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 – November 2019 Newsletter

Welcome to the November ‘19 edition of AOE Compliance Connection, AOE’s monthly newsletter. This month, we continue our series focused on ACCME Accreditation with Commendation with a focus on Category #2: Addresses Public Health Priorities. Also, in this month’s newsletter, we share a brand new report from the ACCME about patient collaboration, along with updates from the three major accreditation boards, ACCME, ACPE and ANCC. Follow us on Twitter and Facebook for our weekly compliance tip and other timely updates!


New Menu for Accreditation with Commendation: Category #2– Addresses Public Health Priorities

Continuing with our New Menu of Criteria for Accreditation with Commendation series, this month we take a look at Category #2: Addresses Public Health Priorities which includes C26, C27 and C28. This category puts focus on those CME providers that have the opportunity to use their CME programs to leverage improvements in public health.

Criterion 26: The provider advances the use of health and practice data for healthcare improvement.

This criterion is all about data use. Examples may include provider use of electronic medical record data or registry data and/or use of public health records and prescribing datasets to help a physician understand and improve their practices. The ACCME notes that, “The collection, analysis, and synthesis of health and practice data/information derived from the care of patients can contribute to patient safety, practice improvement, and quality improvement.”

Per the FAQs outlined on the ACCME webpage, CME providers do not need to teach learners how to conduct an analysis or synthesis of data. However, they do need to show that CME activities include teaching about the collection and/or analysis and/or synthesis of health and practice data. Further, the ACCME clarifies that use of clinical registry data in CME is compliant if the data is used to teach about healthcare improvement. Lastly, CME providers should follow institutional policies and practices regarding protection of confidential and identifiable information when including health or practice data in CME activities.

In order to achieve compliance with C26, a CME provider must provide evidence of specific examples based on its program size (Small: 2; Medium: 4; Large: 6; Extra-Large: 8).

Criterion 27: The provider addresses factors beyond clinical care that affect the health of populations.

The ACCME refers to this as “implementation science,” and compliance with this criterion involves reaching past the immediate audience and their practices. A CME provider must demonstrate a desire and ability to change the public health environment and the health of populations. This criterion is focused on barriers to optimum health, that fall outside the realm of clinical medicine. Examples include economic, social and environmental conditions, healthcare systems and access to care. In addressing this criterion, it is helpful to clearly identify the population, pinpoint the barriers that exist and formulate strategies to address such barriers.

The ACCME doesn’t require use of a specific definition of public or population health but refers to “fulfilling society’s interest in assuring conditions in which people can be healthy” (Committee for the Study of the Future of Public Health, 1988, p.19) [Institute of Medicine (1988). The ACCME FAQs clarify that teaching learners how to educate the public/community would count towards meeting this criterion.

The Standard for C27 indicates that a provider must attest to meeting the criterion in at least 10% of activities (but no less than two) during the accreditation term and provide evidence of specific examples based on program size (Small: 2; Medium: 4; Large: 6; Extra-Large: 8).

Criterion 28: The provider collaborates with other organizations to more effectively address population health issues.

This criterion is all about meaningful collaboration. “Organizations” refers to external organizations, not various departments in the same hospital, health care system, etc. Examples include working with the local public health department, a medical records company, or a public advocacy group. Collaboration is a main focus and undertone of the new commendation criteria as a whole, and for C28 it’s important to articulate the “why” behind the collaboration. Additionally, it’s important that a CME provider is clear about how the collaboration affects population health and ties to the CME provider’s mission.

Per the ACCME FAQs, a CME provider must demonstrate how collaborations augment its ability to address population health issues but does not have to demonstrate these approaches with examples of specific CME activities.

In order to achieve compliance with C28, a CME provider must “Demonstrate the presence of collaborations that are aimed at improving population health” with four examples from the accreditation term.

If you are interested in training and/or strategic planning as related to the New Menu of Criteria for Accreditation with Commendation, please contact AOE Consulting at


ACCME Releases Patient Engagement Report

Late last month, the ACCME released a report designed to provide strategies for educators on engaging patients as partners in both the planning and teaching components of CME. In the report, titled Learning Together: Engaging Patients as Partners in Accredited Continuing Medical Education, the ACCME argues that patients, through their participation, “increase the meaning, relevance, and effectiveness of CME and contribute to improving care for patients and communities”.

At the 2019 ACCME Annual Meeting, a track dubbed “Learning Together” featured strategies for patient collaborations and strategies for patient-centered research design. The feedback and perspective of the patient-partners who participated in this Learning Track together is featured in the ACCME’s latest report.

