Annual Audit of Participation in Continuing Education Program
Approval Date: February 2008
Review Date: December 2010
Review By: Continuing Education Program Committee
1. Purpose
The Annual Audit of Participation in the RACMA Continuing Education Program is part of the ongoing evaluation and assessment of the College’s Continuing Education Program.
The Annual Audit is conducted as a random sample of Fellows and Members, who are asked to provide documentation about their CEP activities in accordance with the procedures outlined below.
2. Background
For some years, RACMA has undertaken an annual audit of participation in the Continuing Education Program, by requesting the selected Fellows and Members to provide their own records of engagement in continuing education activities.
This approach is one taken by a number of medical Colleges, and in the early 2000s, there were discussions between some Colleges about several aspect of their Continuing Education Programs, including the development of a common methodology. This occurred around the time of the discussions about the LEAP framework, and was the forum in which the decision regarding a consistent audit sample size of 5% of Fellows and members was initially agreed.
The annual audit had previously been coordinated by the College’s Administrative Officer, who then reported on whether the selected Fellows/Members had responded, based on whether relevant documents had been submitted. The quality of the documentation was not routinely assessed, and only limited feedback was then provided to individuals or to CEP Coordinators. The 2006 annual audit, which was undertaken at a time of significant change in the staffing of the National Secretariat, demonstrated the need to review current procedures including delineation of the roles of the Secretariat and CEP Coordinators in regards to the annual audit; to establish specific documentation requirements for those selected for the audit; to set out reporting requirements for outcomes of the Audit to the CEP Committee; and to develop feedback loops to Fellows and Members selected for the Audit.
In 2007, the CEP Committee reviewed the current situation regarding the annual audit, and agreed that given the decision to actively move towards mandatory participation in the College’s Continuing Education Program, the Annual Audit would in future involve a sample of 10% of Fellows and 10% of Members each year, and would set out guidelines for submission of documentation as evidence of participation in professional development. In light of the need to complete this task, Council was advised that there would be no annual audit in 2007, and with Council’s support, the revised audit process is to recommence in 2008.
3. Objectives of the Annual Audit of Participation in Continuing Education Program
The objectives of the Annual Audit are to:
1. Check the integrity of the RACMA approach to continuing education, that is, that the Program’s focus on adult learning principles is supported by the educational activities of Fellows and Members selected for the annual audit, including evidence of participation
2. Confirm though a random audit that individual Fellows and Members are undertaking the required CEP learning plan cycle and associated activities, through their providing of appropriate documentation
3. Review the quality of the retained documentation, to ensure it meets the requirements of RACMA in relation to demonstrating involvement
4. Provide feedback to Fellows and Members selected by the audit in relation to quality of documentation of training plans, reviews and activities, completeness of the certification process and any issues relating to the nature of learning activities, and
5. To inform Council, Fellows and Members of opportunities to improve the CEP Traing Plan and activities processes.
4. Procedures for Conduct of the Annual Audit
RACMA has determined its policy on Mandatory Participation in the College’s Continuing Education Program, and has defined which Fellows and Members are required to participate in the Program. All participating Fellows and Members are eligible to be selected for the Annual Audit.
The procedures for conducting the Audit are as follows:
i) In the fourth quarter each year a random sample of 10% of participating Fellows and Members will be selected to participate in the Annual Audit. The list of selected participants will be provided to the national Director and CEP Coordinators for information and reference as needed.
ii) Selected Fellows and Members will be advised in writing/via email that they have been selected by the Secretariat, who will also include the RACMA Policy on the Annual Audit, and information as to what is required for submission and the associated timelines.
iii) Selected Participants will have 2 months to respond to the audit during which two reminders will be sent by the Secretariat.
iv) Participants will be requested to submit the following information:
1. A copy of their CEP Training Plan and last Annual Review, signed off by their CEP Coordinator or Learning Set Group, whichever is appropriate.
2. A log of the activities undertaken to fulfil the requirements of their plan.
3. Certificates/evidence of attendance at formally organised CEP activities, e.g. workshops, conferences, courses.
4. For Conjoint Fellows or Members who are also Fellows of another medical College, and wish to refer to the CEP of another medical College, evidence of participation in that College CEP program may be submitted, provided details about the specific RACMA-related activities undertaken in that other College are included. (A ‘certificate of completion’ in the professional development program of another college is not sufficient without detail requesting recognition of the specific relevant activities.)
5. Participants may submit copy of their electronic logbooks if using the RACMA on-line CEP tool, the ACCRM Tool or an electronic log of another medical college.
v) Selected Participants will initially return their documentation to the National Secretariat, who will review the submission against the Annual CEP Audit Checklist to ensure that key documents have been provided. Where key documents are not included, the Secretariat will contact the selected participant in the first instance, to address cases of oversight.
vi) Completed documentation for each individual will be forwarded in a separate email to the relevant CEP Coordinator, to ensure that information about individuals is managed confidentially. The CEP Co-ordinator will review the information and confirm that it meets the audit objectives, identifying any areas of individual or system concern. Any concerns may be discussed with the National Director if needed, and returned to the National Secretariat for collation into the overall Annual Audit report.
vii) The Annual Audit Report will be presented to the National Director Continuing Education/Recertification in the form of recommendations about:
1. The satisfactory participation of the Fellow/Member in the CEP.
2. Any issues identified through the CEP audit.
viii) At the end of each annual audit process, each participant will receive a letter signed by the National Director Continuing Education/Recertification and openly copied to the relevant CEP Coordinator to acknowledge their CEP participation. These letters will be prepared by the National Secretariat, and may include any systems issues that were identified during the annual audit process.
ix) An annual Report on the Audit will be prepared for the CEP Committee and once agreed, will be presented to Council. It will include the names of those who participated, the individual and overall outcomes of the Annual Audit, and any recommendations for improvement requiring Council’s approval.
5. Reporting Requirements and Evaluation of the Annual Audit
The National Director and the CEP Committee will receive reports regarding progress with the Annual Audit, and at the audit’s completion, will review and evaluate the outcomes in order to identify and act upon key issues or improvements.
The National Director Continuing Education/Recertification will report annually to Council on the outcomes of the Annual Audit, and will provide any recommendations for improvement requiring Council’s approval.
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