Medical Society of The State of New York

application for

AMA PRA CATEGORY 1 tmCME CREDIT


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PLEASE NOTE

This application should be received by MSSNY three monthsprior to the program to be eligible for consideration.

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MEDICAL SOCIETY OF THE STATE OF NEWYORK

EducationalProvidership Agreement

PLEASE REVIEW AND RETURN SIGNED COPY WITH YOUR APPLICATION

Step IApplicant must contact MSSNY’s Office of Continuing Education at least three (3) months prior to the date(s) of the educational activity to schedule a planning meeting. For information on how to develop a CME activity see the Application Instructions and Quick Reference for planning a CME Activity. In addition, review the Essential Elements required for AMA PRA Category 1 credittm

Step IIA planning meeting must be held to discuss preliminary program agenda, faculty, and budget. It is suggested that all programs should have at least 2 physicians on the planning committee.

Step IIIThe completed application for AMA PRA Category 1 credits tm and all supplemental documents are submitted to the MSSNY Subcommittee on Educational Programs for review and approval or disapproval. Payment will be invoiced.

Requirements for CME activities are the responsibility of the organization making the application.

Step IV.Planning and submission

Step V.Implementation: Must submit draft copies of ALLbrochures and advertisements to MSSNY’s CME office for approval prior to printing. All printed materials must include the MSSNY Accreditation statement.

All commercial supporters should be acknowledged as supporters, not sponsors, on all printed materials.

For Enduring Materials - the videos, audio, printed materials and online CME activities have additional requirements. See Enduring Material policy.

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Step VI.Applicant receives a written report of the Subcommittee’s decision.

Step VII. Evaluation: The following materials are due in MSSNY’s CME office four (4) weeks after completion of the activity or series:

  • Actual attendance list of MD/DO’s and non-MD/DO’s including total numbers
  • MD/DO-only evaluation and faculty evaluation summary, including outcomes data
  • One copy of the syllabus and handout materials
  • A final budget report including all industry support information
  • The MSSNY monitor’s evaluation form

Joint Providership Fees:

Joint Sponsorship Fee:$1000 plus $150 per credit

This fee is for the one-time presentation of a live activity, the production of an enduring material or internet based activity or presentation of a regularly scheduled series.

Joint Sponsorship Fee:$500 plus $150 per credit

This fee is foreach additional repeatpresentation of a live activity.

Activity Review Fee: If MSSNY sends a monitor to perform an activity review, it is the Joint Sponsor’s responsibility to pay the monitor’s expenses. This includes, but is not limited to, registration fees and any travel expenses. An invoice with original receipts will be sent after the activity is held.

I have read and understand my responsibilities ______.

Program Coordinator Date

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APPLICATION FOR EDUCATIONALPROVIDERSHIP OF A CME ACTIVITY

1. Type of Providership requested: Choose one

□Joint Providership (applicant is a non-accredited provider)

□Direct Providership (applicant is a MSSNY staff person)

PLANNING

Education must develop or increase knowledge, skills and/or professional performance a physicianusesfor patients, public or the profession. The subject area must encompass the scope depth appropriate for physiciansbe planned, presented evaluated in terms of measurable educational objectives definingthe level of competence/performance to be achieved.

2. Describeyour target audience:

3. Describe Gaps in Competence and/or Performance (C2)

a.What practice-based issue (gap between current best practice) will be addressed in this activity?

b.How did you know this was a gap for yourphysician-learners? (as identified in Q3a)?

( ) Learner Evaluations( ) Objective data or statistics* ( ) Risk Management

( ) Medical Audit( ) Quality Improvement Report* ( ) Survey

( ) New technology/technique*( ) Regulatory changes* ( ) Other*

c.*Identify the data source(s):

  1. Based on answers to 3b, describe how you sure are it is a gap for your learners:

e.Why does the practice gap exist?

4. Application of Identified Gaps to Planning Content

Based on answers to Q3, listgapsyou identified and desired results for learners(Add lines as needed).

a.Identified Need that underlies the Gap:

Content will change: ___Knowledge/Competence ___Performance ___Patient outcome

b.If this educational activity teaches “best practices”, what do you expect learners to change to their currentpractice based on the strategies taught in this activity?

