Southern Regional Area Health Education Center
Continuing Medical Education Program
Application
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ACTIVITY TITLE
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START DATE
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END DATE
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START TIME
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END TIME
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VENUE
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CITY, STATE
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SPONSORSHIP AND COURSE MANAGEMENT
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EVENT TYPE
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STAND-ALONE
SERIES
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IF STAND-ALONE
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TYPE OF SPONSORSHIP
Direct
Co-Provided
Joint – Name of Sponsor Organization:
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TYPE OF ACTIVITY
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Live Activity (Face-to-Face)
Live Webinar
Series
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Online/Enduring
Journal-Based
Other, please list
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IF SERIES
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New Request Renewal
Lecture
Case Conferences
Grand Rounds
Tumor Board
Committee Learning
List day of week and month:
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CREDIT HOURS
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Total number of hours of AMA PRA Category 1 Credit(s)TM requesting
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CME COURSE MEDICAL DIRECTOR (must be an expert in course content)
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Name/Credentials:
Title:
Address:
Telephone:
Email:
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SITE COORDINATOR
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Name:
Title:
Address:
Telephone:
Email:
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PLANNING INFORMATION
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ACCME Guidelines require the following decisions in planning a CME activity be independent of commercial interest. These decisions include: 1) identification of needs; 2) determination of objectives; 3) selection of presentation of content; 4) selection of personnel and organizations who would be in a position to control the content; 5) selection of educational methodology; 6) evaluation of the activity.
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Planning Meeting Type:
Email correspondence Conference call Face-to-face meeting
Attach dates, times, attendees and summary of meeting.
Planning Committee Members:
List below the individuals who are involved in planning this activity. Each person involved in the planning must complete a disclosure form.
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Name
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Affiliation
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Disclosure Form on File
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A SR-AHEC CME representative must be involved in the planning process from the beginning. (C22)
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BUILDING BRIDGES (C18, 20)
Bridges are built with other stakeholders through collaboration and cooperation.
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Are there other initiatives within your facility working on this issue? No Yes
If yes, who:
If yes, could they be included in the development and/or execution of this activity? No Yes they were involved in planning (reviewing content and distributing flyers to the practices)
Are there external stakeholders (in your county or region) working on this issue? No Yes
If yes, who:
If yes, could they be included in the development and/or execution of this activity? No Yes
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TARGET AUDIENCE (C4)
Continuing Medical Education consists of educational activities that are designed and directed to serve the clinical and professional performance of practicing physicians and other health care professionals.
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Check all that apply:
Physicians: Primary Care Specialist – Please list:
Advanced Practice Professionals
Other:
Estimated Attendance:
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SCOPE OF PRACTICE (C4)
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Explain why this activity is a good match for the target audience’s scope of practice.
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NEEDS ASSESSMENT(C2)
Needs assessment data from multiple sources MUST be used to plan all CME activities. Supporting documentation MUST be included with the application. Check all methods that apply and attach supporting documents.
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Evaluation from previous CME activities or survey results (e.g., past evaluation summary or survey results with relevant suggestions highlighted)
Expert opinion, faculty expertise, or advice from experts (e.g., attach minutes, notes, relevant publications, or bibliographies)
Data from internal or external sources such as NIH or public health agencies (e.g., attach relevant reports, articles, mandates, state/national surveys, or other such documents)
New medical technology (e.g., articles, reports, etc.)
Research finding (e.g., attach relevant research reports or journal articles)
Literature reviews (e.g., attach journal articles, internet searches, medical data base search information, etc)
Hospital admissions and diagnosis data
Medical audits/quality assurance information (e.g., attach QA minutes/reports, input from Physician Review Organizations)
Formal or informal needs requests from physicians, (e.g., notes from conversations, survey results, etc.)
Professional, Society Requirements
Legislative, Regulatory or Organizational Requirements (OSHA, JCAHO, IRB) affecting patient care
Other, please explain:
You may also use as a resource the areas that your hospital/organization has identified with for Core Measures or the IHI 5 million Lives Campaign or Healthy North Carolina 2020 Objectives.
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PURPOSE/COURSE DESCRIPTION
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What is the overall purpose for conducting this activity? What do you hope to accomplish by offering the activity?
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PHYSICIAN COMPETENCIES (C6)
CME activities should be developed in the context of desirable physician attributes. Please indicate which ACGME or Institute of Medicine Core Competencies are being addressed in this activity. See Appendix I for definitions of Core Competencies. Check all that apply.
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ACGME
Patient Care
Practice Based Learning and Improvement
Medical Knowledge
Systems Based Practice
Professionalism
Interpersonal Skills and Communication
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IOM
Provide Patient-Centered Care
Work in Interdisciplinary Teams
Employ Evidence-based Practice
Apply Quality Improvement
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OBJECTIVES (C6)
The audience must be provided information about the activity’s goals and/or objectives before the activity occurs. Based on what you hope to accomplish, list objectives (1 per hour of content and 1 per topic of discussion) you would like for participants to accomplish as a result of their participation in this activity.
