A1 - DHP CPD Activity Accreditation Standards

DHP - AS Continuing Professional Development (C PD) Activity Accreditation Standards

CPD ACCREDITATION STANDARDS: CATEGORY 1 GROUP LEARNING ACTIVITIES

Department of Healthcare Professions

Preamble:

Group learning is an important professional development activity for healthcare practitioners practicing in the State of Qatar. Group learning provides an opportunity to confirm or expand areas of knowledge or practice management, to identify potential new therapies or approaches for practice and to share practice issues or experiences with peers.

The DHP-AS CPD Framework includes several types of accredited group learning activities under Category

1. This document outlines the accreditation standards and approval process for:
   

Healthcare practitioner documentation and verification requirements

To receive CPD credits, healthcare practitioners must document each learning activity in the CPD Portfolio provided by the Department of Healthcare Professions – Accreditation Section (DHP-AS).

The certificate of attendance provided by the CPD provider organization must be provided to the DHP-AS by the healthcare practitioner upon request.

Conferences, Symposia, Seminars, Workshops

Approval process:

All conferences, symposia, seminars and workshops developed for inclusion within Category 1 of DHP-AS’s

CPD Framework must be either:

• Reviewed and approved by the DHP-AS or
  
• Be developed by a DHP accredited CPD provider fulfilling and complying with the DHP-AS standards.

The materials used to promote or advertise accredited conferences, symposia, seminars and workshops must include the accreditation statement:

“This activity is an Accredited Group Learning Activity (Category 1) as defined by the Department of

Healthcare Professions - Accreditation Section and is approved for a maximum of xx hours.”

Accredited conferences, symposia, seminars and workshops in Category 1 are approved for a maximum of one year from the start date of the activity (for example from the first day of the conference, symposia, seminar and/or workshop).

Accreditation for conferences, symposia, seminars and workshops may not be granted retroactively.

Required documentation to be provided to all participants

A certificate of participation or written confirmation signed by the chair of the Scientific Planning Committee must be issued for all accredited group learning activities. The certificate of participation must specify the following elements:

The organization that developed the conference, symposium, seminar or workshop is responsible to determine the actual number of hours that each learner is eligible to record for credit.

The organization that developed the conference, symposium, seminar or workshop is responsible for maintaining all records (including attendance records) for a 6-year period.

Accreditation Standards:

Accredited conferences, symposia, seminars and workshops must meet each of the following standards:

Part A: Administrative Standards

All accredited conferences, symposia, seminars and workshops must meet the following administrative standards.

CSSW Administrative Standard 1.1:All accredited conferences, symposia, seminars and workshops must be developed by an eligible organization as defined by the DHP-AS.

Eligible organizations include:

• Governmental or non-governmental healthcare professional academic institutions (or those involved in the education of healthcare professionals). Includes organizations that are eligible to become registered/licensed within the next two years.
• Governmental or non-governmental healthcare facilities. Includes organizations that are eligible to become registered/licensed within the next two years.
• Other organizations as defined by the DHP-AS.

(Note: Only locally-developed CPD activities are eligible for DHP-AS CPD accreditation).

CSSW Administrative Standard 1.2:All accredited conferences, symposia, seminars and workshops must have a scientific planning committee (SPC) that is representative of the intended target audience.

The membership of the scientific planning committee (SPC) responsible for the planning process must be representative of the target audience. The target audience is defined as the group of healthcare practitioners whose needs the group learning activity is designed to address. Therefore the target audience must be identified before the planning process has been initiated to enable the membership of the SPC to be chosen accordingly.

There is no minimum or maximum number of members required to sit on the SPC. If the CPD activity is aimed at only one type of healthcare practitioner, demographic factors (for example urban versus rural practice) should be considered in selecting the appropriate mix of members for the SPC.

The SPC is ultimately responsible for the following program elements:

• Identifying the educational (learning) needs of the target audience.
• Developing the educational objectives based on the identified learning needs.
• Selecting the educational methods best suited to address the learning needs.
• Selecting the individuals who will serve as facilitators/speakers.
• Developing the content or evidence.
• Evaluating the outcomes of the activity.

CSSW Administrative Standard 1.3: All accredited conferences, symposia, seminars and workshops must maintain attendance records and provide participants with a certificate of participation that includes the appropriate accreditation statement.

A certificate of participation or written confirmation signed by the chair of the SPC must be issued to participants for all accredited group learning activities. The certificate must specify the following elements:

The organization that developed the conference, symposium, seminar or workshop is responsible to determine the actual number of hours that each learner is eligible to record for credit.

The organization that developed the conference, symposium, seminar or workshop is responsible for maintaining attendance records for a 6-year period.

Part B: Educational Standards

All accredited conferences, symposia, seminars and workshops must meet the following educational standards.

CSSW Educational Standard 1.1:All accredited conferences, symposia, seminars and workshops must be planned to address the identified learning needs of the target audience.

A needs assessment of the target audience must be performed to identify areas of knowledge, skills, performance and/or healthcare outcomes that the CPD activity intends to address or improve.

The needs assessments strategies can include multiple sources of data to identify the needs of its target audience(s) to plan educational initiatives. Sources of data include (but are not limited to) participant surveys, focus groups or evaluation forms; literature reviews; assessments of knowledge, competence, performance or quality of care provided to patients. The needs assessment should be used to inform:

• the development of learning objectives.
• the selection of learning formats.
• the development of the relevant educational content.
• the creation of the evaluation strategies.

CSSW Educational Standard 1.2:Learning objectives must be developed for the overall group learning activity and each individual session. The learning objectives must be written from the learner’s perspective to clearly describe what information or skill(s) learners will acquire by participating in the activity and be provided to potential participants prior to the learning activity.

The SPC must ensure that the identified learning needs of the target audience are utilized in the development of the learning objectives.

CSSW Educational Standard 1.3:The selected learning formats should be aligned with the identified needs of the target audience.

The SPC must ensure that the selected learning formats are consistent with the identified need(s) and stated learning objectives.

CSSW Educational Standard 1.4:At least 25 per cent of the total education time must be allocated to support interactive learning.

The SPC is responsible to ensure that there is adequate opportunity for interactive learning. The materials used to promote or advertise the CPD activity (such as the program and/or brochure) must identify the opportunities for interactive learning.

Interactive learning can occur through (for example) question and answer periods, case discussions, skills training, etc.

Interactive learning helps participants to understand, translate and apply the content presented in their specific practice contexts. Interaction promotes sharing between (and among) participants and the facilitators/speakers, contributes to a supportive learning environment and enables speakers to determine the degree to which participants understand the content.

CSSW Educational Standard 1.5:Participants must be provided with an opportunity to evaluate individual sessions and the overall CPD activity.

Accredited conferences, symposia, seminars and workshops must provide participants with an opportunity to evaluate each individual session and the overall CPD activity. The evaluation system must:

• allow participants to identify whether the overall and individual session learning objectives were met;
• provide opportunities for participants to identify the potential impact of the activity for their practice;
• ask participants to identify whether the content was balanced and free of commercial or other sources of bias (including an open text box where learners may offer further details if content was not balanced and free of commercial or other sources of bias);
• ask participants whether members of the SPC, speakers, moderators, facilitators and/or authors disclosed their relationships as required by the DHP-AS Conflict of Interest Declaration Policy.

Additional evaluation strategies, where applicable, may be based on:

• measures of improved healthcare practitioner competence or performance;
• measures of improved healthcare outcomes;
• feedback provided by coaches or facilitators/speakers related to participants’ learning.

Part C: Ethical Standards

All accredited conferences, symposia, seminars and workshops must adhere to the DHP-AS Ethical Standards for Accredited CPD Activities.

