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SIGNATURE DATE APPROVED
Director of Operations
Behavioral Health Services _Signature on File___ _02/03/2021______
SUBJECT:
Continuing Education Course Approval for HCA Programs
PURPOSE:
This procedure outlines the process to obtain approval from the Health Care Agency (HCA)
Continuing Education program for offering Continuing Education (CE) or Continuing Medical
Education (CME) credits (also known as hours) for learning activities. Continuing Education
learning activities update licensed clinicians' knowledge and skills consistent with established
accreditation standards. Licensed clinicians are required by their licensing boards to obtain
Continuing Education credits in order to renew their licenses.
POLICY:
The Health Care Agency shall provide Continuing Education for its employees and Behavioral
Health Services’ (BHS) Behavioral Health Training Services (BHTS) program shall obtain
accreditation in order to provide for these Continuing Education Courses when appropriate.
SCOPE:
This Policy and Procedure applies to all HCA staff members requesting HCA accreditation
approval for Continuing Education courses.
REFERENCES:
Policies and Procedures for American Psychological Association Approval of Sponsors of
Continuing Education for Psychologists
California Association of Marriage and Family Therapists (CAMFT) Continuing Education
Provider Information
California Medical Association (CMA) Continuing Medical Education (CME) Accreditation
Requirements (May, 2019)
California Board of Registered Nursing (BRN) Continuing Education for License Renewal
https://www.rn.ca.gov/licensees/ce-renewal.shtml
https://www.rn.ca.gov/pdfs/applicants/cep-app.pdf
Health Care Agency
Behavioral Health Services
Policies and Procedures
Section Name:
Sub Section:
Section Number:
Policy Status:
Human Resources
Staff Development
03.01.01
New Revised
SUBJECT: Continuing Education Course Approval for HCA Programs
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FORMS:
Please contact the Behavioral Health Training Services program at 714-667-5600, BH Training
Request BHTrainingRequest@ochca.com, or visit https://intranet.ochca.com/bhs/bhts/ for
updated copies of these forms:
CE Application form
Disclosure of Relevant Financial Relationships form for presenters
Disclosure of Relevant Financial Relationships form for planners and committee members
Documentation of Verbal Disclosure to Learners
PROCEDURE:
I. The application process, the notification of course approval and the final documentation
are outlined in this procedure. The BHTS program is the part of HCA which oversees the
accreditation process with various CME/CE approval agencies. As part of the BHTS
program, the Continuing Education Coordinator (CEC) will review and ensure CE courses
meet or exceed requirements for the education content and satisfies the format required
by the State. Below is a listing of available CME and CE accreditations.
A. CME credits for Physicians through accreditation by the California Medical
Association (CMA).
B. CE credits for Psychologists through accreditation by the American Psychological
Association (APA).
C. CE credits for Licensed Clinical Social Workers (LCSWs), Licensed Marriage
Family Therapists (LMFTs), Licensed Professional Clinical Counselors (LPCCs),
and Licensed Educational Psychologists (LEPs) through accreditation by the
California Association of Marriage and Family Therapists (CAMFT).
D. CE credits for Nurses (RNs) through accreditation by the California Board of
Registered Nursing (BRN).
E. CE credits for Alcohol and Other Drug (AOD) Counselors through compliance with
California Code of Regulations §13055 of Chapter 8, Division 4, Title 9.
II. Application Process
A. HCA staff identifies training needs and develops the Continuing Education course
to be submitted for approval through the Continuing Education Coordinator (CEC).
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B. The Continuing Education Training Coordinator (CETC) is responsible for following
the procedures outlined in the CE Application and submitting the application packet
to the CEC.
C. If approval is desired for several available disciplines, such as physicians and
psychologists, the BHTS program coordinates the application process.
D. In planning a Continuing Education course, the CETC should consider all of the
following information which may be used to complete an application for continuing
education credits.
1. How did HCA determine there was a need for this program? There are
typically three reasons to offer continuing education presentations.
a) HCA has a Demonstrated Needs Assessment – From QI data,
committee studies of care, county data, national trends from national
data, professional literature review, US health data
b) HCA staff have Expressed Needs – From requests submitted on
participants’ activity evaluation forms, surveys of potential
participants, informal verbal comments, patient problems, consensus
c) HCA has a Presumed Needs Assessment – New methods of
diagnosis, treatment, or technology, input from experts regarding
advances in medical knowledge, regulatory changes affecting
patient care
2. What are the learning goals for the program? Learning goals relate to the
purpose of the program.
a) What topics will be covered and how will they be taught?
b) How will the program address the identified needs?
c) Describe the program:
i) Briefly and broadly describe the program (e.g., diagnosing,
treating, one illness vs. many, basic science vs. clinical, etc.).
ii) Pragmatically decide on a format such as lecture discussion,
panel, etc. which would facilitate achievement of the learning
goals.
