8/30/2016
Regularly Scheduled Series
CME Program Series Application
Quillen College of Medicine, East Tennessee State University, Office of Continuing Medical Education
Thank you for considering us to support you in your continuing medical education activity plans. Completing this application is one of the earliest steps in working with us to achieve your education goals. Should you wish, you may call us before you begin the application so we can have a preliminary discussion on your plans. That should make the application process easier for you. We can be reached at 423 439 8081.
For information that can provide a resource as you complete the application, hover your mouse over the footnotes both here and throughout this document:
- Application instructions:[i]
- Deadlines:[ii]
- Important information related to the months the Board does not meet[iii]
- Regularly Scheduled Series for which Educational Grants are being sought[iv]
- Contact Information[v]
Activity Type / Office Use Only
- What type of series are you proposing?
Journal club
M&M, or Case Conference (except cancer case conferences, which have their own application)
Medical staff lecture series
Clinical guideline or pathway development
Other. Please call us at 423 439 8081 to determine which application you should be using. / Additional Planner Comments
Series Information / Office Use Only
- Proposed Series Name:
- Has this activity been accredited in the past by the ETSU Office of CME?
Yes. When? / Additional Planner Comments[vii]
- Brief description of proposed series[viii]
- Proposed Start Date:
- Frequency of the program:
Semi Annually
Quarterly
Bi monthly (6 meetings per year)
Monthly
Bi-weekly (25 meetings per year)
Weekly
Day of the Week
Monday
Tuesday
Wednesday
Thursday
Friday
Week of the Month
First Week
Second Week
Third Week
Fourth Week
Other: / Additional Planner Comments
- Beginning and ending time of the session:
- Proposed number of education hours for each session in the series:
- Location:
City: / Additional Planner Comments
- This series is being planned by:
A hospital/healthcare network or its affiliated medical staff organization
Other: Please describe / Additional Planner Comments
- What is the name of the sponsoring organization?
Documenting the Need / Office Use Only
- What leads you to believe this education is needed?
- What data do you have that supports this need?
Potential participant’s request
Organizational mandate or new initiative
Emerging clinical guidelines or new technology
ABMS/ACGME competencies that need to be addressed
Other. Please explain: / Additional Planner Comments[x]
- Why do you believe your learners need this education?
They have the knowledge, but need additional tools, processes or skills to act on that knowledge (A Competency need)
They have the knowledge and skills, but need support in performing at a consistent level (A Performance need) / Additional Planner Comments[xi]
Planner Note: For PARS DATA, this activity is considered
A Competency Activity
A Performance Activity
A Patient Outcome Activity
- What barriers to learning do you believe might exist in your potential learners?[xii]
- How will you design your activity to help break down those barriers?
- All Continuing Medical Education is required to contribute to physician competency. The following is a list of ABMS/ACGME Physician Competencies. Please check those that would be addressed in this series.
Practice-based learning and improvement[xv]
Interpersonal and communication skills[xvi]
Professionalism[xvii]
Medical knowledge[xviii]
Systems-based practice[xix] / Additional Planner Comments
Program Format / Office Use Only
- Please describe the program format for the series
Lecture
Panel discussion
Simulation
Small group discussion
Skill-based training
Other. Please describe: / Additional Planner Comments
Planner Note: For PARS DATA, this conference is categorized as
Case-based presentations
Lecture
Panel discussion
Simulation
Skills-based training
Small group discussion
Other. Please describe:
- Note: Applies to Case-based conferences only:
No, do not intend to video conference this case conference
Yes, we would like to video conference this activity
- To what site(s)?
- Will the technology allow for real-time discussion between both sites?
Yes. If yes, applicant must list the name and contact information for the person at the remote site that will be accountable for management of the learning activity while it is occurring. ETSU will confer with that individual for training and to review accountabilities. Please list individual’s name and contact information here: / Additional Planner Comments:[xx]
Learning Objectives / Office Use Only
- What will you look for (in learner competency, performance or patient outcomes) that will indicate this activity has been successful?[xxi]
- How and when will you measure this expected outcome?
- Please translate these desired outcomes into 1-3 learning objectives for the activity:
1
2
3 / Additional Planner Comments[xxx]
Target Audience / Office Use Only
- Who is your intended physician audience?
Internal Medicine Physicians
OB/GYN Physicians
Pediatricians
Psychiatrists
Surgeons
Emergency Medicine Physicians
Other Specialists – Please List: / Additional Planner Comments
- Who is your intended non-physician audience?
