Continuing Education Interdisciplinary Application

METHODIST LE BONHEUR HEALTHCARE CONTINUING EDUCATION INTERDISCIPLINARY APPLICATION (please submitted typed application a minimum of 30 days in advance of activity)

This document collects all information necessary to plan and develop a proposed CE activity for healthcare professionals. Completion of the entire form is necessary to meet accreditation requirements and be approved for continuing education credit.

Date Submitted: ______Requested by:

Proposed Activity Information Type of Activity: Course Regularly Scheduled Series (RSS) or Class (RSC) Internet Enduring Internet Live Other (explain) Title of Activity: Purpose Statement:

Beginning Date Ending Date Day of Week Frequency of Meeting: Weekly Bi-Monthly Monthly Quarterly Other Location:

Program/Course Director (This is the person with overall responsibility for planning, developing, implementing, and evaluating the content and logistics of the CE activity.)

Name/Degree: Address: Phone/Fax: Email: ______

Program/Activity Coordinator (The Program/Activity Coordinator or CME/CNE Designee is the individual responsible for the operational and administrative support of the certified CME/CNE activity.)

Name: ______Address: Phone/Fax: Email: ______

*Content Nurse (The nurse who actively planned this activity with the planning committee.)

Name & Credentials: ______Address: ______Phone/Fax: Email: ______

*Nurse Planner (The designated nurse educator who reviewed and approved this activity)

Name & Credentials: ______Address: ______Phone/Fax: Email: ______Approval (signature) *Required only if nursing contact hours are requested.

of 7 Revised 6/2016 Planning Committee Members All individuals listed will be required to complete a CE Bio or Resume and submit a COI disclosure form. Please include members that represent credits being requested. Include credentials and degrees. Use separate sheet, if necessary. For activities requesting continuing nursing education credits, the planning committees must have a nurse planner and one content expert nurse to plan each educational activity.

1. 2. 3. 4.

Proposed Faculty Attach a list of speakers and proposed honoraria for each.

Name: Honorarium: Name: Honorarium: Name: Honorarium: Name: Honorarium:

Faculty recommended due to (please check all that apply) Subject matter expert Excellent teacher/communicator Experienced in CE Other (please explain)

Are proposed honoraria within policy requirements established by MLH? Yes No N/A

All of the following steps of the planning process must be taken independent of commercial interests. All persons in a position to control content must disclose all relevant financial relationships with a commercial interest.

1. Resume or CV for all Faculty, Planning Committee and Staff are attached. Yes No 2. Conflict of Interest (COI) forms for all Faculty, Planning Committee are attached. Yes No 3. Proposed activity schedule with exact times provided for each topic/presentation or activity including the method of instruction.

Target Audience (C4) CE Content must relate to the current or potential scope of practice in the interprofessional target audience. Please check all that apply.

Physicians NP/APRNs PA Nurse (RN/LPN) Pharmacist OT PT Fellows Residents Dentists Dietitian Sonographer Students Other

Credit Requested (Check all that apply.) (If other categories of credit are desired, please discuss the process with the CME/CNE Director)

American Medical Association Category 1 (AMA PRA) American Academy of Family Physicians (AAFP) (please note AAFP Member must be involved with planning the activity) American Nurses Credentialing Center (ANCC) Accreditation Council for Pharmacy Education (ACPE) Other

of 7 Revised 6/2016 Need Assessment (C1) Please explain how this CE activity will align with the mission of Methodist Le Bonheur Healthcare. Check all that apply. Evidence of the needs assessment data must be retained in the activity file and be available to accrediting bodies upon request.

Aligns with MLH goals Designed to assist physicians and healthcare professional gain competency & improve performance Evaluations Promotes the practice of evidence-based medicine and healthcare Designed to assist in the dissemination of new medical health care knowledge Other (please explain)

Describe the evidence from the needs assessment that led you to plan this activity. Identify the source(s).

Professional Practice Gaps (C2, C3) A professional practice gap is the difference between current practice and optimal practice. It can also be described as the difference between what actually occurs and what should occur to give the best possible care to patients. CE is intended to be designed to address gaps in knowledge, competence, or performance. Please indicate if this activity will change competence, performance or patient outcomes. (Check all that apply)

Competence/Knowledge Performance/Skills Patient Outcomes Practice Other

Please explain how the content of the CE activity is related to what the learners actually do in their professional practice (C4).