Accreditation Standards: At-A-Glance

Part A: Administrative Standards

• CSSW Administrative Standard 1.1: All accredited conferences, symposia, seminars and workshops must be developed by an eligible organization as defined by the DHP-AS.
• CSSW Administrative Standard 1.2: All accredited conferences, symposia, seminars and workshops must have a scientific planning committee (SPC) that is representative of the intended target audience.
• CSSW Administrative Standard 1.3: All accredited conferences, symposia, seminars and workshops must maintain attendance records and provide participants with a certificate of participation that includes the appropriate accreditation statement.

Part B: Educational Standards

• CSSW Educational Standard 1.1: All accredited conferences, symposia, seminars and workshops must be planned to address the identified learning needs of the target audience.
• CSSW Educational Standard 1.2: Learning objectives must be developed for the overall group learning activity and each individual session. The learning objectives must be written from the learner’s perspective to clearly describe what information or skill(s) learners will acquire by participating in the activity and be provided to potential participants prior to the learning activity.
• CSSW Educational Standard 1.3: The selected learning formats should be aligned with the identified needs of the target audience.
• CSSW Educational Standard 1.4: At least 25 per cent of the total education time must be allocated to support interactive learning.
• CSSW Educational Standard 1.5: Participants must be provided with an opportunity to evaluate individual sessions and the overall CPD activity.

Part C: Ethical Standards

• All accredited conferences, symposia, seminars and workshops must adhere to the DHP-AS Ethical

Standards for Accredited CPD Activities.

Approval process:

Educational Rounds and Journal Clubs

Each series of educational rounds (including morning report in healthcare facilities) and journal clubs developed for inclusion within Category 1 of DHP-AS’s CPD Framework, must be either:

• Reviewed and approved by the DHP-AS or
  
• Be developed by a DHP accredited CPD provider fulfilling and complying with the DHP-AS standards.

The materials used to promote or advertise the approved series of educational rounds and journal clubs

(such as a program and/or brochure) must include the accreditation statement:

“This activity is an Accredited Group Learning Activity (Category 1) as defined by the Department of

Healthcare Professions - Accreditation Section and is approved for xx hours.”

Accredited educational rounds and journal clubs in Category 1 are approved for a maximum of three years from the start date of the activity (for example from the first date the first round or journal club is held).

Required documentation to be provided to all activity participants

A certificate of participation or written confirmation signed by the chair of the Scientific Planning Committee must be issued for all accredited group learning activities. The certificate of participation must specify the following elements:

The Scientific Planning Committee Chair of the educational round or journal club is responsible to determine the actual number of hours that each learner is eligible to record for credit.

The organization that developed the educational rounds or journal clubs is responsible for maintaining all records (including attendance records) for a 6-year period.

Accreditation Standards:

Accredited educational rounds and journal clubs must meet each of the following standards:

Part A: Administrative Standards

All educational rounds and journal clubs must meet the following administrative standards.

ERJC Administrative Standard 1.1:All accredited educational rounds and journal clubs must be developed by an eligible organization as defined by the DHP-AS.

Eligible organizations include:

• Governmental or non-governmental healthcare professional academic institutions (or those involved in the education of healthcare professionals). Includes organizations that are eligible to become registered/licensed within the next two years.
• Governmental or non-governmental healthcare facilities. Includes organizations that are eligible to become registered/licensed within the next two years.
  
• Other organizations as defined by the DHP-AS.

(Note: Only locally-developed CPD activities are eligible for DHP-AS CPD accreditation).

ERJC Accreditation Standard 1.2: All accredited educational rounds and journal clubs must have a Scientific Planning Committee (SPC) that is representative of the intended target audience and accountable to the head of the department, chief of staff or equivalent.

The membership of the Scientific Planning Committee (SPC) responsible for the planning process must be representative of the target audience. The target audience is defined as the group of healthcare practitioners whose needs the group learning activity is designed to address. Therefore the target audience must be identified before the planning process has been initiated to enable the membership of the SPC to be chosen accordingly.

There is no minimum or maximum number of members required to sit on the SPC. If the CPD activity is aimed at only one type of healthcare practitioner, demographic factors (for example urban versus rural practice) should be considered in selecting the appropriate mix of members for the SPC.

The SPC is ultimately responsible for the following program elements:

• Identifying the educational (learning) needs of the target audience.
• Developing the educational objectives based on the identified learning needs.
• Selecting the educational methods best suited to address the learning needs.
• Selecting the individuals who will serve as facilitators/speakers.
• Developing the content or evidence.
• Evaluating the outcomes of the activity.

ERJC Administrative Standard 1.3: All accredited educational rounds and journal clubs must maintain attendance records and provide participants with a certificate of participation that includes the appropriate accreditation statement.

A certificate of participation or written confirmation signed by the Chair of the Scientific Planning Committee must be issued for all accredited group learning activities. The certificate of participation must specify the following elements:

The Scientific Planning Committee Chair of the educational round or journal club is responsible to determine the actual number of hours that each learner is eligible to record for credit.

The Scientific Planning Committee Chair of the educational round or journal club is responsible for maintaining attendance records for a 6-year period.

ERJC Administrative Standard 1.4:All accredited educational rounds and journal clubs must occur at least 6 times per year.

Educational rounds and journal clubs are developed to address the needs of healthcare practitioners practicing within an institution or local context, have a frequency that exceeds traditional conferences, symposia, seminars and workshops, and can be sequenced to facilitate learning and change.

Part B: Educational Standards

All accredited educational rounds and journal clubs must meet the following educational standards:

ERJC Educational Standard 1.1: All accredited educational rounds and journal clubs must be planned to address the identified learning needs of the target audience.

A needs assessment of the target audience must be performed to identify areas of knowledge, skills, performance and/or healthcare outcomes that the CPD activity intends to address or improve.

The needs assessments strategies can include multiple sources of data to identify the needs of its target audience(s) to plan educational initiatives. Sources of data include (but are not limited to) participant surveys, focus groups or evaluation forms; literature reviews; assessments of knowledge, competence, performance or quality of care provided to patients. The needs assessment should be used to inform:

• the development of learning objectives.
• the selection of learning formats.
• the development of the relevant educational content.
• the creation of the evaluation strategies.

ERJC Educational Standard 1.2: Learning objectives must be developed for the overall series and each individual occurrence of an educational round or journal club. The learning objectives must be written from the learner’s perspective to clearly describe what information or skill(s) learners will acquire by participating in the activity and be provided to potential participants prior to the learning activity.

The SPC must ensure that the identified learning needs of the target audience are utilized in the development of the learning objectives.

ERJC Educational Standard 1.3:The selected learning formats should be aligned with the identified needs of the target audience.

The SPC must ensure that the selected learning formats are consistent with the identified need(s) and stated learning objectives.

ERJC Educational Standard 1.4:At least 25 per cent of the total education time must be allocated for interactive learning.

The SPC is responsible to ensure that there is adequate opportunity for interactive learning. The materials used to promote or advertise the CPD activity (such as the program and/or brochure) must identify the opportunities for interactive learning.

Interactive learning can occur through (for example) question and answer periods, case discussions, skills training, etc.

Interactive learning helps participants to understand, translate and apply the content presented in their specific practice contexts. Interaction promotes sharing between (and among) participants and the facilitators/speakers, contributes to a supportive learning environment and enables speakers to determine the degree to which participants understand the content.

ERJC Educational Standard 1.5:Participants must be provided with an opportunity to evaluate individual activities and the overall series of activities.

Accredited educational rounds and journal club activities must provide participants with an opportunity to evaluate each individual activity and the overall series. The evaluation system must:

• allow participants to identify whether the overall and individual session learning objectives were met;
• provide opportunities for participants to identify the potential impact of the activity for their practice;
• ask participants to identify whether the content was balanced and free of commercial or other sources of bias (including an open text box where learners may offer further details if content was not balanced and free of commercial or other sources of bias);
• ask participants whether members of the SPC, speakers, moderators, facilitators and/or authors

disclosed their relationships as required by the DHP-AS Conflict of Interest Declaration Policy. Additional evaluation strategies, where applicable, may be based on:

• measures of improved healthcare practitioner competence or performance;
• measures of improved healthcare outcomes;
• feedback provided by coaches or facilitators/speakers related to participants’ learning.