5. Preparing Measurable Learning Objectives (C3)

Educational objectives are not simply what the participants will learn. They must clarify outcomes for change in competence, performance and/or patient outcomes.

a.If focus is changing knowledge/competence, will the activity provide information allowing learners to change their approach to diagnosis or management? What practice strategies are offered to help a learner develop or expand?

  1. If focus is performance-based changes how will learners assess their practice to understand how often to approach a patient on issues describe in this CME? What can this CME do to help learners change their practices? Is a new skill being taught?
  2. If focus is on changing patient outcomes, will learners be able to assess if their patients are getting best possible outcomes from treatment, as described in the presentation? What can this CME do to change patients’ outcomes?

Based on your answers to Question 4 and using the descriptions above,LIST your measurable learning objectives:

6. Barriers and Opportunities (C18, 19)

What could block the learner from implementing the new learned behaviors, strategies or skills taught in this activity?(ie: staffing, policy/schedule restrictions, insurance reimbursement, lack of resources, etc)

___This activity addresses no relevant system barriers.

___The following barriers have been identified and will be addressed in the educational content (

7.Program Format:

Based on the previous steps, what format(s) will be used for this activity?

( ) Live*( ) Enduring material( ) Internet( ) PIP( )Other______

*Attach an agenda with start and end times of live educational activity.

a. What is the educational design of the activity?

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( ) Didactic Lecture

( ) Symposium

( ) Case presentation

( ) Train the Trainer

( ) Online

( ) Webinar

( ) Enduring material: Type:______

( ) Regularly Scheduled Series: SEE Q17

( ) Other______

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Attach activity materials (powerpoint, slides etc) with appropriate disclosure statements.

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8. Planners and Presenters

a.Faculty should have a demonstrated expertise, strong presentation communication skills, and be able to address the needs objectives of the activity without a conflict of interest.

Attach your faculty listincluding moderators:(click on underlined area).

Attach a CV or bio for each faculty member.

Attach a copy of the faculty letter/invitation(click on underlined area).

b.List the names of all the activity planners:

9. Physician Competencies and Attributes

Competencies Attributes are national goals for physicians associated with targeted specialty(ies) that should be addressed whenever possible in planning CME.

  1. Based on the List of Desirable Physician Attributes below, which competency areas have been addressed during the planning of this CME activity? Check all that apply. (C6)
  2. Describe how each competency has been addressed during the planning of this CME activity?

Institute of Medicine Core Competencies

____Provide patient-centered care:identify, respect & care about patient differences, values, preferences expressed needs; relieve pain suffering; coordinate continuous care; listen to, clearly communicate with educate patients; share decision making management; continuously advocate disease prevention, wellness, healthy lifestyle promotion, including focus on population health

____Work in interdisciplinary teams– cooperate, collaborate,communicate integrate carein teams to ensure care iscontinuous reliable. Employ evidence-based practice. Integrate best research withclinical expertise patientvalues for optimum careparticipate in learning andresearch activities to the extent feasible

____Apply quality improvement -identify errors hazards in care; understand implementbasic safety principles,like standard-ization simplification; continuallyunderstand measure qualityof care in terms of structure,process outcomes inrelation to patient & community needs. Design test interventions to change processes systems of care, with objective of improving quality

___ Utilize informatics: communicate, manage,knowledge, mitigate error, support decision makingusing information technology

ACGME/ABMS Competencies

____Patient carethat is compassionate, appropriate, and effective for the treatment of health problems the promotion of health.

____Medical knowledgeof established evolving biomedical, clinical, cognate sciences application of knowledge to patient care

____Practice-based learningand improvement that involvesinvestigation and evaluation ofown patient care, appraisaland assimilation of scientificevidence, and improvements inpatient care.