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Following this activity, the participant should be able to: (Please use measureable terms such as, explain, analyze, describe, choose, discuss, review, disclose, list, compare, assess, measure)
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K,C,P
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Please determine whether each objective is one of physician knowledge (K) (awareness and understanding), competence (C) (ability to apply knowledge, skills and judgment) or performance (P) (what is actually being done in professional practice).
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EDUCATIONAL PLANNING WORKSHEET (C2, C3, C11)
At least one need/practice gap must be identified, and others may be added as needs arise.
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STEP 1: Identify the need. Needs assessment is the systematic process of gathering information and using it to determine instructional solutions to close the gap between actual and optimal knowledge. What information did you use to identify this professional practice gap in your audience?
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STEP 2: Identify gap(s). Describe specific needs or problem areas that were identified.
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STEP 3: Formulate learning objective(s). Based on what you hope to accomplish, list objectives that will address the practice gap.
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STEP 4: Evaluate your program and look at outcomes measurement. The ultimate goal of CME activities is to promote improvements in healthcare. How will you know if your activity makes a difference or helps change physician behavior or patient health outcomes?
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What is the clinical problem that you want to address in the CME activity?
What medical issues need more attention?
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Why does the clinical problem exist?
How can we close the practice gap?
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What do you expect the provider to learn during the activity?
What do physicians need to be able to do that they are not doing now?
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How can the provider apply what is learned to their practice setting?
How will you implement your changes or measure if your change is making an impact?
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Example:
Clinical/Quality data indicated diabetic patients continue to develop foot sores and infections leading to serious complications.
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Example:
Providers are not performing foot exams on diabetic patients at each office visit.
Knowledge (knows)
Competency (knows how)
Performance (does)
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Example:
Identify the process for performing foot exams on diabetic patients at each office visit.
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Example:
Develop a standardized process (example: checklist) for performing and documenting foot exams on diabetic patients.
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Knowledge (knows)
Competency (knows how)
Performance (does)
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Knowledge (knows)
Competency (knows how)
Performance (does)
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FACULTY (C7)
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Who identified the speakers and topics?
Course Director
Planning Committee
Other Physicians
CME Provider
Others- provide name and source:
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What criteria were used in the selection of speakers?
Expert in subject area
Excellent teaching skills
University faculty
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Were any employees of a pharmaceutical company and/or medical device manufacturer involved with the identification and/or selection of speakers and/or topics? Yes No
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List the faculty name, title, and affiliation. Insert rows for additional speakers or attach a separate sheet.
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Speaker
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Academic Title
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Affiliation
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Bio/CV Attached
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Disclosure
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ACTIVITY AGENDA
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Attach a copy or include here the proposed schedule with time/topic/speaker/breaks and registration times included.
*copies of all presentations are due 2 weeks prior to the date of the program for review.
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EDUCATIONAL DESIGN / METHODLOGY (C5)
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What instructional methods will be used? (Check all that apply.)
Lecture/didactic
Panel discussions
Case studies
Interactive workshops
Interactive webinar
Live demonstration of procedure
Video demonstration of procedure
Online, enduring
Other, please describe:
Explain how this format supports your objective(s) and your desired outcome(s). The objectives are knowledge based with the final portion of the day using case studies to assess competency.
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NON-EDUCATIONAL STRATEGIES (C17)
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What other strategies could be used to enhance the objectives or facilitate a change in your learners as an adjunct to this activity? Examples include patient surveys, patient information packets, pocket guides, posters throughout the hospital, and email reminders to the learners (i.e., summary points from the lecture/new information).
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IDENTIFIED BARRIERS (C18, C19)
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What potential barriers do you anticipate attendees may have in incorporating new knowledge, competency, and or performance objectives into practice? Select one minimum.
Lack of time to assess/counsel patients
Lack of administrative support/resources
Insurance/reimbursement issues
Patient/family compliance issues (demographics, resources, knowledge and or skill)
Lack of consensus on professional guidelines
Cost
Health Literacy
Lack of coordination of patient care
Government/Regulatory Issues
No barriers
Other:
Explain how these barriers will be addressed in this activity?
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EVALUATION PROCESS (C3, C11)
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How will you measure changes in competence, performance or patient outcomes? How will you know if your activity makes a difference or helps change physician behavior or patient health outcomes?
Activities are encouraged to measure level 3 outcomes or above. Check all the levels of outcomes you intend to assess or measure, indicate expected date of completion.
Outcome Level
Level 1 (Reaction/Satisfaction) – Participant satisfaction with the activity (self-report at end of activity) – required. How will this be measured?
Level 2 (Classroom Competency) – Intent to change behavior or practice; change in participant knowledge, skills or attitude (self-reported or observed at end of activity). How will this be measured?
