Live Activity

1/24/2017 Live Activity CME Program Application

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 meetiii o Live programs for which Educational Grants are being soughtiv o Live programs for which brochures must be developedv  Contact Informationvi Activity Type Office Use Only 1. What type of activity are you A live, one-time activity, conference, Additional Planner proposing? symposium, or seminar Comments Other. Please call us at 423 439 8081 to determine which application you should be using.

Activity Information Office Use Only 2. Proposed Activity Name: Additional Planner Commentsvii

3. Has this activity been No Additional Planner accredited in the past by the Commentsviii ETSU Office of CME? Yes. When?

4. Brief description of proposed Additional Planner activityix Comments

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

5. Proposed Date: Additional Planner Comments

6. Activity proposed beginning Additional Planner and ending time: Comments

7. Proposed number of Additional Planner education hours for the Commentsx activity:

8. Location: (city and facility) Facility: Additional Planner Comments City:

9. This activity is being planned An Academic Medical Additional Planner by: College/Department Comments A hospital/healthcare network or it’s affiliated Medical Staff Organization Other: Please describe

10. What is the name of the Additional Planner sponsoring college, Comments department or organization?

Documenting the Need Office Use Only

11. What leads you to believe Additional Planner this education is needed? Commentsxi 12. Why do you believe your Learners need additional knowledge (A Additional Planner learners need this Knowledge need) Commentsxii education? They have the knowledge, but need additional tools, processes or skills to Planner Note: For (Please note: no education act on that knowledge (A Competency PARS DATA, this will be approved that need) activity is considered imparts only knowledge. All They have the knowledge and skills, but A Competency educational activities must need support in performing at a Activity also address either consistent level (A Performance need) A Performance competency or Activity performance.) A Patient Outcome Activity 13. What data do you have that Requests by participants in previous Additional Planner supports this need? xiii education activities Commentxiv Organizational mandate or new

initiative Emerging clinical guidelines or new technology Focused discussion with the physicians who would potentially attend the seminar Quality improvement or performance data Primary research on physicians in the targeted communities Other. Please explain:

14. All continuing medical Patient carexv education must contribute Practice-based learning and to physician competency. improvementxvi The following is a list of Interpersonal and communication ABMS/ACGME Physician skillsxvii Competencies. Please check Professionalismxviii those that would be Medical knowledgexix addressed in this activity. Systems-based practicexx

15. What barriers to learning do Additional Planner you believe might exist in Comments your target audience?xxi 16. How will you design your Additional Planner activity to help break down Commentsxxii those barriers?

Program Format Office Use Only 17. Please describe the program Case-based presentations Additional Planner format for the activity (check Lecture Comments any that apply) Panel discussion Simulation Planner Note: For Skills-based training PARS DATA, this Small group discussion conference is Other. Please describe: categorized as Case-based presentations Lecture Panel discussion Simulation Skills-based training Small group discussion 3 Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, 1/24/2017 1/24/2017

Other. Please describe:

Learning Objectives Office Use Only 18. What will you look for (in Additional Planner learner competency, Commentsxxiv performance or patient outcomes) that will indicate this activity has been successful?xxiii 19. How and when will you Additional Planner measure this expected Commentsxxv outcome? 20. Please translate these desired As a result of participating in this activity, Additional Planner outcomes into 2-5 learning the attendee should be able to……. Commentsxxxii objectives for the activity: 1.

(For assistance in crafting your objectives, hover you mouse over a footnote number to view examples of verbs that convey “Knowledge”xxvi , “Comprehension”xxvii, “Analysis”xxviii, “Ability to Evaluate”xxix, “Application”xxx “Skill demonstration”xxxi)

Target Audience Office Use Only 21. Who is your intended Family Medicine Physicians Additional Planner physician audience? Internal Medicine Physicians Comments OB/GYN Physicians Pediatricians Psychiatrists Surgeons Emergency Medicine Other Specialists – Please List:

22. Who is your intended non- Advanced Practice Nurses Additional Planner physician audience? Physician Assistants Comments Pharmacists Psychologists Nurses Medical or Nursing Students

Other Specialists – Please List:

23. From what college, ETSU Additional Planner department, community, NE TN Region Comments region, or organization do Knoxville Region you expect your attendees to SW VA Region come? State of Tennessee National An Organization’s Medical Staff – Please list: Other– Please List:

28. Target Audience Size Physicians : (excluding residents) Additional Planner NP/PAs: Comments Non Physicians: (including residents)

Commercial Financial Support Office Use Only 24. Do you intend to seek Yes Additional Planner commercial support for this No Commentsxxxiii activity?

Additional Planner Comment for PARS Data

Anticipating: Grants Exhibits

Activity Director Information 25. Name of Activity Directorxxxiv

26. Title

27. Specialty

28. Organization Name / College / Department 29. Address

30. E-mail Address

31. Phone

32. Fax

Planning Committeexxxv 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 Yes responsible for the day to day No. If no, please detail below: support of this activity? Responsible individual’s name Department Position Phone number Fax number Email address

(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 [email protected]. 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 [email protected].