Physician Assistants
Pharmacists
Psychologists
Nurses
Medical or Nursing Students
Other Specialists – Please List: / Additional Planner Comments
- From what department, community, region, or organization do you expect your attendees to come?
College of Medicine Department:
Health Science College:
Tri-Cities
NE TN Region
Knoxville Region
SW VA Region
State of Tennessee
National
An Organization’s Medical Staff – Please list:
Other– Please List: / Additional Planner Comments
- Target Audience Size
Physician Residents
APNS/PAs
Other Non-Physicians / Additional Planner Comments
Commercial Financial Support / Office Use Only
- Do you intend to seek commercial support for this activity? [xxxi]
No / Additional Planner Comments[xxxii]
Additional Planner Comment for PARS Data
Anticipating:
Grants
Exhibits
Activity Director Information
- Name of Activity Director[xxxiii]
- Title
- Specialty
- Department / College / Organization
- Address
- E-mail Address
- Phone
- Fax
Planning Committee[xxxiv]
Name and Title / Specialty / Phone Number / E-mail Address
Contact Information
- Contact Person Name
- Title
- Organization
- Address
- Phone Number
- Fax Number
- Is this the person who is responsible for the day to day support of this series?
No. If no, please provide details below:
On-site Coordinator Information
- On-site coordinator Name
- Title
- Organization
- Address
- Phone Number
- Fax Number
(More)
Next Steps
You may call the Office of Continuing Medical Education during business hours to receive assistance with completing this application, or to discuss anything related to your potential activity. Our number is 423-439-8081.
Save this as a Word document, and email it to.
. Within a few days one of our educational planners will give you a call. BECAUSE WE WILL BE ADDING ADDITIONAL COMMENTS TO THE DOCUMENT, WE MUST RECEIVE IT IN ITS ELECTRONIC FORMAT.
Submit Required Attachments
Below is the list of additional required attachments. Your application cannot be processed without the following. All required attachments can be sent electronically or faxed. Our fax number is 423 439 8040. Our application e-mail address is .
Action / ActivityDirector / Contact Person / All Planning Committee Members / Academic Department Chair or Healthcare Executive / Instructions
Provide CV or Resume / Required / Required only if he/she participates on Planning Committee / Required / Not required / Please see instructions below to include your CV
Complete Conflict of Interest Disclosure / Required / Required only if he/she participates on Planning Committee. / Required / Not required / Go to this link to complete. Please copy and send this link to all that need to complete a conflict of interest.Please note, you must have your CV ready to attach to your conflict of interest disclosure.
Sign Required Signatures Form / Signature Required / Not Required / Not Required / Sign Required Signatures Form / Required Signature Form can be obtained at this link: It can be copied and given to the Activity Director and the Chair/Healthcare Executive for signatures. They do not both need to sign the SAME form. We will accept either electronic or faxed copies.
-End of Document -
Footnotes
1 / East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education[i] Instructions:
- This application is in MS Word, and is a form. To complete, put your cursor in a grey shadowed area and start typing. It is difficult to spell check in a Word Form, so be aware that this is not a problem to us if your spelling is not perfect. If you are the person completing this application, it is important that you have significant information on the need, focus and expected outcomes of the proposed activity.
- If this is the first time you have completed one of our applications, we do not expect you to complete this application flawlessly. Once we have received it, our planners will assist you in further refining your application until it is ready for the Advisory Board’s review. This consultation process is what makes it necessary for the application to be submitted according to the deadlines.
- You may contact us at any time if you need clarification on the application or the process.
- Once the application is complete, you may either e-mail it to or call the Office of Continuing Medical Education at (423)439-8081. The contact information is listed at the end of the application.
[ii] Deadlines:
- All applications and their supporting documentation receive a thorough internal review before they are submitted to the Advisory Board. Deadlines are set to accommodate that internal review, and to provide the best opportunity for the activity to be approved.
- Advisory Board meetings are the first week of the month. Applications for live conferences must be received by the 10th day of the month preceding the next Advisory Board meeting. For example, an application that is going to be reviewed by the board the first week of May must be submitted to the Office of Continuing Medical Education by April 10.
[iii] The Advisory Board does not meet in December or July. Applications which would ordinarily be submitted for December or July review, will need to be reviewed at the November or June meetings respectively.
