Policy on CPD Compliance Audit

CPD600 v10

 

Timeframe for review:                                  Every five years, or earlier if required

Next major review to be completed by:     September 2031

Content owner:                                             Member Support/GM, People Culture & Experience

Approval Authority:                                      Council of Education

Accessibility:                                                 Public (website)

 

Version	Date	Pages revised / Brief Explanation of Revision
v1	Jun-2018	Approved by Council of Education
v2	May-2019	Revisions throughout to clarify compliance and selection for compliance audit.
v3	Jan-2020	Update to reflect single CPD program
v4	Jan-2022	Change of responsibilities
v5	Sep-2022	Change to auditee selection cohorts Revised to reflect change in terminology from ‘Cultural Competence’ to ‘Cultural Safety’
v6	Jul-2023	Contemporaneous review, including revision to reflect changes to the ACEM CPD Program to a one (1) year program cycle.
v7	Mar-2024	Revision of Immunity to Audit to reflect AMC standards and revision to MCNZ reporting of non-compliance
v8	Sep-2024	Update to include Associate members (Intermediate/Advanced) Change to Audit submission period Change deadline for additional information submission Update to reference ACEM CPD Platform Update to reference Culturally Safe Practice – Health Outcome
v9	Dec-2024	Updated to reference members who ‘Opt Out’ of the ACEM CPD program with an open audit
V9.1	Jan-2026	'Applying universal changes regarding nomenclature. Removal of references to Certificants, Diplomates, and Advanced Diplomates following the retirement of those membership categories effective 1 February 2026
V10	Sep-2026	Clarify 3.1 (Selection for Audit) Update and Clarify 3.2 (Immunity from Audit) Update 3.3 (Notification of Selection) Addition of 5.1 (Participants found compliant after audit) Addition of 5.3 (Non-compliant participants subsequently withdrawing from ACEM CPD) Addition of Appendix A Other Minor changes for clarity

 

Copyright

2026. Australasian College for Emergency Medicine. All rights reserved.

 

The Australasian College for Emergency Medicine (ACEM; the College) provides a Continuing Professional Development (CPD) program to ensure medical practitioners practicing in the field of emergency medicine maintain and improve their knowledge and skills as applicable to their professional practice. The ACEM CPD Program is designed to meet the requirements of the Medical Board of Australia (MBA) and the Medical Council of New Zealand (MCNZ) for the purposes of individual practice.

This policy is made pursuant to Regulation E: Recertification. The purpose of the ACEM CPD Program is to:

• support medical practitioners to maintain, improve and broaden their knowledge, expertise and competence, and develop the personal and professional qualities required throughout their professional lives[1].
• provide assurance to the community that participants are meeting their CPD obligations and standards for continuing medical registration and recertification; and
• comply with relevant legislation and other jurisdictional requirements.

 

2. Terminology

ACEM; the College means the Australasian College for Emergency Medicine.

College member means a person admitted as a member of the College pursuant to the provisions of the ACEM Constitution and  associated regulations.

Auditee means any participant selected for a compliance audit.

CPD Year means the 12-month period starting on 1 January and ending on 31 December the same year.

Participant (except where the context otherwise allows) means any person participating in the ACEM CPD Program.

Practice, clinical practice, and non-clinical practice have the same meanings as those given by the Medical Board of Australia or the Medical Council of New Zealand, according to the appropriate jurisdiction.

Completion means a participant has recorded the minimum requirements of the ACEM CPD Program for the CPD Year.

Compliant means a participant has successfully passed a CPD compliance audit for the CPD Year.

MBA means the Medical Board of Australia

MCNZ means the Medical Council of New Zealand

Non-Compliant means a participant of the ACEM CPD Program for the CPD Year who meets any of the following criteria:

• does not satisfy minimum CPD requirements for a CPD Year;
• fails to submit their audit by the due date;
• fails a compliance audit – results in non-compliance.

Recording Period means the CPD Year and a 15-day period immediately following the end of the CPD Year during which the participation in approved CPD activities can be recorded by participants.

Withdraw, means unenrolling from the ACEM CPD Program in the context of this policy, such as nominating another CPD Home, resigning membership, declaring retirement or being terminated.

