Cme Activity Planning and Approval Form

CONTINUING MEDICAL EDUCATION 1462 Clifton Road NE, Suite 276 Atlanta, GA 30322 Phone: 404-727-5695, Fax: 404-727-5667, Email: [email protected] CME ACTIVITY PLANNING AND APPROVAL FORM This form is designed to facilitate the planning, implementation, and evaluation of a continuing medical education activity that will comply with the Essential Areas and Standards of the Accreditation Council for Continuing Medical Education. After an initial meeting with OCME staff, please submit this completed form with required signatures and documentation to the CME Program Manager not later than six (6) months prior to the date of the program. ACTIVITY INFORMATION Program Title: This activity is presented by the Department(s) of: Division(s) of:

Date(s): Anticipated Location: Smart Key #: Anticipated Registration Fee: Anticipated # of participants:

TYPE OF ACTIVITY: (Please check all that apply) Course: (conference, symposium, workshop, etc.) – Draft agenda with topics and times must be provided. Regularly Scheduled Series (RSS)- Frequency: □ 2/week □1/week □ 2/month □1/month □Quarterly Other:_____ Enduring Material - is a non-live CME activity that "endures" over time. It is most typically a DVD, webcast, internet CME. Other type of activity, please specify: ACTIVITY COURSE DIRECTOR: The physician or basic scientist who has overall responsibility for planning, developing, implementing, and evaluating the content and logistics of a certified activity. Name: Title: Department: Phone: Fax: Email: APPROVAL AND RECOMMENDATION I approve and recommend the implementation of this continuing medical education activity. I attest that this activity will comply with the Essential Areas and Standards of the ACCME regarding balance of scientific integrity and objectivity of content.

Department Chair Date

Course Director Date

Executive Director, Continuing Medical Education Date

For OCME Use Only Credit Hours Approved: ______Date Received: ______

Administrative Fee: ______ Joint sponsor: ______

Contact Person: ______Email: ______

Executive Director Preliminary Approval: ______Date:______

CAF 2011 Page 1 ACTIVITY PLANNING COMMITTEE - In addition to the activity course director, list the names, affiliation and emails of persons responsible for the design and implementation of this activity. Name: Affiliation: Email:

Name: Affiliation: Email:

□ Check here if additional planning committee members. Please attach list.

G Sources of Educational Needs – C2 – This activity will address specific issues related to deficiencies in N I participant knowledge/competence or performance as reflected in what the learner is currently doing N

N versus what the learner should be doing. How did you identify these deficiencies? Select all that apply

A and provide supportive documentation for each. (REQUIRED) Select at least 1. L P

L National Practice Standards – attach summary. Please highlight specific information related to areas of A educational need/topic of interest that will be presented. N

O Departmental discussion meetings – attach minutes identifying issues related to quality of care of patient I

T safety. A

C Emerging Research or Technology of clinical relevance – attach summary data (not entire article) or U description of new technology D

E Patient Care Audits / Quality Improvement data – attach data summary ie. audit reports, chart reviews

Review of board examinations and/or Maintenance of Certification requirements – attach copy of requirements/update Regulatory, Legislative Requirements - attach copy of requirement / policy change that may have implications for medical practice. Need for practice improvement as identified by 1) the learner (i.e. group survey or request from individuals); or 2) specialists recognizing suboptimal practice among non-specialists; or 3) expert opinion from those in the field or related medical societies. – attach copy of survey results, summary of trends in suboptimal care, or name of expert or medical society medical societies and summary of recommendations. Other: G

N Emory CME Mission - Alignment C3 – Please review the Emory CME Mission Statement and indicate I

N which of the following categories best aligns with the proposed activity. Check all that apply. N A

L Mission Statement – See Reference Page P

L Designed to give physicians and other healthcare professionals current knowledge to advance the A

N prevention, diagnosis and treatment of disease in the population. O

I Designed to improve physician performance by providing an opportunity to practice new knowledge in a T

A safe, controlled environment with a faculty expert and feedback on performance (typically a hands-on

