Policy

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Audit and Monitoring Policy

Background

CPD Home is committed to supporting its subscribers to:

undertake meaningful professional development
meet their Continuing Professional Development (CPD) requirements under the Medical Board of Australia (MBA) Registration Standard: Continuing Professional Development (the Standard)
easily demonstrate that they have done so should they be audited by the MBA or AMA CPD Home.

CPD Home under the Criteria for AMC Accreditation of CPD Homes is required to regularly audit medical practitioners’ CPD records to assess the completeness of evidence and educational quality of activities undertaken.

CPD Home is also committed to the continuous improvement of its CPD Program of Learning (CPD Program) and the services it provides to its subscribers. CPD Home’s audit of subscribers will also facilitate the identification of trends or provide an indication of where our CPD Program or service provision could be improved.

Purpose

In auditing subscribers, CPD Home:

demonstrates its compliance with the Criteria for AMC Accreditation of CPD Homes
provides an accountability mechanism that supports and substantiates participating subscribers’ compliance with the MBA’s Registration Standard: Continuing professional development (the Standard)
provides assurance to the community that the CPD activities participating subscribers undertake are relevant to their registered scope of practice and aimed at improving their practice
enables early identification of subscribers who may need support with:
- preparing their written continuing professional development (CPD) plan
- identifying compliant CPD activities
- progressing, recording, verifying and keeping track of these activities against the Standard, or
- accessing some other intervention afforded in response to an exceptional circumstance and
provides a mechanism for informing its own quality improvement activities.

Objective

To inform subscribers how CPD Home will fulfil its audit obligations as a CPD home, and to outline the process for undertaking audits to monitor and support subscribers’ progression to completion of their CPD requirements.

Scope

This policy applies to all subscribers of CPD Home.

Definitions

Please refer to the Glossary for definition(s) of terms that apply to this policy.

Subscriber monitoring

CPD Home will monitor 100% of participating subscribers CPD completions, to ensure they are compliant with and tracking towards meeting their annual CPD requirements.

Where participating subscribers are identified as being at risk of not meeting their CPD requirements for the CPD year, CPD Home will contact the subscriber to encourage engagement and provide any required support and guidance.

In line with our Compliance and Remediation policies we will work with participating subscribers to eliminate any gaps in compliance and to minimise the administrative impact in the event they are selected for audit by the MBA and / or CPD Home.

CPD Home will complete quarterly audit runs to monitor 100% of subscribers progress towards meeting their CPD requirements.

Subscribers granted a CPD exemption will continue to be monitored via quarterly audit runs. However, they will be excluded from automated notifications and instead will be followed up by CPD Home as appropriate to the conditions of their variation or referral.

Subscriber audits

In the first quarter of each CPD year commencing 2024, CPD Home will audit at least 5% of its subscribers from the previous CPD year to ensure CPD compliance against the Standard. These audits will be conducted randomly save for subscribers who are exempt from participating. Any trends emerging from the CPD Home audits will be analysed and reported to Management for quality improvement and ensuring adequate resourcing.

Action

Subscriber monitoring

Subscribers will be assessed as at risk of not meeting their CPD requirements for the CPD year against the following criteria:

Completion of a written CPD Plan (by 31 March)
Three focus topics are tagged in the CPD Plan
Planned learning activities have been identified and cover:
- at least one program-level requirement for each domain of learning, and
- if applicable, relevant specialist high-level CPD requirements
the number of hours recorded against:
- Domain 1: Educational Activities
- Domain 2: Reviewing Performance and Measuring Outcomes
Recorded reflections for completed CPD activities
Presence of accepted supporting CPD evidence.

Subscribers deemed to be at risk of not meeting their CPD Program requirements for the CPD year will be contacted by CPD Home. In contacting at risk subscribers, CPD Home will email a notification that they may be at risk of not meeting their CPD Program requirements with advice on what action to take to keep on track, including contacting CPD Home for guidance. Notifications will be prepopulated from the data extracted in the audit report.

At the end of the following month a secondary audit will be run to assess if there has been any activity by the subscriber in response to the notification. Should no activity be recorded on the CPD Tracker, the at-risk subscriber will be personally contacted by CPD Home to offer support and guidance to assist them progress towards completion. Should the subscriber be experiencing exceptional circumstances that would make them eligible for an exemption, CPD Home will offer guidance on seeking a variation to or exemption from their CPD requirements.

Quarterly audit runs to monitor 100% of subscribers will be performed as follows:

Q	End of period	Date of Primary Audit Run	Assessment Protocol	Supporting Evidence uploaded	Automated Notifications sent to at risk subscribers	Date of Secondary Audit Run	Personal Contact made
1	31/03	30/04	No written CPD Plan		Within next 5 working days	31/05	Within next 5 working days
2	30/06	30/07	Less than 50% of required CPD hours recorded	Supporting documents uploaded to 75% recorded activities	Within next 5 working days	31/08	Within next 5 working days
3	30/09	30/10	Less than 75% of required CPD hours recorded	Supporting documents uploaded to 75% recorded activities	Within next 5 working days	30/11	Within next 5 working days
4	31/12	30/01	Less than 100% of required CPD hours recorded	Supporting documents uploaded to 100% recorded activities	Within next 5 working days	28/02	Within next 5 working days

Subscriber audits

At the conclusion of the CPD year, CPD Home will audit at least 5% of subscribers in the first quarter of the following year. For each subscriber audited, CPD Home will verify the following minimum criteria is met.