Part C: Ethical Standards

All accredited educational rounds and journal clubs must adhere to the DHP-AS Ethical Standards for

Accredited CPD Activities.

Accreditation Standards: At-A-Glance

Part A: Administrative Standards

• ERJC Administrative Standard 1.1: All accredited educational rounds and journal clubs must be developed by an eligible organization as defined by the DHP-AS.
• ERJC Accreditation Standard 1.2: All accredited educational rounds and journal clubs must have a Scientific Planning Committee (SPC) that is representative of the intended target audience and accountable to the head of the department, chief of staff or equivalent.
• ERJC Administrative Standard 1.3: All accredited educational rounds and journal clubs must maintain attendance records and provide participants with a certificate of participation that includes the appropriate accreditation statement.
• ERJC Administrative Standard 1.4: All accredited educational rounds and journal clubs must occur at least 6 times per year.

Part B: Educational Standards

• ERJC Educational Standard 1.1: All accredited educational rounds and journal clubs must be planned to address the identified learning needs of the target audience.
• ERJC Educational Standard 1.2: Learning objectives must be developed for the overall series and each individual occurrence of an educational round or journal club. The learning objectives must be written from the learner’s perspective to clearly describe what information or skill(s) learners will acquire by participating in the activity and be provided to potential participants prior to the learning activity.
• ERJC Educational Standard 1.3: The selected learning formats should be aligned with the identified needs of the target audience.
• ERJC Educational Standard 1.4: At least 25 per cent of the total education time must be allocated for interactive learning.
• ERJC Educational Standard 1.5: Participants must be provided with an opportunity to evaluate individual activities and the overall series of activities.

Part C: Ethical Standards

• All accredited educational rounds and journal clubs must adhere to the DHP-AS Ethical Standards for Accredited CPD Activities.

On-line Synchronous and Blended Group Learning

Approval process:

All on-line synchronous or blended group learning activities developed for inclusion within Category 1 of

DHP-AS’s CPD Framework, must be either:

• Reviewed and approved by the DHP-AS or
• Be developed by a DHP accredited CPD provider fulfilling and complying with the DHP-AS standards.

The materials used to promote or advertise accredited on-line synchronous or blended group learning activities (such as a program and/or brochure) must include the accreditation statement:

“This activity is an Accredited Group Learning Activity (Category 1) as defined by the Department of

Healthcare Professions - Accreditation Section and is approved for xx hours.”

Accredited on-line synchronous or blended group learning activities in Category 1 are approved for a maximum of one year from the start date of the activity (for example from the first day the material is available to learners).

Accreditation of on-line synchronous or blended group learning activities may not be granted retroactively.

Required documentation to be provided to all participants

A certificate of participation or written confirmation signed by the chair of the Scientific Planning Committee must be issued for all accredited group learning activities. The certificate of participation must specify the following elements:

The organization that developed the on-line synchronous or blended group learning activity is responsible to determine the actual number of hours that each learner is eligible to record for credit.

The organization that developed the on-line synchronous and blended group learning is responsible for maintaining all records (including attendance records) for a 6-year period.

Accreditation Standards:

Accredited on-line synchronous and blended group learning activities must meet each of the following standards:

Part A: Administrative Standards

All on-line synchronous and blended group learning activities must meet the following administrative standards.

OSBGL Administrative Standard 1.1: All accredited on-line synchronous or blended group learning activities must be developed by an eligible organization as defined by the DHP-AS.

Eligible organizations include:

• Governmental or non-governmental healthcare professional academic institutions (or those involved in the education of healthcare professionals). Includes organizations that are eligible to become registered/licensed within the next two years.
• Governmental or non-governmental healthcare facilities. Includes organizations that are eligible to

become registered/licensed within the next two years.

• Other organizations as defined by the DHP-AS.
  

(Note: Only locally-developed CPD activities are eligible for DHP-AS CPD accreditation).

OSBGL Administrative Standard 1.2:All accredited on-line synchronous or blended group learning activities must have a scientific planning committee (SPC) that is representative of the intended target audience.

The membership of the scientific planning committee (SPC) responsible for the planning process must be representative of the target audience. The target audience is defined as the group of healthcare practitioners whose needs the group learning activity is designed to address. Therefore the target

audience must be identified before the planning process has been initiated to enable the membership of the SPC to be chosen accordingly.

There is no minimum or maximum number of members required to sit on the SPC. If the CPD activity is aimed at only one type of healthcare practitioner, demographic factors (for example urban versus rural practice) should be considered in selecting the appropriate mix of members for the SPC.

The SPC is ultimately responsible for the following program elements:

• Identifying the educational (learning) needs of the target audience.
• Developing the educational objectives based on the identified learning needs.
• Selecting the educational methods best suited to address the learning needs.
• Selecting the individuals who will serve as facilitators/speakers.
• Developing the content or evidence.
• Evaluating the outcomes of the activity.

OSBGL Administrative Standard 1.3: All accredited on-line synchronous or blended group learning activities must maintain attendance records and provide participants with a certificate of participation that includes the appropriate accreditation statement.

A certificate of participation or written confirmation signed by the chair of the Scientific Planning Committee must be issued for all accredited group learning activities. The certificate of participation must specify the following elements:

The organization that developed the on-line synchronous or blended group learning activity is responsible to determine the actual number of hours that each learner is eligible to record for credit.

The organization that developed the on-line synchronous or blended group learning activity is responsible for maintaining attendance records for a 6-year period.

Part B: Educational Standards

All accredited on-line synchronous and blended group learning activities must meet the following educational standards:

OSBGL Educational Standard 1.1:All accredited on-line synchronous or blended group learning activities must be planned to address the identified learning needs of the target audience.

A needs assessment of the target audience must be performed to identify areas of knowledge, skills, performance and/or healthcare outcomes that the CPD activity intends to address or improve.

The needs assessments strategies can include multiple sources of data to identify the needs of its target audience(s) to plan educational initiatives. Sources of data include (but are not limited to) participant surveys, focus groups or evaluation forms; literature reviews; assessments of knowledge, competence, performance or quality of care provided to patients. The needs assessment should be used to inform the:

• development of learning objectives.
• selection of learning formats.
• development of the relevant educational content.
• creation of the evaluation strategies.

OSBGL Educational Standard 1.2:Learning objectives must be developed for the on-line synchronous or blended group learning activity. The learning objectives must be written from the learner’s perspective to clearly describe what information or skill(s) learners will acquire by participating in the activity and be provided to potential participants prior to the learning activity.

The SPC must ensure that the identified learning needs of the target audience are utilized in the development of the learning objectives.

OSBGL Educational Standard 1.3:The selected learning formats should be aligned with the identified needs of the target audience.

The SPC must ensure that the selected learning formats are consistent with the identified need(s) and stated learning objectives.

OSBGL Educational Standard 1.4: At least 25 per cent of the total education time must be allocated to support interactive learning.

The SPC is responsible to ensure that there is adequate opportunity for interactive learning. The materials used to promote or advertise the CPD activity (such as the program and/or brochure) must identify the opportunities for interactive learning.

Interactive learning can occur through (for example) question and answer periods, case discussions, skills training, etc.

Interactive learning helps participants to understand, translate and apply the content presented in their specific practice contexts. Interaction promotes sharing between (and among) participants and the facilitators/speakers, contributes to a supportive learning environment and enables speakers to determine the degree to which participants understand the content.

OSBGL Educational Standard 1.5:Participants must be provided with an opportunity to evaluate the on-line synchronous or blended group learning activity.

Accredited on-line synchronous or blended group learning activities must provide participants with an opportunity to evaluate each individual session and the overall CPD activity. The evaluation system must:

• allow participants to identify whether the overall and individual session learning objectives were met;
• provide opportunities for participants to identify the potential impact of the activity for their practice;
• ask participants to identify whether the content was balanced and free of commercial or other sources of bias (including an open text box where learners may offer further details if content was not balanced and free of commercial or other sources of bias);
• ask participants whether members of the SPC, speakers, moderators, facilitators and/or authors disclosed their relationships as required by the DHP-AS Conflict of Interest Declaration Policy.