C workshop or procedure-oriented activity). U

D Designed to significantly impact patient outcomes and will measure result. E

CAF 2011 Page 2 CAF 2011CAF

EDUCATIONAL PLANNING EDUCATIONAL PLANNING ( What arethe practicWhat listed above.listed patient practice (performance);Mustneeds/objectivesdo in oroutcomes. the what they educational to relate ResultsC3 – - Desired improve patientimprove outcomes Health Population Patient Outcomes practicesmodify their Performance knowledgestrategies / Give physicians/ abilitiesnew Competence/Knowledge appropriate:Choose objectives can then beidentified.) thenobjectives can be, andfromprogramidentify what ought towhich goalsto measure gaps between andwhat is and needsunderlying educational and the deficiencies/gaps practice.assessmentsyouin (Needs enable iscurrentlyversus what the reflected in learner what the doinglearnerbe doing.the should List to address specific knowledge/competence orissues relateddeficiencies participant in performance as C3 C2,- Needs Educational – and Practice Gaps Professional Identifying address with thisaddresswith activity?) Professional Practice Gap

– Help physicians– Help e -based issues we want to – Help – / What doyouchange:the participant’s strategies tohope or What clinical(competence); – –

of an appropriate evaluative tool. appropriate of an usebemust the with measurable specific examples. They Give (what learner(what should doinknow to and/or be able the order to the gaps betweenare doing order what they close and what theyonthe best be doingand should based available evidence?)available Educational Needs Educational (Objectives)Needs List, using action verbs. using List, action This activity will This Page Page 3 Target Audience and Scope of Practice - C4 Who are the learners we wish to engage? Be sure that the educational content of this activity is relevant to those selected and is directly related to what they actually do in their professional practice. Select all that apply. Geographic Location: Provider Type: Specialty: Internal (Emory) Primary care All specialties Oncology only physicians Local/regional Specialty physicians Anesthesiology Ophthalmology National Pharmacists Cardiology Orthopedics International Psychologists Dermatology Otolaryngology Physician Assistants Emergency Pathology Medicine Nurses Endocrinology Pediatrics Nurse Practitioners Family Medicine Psychiatry Other (specify): Internal Medicine Radiology Neurology Surgery Neurosurgery Urology OB/GYN Other (specify): Education format – C5 Based on the identified educational needs and desired results, choose the appropriate educational format this activity will utilize. Please select all that apply. Competence/ knowledge Performance Patient Outcomes

Didactic lectures Hands-on procedural/skills Reinforcing materials such workshops as pocket cards, mobile instruments, etc. Small groups/ Panel Case-Based Presentations Reinforcing activities such discussions as chart audits, hospital QI date review, etc. Demonstrations Simulation labs Other:

Interactive (use of audience Standardized patient response system) Journal review, Other: Mortality/Morbidity data review;

Desirable Physician Attributes – C6 Through ABMS' Maintenance of Certification (MOC) process, board certified physicians in 24 medical specialties build six core competencies for quality patient care in their medical specialty. ABMS MOC assures that the physician is committed to lifelong learning and competency in a specialty and/or subspecialty by requiring ongoing measurement of these competencies. Please select all of the core competencies that apply.

Patient Care-Provide care that is compassionate, appropriate and effective treatment for health problems and to promote health.

Medical Knowledge-Demonstrate knowledge about established and evolving biomedical, clinical and cognate sciences and their application in patient care.

Interpersonal and Communication Skills-Demonstrate skills that result in effective information exchange and teaming with patients, their families and professional associates (e.g. fostering a therapeutic relationship that is ethically sounds, uses effective listening skills with non-verbal and verbal communication; working as both a team member and at times as a leader).

CAF 2011 Page 4 Professionalism-Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations.

Systems-based Practice-Demonstrate awareness of and responsibility to larger context and systems of healthcare. Be able to call on system resources to provide optimal care (e.g. coordinating care across sites or serving as the primary case manager when care involves multiple specialties, professions or sites).

Practice-based Learning and Improvement-Able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence and improve their practice of medicine.

