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 – January 2019 Newsletter

Welcome to the January 2020 edition of AOE Compliance Connection, AOE’s monthly newsletter. We hope this new decade ushers in a season of productivity and creativity for you and your organization! In this month’s newsletter, we continue our series focused on ACCME Accreditation with Commendation with a focus on Category #3: Enhances Skills. We’ll also share timelines and board-specific Annual Reporting. For weekly compliance tips and other timely updates, follow us on Twitter and Facebook!


New Menu for Accreditation with Commendation: Category #3– Enhances Skills

Continuing in our New Menu of Criteria for Accreditation with Commendation series, this month we’ll be diving in on Category #3: Enhances Skills, which includes C29, C30, C31 and C32. This category is focused on supplementary education and tools to support learners.

Criterion 29: The provider designs CME to optimize communication skills of learners.

This criterion is focused on teaching and improving communication skills. Examples include: communication with patients and presentation, leadership and teaching skills. Communication skills may include verbal, nonverbal, listening and writing skills. This criterion ultimately seeks to recognize accredited providers that help learners become more self-aware of their communication skills and offer specific CME activities to improve those skills. In order to demonstrate compliance with C29, the provider must develop accredited CME initiatives that provide evaluation of observed skills and formative feedback to all learners regarding their communication skills. Observation can be done in many ways through videos, surrogates, direct observation and writing reports, among other methods.

The ACCME clarifies that there is not a prescribed method of feedback – it can be provided in person or virtually, in writing or orally and can be provided to an individual or to a group such as in a team simulation. Lastly, self-reported or self-assessed observed behavior alone is not enough to meet the requirements for C29.  

Per the Standard, in order to achieve compliance with C29, a CME provider must provide evidence of specific examples based on its program size (Small: 2; Medium: 4; Large: 6; Extra-Large: 8).

Criterion 30: The provider designs CME to optimize technical and procedural skills of learners.

Criterion 30 mirrors Criterion 29, however, instead of focusing on communication skills, C30 is about teaching technical skills. Examples include teaching operative skills, device use, resuscitation, instruction regarding procedures, etc. This criterion recognizes providers that offer CME to help learners gain, retain or improve technical and/or procedural skills. Similar to C29, the accredited provider must provide CME aimed at addressing technical and/or procedural skills that is inclusive both of an evaluation of observed skills and that provides formative feedback to all learners. Ultimately, C30 is looking specifically at a CME provider’s ability to build skill development programs. As with C29, the ACCME allows for a lot of margin as to what observation may entail.  

This criterion also encompasses non-clinical skills if the skill “is an observable psychomotor skill that requires expertise and practice.” Breakout sessions in which not every learner participates would not meet compliance with C30 as the Critical Elements require that every learner in an activity is expected to have been observed and given feedback.

As with C29, to achieve compliance with C30 a CME provider must provide evidence of specific examples based on its program size (Small: 2; Medium: 4; Large: 6; Extra-Large: 8).

Criterion 31: The provider creates individualized learning plans for learners.

The Rationale for C31 indicates, “This criterion recognizes providers that develop individualized educational planning for the learner; customize an existing curriculum for the learner, track learners through a curriculum; or work with learners to create a self-directed learning plan where the learners assess their own gaps and select content to address those gaps. The personalized education needs to be designed to close the individual’s professional practice gaps over time.” The ACCME calls these “longitudinal learning plans.” The accredited provider must track learners repeated engagement with a longitudinal learning plan over weeks or months and provide individualized feedback to the learner in order to bridge practice gaps. Individualized plans allow learners to remediate or accelerate learning. 

A tracking system related to credit or MOC requirements would not meet the intent of this criterion. The spirit of C31 is for the provider to develop – with the learner – a learning plan with individualized feedback that will help the learner address his/her own personal practice gaps.

The Standard for C31 indicates that a provider must submit evidence of repeated engagement and feedback for a minimum number of learners based on its program size (Small: 25; Medium: 75; Large: 125; Extra-Large: 200). 

Criterion 32: The provider utilizes support strategies to enhance change as an adjunct to its CME.

This criterion is for providers that create and make available supplemental services such as reminders, resources like online apps, etc. that reinforce or sustain change. A key requirement of this criterion is to conduct periodic analysis to see if such services are effective and to adjust and evolve them as necessary. 

The ACCME doesn’t outline how often the analysis of support strategies needs to be conducted. The expectation is that the analysis occurs at least once per accreditation term for each strategy employed. Further, the expectation is to demonstrate how the support strategy evolved based on the analysis conducted. 

The Standard for C32 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).

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 


Proposed Revisions to ACCME Standards and Definitions

On January 7, 2020, the ACCME announced proposed updates, clarifications, and revisions to its Standards, definitions, and policies regarding how accredited organizations operate. The stated purposes for these proposed changes were to “streamline, clarify, and modernize the Standards” and to ensure independence of accredited medical education from commercial influence.

Many of the proposed changes attempt to clarify definitions and set forth new terms, such as:

  • The term “continuing medical education” would be replaced by the term “accredited continuing education (ACE).”
  • Instead of requiring accredited providers to “resolve” relevant conflicts of interest among those planning/controlling ACE content, the new Standards would require providers to “mitigate” the potential effect of financial relationships on ACE.
  • New terms of “eligible entities” (organizations eligible for accreditation) and “ineligible entities” (those not eligible for accreditation) are set forth in an attempt to demonstrate the separation of commercial interests from organizations developing accredited continuing education.

