CME Activity Application Regularly Scheduled Sessions (RSS)

CME Activity Application– Regularly Scheduled Sessions (RSS)

All CME activities must reflect the UHS-PEP Mission.C1

Applications are due August 15 of each year. Credit may not be offered for a session until application is signed & approved by CME/UHS-PEP. Templates & instructional forms are available at

Activity Information

Organization/Department: Activity Title: Location:

Start Date: End Date: Frequency:

Activity Director: Email address:

Address: Phone number: Fax number:

Activity Coordinator: Email address:

Address: Phone number: Fax number:

Date Planning Started:

Type (Format of Activity/Educational design)C5

Live activity
Lecture/Grand Rounds / Round Table/Group Discussion / Simulation / Webinar
Case Studies / Skill demonstration / Teleconference / Journal Club
Archived recording of a live activity (Contact CME Representative for more information)

Attach scheduleof planned session dates

Requested Number of AMA PRA Category 1 Credits™

(1 credit = 60 minutes of content participation– does not include breaks, meals, etc)

Planning CommitteeMembers:C8

Attach completed Conflict of Interest forms for ALL planning committee members listed below

Name / Email / Relevant relationships listed on COI Disclosure form
Ex: John Smith, MD / / Research grant/Pfizer

Attach additional sheets as necessary

Who identified the speakers and topics?C7 (Check all that apply.)

ActivityDirector / Planning Committee / Other

Criteria used in the selection of speakers:
Were employees of a pharmaceutical or medical device manufacturer involved with the identification of speakers and/or topics?C7

No Yes, please explain:

Presenters & ParticipantsC8, C9, C10 THIS SECTION REQUIRED FOR CASE CONFERENCES & JOURNAL CLUBS

This information may be submitted after the Application but isREQUIRED before credit approval will be designated:

Activity objectives need to be communicated to the presenters/participants and disclosure information provided at each session
Presenters who have disclosures are subject to ACCME rules for Conflict of Interest Disclosure and resolution; their content may require review by VCU CME two (2) weeks prior to the activity date to ensure fair, balanced and objective presentations.
FOR CASE CONFERENCES & JOURNAL CLUBS: All attendees and presenters (those presenting a case or journal article) who participate in this activity are required to submit a COI form annually.

Attach completed Conflict of Interest forms for ALL presenters/participants listed below

Name / Degree(s) / Affiliation / Title / Email / Relevant relationship listed on COI Disclosure form
Ex: John Smith, MD / MD, PhD / VCU, Professor of Surgery / / Research grant/Pfizer

Attach additional sheets as necessary

Planning
Target AudienceSelect all that apply
Geographic Location: / Health Care Professional: / Specialty:
Internal only/RSS / Primary care physicians / All specialties / Oncology
Local/regional / Specialty physicians / Anesthesiology / Orthopaedics
National / Pharmacists / Cardiology / Pain
International / Psychologists / Dermatology / Pathology
Physician Assistants / Emergency Med / Pediatrics
Nurses / Family Medicine / PM&R
Nurse Practitioners / Gastroenterology / Psychiatry
Social Work / General Medicine / Radiology
Technologists / Hepatology / Radiation Oncology
Other: / Neurology / Rheumatology
OB/GYN / Surgery
Other:

How did you choose your topics:C2, C16
For each source utilized, complete steps 1-3.

Instructional forms are available at

Step 1: Identify Source for Best Practice or Desirable Attribute(s) by checking appropriate boxes below Example: ABMC MOC communication with patients/caregivers (AAFP) / Step 2: Provide Key Points from the Source Summary in the text boxes below(Summary of diagnostic criteria in language that the patient and family understand) / Step 3: Identify Source in text boxes below(file name, URL, publication name and date) Example: Guidelines for Managing Alzheimer’s Disease, 2002
Review of changes in quality of care as revealed by medical audit or other patient care reviews, or P.I data. Documentation examples: audit reports, chart reviews,AHRQ
Ongoing census of diagnoses made by physicians and staff.
Documentation examples: summary of notes, minutes of meetings, clinical practice data.
Advice from authorities in the field or relevant medical societies.
Documentation examples: list of expert names/medical societies AND summary of recommendation(s).
Please Attach formal or informal requests or surveys of the target audience, faculty, or staff
Documentation examples: summary of requests or surveys including previous outcomes. Note, must show information related to areas of education need.
Discussion in departmental or planning committee meeting. If selected, a second source must also be utilized.
Documentation examples: summary of meeting minutes showing information related to areas of need
Data from peer-reviewed journals, government sources, consensus reports. Documentation examples: abstract/full journal articles, government documents describing educational need and physician practice gaps.
Review of board examinations and/or re-certification requirements.
Documentation examples: board review/update requirements.
New technology, methods of diagnosis/treatment.
Documentation examples: description of new procedure, technology, treatment, etc.
Legislative, regulatory or organizational changes affecting patient care.
Documentation examples: Copy of the measure(s)/change(s).
Joint Commission Patient Safety Goal/Competency
Documentation examples: copy of the safety goal and/or IOM, ACGME, Specialty competency
National priorities:
Documentation examples: MRSA, Disaster Planning, Cultural Competency
Public health data:
Other

Changes and Improvement (Gap Analysis):C2

Identification of gaps, needs, etc. should be completed by the Activity Director/Planning Committee.

Instructional forms are available at

Professional Practice Gaps
A professional practice gap is defined as the difference between ACTUAL (what is) and IDEAL (what should be) in regards to knowledge, competence, or performance.
Competence is defined as the ability to apply knowledge, skills, and judgment in practice (knowing how to do something).
Performance is defined as what one actual does, in practice.