T Outcomes Measurement – C11 N E What type of evaluation method/tool(s) will you use to determine the activity’s effectiveness at achieving M

E the desired results and creating change in learner competence, performance or patient outcomes? V O

R Competence/Knowledge – Give Performance – Help physicians Patient Outcomes /

P physicians new abilities / strategies / modify their practices Population Health – Help M I knowledge improve patient outcomes D

N Post-activity survey Peer Review / Direct Patient Chart Audits A

Observation N Customized Pre and Post Tests Case Based Studies Hospital QI data O I T

A Audience Response System Follow-up survey/interview Patient Feedback U

L (ARS) about actual change in practice A

V (done at various intervals after E course Adherence to various Mortality/Morbidity data guidelines as evidenced by QI data Other: Other: Other:

Commercial Relationships - C7, C8, C9, C10

Educational Grants – See reference page for additional information The basic guiding principles of a CME certified activity are that the activity be 1) independent from the interests of commercial entities; 2) transparent; and 3) a separate activity from product promotion. Decisions regarding the need, educational objectives, selection and presentation of content, speakers, educational design and evaluation must be made free of influence from any commercial interest. Any and all funds and in-kind support given by a commercial supporter for this activity must be made known to the Emory CME Office.

Do you plan to solicit educational grants? No Yes

(if yes, all Letter(s) of Agreement must be signed and submitted prior to the program).

Conflict of Interest All individuals in a position to control the content of this CME activity must disclose any relationship with a commercial interest that 1) benefits the individual in any financial amount and 2) has occurred within the past 12 months. A conflict of interest is present when the individual has both a financial relationship with a commercial entity and has the opportunity to affect content relevant to the products/services of that commercial entity. If a conflict of interest is determined to exist, the conflict must be resolved prior to participation in this CME activity by:  Altering the financial relationship with the commercial entity; and/or  Altering the individual’s control over CME content about the products/services of the commercial entity.

CAF 2011 Page 5 In order to preserve the independence of this continuing medical education activity, an individual with an unresolved conflict of interest must not have responsibility for, or control of, the content or planning related to the unresolved conflict. Individuals who refuse to disclose their financial relationships must be excluded from participation in all aspects of the activity.

What non-educational strategies can you implement to enhance change as a supplement to the educational activity? C17 (The goal is to incorporate into the planning something that reinforces, or extends the learning that takes place during the CME activity. i.e. providing model patient handouts; post-activity follow-up containing supplemental materials; a list of helpful URLs or “pearls”; a blog site. (OPTIONAL)

Incorporating performance improvement into the curriculum C16, C21 Please describe how you can incorporate opportunities for addressing patient safety, quality, implementation of best practices and overall professional practice improvement into this CME activity. i.e. (Are there any QI projects that you or your department are engaged in? Does the Risk Management department encounter some issues that your content could address? Are there billing/coding practices that can be improved related to this activity?) (OPTIONAL)

Stakeholder Collaboration and Cooperation C18, C19, C20 Are there other initiatives within Emory University School of Medicine or outside Emory working on this issue? If yes, who and in what way? If yes, can they be included in the development or implementation of this activity?( i.e. Emory-GA Tech; Emory – AHA; Emory – GA Cancer Center; etc.) (OPTIONAL)

Description: Provide a thorough description of this program, including who will benefit most by attending; specific content (topics of medicine or disease states) it will address; and the most important lessons the learner will leave with. This description may be used in the marketing and promotion of the activity, i.e., brochure, journal ads, websites, flyers.

CAF 2011 Page 6 Additional Comments

Full compliance with the ACCME Essential Areas and Policies is required for all Emory University School of Medicine continuing medical education activities. Failure to comply may result in the withdrawal of CME credit approval.

Attachments (Please attach the following to this form):

Tentative Program Agenda (including session times so that credit hours can be calculated)

List of proposed Faculty (including name, title, affiliation, address, phone, fax and email address with honorarium amounts, if applicable)

Financial Disclosure Form (from each person involved with the development of educational content)

Needs Assessment documentation (summaries/abstracts only)

After this application and supporting documentation are reviewed and approved by the Office of Continuing Medical Education, a signed copy of Page 1 will be returned to the Course Director.

Incomplete applications will be returned.

Do not submit if less than 6 months before the intended date of the program.

Revised: 10/09; 02/11; 7/13

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