Additional evaluation strategies, where applicable, may be based on:

• measures of improved healthcare practitioner competence or performance;
• measures of improved healthcare outcomes;
• feedback provided by coaches or facilitators/speakers related to participants’ learning.

Part C: Ethical Standards

All accredited on-line synchronous or blended group learning activities must adhere to the DHP-AS Ethical

Standards for Accredited CPD Activities.

Accreditation Standards: At-A-Glance

Part A: Administrative Standards

• OSBGL Administrative Standard 1.1: All accredited on-line synchronous or blended group learning activities must be developed by an eligible organization as defined by the DHP-AS.
• OSBGL Administrative Standard 1.2: All accredited on-line synchronous or blended group learning activities must have a scientific planning committee (SPC) that is representative of the intended target audience.
• OSBGL Administrative Standard 1.3: All accredited on-line synchronous or blended group learning activities must maintain attendance records and provide participants with a certificate of participation that includes the appropriate accreditation statement.

Part B: Educational Standards

• OSBGL Educational Standard 1.1: All accredited on-line synchronous or blended group learning activities must be planned to address the identified learning needs of the target audience.
• OSBGL Educational Standard 1.2: Learning objectives must be developed for the on-line synchronous or blended group learning activity. The learning objectives must be written from the learner’s perspective to clearly describe what information or skill(s) learners will acquire by participating in the activity and be provided to potential participants prior to the learning activity.
• OSBGL Educational Standard 1.3: The selected learning formats should be aligned with the identified needs of the target audience.
• OSBGL Educational Standard 1.4: At least 25 per cent of the total education time must be allocated to support interactive learning.
• OSBGL Educational Standard 1.5: Participants must be provided with an opportunity to evaluate the on-line synchronous or blended group learning activity.

Part C: Ethical Standards

• All accredited on-line synchronous or blended group learning activities must adhere to the DHP-AS Ethical Standards for Accredited CPD Activities.

CPD ACCREDITATION STANDARDS: CATEGORY 3 ASSESSMENT ACTIVITIES

Department of Healthcare Professions

Pre-amble:

Engaging in assessment activities is an important learning strategy to assist healthcare practitioners to use external measures with feedback to identify where knowledge, competence or performance is up-to- date and areas that require further improvement. Assessment activities provide healthcare practitioners with processes and tools to generate data and obtain feedback to guide future learning.

The DHP-AS CPD Framework includes several types of accredited assessment activities under Category 3. This document outlines the accreditation standards and approval process for:

Healthcare practitioner documentation and verification requirements

To receive CPD credits, healthcare practitioners must document each learning activity in the CPD Portfolio provided by the Department of Healthcare Professions – Accreditation Section (DHP-AS).

The certificate of attendance provided by the CPD provider organization must be provided to the DHP-AS

by the healthcare practitioner upon request.

Knowledge Assessment Programs

Approval process:

All knowledge assessment programs developed for inclusion within Category 3 of the DHP-AS’s CPD

Framework, must be either:

• Reviewed and approved by the DHP-AS or
• Be developed by a DHP accredited CPD provider fulfilling and complying with the DHP-AS standards.

The materials used to promote or advertise accredited knowledge assessment programs must include the accreditation statement:

“This program is an Accredited Knowledge Assessment Program (Category 3) as defined by the

Department of Healthcare Professions - Accreditation Section and is approved for xx hours”.

Accredited Knowledge Assessment Programs in Category 3 are approved for a maximum of three years from the start date of the activity.

Accreditation of knowledge assessment programs may not be granted retroactively.

Knowledge assessment programs are designed to assess knowledge or the application of knowledge in specific areas, topics or domains. Knowledge assessment programs use structured formats, such as multiple-choice or short-answer questions, that may include a clinical scenario, and require participants

to select the appropriate response. Participants receive feedback on the answers they selected to provide opportunities to identify areas for improvement and future learning.

The DHP-AS CPD Framework values the role of knowledge assessment programs as an innovative formative assessment strategy for the continuing professional development of healthcare practitioners.

Required documentation to be provided to all participants

A certificate of participation or written confirmation signed by the chair of the Scientific Planning Committee must be issued for all assessment activities. The certificate of participation must specify the following elements:

The organization that developed the knowledge assessment program is responsible to determine the actual number of hours that each learner is eligible to record for credit.

The organization that developed the knowledge assessment program is responsible for maintaining all records (including participation records) for a 6-year period.

Accreditation Standards:

Accredited knowledge assessment programs must meet each of the following standards:

Part A: Administrative Standards

All accredited knowledge assessment programs must meet the following administrative standards.

KAP Administrative Standard 1.1: All accredited knowledge assessment programs must be developed by an eligible organization as defined by the DHP-AS.

Eligible organizations include:

• Governmental or non-governmental healthcare professional academic institutions (or those involved in the education of healthcare professionals). Includes organizations that are eligible to become registered/licensed within the next two years.
• Governmental or non-governmental healthcare facilities. Includes organizations that are eligible to become registered/licensed within the next two years.
• Other organizations as defined by the DHP-AS.

KAP Administrative Standard 1.2: All accredited knowledge assessment programs must have a scientific planning committee (SPC) that is representative of the intended target audience.

The membership of the scientific planning committee (SPC) responsible for the planning process must be representative of the target audience. The target audience is defined as the group of healthcare practitioners whose needs the assessment activity is designed to address. Therefore the target audience must be identified before the planning process has been initiated to enable the membership of the SPC to be chosen accordingly.

There is no minimum or maximum number of members required to sit on the SPC. If the CPD activity is aimed at only one type of healthcare practitioner, demographic factors (for example urban versus rural practice) should be considered in selecting the appropriate mix of members for the SPC.

The SPC is ultimately responsible for the following program elements:

• Identifying the educational (learning) needs of the target audience.
• Identifying the relevant knowledge areas to be covered.
• Developing the educational objectives based on the identified learning needs.
• Selecting the assessment methodology (MCQ, SAQ etc.).
• Selecting the authors to develop the questions, content and best answers.
• Developing the content or evidence.
• Determining how feedback will be provided to participants.
• Evaluating the outcomes of the activity.

KAP Administrative Standard 1.3: All accredited knowledge assessment programs must maintain participation records and provide participants with a certificate of participation that includes the appropriate accreditation statement.

A certificate of participation or written confirmation signed by the chair of the Scientific Planning Committee must be issued for all assessment activities. The certificate of participation must specify the following elements:

The organization that developed the knowledge assessment program is responsible to determine the actual number of hours that each learner is eligible to record for credit.

The organization that developed the knowledge assessment program is responsible for maintaining attendance records for a 6-year period.

Part B: Educational Standards

All accredited knowledge assessment programs must be developed to meet each of the following educational standards:

KAP Educational Standard 1.1: All accredited knowledge assessment programs must be planned to address the identified learning needs of the target audience.

A needs assessment of members of the target audience must be performed to identify areas of current or new knowledge or application of knowledge the program intends to address.

The needs assessments strategies can include multiple sources of data including, but not limited to, participant surveys, focus groups, review of evaluation forms; literature reviews; formal assessments of knowledge, competence, performance or quality of care provided to patients. The needs assessment should be used to inform the:

• development of learning objectives.
• selection of learning formats.
• development of the relevant educational content.
• creation of the evaluation strategies.

KAP Educational Standard 1.2: Learning objectives must be created for the overall program or individual modules (if applicable). The learning objectives must be written from the learner’s perspective to clearly describe what information or skill(s) learners will acquire by participating in the activity and be provided to potential participants prior to starting the knowledge assessment program.

The SPC must ensure that the identified learning needs of the target audience are utilized in the development of the learning objectives.

