Quillen College of Medicine, East Tennessee State University, Office of Continuing Medical

1/24/2017

Live Course/Class

CME Program 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]

o  Important information related to the months the Board does not meet[iii]

o  Course/class for which Educational Grants are being sought[iv]

·  Contact Information[v]

Activity Type / Office Use Only
1.  Type of Course/Class / A course/class which may be offered once or more times during the year. Each time the course/class is offered participants change, but not the content. Example: ACLS, Fundamentals of Critical Care
Other, please describe. / Additional Planner Comments
Course/Class Information / Office Use Only
2.  Proposed Course/Class Name: / Additional Planner Comments[vi]
3.  Has this activity been accredited in the past by the ETSU Office of CME? / No
Yes. When? / Additional Planner Comments[vii]
4.  Brief description of proposed course/class / Additional Planner Comments
5.  Is this a class (in which the content is offered during multiple sessions) or is it course (in which all the content is offered in one session)?
Note: Please attach a schedule for the course/class for the application year, including number of times it is offered, proposed dates, and start and end times / Class
How many sessions are there in one class?
How many hours of contact are there in each session?
How many hours of contact are there in the entire class?
Course
How many times in the next year to you anticipate this course being offered?
How many hours of contact in the course? / Additional Planner Comments
6.  Location: (city and facility) / Additional Planner Comments
7.  When do you expect this course/class to first be held? / Additional Planner Comments[viii]
8.  This course/class is being planned by: / Medical school/department
A hospital/healthcare network or its affiliated medical staff organization
Other: Please describe / Additional Planner Comments
Documenting the Need / Office Use Only
9.  What leads you to believe this education is needed? / Additional Planner Comments[ix]
10.  What data do you have that supports this need? / Quality improvement or performance data
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]
11.  Why do you believe your learners need this education?
(Please note: no education will be approved that imparts only knowledge. All educational activities must also address either competency or performance.) / Learners need additional knowledge (A Knowledge need)
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
12.  What barriers to learning do you believe might exist in your potential learners?[xii] / Additional Planner Comments
13.  How will you design your activity to help break down those barriers? / Additional Planner Comments[xiii]
14.  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. / Patient care[xiv]
Practice-based learning and improvement[xv]
Interpersonal and communication skills[xvi]
Professionalism[xvii]
Medical knowledge[xviii]
Systems-based practice[xix] / Additional Planner Comments
Course/Class Format / Office Use Only
15.  Is this Course/Class being offered in conjunction with a third party who stipulates the content, instructor requirements, format, and stipulates the mode and/or content of testing? / No, we are developing the content and choosing the instructor(s)
Yes, the course/class specifics are stipulated by a third party
Who is that third party?
What do they stipulate?
Content
Format
Schedule
Instructor qualifications
Testing process and execution
Hand out materials
Testing forms
Sign in Sheets
Evaluations forms / Additional Planner Comments
16.  What format will be used to support the learning?[xx] / 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: / 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:
Learning Objectives / Office Use Only
17.  What will you look for (either in clinical practice or patient outcomes) that would indicate this course/class has been successful? / Additional Planner Comments
18.  How and when would you measure that outcome? / Additional Planner Comments
19.  Please translate these desired outcomes into 2-3 learning objectives for the course/class:
(For assistance in crafting your objectives, hover you mouse over a footnote number to view examples of verbs that convey “Knowledge”[xxi] , “Comprehension”[xxii], “Analysis”[xxiii], “Ability to Evaluate”[xxiv], “Application”[xxv] “Skill demonstration”[xxvi]) / As a result of participating in this course/class, the attendee will be able to…….
1
2
3 / Additional Planner Comments
Target Audience / Office Use Only
20.  Who is your intended physician audience? / Internal Medicine Physicians
Family Medicine Physicians
OB/GYN Physicians
Surgeons
Pediatricians
Psychiatrists
Emergency Medicine Physicians
Pathologists
Other Specialists – Please List: / Additional Planner Comments
21.  Who is your intended non-physician audience? / Advanced Practice Nurses
Physician Assistants
Pharmacists
Psychologists
Nurses
Medical or Nursing Students
Other Specialists – Please List:
22.  From what department, community, region, or organization do you expect your attendees to come? / ETSU
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
28.  Target Audience Size per course/class / Physicians (excluding residents)
Physician Residents
APNS/PAs
Other Non-Physicians / Additional Planner Comments
Commercial Financial Support / Office Use Only
23.  Do you intend to seek commercial support for this activity? [xxvii] / Yes
No / Additional Planner Comments[xxviii]
Additional Planner Comment for PARS Data
Anticipating:
Grants
Exhibits
Activity Director Information
24.  Activity Director name[xxix]
25.  Title
26.  Specialty
27.  Organization Name / College / Department
28.  Address
29.  E-mail Address
30.  Phone
31.  Fax
Planning Committee[xxx]
Name and Title / Specialty / Phone Number / E-mail Address
Contact Information
Contact Person Name
Title
Organization
Address
Phone Number
Fax Number
E-Mail
Is this the person who is responsible for the day to day support of this course/class? / Yes
No. If no, please detail below:
Responsible individual’s name
Department
Position
Phone number
Fax number
Email address

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 / Activity
Director / 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 / Must be submitted electronically at the same time as the completed Conflict of Interest Disclosure (see below).
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.
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

9 / East Tennessee State University, Quillen College of Medicine, Office of Continuing Medical Education, 1/24/2017

[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 Course/class. Please discuss this with your CME Planner, and be aware that NO commercial support can be requested or received by any party to the course/class 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: http://www.etsu.edu/com/cme/

[vi] Planner Notes: If this is a Joint Providership, 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] Please notate if this activity begins the day of the board meeting, the beginning of the next calendar month, or the date of the first activity.

[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 improvement involves 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 is manifest 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] Examples of Educational Format:

·  Case presentations;

·  Clinical skills assessments;

·  Computer assisted learning;

·  Lecture; Hands on skills lab;

·  Panel discussion; Self assessment;

·  Simulation or standardized patients;

·  Teleconferencing;

·  Video or audio presentations;