.

CME Office Plan

If you haven’t already, take time to map out activities for the upcoming year. Having a master calendar and plan will help frame planning and keep your CME program on track. Here are a few things to consider:

  • Volume and Types of Activities: How many large conferences will you do? How many RSS activities versus enduring activities, etc. are you planning?
  • Commercial Support: Will you be soliciting any commercial support? By what date do you need to submit grant requests for each program?
  • Direct versus Joint Providership: How many of your activities will be directly provided versus jointly provided? Are there any tweaks that you need to make to your relationship with existing joint providers?

Disclosure Collection Plan

If you are collecting an annual disclosure form, have you already sent a form completion request to anyone in a position to control the content of CME activities? If not, do you plan to send the request before the holidays or will you send it at the beginning of January? Ensure that you have a plan in place to avoid any last-minute chaos when January rolls around.

Activity File Set-Up

Set-up new 2018 activity files now so that your CME program is already organized moving into 2018. As shared in our April 2017 newsletter article, “Practical Management of Your CME/CE Program,” we recommend utilizing a standard activity file structure to keep files organized for an audit or any unexpected transitions. We also suggested use of a disclosure grid to keep track of reported disclosures, determination of relevance, and resolution of conflicts-of-interest. Setting up each activity’s disclosure grid now helps provide an organized foundation for starting 2018.

These are just a few best practices that can get lost in the end-of-year shuffle. However, a couple hours of planning now can save time and energy a month from now.

Upcoming Activities/Education Opportunities

  • Self-Study for ACCME Accreditation Webinar
    December 8, 2017, Online
  • Alliance 2018 Annual Conference
    January 20-23, 2018, Orlando, FL
  • PTAP Introductory Workshop
    January 25, 2018, Silver Spring, MD
  • ANCC Primary Accreditation New Applicant Workshop
    April 3, 2018, Silver Spring, MD
  • ACCME 2018 Meeting: Building an Educational Home Together
    April 17-19, 2018, Chicago, IL


CME Watch

AOE’s video blog that provides updates on the CME/CE industry. AOE’s Managing Director Annika Gill gives insights on CME/CE current events and best practices.

More >


Weekly Compliance Tip

If a potential faculty presenter was previously employed by an ACCME-defined commercial interest, are they ineligible from participating in our activity?

Not necessarily.  The financial relationships…

More >


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