 

As mandated by standards set by the MBA and MCNZ, and pursuant to ACEM regulations on recertification (refer to Regulation E1.2, E2.2, E3.2 and E4.2), the ACEM CPD Committee shall conduct a compliance audit annually to determine whether auditees are compliant with the requirements of the ACEM CPD Program.

3.1 Selection for Audit

For each CPD Year, a sample of Random Auditees is drawn for compliance audit. The sample consists of

• a minimum of five per cent (5%) of ACEM Fellows (FACEMs)
• and a minimum of five per cent (5%) of other participants in the ACEM CPD Program.

Mandatory Auditees are selected in addition to, and do not count towards, the minimum percentages above.

Random auditees

All CPD participants are eligible for Random Selection unless considered immune under section 3.2.

Mandatory auditees

For the purposes of this policy, mandatory auditees are those participants who:

• have been granted a deferral from the audit process in relation to the CPD Year immediately preceding the year to which the current audit relates;
• failed to record minimum requirements in respect of the CPD Year to which the audit relates;
• failed to submit a compliance audit by a nominated due date in the immediately preceding CPD Year to which the current audit relates;
• failed a compliance audit in the immediately preceding CPD Year to which the current audit relates; and/or
• are nominated by the Chair of the CPDC or delegate (eg as a condition of exemption, special consideration, or return to practice program)

3.2 Immunity from Audit

Immunity from CPD compliance audit selection will be provided to CPD participants on any of the following grounds:

• Participants who have no requirements for the CPD year, either due to their CPD commencement date or being granted a full CPD exemption.
• Participants who received a Special Consideration for Extenuating Circumstances that specifically makes them immune from Audit.
• All Honorary Fellows, pursuant to Regulation E 1.1.2
• All Retired Fellows, pursuant to Regulation E 1.1.2.
• Participants who withdraw from ACEM CPD for the year being audited, before Recording Period ends for that year (e.g. withdrawing from the 2026 CPD Year before 15 Jan 2027)
• International Affiliates who do not hold an eligible college role, defined in Appendix A.

No immunity from CPD compliance audit selection will be provided on the following grounds:

• Participants who withdraw for the CPD year being audited, for reasons other than retirement, after the Recording Period ends, e.g. withdrawing from the (2026 CPD Year after 15 Jan 2027).
• International Affiliates who hold an eligible college role, defined in Appendix A.
• Participants who participated in a previous audit, irrespective of the audit outcome. In accordance with standards set by the MBA and MCNZ, these participants must remain eligible. This may result in individuals being selected in consecutive years.

Non-immune auditees who withdraw from the ACEM CPD Program without meeting audit requirements will be deemed as non-compliant.

3.3 Notification of Selection

Participants may be advised of their selection for audit at any time, e.g. when a partial exemption is granted with audit conditions. All auditees shall be advised of their selection in writing and shall be offered guidance and support as soon as their selection is determined.

Within five (5) business days after the end of the Recording Period (15 January):

• All auditees will be officially notified by email and SMS that audit finalisation has commenced.
• All auditees will be provided three (3) weeks from the date of notification to submit their audit return for an initial assessment.
• After the initial assessment, auditees will be advised of missing evidence (if any) and provided with up to three (3) weeks to provide it.

ACEM will take all reasonable steps to establish contact with every auditee. However, it remains the auditee’s responsibility to maintain accurate contact information (email and mobile number) on the ACEM Portal.

3.4 Extenuating circumstances

Applications for extension of time, deferral or waiver may be granted pursuant to the provisions of the ACEM Exceptional Circumstances and Special Consideration Policy (TA79). Applications should be submitted on the prescribed form together with all required information. Applications will be considered by the Chair of the ACEM CPD Committee and applicants notified of the outcome as soon as practicable.

3.5 Audit Requirements

3.2.1  Auditees selected for compliance audit will be audited against the minimum annual requirements.

3.2.2  Auditees who fail to pass the compliance audit of any given year will subsequently be audited against the minimum requirements of the following CPD Year.

 

Unless an exemption has been granted, auditees must submit evidence of the following activities. The documentation uploaded to the ACEM CPD Platform must meet the requirements of the CPD Provision of Evidence Guideline (CPD639).