Some of the proposed changes that seem to prioritize separating ACE content from non-ACE messages are:

  • Require accredited providers to manage “ancillary marketing” that occurs around ACE. 
  • Make explicit that nonaccredited education, even if not promotional, cannot be interleafed within accredited education. 
  • Require accredited providers to obtain consent from learners before they can share learner contact information with any “ineligible entities.”

The ACCME will accept comments about the proposed changes via an electronic survey until February 21, 2020. The ACCME Board will address the proposed changes and potentially ratify them at its March 2020 meeting. All approved changes will be made over a transition period that will allow accredited providers and other stakeholders to adjust/alter practices.

To access AOE’s complete synopsis, please click here.  As well, you can download a complete copy of the ACCME’s proposed changes 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.


The ACCME's deadline for 2019 year-end reporting is March 31, 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.

These four steps may assist with your year-end reporting:

  1. Enter/Update Contact Information - Providers should confirm/update organizational primary contact information. New this year is the ability to add more specific contact information, if applicable.
  2. Upload Data - Providers must enter required activity data either manually or via batch upload into PARS. There are two ways to batch upload your data into PARS, tab-delimited or XML. Regardless of the method your organization uses, you will need to ensure all activities are "closed" before submitting the final report.
  3. Program Summary Data - Providers must manually complete the financial data on the Program Summary tab in PARS with the required information. Note, for any fields that do not apply to your organization you must enter a "0" in the blank fields.
  4. Attest - After all activity data has been entered, providers must complete the attestation confirming that their data is ready to be reviewed by the ACCME. Note, after the provider has attested, they will not be able to edit their activity data or program summary.

As a reminder, the ACCME sent annual fee invoices via e-mail in December 2019. This is the first year for the new tiered fee structure so be sure to check your invoice for the correct amount for your organization. The deadline to complete payment is January 31, 2020.


All ANCC Accredited Providers are required to submit an annual report to the ANCC and now is the best time to begin this process!  The submission should include activity data from January 1, 2019 through December 31, 2019 with a deadline of April 1, 2020.

Submission of the annual report is conducted entirely via the Nursing Activity Reporting System (NARS).  The ANCC provides a number of resources, tips and FAQs available to help organizations prepare for this milestone.

For reporting, there are several required components for each accredited activity provided throughout the 2019 year:

  • Activity name and date
  • Target audience
  • Total number of participants and total number of registered nurses
  • Total number of contact hours (nursing credits) offered upon activity completion
  • Activity providership – direct or jointly provided
  • Amount of commercial support received, if applicable

If annual reporting is not completed by the communicated deadline, the Accredited Provider is at risk for additional fees and/or suspension and is not considered “in good standing.”

Helpful Preparation Tips:

  • Activity data may be submitted manually through the web interface or automatically as a batch upload.
  • There are more fields available for completion than are required by the ANCC; Accredited Providers only need to complete the required fields (see above list).
  • Activity locations only need to be provided for activities categorized as “C” (course), and “RSS” (regularly scheduled series).
  • Demographic information for organizations may be updated through NARS; however, providers should always ensure to notify the ANCC if there are any changes.

In addition to annual reporting, the ANCC will send invoices to Accredited Providers for remittance of annual ANCC fees. The standard deadline for payment is within 30 days of invoice receipt.


In its most recent provider e-Update, the ACPE debuted CPE Monitor Plus for Pharmacists, and announced a 2020 CPE administrator educational opportunity.

  1. CPE Monitor Plus for Pharmacists: The upgraded version of CPE Monitor, called “CPE Monitor Plus” is now available on desktop computers and mobile devices. Those who upgrade their plan from the standard plan to “plus” can access these key features on any device of their choosing:  license status screen showing hours completed and hours needed for each license; breakdown of renewal requirements (50 states & District of Columbia); notifications regarding CPE cycles; detailed transcripts for each state license; ability to upload credits to licenses in states where this is allowed; access to ACPE’s continuing professional development (CPD) tools; access to ACPE’s Pharmacists’ Learning Assistance Network (P.L.A.N.) to find CPE (available to both standard and plus users); and the ability to edit license information in e-Profile (plus and standard). The upgrade is available for an annual fee of $29.95.
  2. CPE Administrator Educational Opportunities: The ACPE has scheduled their Spring 2020 Continuing Education Administrator Workshop for April 27-28, 2020 in Chicago. This annual workshop provides a basic knowledge of the ACPE accreditation process and includes training and group activities on the ACPE Standards for Continuing Pharmacy Education, Policies and Procedures Manual, Provider Web Tool, and Continuing Professional Development for the CE Professional. The CE Administrator Workshop also provides valuable networking opportunities.  Registration is now live at this site, and ACPE encourages questions to be directed to

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

Upcoming Activities/Education Opportunities

  • ANCC Nursing Continuing Professional Development (NCPD) Summit
    March 18, 2020, Nashville, TN
  • ANCC Annual Symposium on CNE
    April 24, 2020, Orlando, FL
  • ACPE Spring 2020 CE Administrator Workshop
    April 27, 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

When calculating outcomes data for Criterion 36, do all learners have to be physicians to be counted towards performance improvement? 

No! For C36, providers must measure and…

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