3. What are the measurable learning objectives for this HCA program?
a) If the learning goals are achieved what will the participants be able
to do with the information learned?
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b) What behaviors will demonstrate their understanding of the material
presented and its application?
c) Accordingly, the objectives are typically written (using words like
“identify,” “describe,” “list,” “explain,” “demonstrate”), so that they
describe measurable behaviors or outcomes the participant will be
able to demonstrate or achieve upon completion of the program.
4. Are cultural/linguistic issues relevant for this program?
a) Demonstrate how cultural/ethnic information/data are used either for
demographic overview of the issue or to establish therapeutic
relationships, diagnosis/treatment, or enhance clinical care
processes. If these issues are not addressed what is the evidence to
suggest they are not relevant?
5. How will this program’s effectiveness be evaluated?
a) All trainings need to be evaluated by some method related to their
effectiveness and relevance to the target audience(s). For CE and
CME trainings specific evaluations are to be used and are provided
by the CE program office.
E. The following items must be submitted together for the review process to start:
1. A CE Application and all supporting documentation are due to CEC at least
sixty (60) calendar days before the course date. A completed CE
Application must include the following:
a) Clear and concise description of course content and objectives with
time estimates.
b) Current resume of each speaker
c) Copies of presentations and handouts
d) Financial statement outlining cost and funding for program (for
conferences)
e) Posttest (required for online/enduring materials trainings)
f) A draft Advertisement or Notice of Course to include:
i) Title of the course
ii) Name(s) of presenter(s) and their qualifications and
affiliations
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iii) Description of the course (including learning objectives)
iv) Intended audience
v) A timed agenda which outlines course content in moderate
detail and identifies all non-instructional time such as breaks
or meals.
vi) Course objectives in behavioral terms
vii) Required credit designation statements regarding all relevant
CE approval agencies—see section g) below.
viii) CMEs can only be advertised after they have been granted.
They are never to be advertised as in process, applied for, or
any other type wording.
ix) The number of actual training hours of continuing education
credit as outlined below.
x) Information on requests for Accommodations.
For example: Accommodations: If you need a disability-
related reasonable accommodation/alternative format for this
training event, please contact BHSwet@ochca.com
beforehand.
xi) Grievance Policy
For example: For any grievance concerning the Orange
County Health Care Agency’s Continuing Education Program,
please write to the Workforce Education & Training Program
at 600 W. Santa Ana Blvd., Suite 510, Santa Ana, CA 92701
or call (714) 667-5600.
xii) Information on when and how CE certificates will be provided
to participants.
For example: Course completion (CE) certificates will be
provided immediately at the end of the training in exchange
for a completed evaluation.
xiii) A post-test must be used to evaluate participant learning for
enduring materials courses such as asynchronous trainings.
g) Course Accreditation Statement for each accrediting body:
i) For CME directly-sponsored activities:
The Orange County Health Care Agency is accredited by California Medical
Association (CMA) to provide continuing medical education for physicians.
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The Orange County Health Care Agency designates this live activity for a
maximum of [insert # of hours of actual training] APA PRA Category 1 Credit(s)
™. Physicians should only claim credit commensurate with the extent of their
participation in the activity.
This credit may also be applied to the CMA Certification in Continuing Medical
Education.
ii) For CME Joint Providership Activities:
This activity has been planned and implemented in accordance with the
accreditation requirements and policies of the California Medical Association
(CMA) through the joint providership of Orange County Health Care Agency
and the (name of non-accredited provider). The Orange County Health Care
Agency is accredited by the CMA to provide continuing medical education for
physicians.
The Orange County Health Care Agency designates this live activity for a
maximum of [insert # of hours of actual training] AMA PRA Category 1
Credit(s) ™. Physicians should only claim the credit commensurate with the
extent of their participation in the activity.
This credit may also be applied to the CMA Certification in Continuing Medical
Education.
iii) For Psychologists:
The Orange County Health Care Agency is approved by the American
Psychological Association to offer continuing education for psychologists.
The Orange County Health Care Agency maintains responsibility for the
program.
iv) For Nurses:
Provider approved by the California Board of Registered Nursing, Provider
#1509, for [insert # of hours of actual training] contact hours.
v) For Licensed Therapists (LMFTs/LCSWs/LPCCs/LEPs):
The Orange County Health Care Agency is approved by the California
Association of Marriage and Family Therapists to sponsor continuing
education for LMFTs, LCSWs, LPCCs, and/or LEPs (Provider # 62340). This
course meets the qualifications for [insert number of hours] hours of continuing
education credit for LMFTs, LCSWs, LPCCs, and/or LEPs as required by the
California Board of Behavioral Sciences.
