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 – March 2020 Newsletter

Welcome to the March 2020 edition of AOE Compliance Connection, AOE’s monthly newsletter. This month, AOE’s newsletter features helpful links about COVID-19, along with a continuation of our series focused on ACCME Accreditation with Commendation. You’ll also find upcoming deadlines for board-specific annual reporting. Follow us on Twitter and Facebook for weekly compliance tips and other timely updates!

Coronavirus (COVID-19) Resources

International spotlight is on the coronavirus (COVID-19) pandemic as the affected population increases around the globe. The CME community is responding: The ACCME has created a Novel Coronavirus Education Resource webpage for the purpose of gathering and sharing resources for the community of clinicians and providers engaged in responding to the coronavirus public health emergency. The ACCME is encouraging the CME community to circulate this link freely, and to stay updated via the Centers for Disease Control and Prevention website.

As of now, the ACCME 2020 Meeting is still scheduled to take place as planned in Chicago, IL, May 6-8. The ACCME has communicated that they will be taking all necessary and recommended precautions to ensure the health and safety of all attendees at the meeting. Updates to this information can be found here.


SCS Updates: Next Steps for Call for Comment

The ACCME has now closed the call for comment regarding the proposed, revised ACCME Standards for Integrity and Independence in Accredited Continuing Education. A summary of those responses will be published with the next few months.

The ACCME Board of Directors will review those responses later this month, at its March 2020 meeting, at which the Board will make modifications and ultimately adopt the new Standards.

The transition plan to the new Standards will include a transition phase as well as education and resources to support the continuing education community’s successful transition to and adoption of the revised Standards.

Until adoption of the revised Standards takes place, the current Standards for Commercial Support remain current and applicable.


New Menu for Accreditation with Commendation

Category #5 – Achieves Outcomes

This is the final installment in our New Menu of Criteria for Accreditation with Commendation series. This month we’ll be diving into Category #5: Achieves Outcomes, which includes C36, C37 and C38. The criteria in this category are all about data and, more specifically, improvements in data. All providers must demonstrate compliance with at least one criterion in the Achieves Outcomes category.

Criterion 36: The provider demonstrates improvement in the performance of learners.

Criterion 36 recognizes providers that can demonstrate the impact of their CME program on the performance of individual learners or groups. To meet compliance with Criterion 36, providers must measure performance changes of learners and demonstrate improvements in the performance of learners. The focus is on individual learners and the ACCME wants to see data regarding the number of learners participating in your accredited CME activities as well as the number of learners whose performance changed.

Per the ACCME, change in performance refers to measured changes in a learner’s or learners' behavior. For example, higher patient communication ratings, fewer coding errors, greater participation in team meetings, more appropriate prescribing, etc. Providers can set their own specific goals and targets for the performance improvement objective and also choose the most appropriate mechanism to measure performance change and how much change in learners is acceptable. The improvement data may emerge from self-reported changes, from practice-level data, or other sources. Improvements in knowledge and plans to change performance would not meet the expectation of this criterion.

The ACCME has clarified that learners whose performance has improved would be calculated based on all learner types – not just physicians. Further, providers are not expected to measure performance change for every learner. The ACCME has indicated that measures of team performance are also acceptable and simulation that includes assessment of a learner’s or learners’ actions, behaviors and skills is an appropriate way to measure performance change.

In order to achieve compliance with C36, a CME provider must demonstrate that in at least 10% of activities the majority of learners’ performance improved. For Self-Study Report submission, currently, a provider must upload the following information into a table:

  • Activity Title
  • Activity Date
  • Activity Type
  • Number of learners that participated in the activity
  • Number of learners whose performance was measured
  • Number of learners that improved their performance
  • Itemize the method(s) used to measure change in performance of learners
  • Data or information that demonstrates the improvements in the performance of learners.

Criterion 37: The provider demonstrates healthcare quality improvements.

This criterion is for providers who demonstrate that their CME program contributes to improvements in processes of care or system performance. The required elements include collaboration in process of quality improvement and improvement in healthcare quality.