Input from target audience representative Professional society guidelines New information, diagnostic techniques, treatment Data from mainstream sources including Treatment plans, etc. journals and websites Performance mandates by various external National quality data sources such agencies (e.g. the Joint Commission) the Joint Commission Institutional credentialing requirements as Specialty specific requirements as mandated by affiliate hospitals determined by departments/hospitals Authoritative national or specialty society Core competencies from ACGME Guidelines and consensus statements Public health data Maintenance of Certification (MOC) Other

Sources of Need Used to Identify Professional Practice Gaps (C2) provide copies or links (Please check all that apply! Evaluation of previous CE Survey of target audience Focus group results Results of chart audits Literature review Regulatory or legislative issues Patient satisfaction data Morbidity/mortality statistics Hospital administration recommendation CE committee recommendation Hospital data related to patient outcomes Development of new technology Environmental Scanning of Other Providers Faculty recommendation Clinical practice data Practice profiles National, regional or state studies/data/ Quality assurance studies guidelines Opinion leader interviews Focus panel Faculty and/or planning committee’s perception of Input from experts regarding medical of learners’ need advances Other (please explain): New methods of diagnosis or treatment Educational Format (C5) How will the CE activity be designed to facilitate a change in the learners? Adult learning principles and the physician learning and change process should be considered when selecting the appropriate method. Please check all that apply.

of 7 Revised 6/2016 Lectures Small Group Discussions Case Presentations Roundtable Discussion Panel Discussion Enduring Materials Internet Patient Simulations Poster Session Observing a procedure Pre and Post Testing (Audience Response System) Literature Review Hands-on workshop Take away messages: summaries, best practices (print and non-print) Other (please specify)

Effective Design Principles: Educational Design Form Requested Hours Please use verbs for writing operational/behavioral objectives (see attached Bloom’s Taxonomy Verb List). Objectives Content (Topics) Time Frame Presenter Teaching Methods List learner’s objectives in Provide an outline of the State the time frame for List the Faculty for each Describe the instructional behavioral terms (at most content for each objective. each objective. objective. strategies & delivery 1 or 2 per hour). It must be more than a methods for each restatement of the objective. objective.

Potential barriers that may prevent Learners from achieving desired results (C18) These may be perceived or real barriers preventing the learners from achieving expected changes in competence, performance or patient outcomes. Please check all that apply.

Lack of time to assess or counsel patients Lack of consensus on professional guidelines Lack of administrative support/resources Insurance/reimbursement issues Cost Patient adherence issues No barriers Other

Please explain how you will try to address potential barriers with this CE activity (C19)

Other supplementary strategies (C17) Are there strategies could be used to enhance change in your learners as an adjunct to this activity? Examples include patient surveys, patient information packets, email reminders to the learners (i.e., summary points from the lecture, new information, posters throughout the hospital, pocket guides).

Yes (list strategies that will be included)

No (please explain)

Please list any other internal or external groups/organizations that may be able to work with us to address this same issue (C20)

Desired Results/Attributes (C6) (Check all that apply.)

Institute of Medical Core ACGME/ABMS ABMS Maintenance of Competencies Competencies Certification Provide patient-centered care Patient Care Residents must be Evidence of professional standing, Page 4 of 7 Revised 6/2016 - Identify, respect, and care about able to provide patient care that is such as an unrestricted medical patients' differences, values, compassionate, appropriate, and license, a license that has no preferences, and expressed needs; effective for the treatment of health limitations on the practice of listen to, clearly inform, problems and the promotion of medicine and surgery in that communicate with, and educate health. jurisdiction patients; share decision making and management; and continuously Evidence of a commitment to advocate disease prevention, Medical knowledge about life-long learning and wellness, and promotion of healthy established and evolving involvement in a periodic self- lifestyles, including a focus on biomedical, clinical, and cognate assessment process to guide population health. (e.g. epidemiological and social- continuing learning. behavioral) sciences and the Work in interdisciplinary application of this knowledge to Evidence of Cognitive teams -Cooperate, collaborate, patient care. Expertise based on performance communicate, and integrate care in on an examination. That exam teams to ensure that care is Practice based learning and should be secure, reliable and valid. continuous and reliable. improvement that involves It must contain questions on investigation and evaluation of fundamental knowledge, up-to-date Employ evidence-based their own patient care, appraisal practice related knowledge and practice -Integrate best research and assimilation of scientific other issues such as ethics and with clinical expertise and patient evidence, and improvements in professionalism. values for optimum care, and patient care. participate in learning and research Evidence of evaluation of Interpersonal and activities to the extent feasible. performance in practice, communication skills that result including the medical care provided in effective information exchange Apply quality improvement - for common/major health problems and teaming with patients, their Identify errors and hazards in care; (e.g., asthma, diabetes, heart families and other health understand and implement basic disease, hernia, hip surgery) and professionals. safety design principles, such as physicians behaviors, such as standardization and simplification; communication and Professionalism, as manifested continually understand and professionalism, as they relate to through a commitment to carrying measure quality of care in terms of patient care. out professional responsibilities, structure, process, and outcomes in adherence to ethical principles, and relation to patient and community sensitivity to a diverse patient needs; and design and test population. interventions to change processes and systems of care, with the Systems-based practice, as objective of improving quality. manifested by actions that demonstrate an awareness of and Utilize informatics - responsiveness to the larger Communicate, manage knowledge, context and system for health care mitigate error, and support decision and the ability to effectively call on making using information system resources to provide care technology. that is of optimal value.

