Allegheny General Hospital Continuing Medical Education

Application for Designation of Category 1 Credit for Formal CME Activities

allegheny general hospital ● Continuing medical education

Application for designation of category 1 credit

for FORMAL cme activities

Introduction

Allegheny General Hospital is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing education for physicians. As an accredited sponsor, Allegheny General Hospital, through the Department of Continuing Medical Education, can designate an activity for Category 1 credit if it meets the following criteria:

· it conforms to the AMA definition of continuing medical education;

· it is based on perceived or demonstrated educational need;

· it is intended to meet the continuing medical education needs of an individual physician or a specific group of physicians;

· the educational objectives for the activity are stated;

· the content and the format are appropriate to accomplish the specified objectives;

· records of attendance are kept;

· evaluation mechanism is defined to assess the quality of the activity and its relevance to the stated needs and objectives;

· the activity conforms to policies of the Hospital;

· if funds from commercial companies are included, the activity conforms to the AMA Ethical Opinion on Gifts to Physicians,

the ACCME Standards for Commercial Support of CME, and the AAMC Guidelines for Commercially Supported CME;

· faculty disclosure of significant relationships with relevant commercial companies is made.

A. Conference Title

Conference Director/

Person submitting application

Contact information: Phone # Fax#

e-mail

Assistant/Secretary

Phone# _ Fax#

e-mail

Signature Date of Application______

—Continued on page 2—

FOR CME USE ONLY

Approved for AMA PRA Category 1 Credit TM

Approved for Patient Safety Credit

Assigned to CME Coordinator:

Not Approved for the following reasons:

signature: ______Date: ______

administrative director, medical education

Revised 07/08/09

A. conference title:

B. date(s)

C. location:

course overview:

target audience

D. credits to be offered (please check all that apply)

Application for Designation of Category 1 Credit for Formal CME Activities

Physician:

AMA PRA Category 1 Credit TM

Patient Safety

ACEP

AAFP

AAP

Dentistry:

AGD

Psychologist:

APA

Health Care Professionals:

ASRT

NATA BOC

Pharmacy

Social Work

Other

Application for Designation of Category 1 Credit for Formal CME Activities

G. are there other groups/institutions involved in the planning? Yes No

If yes, please list:

Application for Designation of Category 1 Credit for Formal CME Activities

How have the needs of the target audience been assessed? Check all applicable statements on the line and indicate the three most frequently used by numbering within parentheses.

A. needs assessment – idendify the learner gaps upon which this activity will be based

How have the needs of the target audience been assessed? The key to planning a CME activity is to clearly identify the ‘gap’ upon which the activity will be based. The ‘gap’ is based on the difference between what your learners DO NOW versus what you WANT THEM TO DO (also known as ‘best practice’). Therefore please carefully state (1) the learners’ current practice, followed by (2) the best practice that you intend for the learner to achieve as a result of this activity, thus (3) identify the ‘gap’ (needs assessment).

1. Current Practice:

2. Best Practice:

3. Resulting Gap:

B. objectives

1. Your ‘gap’ analysis above should have identified very specific gap(s) for this activity. What are the overall learning objectives you hope to achieve through this CME activity to assure those gaps are addressed and closed? These objectives may include changes in problem solving, diagnostic or operative skills, improvements in knowledge, attitudinal changes or improved understanding of complex relationships. Learning objectives should link both the gap and result you intend to achieve,

2. How will these overall learning objectives be communicated to the audience? (Check as many as apply.)

In written materials in advance of the conference (e.g., Flyer, Web site, brochure, etc)

In written materials during the conference (e.g., Syllabus)

Verbally at the beginning of the conference

Included in the evaluation

Other:

Application of Desirable Physician Attributes to CME Content
INSTRUCTIONS Planners are required to address nationally established goals for physician core competencies as developed by the Institute of Medicine, Accreditation Council on Graduate Medical Education (ACGME), Association of American Medical Colleges (AAMC), and the American Board of Medical Specialties (ABMS) related to specialty maintenance of certification. Based on the following chart that lists ABMS, ACGME and PA Patient Safety competencies, please indicate in the last column the specific areas of content (and the competency number identifier) in your planned CME activity that will address those national competencies. Additional competencies are listed in Appendix E.
National Priorities for Physician Attributes
ABMS (MOC)/ACGME Competencies / Content Reflecting These Competencies in Your CME Activity
1-Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health
2-Medical knowledge about established and evolving biomedical, clinical, and cognate (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
3-Practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care
4-Interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and other health professional
5-Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
6-Systems-based practice, as manifested 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.
Pennsylvania Patient Safety and Risk Management Activities
7-Improving medical records and record keeping
8-Reducing medical errors
9-Professional conduct and ethics
10-Improving communication among physicians and with other health care personnel
11-Communication between physicians and patients
12-Preventive medicine education
13-Health care quality improvement / INSTRUCTION: ENTER APPLICABLE NUMBER(S) IN BOX FOLLOWED BY DESCRIPTION OF CONTENT THIS CME ACTIVITY WILL ADDRESS:
· Example: 1, 2, 3, 6, 7 & 8: Treatment options supported by evidence and the decision making process is evaluated and discussed demonstrating the collaboration of the multidisciplinary teams which includes: radiation therapy, surgery, medical oncology, pathology, radiology, social work, behavioral medicine, nutritional and chaplaincy services.
ENTER NUMBERS CHOICES IN THE BOXES BELOW:
·
·
·
·