The concept of patient collaboration isn’t a new one for the ACCME; an entire criterion in the Menu of Criteria for Accreditation with Commendation focuses on recognizing organizations that incorporate patients as planners and faculty in CME planning. The full report can be viewed here.


Accreditation Board Bulletin

Part of the service that AOE provides to readers are weekly compliance tips and monthly CME/CE community news for ACCME, ANCC and ACPE.


You asked and the ACCME listened! The Program and Activity Reporting System (PARS) has been updated with three new optional contact information fields. Keep in mind that the only required field is still the primary contact.

Previously, PARS had four contact fields that could be utilized: Primary Contact (required), Billing Contact (optional), CEO Contact (optional) and Staff Contact (optional). Now with the new additions, providers have more options to direct the ACCME to the correct contact person depending on the topic.

The new optional contact types are as follows:

  1. ACCME Website Contact: This individual addresses inquiries and triages questions from external users and learners. This individual will be published as your organizations contact in the Find a CME Provider section of the ACCME website. If a person is not designated, then the primary contact is the default.
  2. Technical Contact: This individual is responsible for information systems and technical updates related to your work in PARS.
  3. Medical Director: This individual serves in a medical leadership role and oversees strategic operations at your organization. This person may be contacted by the ACCME to discuss strategic initiatives related to CME and healthcare leadership.

As previously mentioned, the three new fields are optional; the only required contact field has not changed from the Primary Contact. Reach out to the ACCME at for more information or utilize the PARS Resources page for additional information regarding PARS.


Within any ANCC Primary Accreditation Provider Unit, the Lead Nurse Planner (LNP) is the director for all chain of communication, whether between the ANCC and the Provider Unit, or between the Provider Unit itself and the LNP and additional nurse planners. Any correspondence or information sharing from the ANCC is directed to the Accredited Provider Unit’s LNP, who is subsequently responsible for communicating and ensuring that ANCC expectations are abided by within their Provider Unit. This oftentimes means that the LNP appoints nurse planners to operate under their leadership to ensure compliance and efficiency. Any additional nurse planners report directly to the LNP who oversees each component of the Provider Unit.

Communication is a necessary component beyond that of just the Provider Unit. The ultimate goal of the Provider Unit is to achieve quality outcomes valuable to other stakeholders in the nursing continuing professional development process, as well as their learners and organizational leaders. From the ANCC’s Lead Nurse Planner: Roles and Responsibilities, the ANCC has provided a model to represent the communication pathways to achieve this goal:


In its most recent provider e-Update, the ACPE released a new topic designator along with guidance to providers on the topic of planning and conducting pharmacy technician CE.

  1. New Topic Designator: Effective January 1, 2020, ACPE-accredited providers will be able to assign a new topic designator (08) for pain management/opioid CE activities. This will include all activities that address components regarding the management and treatment of pain, including the prescribing, distribution and use of opioid medications. This also includes activities that cover the risks, symptoms, and treatment of opioid misuse/addiction.
  2. Guidance to Plan/Conduct CE for Pharmacy Technicians:

The newly revised ASHP/ACPE Accreditation Standards for Pharmacy Technician Education and Training Programs emphasizes these recent updates to the Standards: Both Advanced-level and Entry-level pharmacy technician education has replaced the outdated concept of “one level fits all” education. In this same vein, all students need to complete an Entry-level program in order to move on to the Advanced-level options. Alternatively, there is a program that guides students through both levels as a continuous program.

More quarterly updates from the ACPE can be found by viewing their provider e-Updates here.

Upcoming Activities/Education Opportunities

  • Advanced CME for MOC: Ask Your Questions Webinar
    November 19, 2019, Online
  • CPE Accreditation Commission Meeting
    November 19-21, 2019, Chicago, IL
  • 2019 MAACME 9th Annual Conference
    November 20-21, 2019, Harrisburg, PA
  • Alliance 2020 Annual Conference (ACEHP)
    January 8-11, 2020, San Francisco, CA
  • ANCC Annual Symposium on CNE
    April 24, 2020, Orlando, FL
  • ACCME 2020 Meeting: Driving Change: Map Your Route to Educational Leadership
    May 6-8, 2020, Chicago, IL
  • ANCC Pathway to Excellence Conference
    May 13-15, 2020, West Palm Beach, FL


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.

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Weekly Compliance Tip

Does demonstrating compliance with C28 have to take place at the activity level?  

The ACCME does not expect providers to demonstrate compliance with C28 at the activity level.  The provider must sufficiently demonstrate how collaborations improve its ability to speak to population health issues, however.

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