Validation that the minimum number of hours have been reached for Domain 1: Educational Activities (12.5 hours) and Domain 2: Reviewing Performance (5 hours) and Measuring Outcomes (5 hours) (total 25 hours), as stated in the Medical Board of Australia Registration Standard: Continuing professional development (the Standard).
Completion of mandatory CPD activities including:
1. a written CPD Plan
2. CPD Plan reflection on learning achievements at the end of the CPD year
3. Completed CPD activities that addressed the four CAPE aspects of the Code, being Culturally Safety Practice, Addressing Health Inequities, Professionalism and Ethical Practice
4. specialist CPD high-level requirements within required periods, if relevant to the registered scope of practice.
Substantiation of the quality and relevance of completed activities.
Substantiation that completed activities are accurately recorded against the annual CPD Home Program requirements.
Substantiation that supporting evidence for each completed CPD activity is uploaded and aligns to the CPD Home Program Guide requirements.

Where a subscriber has a limited or niche scope of practice, CPD Home may convene an ad-hoc panel of peers to advise on whether the learning activities undertaken by the Subscriber being audited are relevant to their scope of practice and align with their CPD Plan.

Where a subscriber is deemed to have not met their CPD compliance requirements for the previous CPD year, appropriate steps will be put in place by CPD Home to support the Subscriber and ensure compliance by 31 March.

Appendices

Glossary

Version Tracking

Version	Date	Comments
1.0	December 2022
1.1	January 2023	Amended to include Subscriber Audit Process.
1.2	February 2023	Added guidance on when peer review of CPD activity claims by a medical practitioner with a limited or niche scope of practice may be required.
1.3	August 2023	Updated Introduction to reflect the joint ownership of CPD Home. Replaced CEO with Executive Lead to reflect current SOP. Removed unrelated glossary terms.
1.4	October 2024	Updated uploading CPD activity end date from 28 February to 31 March the following CPD year, and subscriber monitoring process. Added Definitions statement and edited glossary. Transferred roles and responsibilities to SOP. Updated minor amendments.
1.5	December 2024	Simplified ‘Subscriber Audits’ verification of criteria.
1.6	March 2025	Edited title to include ‘Monitoring’. Amended background to include AMA CPD Home as an organisation required to conduct CPD audits of its subscribers.
1.7	October 2025	Replaced Executive Lead with Management. Replaced ‘exceptional circumstances and special consideration’ with ‘exemption’. Updated glossary and made minor amendments.

Appendix 1

Glossary

Term	Definition
Audit run	SQL query report selecting key data metrics to inform CPD Home of a subscriber’s progress against their CPD requirements.
CPD Tracker	CPD Home’s online tracking tool enabling subscribers to record courses, events and other completed CPD activities. Each CPD activity record includes the length of time, area for self-reflection and optional storage of learning evidence.
CPD Home Program of Learning	The CPD Home Program of Learning (CPD Program) provides a pathway for Australian registered medical specialists, international medical graduates, PGY2+ trainees and non-vocationally registered doctors to engage in an accredited CPD program. From 1 January 2024, the CPD Program is a mandatory program for subscribers to the CPD Home service.
CPD requirements	Means CPD requirements against the Standard, as follows: develop a written annual CPD Plan complete a minimum of 50 hours per year of CPD activities that are relevant to your scope of practice and individual professional development needs allocate your minimum 50 hours per year between the following types of CPD activities at least 12.5 hours (25 percent of the minimum) in educational activities at least 25 hours (50 per cent of the minimum) in activities focused on reviewing performance and measuring outcomes, with a minimum of five hours for each category; and the remaining 12.5 hours (25 percent of the minimum), and any CPD activities over the 50-hour minimum across any of these types of CPD activities, including any relevant specialist high-level CPD requirements reflect on your CPD goals at the end of the year in preparation for your next CPD Plan retain records of your annual CPD compliance for auditing purposes by your CPD home and the MBA for three years after the end of each one-year cycle.
CPD year	CPD year commences 1 January and concludes 31 December.
Exemption	CPD requirements for the CPD year are waived in part or full.
Participating subscriber	Subscribers to CPD Home who do not have an exemption and who by default are participating in the CPD Program.
the Standard	The Medical Board of Australia’s (MBA)’s revised Registration Standard: Continuing professional development.
Variation	The hours required for CPD activities across the two domains of learning, being Domain 1: Educational Activities and Domain 2: Reviewing Performance and Measuring Outcomes as per the Standard for the CPD year, are proportionally reduced to reflect the period where the subscriber did not practise medicine.

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