[iv]Commercial support is rarely sought for Regularly Scheduled Series. Please discuss this with your CME Planner, and be aware that NO commercial support can be requested or received by any party to the series except by the Office of Continuing Medical Education.
[v] Office of Continuing Medical Education
James H. Quillen College of Medicine
East Tennessee State University
Box 70572
Johnson City, TN 37614-1708
Phone: 423-439-8081
Fax: 423-439-8040
Email: .
Website:
[vi]Planner Notes: If this is a Joint Sponsorship, please add the entity name to the front of the program name.
[vii]Planner Notes: Please notate the program number from when it was previously held. Please also notate the number of time the program met last year/the number of times it was approved to meet.
[viii] EXAMPLE “Monthly lecture series for faculty and residents focused on emerging technology in cardiology”
[ix]Planner Notes: Please translate the need into the “Learning Gap”
[x]Planner Notes: Please comment if the data is adequate as is or if you are supplying additional data (and attach or note the citation where it can be accessed)
[xi]Planner Notes: Please accept or modify as appropriate, assuring the need matches the format and objectives. Also notate if the activity as envisioned by the applicant is designed to address competency or performance, and not impart only knowledge.
[xii]Examples of barriers to learning might include such issues as beliefs and attitudes, technology, schedules, organizational dynamics
[xiii]Planner Notes: Please comment on whether or not the barriers have been adequately addressed
[xiv]Patient care that is compassionate, appropriate, and effective for the treatment of health.
[xv]Practice-based learning and improvementinvolves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvement in patient care.
[xvi] Interpersonal and communication skill results in effective information exchange and teaming with patients, their families, and other health professionals.
[xvii]Professionalism ismanifest by commitment to carryout professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.
[xviii]Medical knowledge demonstrates established and evolving biomedical, clinical and cognate (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.
[xix]System-based practice is manifest by actions that demonstrate an awareness of and responsiveness to the larger context and system for health care and the ability to effectively call on system resources to provide care that is of optimal value.
[xx] With Joint Sponsorships, only case-based conferences can be video conferenced, and then only if the technology allows for real time discussion and participation at each site. The planner will need to discuss with the applicant that before approval, the Joint Sponsor will need to designate an onsite contact person at the remote participating site, and that they will need to be educated by ETSU on the process and use of the forms, including deadlines. Planner needs to comment on this discussion in the application.
[xxi] An example would be an observed improvement in the type and timing of diagnostic testing on potential stroke patients after physician education on the new evidence based guidelines on Acute Stroke.
[xxii] Planner Notes: Please accept or modify as appropriate
[xxiii] Planner Notes: Please accept or modify as appropriate
[xxiv]Verbs that inform: Cite, Define, Describe, Identify, List, Name, Recite, Record, Recognize, Select, State, Summarize, Update, Write
[xxv] Verbs that denote comprehension: assess,associate, classify, compare, contrast, demonstrate, describe, differentiate, distinguish, estimate, explain, locate, identify, interpret, predict, report, review
[xxvi] Verbs that indicate analysis: analyze, appraise, contrast, criticize, detect, differentiate, distinguish, evaluate, infer, measure, question, summarize
[xxvii]Verbs used to evaluate: assess, choose, compare, critique, decide, determine, estimate, evaluate, measure, rate, recommend, select
[xxviii] Verbs that demonstrate application: apply, calculate, choose, demonstrate, develop, examine, illustrate, interpret, locate, operate, practice, predict, report, review, select, treat, use, utilize
[xxix] Verbs that demonstrate skills: demonstrate, diagnose, integrate, manage, measure, operate, perform, record
[xxx]Planner Notes: Please refine and format as required
[xxxi] Commercial support is rarely sought for Regularly Scheduled Series. Please discuss this with your CME Planner, and be aware that NO commercial support can be requested or received by any party to the series except by the Office of Continuing Medical Education.
[xxxii] Planner Notes: If commercial support will be sought, please define what kind of support
[xxxiii] The Activity Director must be a physician or nurse practitioner. The Activity Director must have direct involvement in the planning of the series, and will need to be in a position to collaborate with the Office of Continuing Medical Education as the planning unfolds.
[xxxiv] EXAMPLE: Medical Staff Grand Rounds e.g.:
- Activity Director (former Chief of Staff or Director of Med Ed)
- Members of the Medical Executive Committee
- VP Medical Affairs or Chief Operating Office
- QI Representative