Desired Results/Outcomes (C11, C12) How do you plan to address the professional practice gaps identified? What do you expect to occur following this activity? Please refer to verb list of writing objectives. After attending this CE activity, the participants will be able to:

Please check the methods of outcome measurement that will be used to measure change in the learners’ competence, performance or patient outcomes.

Program Evaluation (written) Program Evaluation (on-line) Post Conference Eval (4-6 weeks) Page 5 of 7 Revised 6/2016 Pre-test Post-test Quality Data Other (please explain)

Will a registration fee be charged? Yes No If yes, please specify amount: ______

Do you plan to seek educational grant(s)8 for this activity? Yes No

If yes, please specify companies you will be applying for and the amount of each request. ______

Management of Commercial Support  Is there any possibility that this Conference will receive support from any commercial interest(s) during this approval period? YES NO NOT CERTAIN Please read the ACCME’s “Standards for Commercial Support.” (http://www.methodistmd.org/pdf/cme/ACCMEStdsCommSuppt.pdf)

Commercial Support Letters of Agreement (LOA)  The ACCME requires a “Letter of Agreement (LOA) for Commercial Support” for all educational grants received from a commercial interest to support CME. LOA’s must be signed by the company’s representative and the CME Provider and/or, in some cases, the joint sponsor/educational partner, if applicable. Signed copies of all LOA’s must be maintained in the CME Department.

Management of Commercial Support: The ACCME requires that all commercial support be appropriately managed by the CME Provider. A financial budget statement is required for each activity where commercial support is received. The budget information must be submitted at the conclusion of the activity.

Acknowledgement of Commercial Support: The ACCME requires that all commercial support be acknowledged to the CME audience prior to the activity.

How will the audience be informed about the commercial support? In writing Verbally Other, explain

A written record of the acknowledgement must be kept and submitted with the appropriate session report.

Disclosure Forms: The ACCME requires that anyone who has the opportunity to influence the content of the CME activity disclose any and all financial relationships they or their significant other has with a commercial interest; and that any potential conflicts of interest be resolved before the activity occurs. The “Managing Conflicts of Interest in CME Activities for AMA PRA Category 1 Credit” Form (template available on CME website) is one mechanism Methodist Le Bonheur Healthcare uses to identify potential conflicts of interest. The course director, planning committee members, speakers, authors, moderators, etc, must complete this form. For case conferences ALL regular attendees should complete form if they intend to contribute to the discussions.

Disclosure forms for speakers not yet identified and/or confirmed may be sent with the appropriate session’s closing report. (template available on CME and CNE websites) Disclosure Verification: The ACCME requires that disclosure of all financial relationships (or the lack thereof) for anyone who has control over CME content is communicated to the CME audience prior to the activity.

How will disclosure information be conveyed to the audience?

In written format: Handouts Slides Other, describe

Verbally, by the Speaker Moderator Other, describe

Required Attachments: Be sure you have attached the following or this document will be returned without review.

Gap analysis documentation (evidence for need) Names, affiliations, CVs or Resumes and disclosures of proposed faculty and planning committee Disclosure Statement for all speaker(s), planning committee members, and program director(s) Detailed agenda and time frame Promotional material draft or template Page 6 of 7 Revised 6/2016 Budget for activity (may not apply to RSS, RSC or Enduring Activities) Draft of evaluation material if standard electronic CNE/CME evaluation isn’t utilized

I understand and agree to the terms set by the requirements in this agreement for Category 1 credit and/or contact hours.

Printed name: ______

Signature: Date: (Conference Director)

I understand that within 30 days after completion of the activity, all post-activity paperwork must be submitted to the Office of CME/CNE.

Printed name: ______

Signature: Date: (Conference Coordinator)

Mail to: Rexann Pickering, PhD, RN Office of Continuing Education 251 S. Claybrook, Suite 222 Memphis, TN 38104

Continuing Education Office USE ONLY □ Approved □ Not Approved □ Insufficient Planning □ Needs Assessment insufficient □ Proposed program incomplete □ Not in keeping with Institutional/CME/CNE Mission

Director, CME/CNE

Date: ______

of 7 Revised 6/2016