____Interpersonal Communication skillsthatresult in effective informationexchange teaming withpatients, families & otherhealth professionals

____Professionalism,as manifested through a commitment tocarrying out professionalresponsibilities, adherence toethical principles, and sensitivityto a diverse patient population

____Systems-based practice, as manifested by actions thatdemonstrate an awareness ofand responsiveness to the largercontext system for healthcare and the ability to effectivelycall on system resources toprovide care that is of optimalvalue

ABMS Maintenance of Certification

____Evidence of professionalstanding,such as anunrestricted licensethat has no limitations on thepractice of medicine.

____Evidence of commitment to lifelong learninginvolvement in periodic selfassessmentprocess to guidecontinued learning

____Evidence of cognitive expertisebased on performance on anexam.That exam shouldbe secure, reliable & valid. Itmust contain questions onfundamental knowledge, up-todate practice-related knowledge, other issues like ethicsprofessionalism

____Evidence of evaluation ofperformance in practice,including the medical careprovided for common/major health problems and physiciansbehaviors, such ascommunication andprofessionalism, as they relate topatient care

10. Partnering and collaboration (C18, 19, 20)

a.Are there other organizations with which you could partner that are also working on this topic? ____YES ____ NO

If YES, describe:

11. Additionaleducational Interventions used to reinforce learning(C17)

a. List any other strategies that will be used to enhance the potential for physician change or reinforce the desired educational results.

12. Proper Preparation of Printed Materials

All printed materials (flyers, brochures, CD/DVD covers, email, etc) must have the proper accreditation and disclosure statements. ALL PRINTED MATERIALS MUST BE APPROVED BEFORE SUBMITTING FOR PRINTING OR DISTRIBUTION TO THE PUBLIC.

Attach a draft copy of all printed materials with proper accreditation and disclosure statements.

13. Certificates

CME certificates must include physician name, activity name, date, and appropriate accreditation statement. Attach a copy of your CME certificate for PhysicianandNon-physician.

FUNDING

This activity must be planned within the ACCME Standards for Commercial SupportSM.

14. Preliminary budget

Include a budget for this CME activity including all ( potential) expenses revenue

15. Commercial Support

a.Is there commercial support for this activity? ____YES ____NO

If NO, how is the activity funded?

Attach a list of commercial supporters

Attach signed MSSNY commercial support agreements for all entities providing financial or in-kind support.

b.If receiving commercial support, how will this support be disclosed to the learners prior to the activity?

___VerballyAttach a copy of the verbal attestation form

___WrittenAttach a copy of the flyer or brochure or handout

c.Will there be exhibitors? ____YES ____NOAttach a list of exhibitors

If Yes:How will you manage the separation of the exhibitors from the educational rooms and learners?

d.Will you be accepting advertisements?____YES ____NO

DISCLOSURE

16. Relevant Financial Relationships (RFR)

This form must be completed by all presenters/planners ifcommercial support is or is not accepted.

Attach completed disclosures from all planners, presenters and moderators.

a.Has any planner or presenter refused to sign an RFR? ____ YES ____ NO

If yes, how was this managed?

c.On the RFR Form,did anyone with the potential to control the content of the activity show aconflict of interest resultingfrom a financial relationship? ____ YES ____ NO

If yes, describe how the conflict of interestwillbe managed?

d.Prior to the start of the CME activity, learners must be informed of any and/or the lack of RFRs for anyone with the potential to control the content of the activity.

Describe how you plan to make the disclosures to your learners prior to the start of the activity:(see Written Disclosure/Accreditation and Objectives Information Form)

___VerballyAttach a copy of the verbal attestation form

___WrittenAttach a copy of the flyer or brochure or handout

EVALUATION

17. Evaluation Tools (including Outcomes Evaluation Assessment) (C11)

The method of evaluation depends on (1) the expected result(to change competence, performance or patient outcomes); (2) format applicability of the tool (3) available resources. How will you evaluate the activity's effectiveness in producing change?Post-activity, how will you ascertain if the practice gap is resolved?

METHOD choices:
Post-activity Evaluation (measures change to competence)
Long-term Post-activity Evaluation (measure change to performance / patient outcomes)
Pre‐Post Test (measures immediate learning)
Learning Contract (commitment‐to‐changequestion)
Audience Response System (identifies if learners understand content and provides learning reinforcement)
Focus Group (qualitative measurement to seek more indepth information)
Post Test (measures transfer of knowledge)
Case discussion or vignette (measures application of knowledge to practice / competence)
Performing specific techniques taught at CME
Medical records review before and after activity
  1. In Question 4, do you plan to change Knowledge/Competence____YES ____NO
  2. Describe the evaluation mechanism
  1. In Question 4, do you plan to change Performance____YES ____NO
  2. Describe the evaluation mechanism
  1. In Question 4, do you plan to change Patient Outcomes____YES ____NO
  2. Describe the evaluation mechanism

Attach a copy of alllearner evaluation and faculty evaluation tools.Templates available.

