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 – September 2018 Newsletter

Welcome to the September edition of AOE Compliance Connection, AOE’s monthly newsletter.  We are excited to share our monthly ACCME, ACPE and ANCC board bulletins along with news from the world of CME.

We thoroughly enjoy what we do at AOE.  We are committed to excellence no matter the task – everything from compliance management to program benchmarking.  We come alongside clients just like you, and help navigate the ever-changing waters of CME compliance to ultimately facilitate success.

This newsletter is just one of the many educational resources we make available to support achievement of success, compliance and peace of mind.

Enjoy this month’s edition of AOE Compliance Connection!  Please visit for even more information, including a library of guidelines and weekly compliance tips.

(And in case you missed it, AOE published an easy-to-digest summary of the ACCME’s 2017 Annual Report here.  Be sure to glance through it for CME trends and data!)


ACCME's "Call for Stories"

The ACCME has issued a “Call for Stories” in preparation for the ACCME 2019 Meeting scheduled to take place in Chicago from April 29-May 2, 2019. They are requesting three different types of submissions from providers and individuals planning to attend the 2019 meeting.

  1. “Share Your Story”This category is designed for providers and individuals to share their CME story (which you can do here). Some questions from the ACCME to consider:
    • How are you changing practice and healthcare through accredited CME?
    • What challenges have you overcome?
    • What have you learned?
    • What inspires you and brings meaning to your work as an educator?
  2. “Inspire and Teach”
    This category is designed for providers and individuals to share their expertise and experience as leaders in the education world. You can submit a proposal for an educational session here. We can learn from each other and collectively improve the skills and performance of our colleagues.
  3. “Demonstrate What Works (or Doesn’t Work!)”
    This category is designed for providers and individuals who wish to share their research and scholarship endeavors. Have you learned something new about what makes CME effective (or ineffective!) in the fields of learner change or healthcare improvement? If so, submit your research study here.

Providers are invited to submit in all three categories, as many times as they desire – there is no limit. The deadline for submission is just a few weeks away: Midnight (CST) on October 5, 2018.

You can view more details about the “Call for Stories” in this informational sheet, prepared by the ACCME.


ACCME Self-Study Outline

ACCME Accreditation: Self-Study Outline and Submission

Earlier this year we provided an update on the new ACCME Self-Study and Performance-in-Practice submission process. This month we’d like to take a deeper-dive into the Self-Study outline and submission process.

In case you missed our prior newsletter article, the ACCME accreditation process is now managed entirely online through the Program and Activity Reporting System (PARS), which has changed how providers submit Self-Study Report narrative and Performance-in-Practice evidence. The Self-Study Report narrative is now submitted via form fields in PARS similar to the grant submission process. Below we’ve highlighted some key information and best practices.

Outline Structure: As in prior accreditation cycles, accredited providers must respond to the Self-Study Report outline by providing narrative descriptions of process and uploading documents as indicated. However, instead of picking two CME activities as examples to describe its processes and mechanisms for Criterion 2 – Criterion 7 (C2-C7), an accredited provider must describe its processes to each criterion individually.

Formatting Guidelines: Since narrative is entered into text form fields within PARS, special formatting such as bullets and tables is not possible. Accredited providers should take this into consideration when drafting Self-Study report narrative. Information should be as clear and succinct as possible without the use of bullets, numbering, tables/charts, etc.

Attachments: While the prior Self-Study Report submission process permitted additional attachments, often included at the end of the narrative text, the new submission method through PARS only permits additional attachments when requested. As such, an accredited provider must ensure that all relevant information is conveyed via the narrative text.

Commendation Criteria: For Option A: Engagement with the Environment (Criteria 16 – 22) a provider must include at least two (2) examples of explicit organizational practices. For Option B: Menu of New Criteria for Commendation (Criteria 23 – 38), the current Self-Study Report outline imposes word limits. This requires that the narrative text provided for each example clearly communicate the key elements for achieving compliance.

Self-Study Report – Final Document: In order to have a central reference document for the ACCME Accreditation Interview, AOE recommends that accredited providers develop a Word and/or PDF version of the cumulative Self-Study Report. Having a Word version of the narrative text also ensures a back-up copy in the event of any technical glitches.

The key to approaching development of Self-Study Report narrative is to have a clear plan and timeline in place. This can streamline the process and ensure that reviews, if applicable, are done in a timely, efficient manner. Generally, AOE recommends that accredited providers begin the reaccreditation process at least nine months in advance of the accreditation term expiration.


Accreditation Board Bulletin

Part of the service AOE provides to readers are weekly compliance tips and monthly CME community news for each of the three key boards.


In general, it is prohibited by the ACCME to engage employees of an ACCME-defined commercial interest as a faculty speaker, steering committee member, planner, manager or other content-controlling role in the design or delivery of a CME activity.  Why?  Because the financial responsibility that an employee has with their employer creates an un-resolvable conflict of interest.  