• FACEM participants

• • Hours of activity
  • High Level Requirement – Procedural skills and Leadership
  • Essential Emergency Medicine Procedural skills
  • Health Outcome requirements
  • Professional Development Plan
  • Annual Conversation (for participants registered with the MCNZ)
  • Other college High Level Requirements (where applicable)

• Participants from other membership categories:

• • Hours of activity
  • Essential Emergency Medicine Procedural skills
  • Health Outcome requirements
  • Professional Development Plan
  • Annual Conversation (for participants registered with the MCNZ)
  • Other college High Level Requirements (where applicable)

• Non-Member CPD participants:

• • Hours of activity
  • Health Outcome requirements
  • Annual Conversation (for participants registered with the MCNZ)

The documentation required for compliance audit as specified in the CPD Provision of Evidence Guideline (CPD639) must be provided to the College via upload to the ACEM CPD Platform.

The documentation required for audit of High-Level Requirements for other College/s is specified by the relevant college.

 

5.1 Participants assessed found compliant after audit

Where a participant successfully passes CPD Audit and is found compliant:

• They will be officially notified by email.
• A Certificate of Annual Completion will be available for download on the ACEM CPD online platform.
• An Audit Compliance Certificate will be available for download on the ACEM CPD online platform.

Where a participant is registered as a practitioner with the MBA or MCNZ

• They will also be reported as compliant to the relevant authority, as and when required by the authority.

5.2 Participants  assessed as non-compliant after audit

A participant will be assessed to be ‘non-compliant’ in the ACEM CPD Program if they meet any of the following criteria:

• fail to record the minimum requirements for a CPD Year.
• fail to submit their audit by the due date.
• fail a compliance audit.

Any participant fassessednon-compliant with the ACEM CPD Program will be notified in writing. An application for reconsideration of the decision may be submitted within 28 calendar days, as per the Reconsideration, Review and Appeals Policy (COR355).

If, after the due reconsideration process, the participant is still non-compliant:

• the participant will be reported as non-compliant to the relevant regulatory authority, as and when required by the authority.
• this information may be conveyed to a prospective or current employer(s) or their agents; and/or
• if the participant is an ACEM member and is deemed non-compliant in 2 consecutive CPD years, the individual may have their College membership suspended or terminated by the ACEM Board.[2]

5.3 Non-compliant participants subsequently withdrawing from ACEM CPD

ACEM Members who opt-out of the ACEM CPD Program after being assessed non-compliant:

• Must still meet applicable ACEM Membership requirements, as per the CPD Homes Policy (P909).
• Will not be precluded from any ACEM CPD compliance audit requirements for the year/s they were enrolled in the ACEM CPD Program. These requirements will be stayed as long as they remain unenrolled in ACEM CPD.
• Will be required to pass the applicable audit requirements before a re-enrolment application in ACEM CPD will be considered.

Non-Member CPD Participants who withdraw from the ACEM CPD Program after being assessed non-compliant:

• Will not be precluded from any ACEM CPD compliance audit requirements for the year/s they were enrolled in the ACEM CPD Program. These requirements will be stayed as long as they remain unenrolled in ACEM CPD.
• Will be required to pass the applicable audit requirements before a re-enrolment application in ACEM CPD will be considered

ACEM is still required to report the compliance status of all participants enrolled in ACEM CPD to the relevant regulatory authority, for each year when they were enrolled.

 

• ACEM Constitution
• ACEM Regulations
• CPD Compliance Audits Standard Operating Procedure (CPD414)
• CPD Provision of Evidence Guideline (CPD639)
• Exceptional Circumstances and Special Consideration Policy (TA79)
• Reconsideration, Review and Appeals Policy (COR355)
• CPD Homes Policy (P909)

 

As Per Regulation E4.1.2, annual participation in the ACEM CPD Program may be optional for International Affiliates.

International Affiliates who opt to participate in the ACEM CPD CPD Program are generally considered immune from audit, unless they hold one of the following College roles:

• Overseas ED Supervisor
• Supervisor-Specialist Training
• Supervisor-EMC/EMD
• Supervisor-Specialist Training (AMC)