REGULARLY SCHEDULED SERIES (RSS)

18. Regularly Scheduled Series (RSS): Is this an RSS? ____YES ____NO

Describe the RSS:

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( ) Grand Rounds

( ) Tumor Board

( ) Mortality and Morbidity Conference

( ) OtherDescribe:

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Describe how often you plan to monitor the RSS: Attach the monitoring tool.

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( ) Weekly

( ) Monthly

( ) Quarterly

( ) OtherDescribe:

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PREVIOUS ACCREDITATION

19.Have you applied for CME credit for this activity in the past? ____YES ____NO

a.If yes, submit a narrative describing the analysis of the outcome data from your previous activity justifying the need for this educational activity. Describe use of evaluation data from the previous activity as part of your needs assessment.Attach evaluation data from the previous activity supporting the continuing need for this activity.

Submitted by: ______Date:______Daytime Phone:______

REQUIREMENTS FOR ACCREDITATION:

ACCREDITATION STATEMENT:All printed materials/CME certificates MUST include the statement as written below. The credit designation statement MUST be offset (italics or bold) from the rest of the statement

For Directly Provided Activities

The Medical Society of the State of New York is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Medical Society of the State of New York designates this (type of activity) for a maximum of (number of credits) AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

For Jointly Provided Activities

This activity has been planned and implemented in accordance with the Accreditation Requirements and Policies of the Medical Society of the State of New York (MSSNY) through the joint providership of MSSNY and (Name of Non-Accredited Provider). MSSNY is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Medical Society of the State of New York designates this (type of activity) for a maximum of (number of credits) AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

DISCLOSURE STATEMENT for use in printed materials

MSSNY relies upon planners and faculty participants to provide educational information that is objective and free of bias. In this spirit & in accordance with MSSNY/ACCME guidelines, all speakers & planners must disclose relevant financial relationships with commercial interests whose products, devices or services may be discussed in the CME content or may be perceived as a real or apparent conflict of interest.Any discussion of investigational or unlabeled use of a product will be identified.

Use the following statement for faculty who have nothing to disclose:

The planners and presenters do not have any financial arrangements or affiliations with any commercial entities whose products, research or services may be discussed in these materials.

Use the following statement for faculty who have financial disclosures:

The following planner/presenter has indicated a relationship: (list name, relationship & name of company)

FUNDING DISCLOSURE STATEMENT EXAMPLES:

This activity has been funded by an unrestricted educational grant from Merck Pharmaceuticals

This activity has been funded by an unrestricted educational grant from the NYS Department of Health.

No commercial funding has been accepted for the activity.

REGISTRATION FOR THE CME ACTIVITY

There MUST be a sign in sheet which clearly identifies the learner. This can be sign in sheet, registration list (the learner must sign or initial) or electronic roster (for online activities). This MUST be sent to MSSNY post-activity.

CERTIFICATES: These must bear the learner name, date & activity title & proper accreditation statement

A CME APPLICATION MAY NOT BE ACCEPTED WITHOUT THE FOLLOWING:

___Completed and signed application agreement

___An agenda with start and end times of all live activities

___Activity materials and all handouts (powerpoints, slides, etc)

___List of planners and presenters

___A CV or bio for each Faculty member

___A copy of the faculty invitation letter (if used)

___List of all commercial supporters

___List of all exhibitors

___The commercial agreement for each commercial supporter

___Preliminary budget

___The Relevant Financial Relationship form for each planner and presenter

___A copy of any non-educational interventions

___The evaluation form(s) for learners and faculty

___Each of any printed materials: brochure, flyer CD/DVD covers etc.

___A copy of the certificates for physicians and non-physicians

___A copy of your sign-in sheet

___Analysis of the outcome data from your previously-approved activity justifying need for this activity.

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