Per the ACCME, healthcare quality improvement refers to improvements in clinical care processes or systems. Measures include quality measures that are validated by outside sources and/or measures that are appropriate and important to a provider’s setting. The ACCME clarified that compliance can be achieved at the activity level. Ultimately, a provider must show that it is collaborating in the process of healthcare quality improvement and demonstrate that the activity/activities resulted in healthcare quality improvement. Lastly, collaboration in the process of healthcare quality improvement is not limited to a single institution. It can occur within or in connection with a healthcare institution such as hospital or health system or more broadly across systems of care.

To meet compliance with C37, an accredited provider must demonstrate healthcare quality improvement related to the CME program at least twice during the accreditation term.

Criterion 38: The provider demonstrates the impact of the CME program on patients or their communities.

Criterion 38 is for providers who demonstrate that their CME program contributed to improvements in patient and community outcomes. This criterion requires that CME providers be intentional about collaborations. Everything that drives physician change in competence or performance increases public health.

According to the ACCME, measures of patient or community health can be self-reported by patients and/or members of the community. Providers can set their own goals and offer evidence for how achievement of goals contributed to improvement in health outcomes for individuals and/or communities served. Further, per the ACCME, patient or community health “are the health characteristics or outcomes related to individuals or to groups of individuals within a geographic location, service area, or other grouping. Health and health outcomes can include incidence and/or prevalence of disease, mortality, vaccinations, nutrition, and social determinants (for example, healthy behaviors, safe environment).”

Similar to Criterion 37, in order to meet compliance, a CME provider must demonstrate improvement in patient or community health in areas related to the CME program at least twice during the accreditation term.

As highlighted in prior articles from this series, the ACCME has a number of resources available on their website including FAQs and Examples of Compliance.

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


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.


The ACCME has recently made improvements to the learner batch upload process in PARS. It is important to note that you will not need to make any changes to the batch upload file formatting. Recent ACCME reporting enhancements include the following:

  1. PARS will process batch upload files even if there are errors in the learner data. Previously, the system would reject an entire file upon submission, now the file will be processed, and a notification will let you know what records need corrected.
  2. You will now be able to submit 2,500 learner records instead of 1,000 at a single time.
  3. PARS now has the ability to detect duplicates.
  4. Error reports will now be available for download to help streamline reporting.
  5. PARS batch uploads can now be processed offline, an email notification will be sent once the file has been processed.
  6. A new upload history page will now show the previous 30 days of learner data submission uploads in PARS.

The ACCME has updated their website with these new enhancements, as well as, created a tutorial to help guide you through the new PARS upload process. For additional questions regarding these new updates please email the ACCME at

Annual Reporting Reminder:

The ACCME's deadline for 2019 year-end reporting has been extended.  The deadline is now April 30th, 2020. As in previous years, data gathered between January 1, 2019 and December 31, 2019  should be entered into the ACCME's Program and Activity Reporting System (PARS). State-accredited providers should check with their specific accreditor for reporting requirements and deadlines.


In the past, the ANCC has awarded Accreditation with Distinction status to accredited providers based on a subjective review of materials submitted rather than providing specific criteria. To restructure this process, the ANCC has released the new criteria that must be met in order to receive Accreditation with Distinction as of January 1, 2020. Organizations will now be required to “demonstrate evidence of exemplary and/or innovative practice” in each of three categories. The options in each category are as follows:

