Policy on CPD Compliance Audit

CPD600 v9

 

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

Document authorisation:            Council of Education

Document implementation:        Executive Director, Education & Training

Document maintenance:             Manager, Education Compliance

 

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

 

Copyright

2024. Australasian College for Emergency Medicine. All rights reserved.

 

1. Purpose and background

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 one-month period immediately following the end of the CPD Year during which the participation in approved CPD activities can be recorded by participants.

 

Pursuant to ACEM regulations pertaining to recertification requirements (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. The CPD compliance audit process is outlined in detail in the ACEM CPD Compliance Audits Standard Operating Procedure (CPD414).

3.1 Selection for Audit

Immediately following the close of each Recording Period, a cohort of a minimum of five per cent (5%) of ACEM Fellows (FACEMs) and a minimum of five per cent (5%) of non-FACEM participants shall be selected for compliance audit in respect of that CPD Year. The cohort shall include any ‘mandatory auditees’.

Mandatory auditees

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

1. 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;
2. failed to record minimum requirements in respect of the CPD Year to which the audit relates;
3. failed to submit a compliance audit by a nominated due date in the immediately preceding CPD Year to which the current audit relates;
4. failed a compliance audit in the immediately preceding CPD Year to which the current audit relates; and/or
5. 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 will be provided to CPD participants who, due to their CPD commencement date or granting of a CPD exemption, have no requirements for the CPD Year.

Auditees who subsequently withdraw from the ACEM CPD Program shall have their audit requirement stayed. Where an individual resigns their membership and subsequently makes application to re-enrol in the ACEM CPD Program, the individual must pass the applicable audit requirements before the re-enrolment application will be considered.

Members who opt-out of the ACEM CPD Program will not be precluded from any ACEM CPD compliance audit requirements for the year/s they were enrolled in the ACEM CPD Program. Members will need to successfully pass the applicable audit requirements to comply with ACEM membership requirements.

3.3 Notification of Selection

Auditees shall be notified in writing that they have been selected for audit and shall be required to submit their audit return within six (6) weeks of the date of notification.

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
  • 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)

• Educational Affiliate, Emergency Medicine Certificants/Diplomates/Advanced Diplomates, Associate (Intermediate) Associate (Advanced) and International Affiliate participants (IA – as required):

• • 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 registered to practice in Australia and/or Aotearoa New Zealand:

• • 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 theACEM CPD Platform.

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

If additional evidence is required, auditees shall be notified in writing and shall be required to comply within a three (3) week period. In extenuating circumstances, an extension of time may be granted upon written request.

 

5.1 CPD Non-Compliance

A participant will be deemed 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 (in which case they will be subject to a compliance audit);
• fail to submit their audit by the due date (in which case they will be subject to a further compliance audit the following year);
• fail a compliance audit (in which case they will be subject to a further compliance audit the following year).

Where a participant is non-compliant with the requirements of the ACEM CPD Program:

• the participant will be referred to the relevant regulatory authority following the failure of an audit
• 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]

 

6. Acknowledgement of Compliance

A CPD ‘Audit Compliance Certificate’ will be available to participants via My ACEM upon successfully passing a compliance audit. An annual 'CPD Completion Certificate' will also be made available to participants following passing of a compliance audit.

 

7. Associated Documents

• ACEM Constitution
• ACEM Regulations
• CPD Compliance Audits Standard Operating Procedure (CPD414)
• CPD Provision of Evidence Guideline (CPD639)
• Exceptional Circumstances and Special Consideration Policy (TA79)