What is the problem the activity is planned to address and how are the intended participants involved?
Ex. HIV providers and patients are faced with a constantly evolving standard of care. This poses a challenge for assuring that HIV treatment is consistent with the most current guidelines.

Educational Needs
An educational need is defined as “the need for education on a specific topic identified by a gap in professional practice.”
Why does the problem exist?
Ex. HIV providers need educational initiatives related to current HIV treatment guidelines.

Learning Objectives
Learning objectives are the take-home messages; what should the learner be able to accomplish after the activity? Objectives should bridge the gap between the identified need/gap and the desired result.

What do we want to change?

Ex. Identify current guidelines in order to provide optimal care to women with HIV.

Desired Results
Desired results are what you expect the learner to do in his/her practice setting. How will the information presented impact the clinical practice and/or behavior of the learner?

How will you know if the activity was effective in producing change? Indicate how this change could be reasonably measured.

Ex. Participant evaluations indicate a high confidence and commitment to changing practice based on increased knowledge of current HIV treatment guidelines.

Desirable Physician Attributes / Core Competencies Addressed with this Activity C6

Check all that apply; for additional information on these competencies please refer to the Desirable Physician Attributes document
ABMS / IOM
Patient care / Patient-centered care
System-based practice / Interdisciplinary teams
Medical knowledge / Utilize informatics
Practice-based learning and improvement / AMA Code of Ethics
Interpersonal and communication skills / Specialty Specific
Professionalism

Engagement:
What educational supplements will be included to enhance the learners’ experience?
Examples: course syllabus, PowerPoint presentations, handouts, reminders, patient feedback, templates, creation/distribution of flow sheet, patient education materials, reference guide

Identified Barriers
What potential barriers do you anticipate attendees may have in incorporating new knowledge, competency, and/or performance objectives into practice?
Example: If the identified barrier is cost, you would attempt to address the barrier by stating “The agenda will allow for the discussion of cost effectiveness and new billing practices”

Select all that apply, one (1) at minimum

Lack of time to assess or counsel patients / Lack of consensus on professional guidelines
Lack of administrative support/resources / Cost Fiscal constraints
Insurance/reimbursement issues / No perceived barriers
Patient compliance issues / Other, specify:

Please provide an answer for EACH question below:C19, C20

Indicate N/A for those that do not apply to activity.

8.1. Please describe how you will attempt to address these identified barriers in the educational activity:

8.2. What other organizations within or outside the institution are working on the issue you are addressing?

8.3. What departments or initiatives within your institution are working on the same issue? C20

8.4. What other institutions could be potential partners in working on this issue? C20

(examples: health dept., EMA, community organizations, software company, medical society)

8.5. Factors outside provider’s control that impact patient outcomes. C18

(examples: financial factors, reimbursement, cost of meds, patient issues, administrative restrictions, and resources.)

8.6. Barriers the learners will encounter while implementing suggested changes or reinforcement. C19 (examples: time limitations, security and interoperability, stereotypes, administrative constraints, lack of patient education)

8.7. Suggested options to overcome barriers the learners encounter while implementing suggested changes. C19 (examples: better use of nursing assistants, information to remove stereotypes)

8.8. Was anyone identified from your PI committee to participate in the planning of this activity, and what was their contribution? C21

Evaluation
Evaluation Form Selected – check one
Standard CME Evaluation Form
Other Evaluation Form (attach sample for review & approval)
Attestations
If the proposed activity is approved for AMA PRA Category 1 credit™, I understand and agree to:
(ALL MUST BE CHECKED OFF)
Yes
Ensure all required information is provided in all of our brochures/announcements.
Pay all fees plus related expenses according to the completed Letter of Understanding.
A CME staff member may monitor the activity for compliance, and agree to pay standard travel costs.
Comply with all ACCME Standards for Commercial Support and VCU CME policies.
Provide accurate Custom Data Import Sheets (CDI) attendance records for all attendees
Notify VCU CME of all pharmaceutical support, vendor support, donations, or grants.
Offer exhibits as a separate function from, and without consideration of, any educational grants.
Budget
(Budget Template must be completed and submitted with application)

Funding:

Yes / No
This activity will request commercial support (financial or in-kind grants or donations) from a pharmaceutical or medical device manufacturer.
*If Yes, contact CME Representative for additional training prior to activity start date.
All planners read and agree to abide by the ACCME Standards for Commercial Support.
Found online:

I understand ALL commercial support (grants and in-kind donations) must be accompanied a Letter of Agreement for Commercial Support of CME.

Projected Amount
REVENUE
Registration Fees
Educational Grants
Exhibit Fees
Other sources
Total Revenue
EXPENSES
Promotional Expenses
Faculty Honoraria
Faculty Travel & Lodging
Venue Costs
Food & Beverage Costs
Entertainment Costs
Educational Supplements (syllabus, handouts, etc.)
Audio-visual Equipment/Service
Accreditation Fees *
Other Administrative Fees
Personnel Costs
Miscellaneous Costs
Total Expenses
Net revenue/(loss) projected

*All RSS activities have accreditation fee of $75 per session. Multiply $75 by the number of planned session dates.

As Activity Director and Coordinator, we attest that all content presented during this activity will be in compliance with the ACCME Policy on Content Validation, and Standards for Commercial Supportof CME.
ACCME Standards for Commercial Support can be found online:
Signature of Activity Director / Date
Signature of Activity Coordinator / Date
TO BE COMPLETED BY UHS-PEP:
All documents have been received and this activity:
aligns with the Mission of UHS-PEP, and
is Approved for AMA/PRA Category 1 credit(s)™.
is Not approved Reason:
______
Director, Continuing Medical Education Date
______
Senior Associate Dean for Professional Education Programs Date