KAP Educational Standard 1.3: All accredited knowledge assessment programs must provide methods that enable participants to compare their knowledge, clinical judgment or attitudes against current scientific evidence in each area or domain.

Accredited knowledge assessment programs must be developed to provide a thorough review of the current scientific evidence for all knowledge areas or domains selected for inclusion.

KAP Educational Standard 1.4 All accredited knowledge assessment programs must provide participants with a process to record their answers to the assessment questions.

Recording answers to each assessment question will enable the knowledge assessment program to provide participants with a summary of their responses to each question.

KAP Educational Standard 1.5: All accredited knowledge assessment programs must provide detailed feedback to participants on their performance.

Accredited knowledge assessment programs must provide participants with specific feedback on their responses (answers which were correct and incorrect) with references that support the correct response based on, for example, evidence from systematic reviews, meta-analysis or clinical practice guidelines. This feedback supports the identification of areas of knowledge, attitudes or clinical judgment that could serve as the basis for future learning activities.

KAP Educational Standard 1.6:All accredited knowledge assessment programs must support participants to reflect on the outcomes for their practice.

Participants can be provided with either:

• an explanation for how to review and interpret the results
• guidance on how to identify areas for further learning.
• An action plan or commitment to change tool.

KAP Educational Standard 1.7: Participants must be provided with an opportunity to evaluate the overall program and each individual module (if applicable).

Accredited knowledge assessment programs must provide participants with an opportunity to evaluate the overall program and each individual module (if applicable). The evaluation system must provide participants with an opportunity to assess:

• whether the overall and individual module learning objectives were met;
• the potential impact of the activity for their practice;
• if the content was balanced and free of commercial or other sources of bias;
• if authors and members of the SPC disclosed their relationships as required by the DHP-AS Conflict of Interest Declaration Policy.

Part C: Ethical Standards

All accredited knowledge assessment programs must adhere to the DHP-AS Ethical Standards for Accredited CPD Activities.

Accreditation Standards: At-A-Glance

Part A: Administrative Standards

• KAP Administrative Standard 1.1: All accredited knowledge assessment programs must be developed by an eligible organization as defined by the DHP-AS.
• KAP Administrative Standard 1.2: All accredited knowledge assessment programs must have a scientific planning committee (SPC) that is representative of the intended target audience.
• KAP Administrative Standard 1.3: All accredited knowledge assessment programs must maintain participation records and provide participants with a certificate of participation that includes the appropriate accreditation statement.

Part B: Educational Standards

• KAP Educational Standard 1.1: All accredited knowledge assessment programs must be planned to address the identified learning needs of the target audience.
• KAP Educational Standard 1.2: Learning objectives must be created for the overall program or individual modules (if applicable). The learning objectives must be written from the learner’s perspective to clearly describe what information or skill(s) learners will acquire by participating in the activity and be provided to potential participants prior to the learning activity.
• KAP Educational Standard 1.3: All accredited knowledge assessment programs must provide methods that enable participants to demonstrate or apply their knowledge, clinical judgment or attitudes.
• KAP Educational Standard 1.4 All accredited knowledge assessment programs must provide participants with a process to record their answers to the assessment questions.
• KAP Educational Standard 1.5: All accredited knowledge assessment programs must provide detailed feedback to participants on their performance.
• KAP Educational Standard 1.6: All accredited knowledge assessment programs must support participants to reflect on the outcomes for their practice.
• KAP Educational Standard 1.7: Participants must be provided with an opportunity to evaluate the overall program and each individual module (if applicable).

Part C: Ethical Standards

• All accredited knowledge assessment programs must adhere to the DHP-AS Ethical Standards for Accredited CPD Activities.

Accredited Simulation Activities

Approval process:

All accredited simulation activities developed for inclusion within Category 3 of DHP-AS’s CPD Framework,

must be either:

• Reviewed and approved by the DHP-AS or
• Be developed by a DHP accredited CPD provider fulfilling and complying with the DHP-AS standards.

The materials used to promote or advertise accredited simulation activities (such as a program brochure)

must include the accreditation statement:

“This is an Accredited Simulation Activity (Category 3) as defined by the Department of Healthcare

Professions - Accreditation Section and is approved for a maximum of xx hours”.

Accredited simulation activities are approved for a maximum of three years from the start date of the activity.

Simulation activities are designed to reflect real life situations to enable participants to demonstrate and receive feedback on their clinical reasoning, communication, situational awareness, problem solving and (where applicable) their ability to collaborate and work effectively within a healthcare team. Simulation activities reflect a range of options including role playing, use of standardized patients, task trainers, virtual simulation, haptic simulation, theatre simulation or hybrids of any of these examples.

The DHP-AS CPD Framework values the role of simulation as an innovative formative assessment strategy for the continuing professional development of healthcare practitioners.

Required documentation to be provided to all activity participants

A certificate of participation or written confirmation signed by the chair of the Scientific Planning Committee must be issued for all assessment activities. The certificate of participation must specify the following elements:

The organization that developed the simulation activity is responsible for maintaining all records

(including participation records) for a 6-year period.

Accreditation Standards:

Accredited simulation activities must meet each of the following standards:

Part A: Administrative Standards

All accredited simulation activities must meet the following administrative standards.

SA Administrative Standard 1.1: All accredited simulation activities must be must be developed by an eligible organization as defined by the DHP-AS.

Eligible organizations include:

• Governmental or non-governmental healthcare professional academic institutions (or those involved in the education of healthcare professionals). Includes organizations that are eligible to become registered/licensed within the next two years.
• Governmental or non-governmental healthcare facilities. Includes organizations that are eligible to

become registered/licensed within the next two years.

• Other organizations as defined by the DHP-AS.

(Note: Only locally-developed CPD activities are eligible for DHP-AS CPD accreditation).

SA Administrative Standard 1.2: All accredited simulation activities must be have a scientific planning committee (SPC) that is representative of the intended target audience and includes individuals with expertise in simulation development.

The membership of the scientific planning committee (SPC) responsible for the planning process must be representative of the target audience. The target audience is defined as the group of healthcare practitioners whose needs the assessment activity is designed to address. Therefore the target audience must be identified before the planning process has been initiated to enable the membership of the SPC to be chosen accordingly.

There is no minimum or maximum number of members required to sit on the SPC. If the CPD activity is aimed at only one type of healthcare practitioner, demographic factors (for example urban versus rural practice) should be considered in selecting the appropriate mix of members for the SPC.

The SPC is ultimately responsible for the following program elements:

• Identifying the educational (learning) needs of the target audience.
• Identifying the relevant competency areas that will be assessed.
• Developing the educational objectives based on the identified learning needs.
• Selecting the technology that will be used in the assessment.
• Developing the content or evidence.
• Determining how feedback will be provided to participants.
• Evaluating the outcomes of the activity.

SA Administrative Standard 1.3: All accredited simulation activities must maintain participation records and provide participants with a certificate of participation that includes the appropriate accreditation statement.

A certificate of participation or written confirmation signed by the chair of the Scientific Planning Committee must be issued for all simulation activities. The certificate of participation must specify the following elements:

1. 1. The title and code of the simulation activit
2. 2. The name and code of the organization(s) that developed the simulation activit
3. 3. The date(s) the simulation activity took place.
4. 4. The location of the simulation activity (i.e. city, country, web-based).
5. 5. The total number of hours the simulation activity is accredited for.
6. 6. The number of hours the learner participated in the simulation activit
7. 7. The applicable accreditation statement.
8. 8. The logo of the MoPH.
9. 9. The logo of the organization(s) that developed the simulation activit

The organization that developed the simulation activity is responsible to determine the actual number of hours that each learner is eligible to record for credit.

The organization that developed the simulation activity is responsible for maintaining attendance records for a 6-year period.

Part B: Educational Standards

All accredited simulation activities must be developed to meet each of the following educational standards:

SA Educational Standard 1.1:All accredited simulation activities must be planned to address the identified learning needs of the target audience.