Level 3 (Application in the Workplace) – Change in participant behavior or practice (self-reported 1-3 months after activity or self-reported at the activity). How will this be measured?
Level 4 (Impact Result) – Change in overall organizational practice or in patient health outcomes (objectively measured before and after activity). How will this be measured?
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DISCLOSURE (C7)
The ACCME requires “the disclosure of the existence of any significant financial interest or any other relationship a faculty member or sponsor has with the manufacturer(s) of any commercial product(s) be disclosed to the audience.” Speakers must also disclose if they will discuss off-label/unapproved use of products.
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How will the audience be informed about disclosures?
Written: Handouts Slides Other, describe
Verbal: Speaker Moderator Other, describe
If disclosures are verbally announced, “Written Documentation of Verbal Disclosure Form” must be signed and returned to SR-AHEC.
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RESOLUTION OF CONFLICTS OF INTEREST (COI)
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Conflicts of interest must be resolved before the activity occurs, preferably during the early planning stages. If COIs are identified, the “Resolution of Conflict of Interest Form” will be used to guide the process for resolution of conflicts by the Administrator of CME.
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COMMERCIAL SUPPORT (C7)
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This activity will receive support from:
Educational grants: yes no
Exhibit fees: yes no
Commercial support: yes no
Please list all received sources and those pending:
SR-AHEC adheres to the Standards for Commercial Support for Continuing Medical Education of the ACCME (www.accme.org). All commercial support to an activity designated for CME credit must be documented by a signed Letter of Agreement for Commercial Support of CME. Exhibit fees are not considered commercial support by the ACCME. However, potential exhibitors should be noted in an attachment.
Acknowledgements – commercial support must be acknowledged to the audience. SR-AHEC acknowledges commercial support in two ways: 1) in printed copy of the course materials; and 2) prior to the start of any activity, the “Written Documentation of Verbal Disclosure Form” is used by the coordinator or moderator to acknowledge all commercial support.
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BUDGET
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What funds will be used to pay expenses for this activity?
Internal department funds
Participant registration fees
Commercial support
State or Federal Grant
Other:
Attach a preliminary budget worksheet or a budget summary. Include all projected revenue and expenses. A final income and expense report is required to finalize the CME accreditation file at the conclusion of the activity. All anticipated commercial support (financial or in-kind grants or donations) being applied for must be submitted.
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MARKETING AND ADVERTISING
SR-AHEC requires that certain information be included on promotional materials – the objectives/purpose, faculty, correct sponsorship, and credit, accreditation and disclosure statements. SR-AHEC must approve promotional materials before they are published. Providers may never publish or announce that “AMA PRA credit has been applied for.”
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How will notification of this educational activity be distributed to the participants prior to the activity?
Brochure/Flyer
Email
Website – URL site:
Fax
Journal (Title)
Other, identify
A copy of the proposed promotional material is attached.
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Please submit the completed application to:
Jennifer Borton, RN, MSN
Administrator, Pharmacy, CME, and Quality Initiatives
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Sarah Moorman, RN, MSN
Director, Pharmacy/CME
Southern Regional AHEC
1601 Owen Drive
Fayetteville, NC 28304
Jennifer.Borton@sr-ahec.org
Sarah.Moorman@sr-ahec.org
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SIGNATURES
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Application submitted by:
Please attest that the coordinator and course medical director have been informed of the Disclosure Policy above and have agreed to comply with this policy: Standards of Commercial Support Standard 6. Also signature below attests that you have received a copy of the Standards of Commercial Support.
Course Medical Director: ________________________________ Date: __________________
Site Coordinator: _______________________________________ Date: __________________
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Internal Use: Sign off on completed/accepted application.
This activity furthers the mission of the SR-AHEC office of CME. (C1)
SR-AHEC CME Director: ________________Date: ________________________
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Appendix I: Definitions of Core Competencies
CME activities should be developed in the context of desirable physician attributes.
Patient Care or Patient-Centered Care: identify, respect, and care about patients’ differences, values, preferences, and expressed needs; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health.
Medical Knowledge: established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social behavioral) sciences and the application of this knowledge to patient care.
Practice-Based Learning and Improvement: involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.
Interpersonal and Communication Skills: that result in effective information exchange and teaming with patients, their families and other health professionals, uses effective listening skills with non-verbal and verbal communication; working as both a team member and at times as a leader.
Professionalism: commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population.
System-Based Practice: actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.
Interdisciplinary Teams: cooperate, collaborate, communicate and integrate care teams to ensure that care is continuous and reliable.
Quality Improvement: identify errors and hazards in care: understand and implement basic safety design principles such as standardization and implications; continually understand and measure quality of care in terms of structure, process and outcomes in needs; and design and test interventions to change processes and systems of care, with the objective of improving quality.
Utilize Informatics: communicate, manage knowledge, mitigate error, and support decisions making using information technology.
Employ evidence-based practice: integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible.
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