  • Structural Capacity (at least one criterion must be met)
    • Evidence demonstrates how a process improvement implemented by the Provider Unit  resulted in meeting learner(s) needs and the outcome that was achieved.
    • Evidence demonstrates a process description and example that the Provider Unit has implemented a formal succession plan, or a mentorship model that promotes professional development and growth for Nurse Planners.
    • Evidence demonstrates a process description and example that the Provider Unit has engaged members from other professions, students, patients, and/or families in planning, implementing, and evaluating CNE activities (e.g. interprofessional continuing education).
  • Educational Design Process (at least two criteria must be met)
    • Evidence demonstrates a process description and example that the Provider Unit uses quality improvement strategies to identify professional practice gaps or opportunities for improvement (root cause analysis, Six Sigma, or similar) and/or consistently uses a multi-modal approach to identify and validate professional practice gaps or opportunities for improvement (focus groups of potential learners, collaboration with stakeholders, or similar).
    • Evidence demonstrates a process description and example that the Provider Unit incorporates competencies into educational activities (QSEN, IOM, IPCE, or similar) and/or integrates selected competencies within content to achieve desired outcomes.
    • Evidence demonstrates a process description and example that the Provider Unit develops CNE activities that actively engage learners within the learning environment (problem-based learning, simulation, education that is learner-centric, CE credit without time as a metric).
    • Evidence demonstrates a process description and example that the Provider Unit used summative evaluation data to develop a future CNE activity and the change was reevaluated for effectiveness.
    • Evidence demonstrates a process description and example that the Provider Unit measured, on different occasions, change in knowledge, skills, and/or practice longitudinally (minimum 90 days); evaluated team performance; and/or evaluated impact on practice and/or patient outcomes.
  • Quality Outcomes (all three criteria must be met)
    • Evidence demonstrates a process description and example that the Provider Unit utilizes innovative and creative approaches (continuous professional development of CNE team members, use of technology, interprofessional collaboration, or similar) to evaluate its effectiveness. Revised January 3, 2020
    • Evidence demonstrates a process description and example that the Provider Unit’s evaluation process resulted in a quality outcome measure that exhibits improvement in healthcare quality, patient, or community outcomes. (If outcomes were not met, identify barriers and challenges to attainment)
    • Evidence demonstrates a process description and example that the Provider Unit has positively impacted the professional practice of nursing and has disseminated the knowledge forward (publication, poster/podium presentation, research).

The Accreditation with Distinction documentation must be submitted as a separate PDF in PAORS at the same time as Self-Study submission, and a template has been provided by the ANCC for this purpose.

Annual Reporting Reminder:

All ANCC Accredited Providers must complete annual reporting by April 1, 2020. The required annual report is to be submitted to the Nursing Activity Reporting System (NARS) and must include activity data from January 1, 2019 through December 31, 2019. Click here for more information.


In January, at the Alliance 2020 Annual Conference, the ACPE hosted an update session to share information and updates across multiple topics.  In last month’s newsletter, we shared two of those updates: 1) A new topic designator (08 for Pain Management/Opioids, and 2) A disclaimer statement update for paper statements of participation. This month, we’d like to share an additional update that pertains to ACPE Continuing Professional Development (CPD) Design.

The ACPE has placed a new emphasis on alignment with learner CPD for providers of continuing education. They have long defined CPD as a “self-directed, ongoing, systematic and outcomes-focused approach to lifelong learning that is applied into practice” that involves the process of active participation in both formal and informal learning. Their model emphasizes the need for bridging the classroom to the workspace, and the ACPE has developed a platform for this purpose that:

  • Allows for learner reflection on education needs, the development of individual goals and plan, and the documentation of this learning and practice impact
  • Takes into account accredited CE as well as any other formal or informal CPD activities the learner undertakes
  • Creates a record of self-directed lifelong learning that can be easily shared with accreditors, employers, etc.

In order to facilitate this, the CPD Platform (called “My CPD”) can be accessed by learners via the CPE Monitor Plus mobile app or web browser. Users can easily view a menu of CPD activities and documentation, as well as browse menu options that include new/open/closed cycles, individual progress, FAQs, and how to contact the ACPE with further questions.

Upcoming Activities/Education Opportunities

  • ANCC Nursing Continuing Professional Development (NCPD) Summit CANCELLED
    March 18, 2020, Nashville, TN
  • MOC Webinar: Planning and Evaluation in Support of CME
    March 24, 2020, Online
  • Getting Started with Joint Accreditation Workshop CANCELLED
    April 2, 2020, Chicago, IL
  • 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

We’d like to create an expedited CME activity related to COVID-19.  What is our next step?  

The ACCME has created a “Planning Form for…

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