The Orange County Health Care Agency maintains responsibility for this
program and its content.
vi) For Alcohol and Other Drug (AOD Counselors):
These Continuing Education Hours comply with section §13055 of Chapter 8,
Division 4, Title 9 of the California Code of Regulations concerning renewal of
an Alcohol or Other Drug (AOD) Counselor Certification. All certifying
organizations shall accept as continuing education hours of training provided
by any county governmental agency
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F. Course is planned with another organization (outside of HCA):
1. The CETC needs to obtain an agreement from all agencies involved
regarding who is responsible for content, presentation, monitoring, record
keeping, advertising, financial arrangements and administrative decisions.
2. In order to “joint-sponsor” a course for continuing education credit, if the co-
sponsoring provider is not accredited, then HCA must assume responsibility
for the content and planning of the activity.
3. In cases where the other organization is also a continuing education
provider with the same accrediting body, then the agreement must clarify
which of the two co-sponsoring organizations shall accept and maintain
responsibility for the activity.
III. Notification of Course Approval
A. Educational programs offered by HCA are not accredited automatically. Each
course offering requires application to the CEC.
B. The CETC shall be notified in writing that the course is approved or if further
documentation or preparation is needed.
C. The CETC shall receive a certificate for the attendees for distribution at the time of
the course.
D. The CETC shall also receive an attendance sign-in/sign-out list and an evaluation
form.
E. Courses can be approved for a maximum of one calendar year, and may be
repeated within that calendar year if the program is identical in content, length and
instructor. The approval may be extended beyond one year if the content of the
course is the same, the information is still current, and an approved instructor is
facilitating the course.
IV. Final Documentation
A. After each course the CETC must submit final documentation to CEC. The final
documentation must include:
1. Course attendance sheets with each participant's name and license number
(these attendance sheets must be separated by license type: CME, APA,
MFT/LCSW, RN, ARF/RCFE)
2. Completed evaluation forms
3. Copy of results of post-test (if applicable—mostly for enduring materials).
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4. Disclosure of relevant financial relationships, documentation of verbal
disclosure to learners, filled out by CETC who was in attendance.
V. Record Requirements
A. The CEC must keep the following records for at least four years:
1. Syllabi for all courses
2. Time and location of courses
3. Course advertisements
4. Instructors' vitae or resumes
5. Attendance rosters with the names of those who attended the course (and
license numbers of licensees who completed the course.)
6. Sign-in and sign-out sheets
7. Documentation of the disclosure of relevant financial relationships (or lack
of such relationships) for instructors or anyone in control of course
content—such as documentation of verbal disclosure to learners filled out
by CETC who was in attendance or of information provided to attendees
prior to start of training.
B. The CEC is required to make the records available to accreditation boards if
audited.
C. Audits are on a random basis to ensure compliance with criteria of each accrediting
body.
D. It is the CEC's responsibility to apply for re-accreditation and to submit all
documentation to the accreditation boards prior to the expiration date.
E. Accreditation is approved varying lengths of time for each type of license.
VI. CME Committee for the CME Program for doctors
A. This committee is comprised of physicians and administrators in the Health Care
Agency.
1. By design, other Continuing Education Training Coordinators sit on this
committee to facilitate coordination between all accreditation functions.
2. Each activity is reviewed by the CME Committee and/or expert content
reviewers to ensure activities meet criteria for CME credits.
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B. The CME committee meets as needed to review the CME Program, and to ensure
that all activities approved for CME credits meet the criteria of the California
Medical Association.
VII. APA Committee is the CE Program for psychologists
A. This committee is comprised of psychologists and other clinicians and
administrators within HCA.
B. The committee reviews course applications and meets as needed to review the
performance of HCA as an approved provider of APA continuing education
activities.
VIII. Commercial support guidelines:
A. To identify potential conflicts, the CETC shall notify the speaker of the need to have
a full disclosure at the time of the presentation, and then asking the speaker to
disclose this information prior to the event. This is particularly relevant to CME
activities.
1. Disclosures must be made regarding the presenter(s) and anyone having
control over the content of the course—such as program planners and
committee members.
B. If the speaker is unable to make an unbiased presentation, then continuing
education credit is not granted for this presentation, or a different speaker is found
for the chosen topic.
C. Presentation material is reviewed prior to the presentation and commercial
references are removed.
D. The CETC will assure that the disclosure does occur, and submit documentation
of this at the end of the program using the form, “Disclosure of Relevant Financial
Relationships, Documentation of Verbal Disclosure to Learners.”