Action Activity Contact All Planning Academic Instructions Director Person Committee Department Members Chair or Healthcare Executive Provide CV Required Required Required Not required Please see instructions below to include or Resume only if your CV he/she participates on Planning Committee Complete Required Required Required Not required Go to this link to complete. Please copy Conflict of only if and send this link to all that need to Interest he/she complete a conflict of interest. Please Disclosure participates note, you must have your CV ready to on Planning attach to your conflict of interest Committee. disclosure

Sign Signature Not Not Required Sign Required Required Signature Form can be obtained Required Required Required Signatures at this link: It can be copied and given to Signatures Form the Activity Director and the Form 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

8 Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, 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 [email protected] 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 Add an additional 90 days of planning time to the above application deadlines if your organization would like assistance in securing educational grants to support the program. PLEASE NOTE THAT NO COMMERCIAL SUPPORT CAN BE REQUESTED OR RECEIVED BY ANY PARTY TO THE ACTIVITY EXCEPT THE OFFICE OF CONTINUING MEDICAL EDUCATION FOR ANY PROGRAMS ACCREDITED BY THE OFFICE OF CME AT ETSU. v If the applicant would like a brochure developed for the program, add 60 days to the application deadline, to assure that adequate planning is underway to have the speaker information available for brochure development. WHILE A BROCHURE OR “SAVE THE DATE” CARD COULD BE MAILED PRIOR TO RECEIVING APPLICATION APPROVAL, NO STATEMENT OF ANY KIND CAN BE INCLUDED RELATED TO CME CREDIT PENDING OR AVAILABLE. vi 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: [email protected] Website: www.etsu.edu/cme vii Planner Notes: If this is a Joint Providership, please add the entity name to the front of the program name. viii Planner Notes: Please notate the program number from when it was previously held ix EXAMPLE A one day conference for pediatricians and family medicine physicians on the developmental problems most frequently encountered in children under the age of 20 in Appalachia. x Planner Notes: Please adjust hours if needed and attach documentation, if available xi Planner Notes: Please translate the need into the “Learning Gap” xii 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. xiii Examples of data that demonstrates need:  Continuous quality improvement data;  Accreditation site visit reports;  Accreditation requirements;  Health policy studies;  Incident reports/Sentinel events;  Patient records and databases;  Professional review organization studies;  Government reports on health statistics, technology developments, etc.;  Practice audits and reviews;  Recent research articles describing the need;  New techniques, protocols, clinical pathways or guidelines;  Organizational policy or board mandates;  Consensus reports from workshops and committees;  Primary research;  Published expert opinions;  Outcomes of physician surveys;  Evaluation summaries from previous CME activities;  Written faculty perceptions and recommendations;  Committee notes;  Focus groups;  Informal discussions with peers; xivPlanner 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) xv Patient care that is compassionate, appropriate, and effective for the treatment of health. xvi Practice-based learning and improvement requires investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and documented improvements in patient care. xvii Interpersonal and communication skill results in effective information exchange and team interaction with patients, their families, and other health professionals. xviii Professionalism is manifest by a commitment to carryout professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. xix 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. xx 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. xxi Examples of barriers to learning might include such issues as beliefs and attitudes, technology, schedules, organizational dynamics xxii Planner Notes: Please comment on whether or not the barriers have been adequately addressed xxiii 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. xxiv Planner Notes: Please accept or modify as appropriate xxv Planner Notes: Please accept or modify as appropriate xxvi Verbs that inform: Cite, Define, Describe, Identify, List, Name, Recite, Record, Recognize, Select, State, Summarize, Update, Write xxvii Verbs that denote comprehension: assess, associate, classify, compare, contrast, demonstrate, describe, differentiate, distinguish, estimate, explain, locate, identify, interpret, predict, report, review xxviii Verbs that indicate analysis: analyze, appraise, contrast, criticize, detect, differentiate, distinguish, evaluate, infer, measure, question, summarize xxix Verbs used to evaluate: assess, choose, compare, critique, decide, determine, estimate, evaluate, measure, rate, recommend, select xxx Verbs that demonstrate application: apply, calculate, choose, demonstrate, develop, examine, illustrate, interpret, locate, operate, practice, predict, report, review, select, treat, use, utilize xxxi Verbs that demonstrate skills: demonstrate, diagnose, integrate, manage, measure, operate, perform, record xxxii Planner Notes: Please refine and format as required xxxiii Planner Notes: If commercial support will be sought, please define what kind of support xxxiv The Activity Director must be a physician or nurse practitioner. The Activity Director must have direct involvement in the planning of the activity, and will need to be in a position to collaborate with the Office of Continuing Medical Education as the planning unfolds. xxxv EXAMPLES: Multidisciplinary (Team) Conference in Geriatrics, e.g.:  Activity Director – Physician (Geriatrician)  Community Physician with interest in geriatrics  Clinical Pharmacist  APN with interest/specialty in geriatrics  Physical Therapist with interest/specialty in geriatrics  Clinical Social Worker or Representative from long-term care facility

EXAMPLES: Pediatric Specialty Conference, e.g.:  Activity Director – Physician (Pediatrician with interest in topic)  Family Medicine Physician  Pediatric Resident/Fellow  FNP Representative from practice site  Public Health Representative