CME RSS Activity Application Carolinas HealthCare System/Charlotte AHEC Office of Continuing Medical Education

Transcription

1 CME RSS Activity Application Carolinas HealthCare System/Charlotte AHEC Office of Continuing Medical Education For additional guidance on completing this application, reference the Application Guide. Activity/Series Title: ACTIVITY INFOMATION Academic Year Approval: January 1, 2017 December 31, 2017 Other Date[s]: Start Time: AM PM End Time: AM PM Organization[s]/Department[s] Sponsoring: Venue: [Address/ P.O Box, City, ST ZIP Code] Tumor Board Weekly [ex. Wednesdays]: M&M Bi Weekly [ex. 2nd & 4th Tuesdays]: Lecture/Didactic Monthly [ex. 3rd Monday]: Type of Activity: Case Conference Round Table Discussion Other: Frequency: Quarterly [ex. 2nd Monday, Oct, Feb, May, Aug]: Other [specify]: Is this series presented as a: Webcast/Webinar Video Conference Physician Couse Director: Title: Address: [Address/ P.O Box, City, ST ZIP Code] Activity Coordinator: Title: Address: [Address/ P.O Box, City, ST ZIP Code] Phone: Phone: COURSE SPONSORSHIP Check sponsorship type and list the organization[s] or entities involved in planning this activity below: Directly Sponsored: All Carolinas HealthCare System entities will be directly sponsored Joint Providership: Non Carolinas HealthCare System entities that are not independently accredited to provide CME will be joint providership Check all that apply and list the number estimated: TARGET AUDIENCE Physicians Physician Assistants/Nurse Practitioners Pharmacists Nurses Other: [Specify types] Physician Specialties: Estimated Attendance: Physicians: Other: SYSTEM GOALS [CHS DEPARTMENTS ONLY] Carolinas HealthCare System has identified the following core measures as areas for improvement. CME activities that incorporate these goals will both improve compliance with these core measures, and provide valuable learning experiences for our attendees. Check all that apply: Patient Safety: Patient Safety Composite Clinical Outcomes: Inpatient mortality, appropriate care measures, chronic disease mgmt., breast cancer screening Service Excellence: Patients likelihood to recommend, physician satisfaction, employee engagement Clinical Efficiency: Acute care inpatient readmission, home health transfers, acute care length of stay

2 GAP ANALYSIS/NEEDS ASSESSMENT Based on your main goal, what are the current gaps in knowledge or practice of the target audience that will be addressed? What is the need for this education? Include quality data [i.e. length of stay, readmissions rates, etc.] of current practice, what you are trying to impact/improve, and how this education will help to close the current gap in knowledge/practice. How were those practice gaps and educational needs identified? