Statement of Work

1. Purpose of this Statement of Work

This Statement of Work (SOW) defines the roles, responsibilities, and requirements for organizations seeking accreditation services through Sutter Health's Accredited Continuing Education (ACE) program.

2. Mission and Vision
Our mission is to foster a culture of continuous professional development, empowering the healthcare team with evidence-based knowledge and skills to optimize health outcomes. By prioritizing interprofessional collaborative education, we aim to enhance team performance in the delivery of compassionate, equitable, and high-quality care to every patient.

Our vision is to be a beacon of excellence in equitable professional development by fostering growth across all disciplines, while building competencies to address implicit bias and social drivers of health that impact patient outcomes.

3. Collaborative Planning and Accreditation Oversight

Activities are developed through a collaborative and consultative planning process between the organization and Sutter Health (ACE).

ACE engages at least two months before the activity date to review the proposed educational activity and determine alignment with accreditation requirements. The organization is responsible for submitting the educational need and practice gap, learning objectives, educational format, faculty, and other required planning materials.

ACE reviews all submitted materials and provides guidance as needed to ensure alignment with:

• ACCME Standards for Integrity and Independence
• Joint Accreditation criteria
• Outcomes expectations
• Content validity, balance, and independence

Sutter Health retains sole authority and responsibility for all accreditation decisions and compliance throughout the lifecycle of the educational activity.

4. Organization Roles and Responsibilities

The organization agrees to:

• Contact ACE at least two months before the planned activity date.
• Submit all required planning materials within established timelines.
• Ensure all planners and faculty complete required financial disclosure forms.
• Ensure educational content is evidence-based, balanced, and non-promotional.
• Submit all educational, promotional, and marketing materials to ACE for review and approval before dissemination.
• Support learner evaluation and outcomes data collection as requested.
• Comply with ACCME and Joint Accreditation standards, applicable Sutter Health policies, and all applicable state continuing education regulations.

5. Promotion and Use of Accreditation Statements
All promotional and educational materials associated must:

• Clearly identify Sutter Health as the accredited provider
• Be reviewed and approved by ACE prior to release
• Gift cards, high-value items, or other incentives may only be used when expressly approved in advance by Sutter Health ACE. Such incentives carry specific regulatory and accreditation expectations; therefore, unauthorized use is strictly prohibited.

6.  Fees
Fees for accreditation-related services, may include planning consultation, compliance oversight, outcomes evaluation, reporting, and record maintenance.
Applicable fees will be communicated and invoiced by Sutter Health in accordance with established fee schedules.

7. Use of Artificial Intelligence (AI) in Activities
Sutter Health aligns with ACCME and recognizes the potential of artificial intelligence (AI) to foster exploration, innovation, and thoughtful experimentation in CE while safeguarding the integrity of educational content, learner trust, and patient confidentiality, including bias and influence.
Responsible Use and Oversight

• AI tools may be used to support educational planning, content development, outcomes analysis, administrative processes, or learner engagement.
• AI tools can be used to conduct professional gaps or learning needs assessments trends, or at-risk populations.
• Human judgment and oversight must remain central to all educational and accreditation-related decisions. Identified, experienced clinicians should have oversight and confirm that recommendations and outputs are accurate, scientifically valid, unbiased, and reliable.
• Sutter Health retains responsibility for ensuring that all educational content whether AI-assisted or not is current science, evidence-based, unbiased, and compliant with the Standards for Integrity and Independence.
• ACE will screen AI-assisted outputs for accuracy, balance, and commercial bias and will document review as part of standard accreditation records.
• AI tools may not be used to generate unvalidated clinical recommendations, auto-produce assessment answers visible to learners, or bypass required accuracy, independence, or bias review.
• Avoid using free or open-access AI platforms for accreditation-sensitive tasks unless explicitly permitted by the organization and accompanied by sufficient risk mitigation

Transparency and Disclosure

• Organizations must disclose the use of AI tools when AI is used to generate, modify, or analyze educational materials, including slides, written content, assessments, or evaluation tools.
• Required disclosures must include:
  • Name of the AI tool
  • Version
  • Date(s) of use
  • Purpose of use (e.g., drafting, data analysis, assessment development)
• AI-assisted content must be reviewed and verified by qualified individuals designated by ACE, with version control and review dates maintained.
• Routine spelling, grammar, or formatting tools do not require disclosure.
• Where appropriate, learners will be informed when educational content was created or edited with AI assistance. Include additional disclosure elements: model/source identification, an indication or statement that outputs were verified by a human reviewer (including who and how), and whether prompts or outputs were stored externally.

Privacy, Security, and Data Protection

• AI tools may not be used to input, store, or process protected health information (PHI), personally identifiable information (PII), or learner data unless explicitly approved by Sutter Health and compliant with institutional, legal, and ethical data privacy requirements.
• Proprietary, unpublished, or sensitive educational materials may only be entered into AI systems approved by Sutter Health and only with appropriate permissions.

Sutter Health reserves the right to review, modify, or prohibit the use of AI tools in provided activities to ensure responsible governance and accreditation compliance.

8. Right to Modify or Revoke Providership

• Sutter Health reserves the right to suspend or discontinue accreditation services for any activity if accreditation requirements are not met or compliance concerns arise.

9. Continuous Improvement

• Activities are evaluated using outcomes-driven methods. Aggregate outcomes data and participant feedback are used by ACE to improve future educational activities and strengthen educational quality and clinical impact.