A needs assessment of the target audience must be performed to identify important areas for assessment of competence or performance or the degree that competence and performance varies across healthcare practitioners or where there is variation in the quality of care experienced by patients.

The needs assessments strategies can include multiple sources including, but not limited to, participant surveys, focus groups or evaluation forms; literature reviews; assessments of knowledge, competence, performance or quality of care provided to patients. The needs assessment should be used to inform the:

• development of learning objectives.
• selection of learning formats.
• development of the relevant educational content.
• creation of the evaluation strategies.

SA Educational Standard 1.2:Learning objectives must be created and provided to potential participants prior to the simulation activity. The learning objectives must be written from the learner’s perspective to clearly describe what outcome(s) or skill(s) learners will acquire from participating in the simulation activity.

The SPC must ensure that the identified learning needs of the target audience are utilized in the development of the learning objectives.

SA Educational Standard 1.3:All accredited simulation activities must describe the method(s) that will enable participants to demonstrate their abilities, skills, clinical judgment or attitudes.

Accredited simulation activities must provide participants with an opportunity to demonstrate their abilities/competencies across the key areas of the simulation activity. Participants must complete all components of the activity.

SA Educational Standard 1.4:All accredited simulation activities must provide detailed feedback to participants on their performance.

Feedback must be provided to an individual or team on how their individual or collective performance compared to competencies or performance established for practice. The purpose of providing specific feedback is to enable participants to identify areas for improvement and the creation of a future learning plan.

The provision of tools to structure the reflection on performance and time for personal reflection is encouraged.

For online accredited simulation activities:

For live accredited simulation activities:

SA Educational Standard 1.5:Participants must be provided with an opportunity to evaluate the accredited simulation activity.

Accredited simulation activities must provide participants with an opportunity to evaluate the activity. The evaluation system must allow or invite participants to assess:

• whether the learning objectives were met;
• the relevance of the simulation activity to their practice;
• the appropriateness of the scenario;
• whether instructors evaluated the competencies, skills and/or attitudes.
• whether instructors provided feedback on performance;
• whether the simulation activity provided sufficient time for instruction, practice and debrief.
• whether facilitators and/or authors disclosed their relationships as required by the DHP-AS Conflict of Interest Declaration Policy.

Part C: Ethical Standards

All accredited simulation activities must adhere to the DHP-AS Ethical Standards for Accredited CPD Activities.

Accreditation Standards: At-A-Glance

Part A: Administrative Standards

• SA Administrative Standard 1.1: All accredited simulation activities must be must be developed by an eligible organization as defined by the DHP-AS.
• SA Administrative Standard 1.2: All accredited simulation activities must be have a scientific planning committee (SPC) that is representative of the intended target audience and includes individuals with expertise in simulation development.
• SA Administrative Standard 1.3: All accredited simulation activities must maintain participation records and provide participants with a certificate of participation that includes the appropriate accreditation statement.

Part B: Educational Standards

• SA Educational Standard 1.1: All accredited simulation activities must be planned to address the identified learning needs of the target audience.
• SA Educational Standard 1.2: Learning objectives must be created for the simulation activity. The learning objectives must be written from the learner’s perspective to clearly describe what outcome(s) or skill(s) learners will acquire by participating in the activity and be provided to potential participants prior to the learning activity.
• SA Educational Standard 1.3: All accredited simulation activities must describe the methods that enable participants to demonstrate or apply their knowledge, skills, clinical judgment or attitudes.
• SA Educational Standard 1.4: All accredited simulation activities must provide detailed feedback to participants on their performance.
• SA Educational Standard 1.5: Participants must be provided with an opportunity to evaluate the accredited simulation activity.

Part C: Ethical Standards

• All accredited simulation activities must adhere to the DHP-AS Ethical Standards for Accredited

CPD Activities.

Multisource Feedback Instruments

Approval process:

All multisource feedback instruments developed for inclusion within Category 3 of DHP-AS’s CPD

Framework must be either:

• Reviewed and approved by the DHP-AS or
• Be developed by a DHP accredited CPD provider fulfilling and complying with the DHP-AS standards.

The materials used to promote or advertise accredited multisource feedback instruments must include the accreditation statement:

“This multisource feedback instrument is an accredited assessment activity (Section 3) as defined by the

Department of Healthcare Professions - Accreditation Section and is approved for xx hours.”

Accredited multisource feedback instruments in Category 3 are approved for a maximum of three years from the start date of the activity.

Accreditation of multisource feedback instruments may not be granted retroactively.

Multisource feedback (MSF), or 360-degree evaluation, is a questionnaire-based assessment method in which peers, patients, and colleagues or co-workers provide ratings on key performance behaviors. MSF assessments can generate reliable data with a reasonable number of respondents and research has shown that participants will use the feedback to contemplate and initiate changes in practice. MSF tools are particularly helpful to assess interpersonal, communication, professionalism, or teamwork behaviors.

The DHP-AS CPD Framework values the role of MSF as a formative assessment strategy for the continuing professional development of healthcare practitioners.

Required documentation to be provided to all participants

A certificate of completion or written confirmation of completion must be issued for all assessment activities. The certificate of completion must specify the following elements:

1. 1. The title and code of the multi-source feedback instrument.
2. 2. The name and code of the organization(s) that developed the MSF instrument.
3. 3. The date(s) the multi-source feedback assessment took place.
4. 4. The location of the multi-source feedback assessment (i.e. city, country, web-based).
5. 5. The total number of hours the multi-source feedback assessment is accredited for.
6. 6. The number of hours the learner participated in the multi-source feedback assessment.
7. 7. The applicable accreditation statement.
8. 8. The logo of the MoP
9. 9. The logo of the organization(s) that developed the multi-source feedback instrument.

The organization that developed the multisource feedback instruments is responsible to determine the actual number of hours that each learner is eligible to record for credit.

The organization that developed the multisource feedback instruments is responsible for maintaining all records (including participation records) for a 6-year period.

Accreditation Standards:

Accredited multisource feedback instruments must meet each of the following standards:

Part A: Administrative Standards

All accredited multisource feedback instruments must meet the following administrative standards.

MSFI Administrative Standard 1.1:All accredited multisource feedback instruments must be developed by an eligible organization as defined by the DHP-AS.

Eligible organizations include:

• Governmental or non-governmental healthcare professional academic institutions (or those involved in the education of healthcare professionals). Includes organizations that are eligible to become registered/licensed within the next two years.
• Governmental or non-governmental healthcare facilities. Includes organizations that are eligible to

become registered/licensed within the next two years.

• Other organizations as defined by the DHP-AS.

(Note: Only locally-developed CPD activities are eligible for DHP-AS CPD accreditation).

MSFI Administrative Standard 1.2 All accredited multisource feedback instruments must have a planning group responsible for overseeing the development and implementation of the multi- source feedback instrument.

The individual(s) who are responsible for the implementation and/or development of the multisource feedback instruments are responsible for the following elements:

• Defining the purpose of the multisource feedback instrument.
• Identifying the relevant competency areas that will be assessed.
• Selecting the data collection tools.
• Determining how feedback will be provided to participants.
• Ensuring that the instrument meets established expectations for validity and reliability.
• Evaluating the impact of the instrument.

MSFI Administrative Standard 1.3:All accredited multisource feedback instruments must have been assessed against one or more measures of validity.

All accredited multisource feedback instruments must have been tested to determine at least one measure of validity (for example face validity, content validity, construct validity or predictive validity). The planning group must ensure that appropriate measures of validity have been assessed.

MSFI Administrative Standard 1.4: All accredited multisource feedback instruments must maintain participation records and provide participants with a certificate of completion that includes the appropriate accreditation statement.

A certificate of completion or written confirmation of completion must be issued for all multi-source feedback activities. The certificate of completion must specify the following elements:

The organization that developed the multisource feedback instruments is responsible to determine the actual number of hours each learner is eligible to record for credit.