Application for Designation of Category 1 Credit for Formal CME Activities

C. activity structure and content

1. How is this CME activity structured to achieve the overall learning objectives? (Check as many methods as apply and indicate the three most frequently used by numbering within the parenthesis.)

Lectures and/or panel discussions followed by question/answer periods
Demonstration of procedures, including use of film, videotape, audio tape, or closed-circuit television
Demonstrations of procedures using patient models
Workshop performance of manipulative skills under supervision
Other or additional explanation:

To assist in preparing unbiased presentations for this CME activity each faculty member should be aware that:

§ Presentations, by themselves or in conjunction with other presentations, must give a balanced view of the therapeutic options.

§ When discussing unlabeled or investigational uses of a commercial product, these uses must be identified as unlabeled.

§ Use of generic names of products contributes to impartiality. If trade names are used, those of several companies should be used.

Each faculty member will be required to submit a completed faculty disclosure form (refer to section IV Faculty Information, C & D on page 5 of this application)

2. How will the faculty be informed of the above requirements concerning content to be presented ?
(Check as many apply)

Verbally by the conference director

Written communication (faculty confirmation letter) by the conference coordinator

Other:

3. What, if any instructional materials do you plan to distribute to participants?

Syllabus

Other: Please specify

D. evaluations

1. How will the evaluation(s) be used? (Check as many as apply)

The evaluations will be used in planning future CME activities (e.g., Topics, speakers, format)

The course director will review the evaluation(s) to determine whether objectives were met.

Feedback will be provided to the speaker(s) by the course director

Other:

A. identify faculty: please list institution and contact information

Application for Designation of Category 1 Credit for Formal CME Activities

• if more space is needed, please insert information here

B. how will the overall learning objectives and the composition of the target audience be communicated to the faculty (check as many as apply.)

Verbally by conference director

Written communication/faculty confirmation letter by the conference coordinator

Other:

C. faculty conflict of interest

ACCME Standards require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. This requirement means that all faculty for the CME activity must disclose to the participants any relationship (e.g., Research grants, consultancies, honoraria and travel, or other benefits or self-managed equity in a company) they have with manufacturer(s) of commercial products they will discuss.
All faculty are required to complete a faculty disclosure form.

D. documentation that disclosure occurred

The ACCME requires that CME maintain documentation that the relationships were ascertained and disclosed.

E. will external faculty receive an honorarium? Yes Noif yes, what amount is being considered?

AGH has established general guidelines for guest faculty honoraria. (Copy available upon request.) Exception to the honoraria guidelines should be obtained in advance from the Department of CME. Without prior approval, amounts outside the guidelines may not be paid.

F. will travel expenses be paid for faculty? Yes No

Airfare (coach) Ground Transportation (mileage/taxi/tolls)

Hotel (room/tax only) (all charges)

Meals

A. will this cme conference involve financial support (or other contributions of materials) from a commercial company such as a pharmaceutical or medical device manufacturer?

Yes No

B. initial request for financial support shall be made by the course director

1. through written correspondence

2. verbal request

C. the cme coordinator will follow-up with the applicable paperwork needed to process the Funding request:

(i.e., grant request letter, invitation to exhibit, letter of agreement, etc.)

please note: to comply with accme requirements, all funding must come through the cme office

D. please provide the following information about the companies selected to support this activity:

(please attach additional sheet if necessary)

Application for Designation of Category 1 Credit for Formal CME Activities

Company Name Rep Name/Contact Info Amount of Support

10.

If more space is needed, please insert information here:

return completed application to:

Continuing Medical Education Allegheny General Hospital

320 East North Avenue Pittsburgh, PA 15212-4772

(412) 359-4952 Telephone (412) 359-8218 Fax