The Standards of Commercial Support speak to this rule a number of times:  Standard 1 (Independence) and Standard 2 (Resolution of Personal Conflicts of Interest) both require providers to manage all relevant financial relationships.  However, there are no adequate resolution strategies to demonstrate compliance when employees of ACCME-defined commercial interests are utilized.  

The ACCME allows for only three special-case exceptions to this rule.  It is permissible for employees of an ACCME-defined commercial interest to be used in a content-controlling position of accredited CME in these specific situations:  

  1. When the CME activity is not related to the business lines or products of their employer.
  2. When the content of the accredited CME activity is limited to basic science research or the processes/methodologies of research, unrelated to a specific disease or compound/drug.  As a note, in this circumstance, the provider must be able to prove that it has processes in place to ensure that employees of ACCME-defined commercial interests have no control over CME content related to clinical applications or recommendations.  
  3. When the employees are participating as technicians in accredited CME activities that teach the safe and proper use of medical devices.

The use of employees of commercial interests is a common compliance violation among providers who do not thoroughly understand the special-use cases.  As such, the ACCME has multiple educational resources to support providers as they navigate independence in accredited CME, such as this FAQ page. 


Each year the American Nurses Credentialing Center (ANCC) has three application cycles for new or renewal accreditation applicants.  The next application cycle, “March Cycle”, will begin with applications due on November 1, 2019.

New applicants, or accredited providers up for reaccreditation, will complete the application online via the Primary Accreditation Online Review System (PAORS).  New applicants must contact in order to register for access.  Once registered, the link to the application is available on the PAORS home page under “My Dashboard”.  To complete the application new applicants will select the link “Start Application” and existing accredited providers will select the link “Renew Application”.

After the submission of the application, access to the Self-Study template will be provided.  Providers are to use the template to develop the Self-Study and compile activity file documentation evidence.  The “March Cycle” deadline to submit all materials for the Self-Study and activity files is March 1, 2019.  The submitted materials are then reviewed by ANCC Accreditation Program appraisers that review the documents according to established ANCC criteria.

The next step in the cycle is the “Virtual Visit”.  Once the appraisers have completed the Self-Study and documentation review, they will schedule a virtual visit with the provider between March 15, 2019 and June 15, 2019.  During the virtual visit, appraisers will ask questions to clarify and validate the submitted materials.  Leading up to, during, or following the virtual visit, appraisers may request additional evidence to assist in their final report of findings that is submitted to the Commission on Accreditation (COA).

The final decision will be communicated to providers between June 1, 2019 and September 1, 2019.  Once the appraisers have supplied their report to the COA, the COA reviews the report and determines the appropriate accreditation decision.  The process is repeated for the “July 2019 Cycle”, beginning with an application deadline of March 1, 2019.

For more information and access to ANCC resources, follow this link.


The most recent provider updates released by the ACPE include some pertinent changes that should be noted by CPE providers.  Of the 10 updates, the four that are most relevant to providers are: 

  1. Provider Web Tool Update
    There are now seven (7) options for topic designators, including the original 1-5.  The two newest options are (6) Immunizations and (7) Compounding. The most appropriate one should be selected in the Provider Web Tool by the provider.  Additionally, the ACPE now allows for the upload of multiple UANs at one time through the Batch Import Activities.
  2. CPE Monitor Update
    This update refers specifically to the late fee policy that was implemented January 1 of this year.  The update includes a new policy regarding late fee override requests:  Providers who upload late credit will receive a fee waiver and policy reminder for their first three requests.  On the fourth (and subsequent) request, providers will receive a $200 late fee.  Other details of this new policy can be read here.
  3. CPE Monitor Mobile App
    Pharmacists can now more easily monitor their CPE compliance with “CPE Monitor Plus”, a subscription that allows pharmacists to view their CPE status by state at a glance, upload certificates from non-ACPE courses to apply them where applicable, receive email alerts regarding CPE cycle deadlines, view all transcripts, generate simple reports, search PLAN and connect to My CPD.  The annual fee is $29.95 (regardless of number of licenses).  More information is available here.
  4. Annual fees due now!
    Providers should have received invoices in August and should pay them upon receipt.  To make this process easier, credit cards ARE accepted by the ACPE, but involve a small handling fee.

Upcoming Activities/Education Opportunities

  • Beginner CME for MOC: Ask Your Questions Webinar
    September 18, 2018
  • Getting Started in Joint Accreditation
    September 28, 2018, Chicago, IL
  • ANCC National Magnet Conference 2018
    October 24-26, 2018, Denver, CO
  • Advanced CME for MOC: Ask Your Questions Webinar
    November 13, 2018
  • MAACME 2018 Annual Conference
    November 14-15, 2018


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

Criterion 26 requires the use of data, but does this mean identifiable patient health or practice data?              

No!  The use of identifiable patient health or practice data is not…

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