The organization that developed the multisource feedback instruments is responsible for maintaining attendance records for a 6-year period.

Part B: Educational Standards

All multisource feedback instruments must be developed to meet each of the following educational standards:

MSFI Educational Standard 1.1: All accredited multisource feedback instruments must be planned to address a defined set of competencies relevant to the practice of the target audience.

Multisource feedback instruments must ensure that the behaviors being examined are observable by selected healthcare practitioners and the ratings are based on observations of the healthcare practitioner’s in practice.

MSFI Educational Standard 1.2:The purpose of the multisource feedback instrument must be communicated on materials available to each participant.

The defined purpose of the multisource feedback instrument will allow healthcare practitioners to determine the relevance of the expected outcomes for their practice.

MSFI Educational Standard 1.3:All accredited multisource feedback instruments must provide a detailed summary of the findings to participants.

Feedback must be based on the specific behaviors or competencies being assessed.

Providing specific feedback to each individual on their demonstration of the specific behaviors being assessed provides an opportunity for participants to identify areas for improvement and/or the creation of a future learning plan.

The provision of tools to structure reflection on the outcomes or the opportunity to discuss the feedback with a preceptor, mentor or coach is encouraged.

MSFI Educational Standard 1.4: All accredited multisource feedback instruments must provide participants with an opportunity to evaluate the activity.

Accredited multisource feedback instruments must provide participants with an opportunity to evaluate the activity. The evaluation system must allow or provide opportunities for participants to assess:

• whether the defined purpose was achieved;
• the potential impact of the activity for their practice;
• the relevance or appropriateness of the multisource feedback data to their practice;
• the utility of the feedback provided to assess specific behaviors or competences;
• the multi-source feedback enabled the identification of areas for future improvement. Additional evaluation strategies, where applicable, may be based on:
• measures of improved healthcare practitioner competence or performance;
• measures of improved healthcare outcomes;

Part C: Ethical Standards

All accredited multisource feedback instruments must adhere to the DHP-AS Ethical Standards for Accredited CPD Activities.

Accreditation Standards: At-A-Glance

Part A: Administrative Standards

• MSFI Administrative Standard 1.1: All accredited multisource feedback instruments must be developed by an eligible organization as defined by the DHP-AS.
• MSFI Administrative Standard 1.2 All accredited multisource feedback instruments must have a planning group responsible for overseeing the development and implementation of the multi-source feedback instrument.
• MSFI Administrative Standard 1.3: All accredited multisource feedback instruments must maintain participation records and provide participants with a certificate of completion that includes the appropriate accreditation statement.

Part B: Educational Standards

• MSFI Educational Standard 1.1: All accredited multisource feedback instruments must be planned to address a defined set of competencies relevant to the practice of the target audience.
• MSFI Educational Standard 1.2: The purpose of the multisource feedback instrument must be communicated on materials available to each participant.
• MSFI Educational Standard 1.3: All accredited multisource feedback instruments must provide a detailed summary of the findings to participants.
• MSFI Educational Standard 1.4: All accredited multisource feedback instruments must provide participants with an opportunity to evaluate the activity.

Part C: Ethical Standards

• All accredited multisource feedback instruments must adhere to the DHP-AS Ethical Standards for Accredited CPD Activities.

Clinical Audit Activities

Approval process:

All clinical audit activities developed for inclusion within Category 3 of DHP-AS’s CPD Framework, must be either:

• Reviewed and approved by the DHP-AS or
• Be developed by a DHP accredited CPD provider fulfilling and complying with the DHP-AS standards.

The materials used to promote or advertise accredited clinical audit activities must include the accreditation statement:

“This is an accredited clinical audit activity (Category 3) as defined by the Department of Healthcare

Professions - Accreditation Section and is approved for xx hours”.

Accredited clinical audit activities in Category 3 are approved for a maximum of three years from the start date of the activity.

Accreditation of clinical audit activities may not be granted retroactively.

Clinical audit activities provide a process for data collection and provision of feedback to individual healthcare practitioners, groups of healthcare practitioners or inter-professional healthcare teams related to how their performance aligns with established practice standards. Clinical audit activities measure current performance against established measures and the feedback provided facilitates the identification of areas where performance meets or exceeds expectations and areas where improvement is either desirable or helpful to improve the outcomes for patients.

The DHP-AS CPD Framework values the role of clinical audit as a formative assessment strategy for the continuing professional development of healthcare practitioners.

Required documentation to be provided to all activity participants

A certificate of completion or written confirmation of completion must be issued for all assessment activities. The certificate of completion must specify the following elements:

1. 1. The title and code of the clinical audit activit
2. 2. The name and code of the organization(s) that developed the clinical audit activity.
3. 3. The date(s) the clinical audit activity took place.
4. 4. The location of the clinical audit activity (e. city, country, web-based).
5. 5. The total number of hours the clinical audit activity is accredited for.
6. 6. The number of hours the learner participated in the clinical audit activit
7. 7. The applicable accreditation statement.
8. 8. The logo of the MoPH.
9. 9. The logo of the organization(s) that developed the clinical audit activity.

The organization that developed the clinical audit activity is responsible to determine the actual number of hours that each learner is eligible to record for credit.

The organization that developed the clinical audit activity is responsible for maintaining all records

(including participation records) for a 6-year period.

Accreditation Standards:

Accredited clinical audit activities must meet each of the following standards:

Part A: Administrative Standards

All accredited clinical audit activities must meet the following administrative standards.

CAA Administrative Standard 1.1:All accredited clinical audit activities must be developed by an eligible organization as defined by the DHP-AS.

Eligible organizations include:

• Governmental or non-governmental healthcare professional academic institutions (or those involved in the education of healthcare professionals). Includes organizations that are eligible to become registered/licensed within the next two years.
• Governmental or non-governmental healthcare facilities. Includes organizations that are eligible to become registered/licensed within the next two years.
• Other organizations as defined by the DHP-AS.

(Note: Only locally-developed CPD activities are eligible for DHP-AS CPD accreditation).

CAA Administrative Standard 1.2 All accredited clinical audit activities must have a clinical audit committee that is responsible for developing the clinical audit activity.

The clinical audit committee is responsible for the following elements:

• Defining the purpose of the clinical audit activity
  
• Identifying the relevant competency areas that will be assessed.
• Identifying the measure(s) that will be used to assess competence or performance
• Selecting the data collection tools.
• Determining the number of patient encounters that will be included.
• Determining how feedback will be provided to participants.
• Evaluating the outcomes of the activity.

CAA Administrative Standard 1.3: All clinical audit activities must maintain participation records and provide participants with a certificate of participation that includes the appropriate accreditation statement.

A certificate of completion or written confirmation of completion must be issued for all assessment activities. The certificate of completion must specify the following elements:

The organization that developed the clinical audit activity is responsible to determine the actual number of hours that each learner is eligible to record for credit.

The organization that developed the clinical audit activity is responsible for maintaining attendance records for a 6-year period.

Part B: Educational Standards

All approved clinical audit instruments must be developed to meet the following educational standards:

CAA Educational Standard 1.1:All accredited clinical audit activities must be planned to assess a defined set of performance (process or outcome) measures relevant to the practice of the target audience.

Accredited clinical audit activities must ensure that the performance measures being assessed are appropriate, in direct control of healthcare practitioners, and where applicable, relevant to the clinical outcomes of patients.

CAA Educational Standard 1.2:The purpose of the clinical audit activity must be communicated on materials available to each participant.

The defined purpose of the clinical audit activity will allow healthcare practitioners to determine the relevance of the expected outcomes for their practice.

CAA Educational Standard 1.3:All accredited clinical audit activities must include a mechanism to provide a detailed summary of performance in comparison to established standards with feedback.

Providing summary data with specific feedback on the performance of an individual healthcare practitioner, a group of healthcare practitioners or an inter-professional team will allow participants to identify areas of practice that require improvement. Feedback must facilitate reflection on performance and enable the development of a future learning plan.

CAA Educational Standard 1.4:All accredited clinical audit activities must provide participants with an opportunity to evaluate the activity.

Accredited clinical audit activities must provide participants with an opportunity to evaluate the activity. The evaluation system must provide participants with an opportunity to assess:

• whether the defined purpose was achieved;
• the potential impact of the clinical audit activity for their practice;
• whether the audit process or measures selected were balanced and free of sources of bias;
• the utility of the feedback;
• if the clinical audit enabled the identification of areas for future improvement;

Part C: Ethical Standards

All accredited clinical audit activities must adhere to the DHP-AS Ethical Standards for Accredited CPD Activities.

Accreditation Standards: At-A-Glance

Part A: Administrative Standards

• CAA Administrative Standard 1.1: All accredited clinical audit activities must be developed by an eligible organization as defined by the DHP-AS.
• CAA Administrative Standard 1.2 All accredited clinical audit activities must have a clinical audit committee that is responsible for developing the clinical audit activity.
• CAA Administrative Standard 1.3: All clinical audit activities must maintain participation records and provide participants with a certificate of participation that includes the appropriate accreditation statement.

Part B: Educational Standards

• CAA Educational Standard 1.1: All accredited clinical audit activities must be planned to assess a defined set of performance (process or outcome) measures relevant to the practice of the target audience.
• CAA Educational Standard 1.2: The purpose of the clinical audit activity must be communicated on materials available to each participant.
• CAA Educational Standard 1.3: All accredited clinical audit activities must include a mechanism to provide a detailed summary of performance in comparison to established standards with feedback.
• CAA Educational Standard 1.4: All accredited clinical audit activities must provide participants with an opportunity to evaluate the activity.

Part C: Ethical Standards

• All accredited clinical audit activities must adhere to the DHP-AS Ethical Standards for Accredited CPD Activities.

Direct Observation Assessment Instruments

Approval process:

All direct observation assessment instruments developed for inclusion within Category 3 of DHP-AS’s CPD

Framework, must be either:

• Reviewed and approved by the DHP-AS or
• Be developed by a DHP accredited CPD provider fulfilling and complying with the DHP-AS standards.

The materials used to promote or advertise accredited direct observation assessment instruments must include the accreditation statement:

“This is an accredited assessment activity (Category 3) as defined by the Department of Healthcare

Professions - Accreditation Section and is approved for xx hours”.

Accredited direct observation assessment instruments in Category 3 are approved for a maximum of three years from the start date of the activity.

Accreditation of direct observation assessment instruments may not be granted retroactively.

Direct observation of clinical or procedural skills is an important process in providing individual healthcare practitioners direct feedback of how their performance aligns with established standards. Direct observation assessment instruments measure current performance against established standards and provide opportunities for feedback to identify areas where performance meets or exceeds expectations and areas where improvement is either desirable or helpful to improve the outcomes for patients.

The DHP-AS CPD Framework values the inclusion of direct observational instruments as a component of a formative assessment strategy to support the continuing professional development of healthcare practitioners.

Required documentation to be provided to all participants

A certificate of completion or written confirmation of completion must be issued for all direct observation assessment activities. The certificate of completion must specify the following elements:

The organization that developed the direct observation assessment instrument is responsible to determine the actual number of hours that each learner is eligible to record for credit.

The organization that developed the direct observation assessment instrument is responsible for maintaining all records (including participation records) for a 6-year period.

Accreditation Standards:

Accredited direct observation assessment instruments must meet each of the following standards:

Part A: Administrative Standards

All accredited direct observation assessment instruments must meet the following administrative standards.

DOAI Administrative Standard 1.1:All accredited direct observation assessment instruments must be developed by an eligible organization as defined by the DHP-AS.

Eligible organizations include:

• Governmental or non-governmental healthcare professional academic institutions (or those involved in the education of healthcare professionals). Includes organizations that are eligible to become registered/licensed within the next two years.
• Governmental or non-governmental healthcare facilities. Includes organizations that are eligible to

become registered/licensed within the next two years.

• Other organizations as defined by the DHP-AS.

(Note: Only locally-developed CPD activities are eligible for DHP-AS CPD accreditation).

DOAI Administrative Standard 1.2 All accredited direct observation assessment instruments must have a planning group that is responsible for developing the instrument.

The individual(s) who develop the direct observation assessment instrument are responsible for the following elements:

• Defining the purpose of the direct observation assessment instrument.
• Identifying the relevant competency areas that will be assessed.
• Identifying the measure(s) that will be used to assess competence or performance
• Selecting the data collection tools.
• Determining the number of clinical encounters that will be included Determining how feedback will be provided to participants.
• Evaluating the outcomes of the direct observation activity.

DOAI Administrative Standard 1.3: All accredited direct observation assessment instruments must maintain participation records and provide participants with a certificate of participation that includes the appropriate accreditation statement.

A certificate of completion or written confirmation of completion must be issued for all assessment activities. The certificate of completion must specify the following elements:

The organization that developed the direct observation assessment instrument is responsible to determine the actual number of hours that each learner is eligible to record for credit.

The organization that developed the direct observation assessment instrument is responsible for maintaining attendance records for a 6-year period.

Part B: Educational Standards

All direct observation assessment instruments must be developed to meet each of the following educational standards

DOAI Educational Standard 1.1:Each direct observation assessment instrument must be planned to assess performance (process or outcome) measures relevant to the practice of the target audience.

Direct observation assessment instruments must ensure that the performance measures being assessed are appropriate, are performed by healthcare practitioners, and where applicable, relevant to the clinical outcomes of patients.

DOAI Educational Standard 1.2:The purpose of the direct observation assessment instrument must be communicated on materials available to each participant.

The purpose of the direct observation assessment instrument will allow healthcare practitioners to determine the relevance of the expected outcomes for their practice.

DOAI Educational Standard 1.3: All direct observation assessment instruments must include a mechanism to provide a detailed summary of performance in comparison to established standards with feedback.

Providing summary data with specific feedback on the performance to participants will allow each healthcare practitioner to identify areas for improvement. Feedback must facilitate reflection on performance and enable the development of a future learning plan.

DOAI Educational Standard 1.4: All direct observation assessment instruments must provide participants with an opportunity to evaluate the activity.

Accredited direct observation assessment instruments must provide participants with an opportunity to evaluate the activity. The evaluation system must provide an opportunity for participants to assess:

• whether the defined purpose was achieved;
• the potential impact of the direct observation activity for their practice;
• the relevance or appropriateness of the assessment process or measures selected for their practice;
• the utility of the feedback provided;
• if the direct observation activity enabled identification of areas for future improvement;

Part C: Ethical Standards

All accredited direct observation assessment instruments must adhere to the DHP-AS Ethical Standards for Accredited CPD Activities.

Accreditation Standards: At-A-Glance

Part A: Administrative Standards

• DOAI Administrative Standard 1.1: All accredited direct observation assessment instruments must be developed by an eligible organization as defined by the DHP-AS.
• DOAI Administrative Standard 1.2 All accredited direct observation assessment instruments must have a planning group that is responsible for developing the instrument.
• DOAI Administrative Standard 1.3: All accredited direct observation assessment instruments must maintain participation records and provide participants with a certificate of participation that includes the appropriate accreditation statement.

Part B: Educational Standards

• DOAI Educational Standard 1.1: Each direct observation assessment instrument must be planned to assess performance (process or outcome) measures relevant to the practice of the target audience.
• DOAI Educational Standard 1.2: The purpose of the direct observation assessment instrument must be communicated on materials available to each participant.
• DOAI Educational Standard 1.3: All direct observation assessment instruments must include a mechanism to provide a detailed summary of performance in comparison to established standards with feedback.
• DOAI Educational Standard 1.4: All direct observation assessment instruments must provide participants with an opportunity to evaluate the activity.

Part C: Ethical Standards

• All accredited direct observation assessment instruments must adhere to the DHP-AS Ethical

Standards for Accredited CPD Activities.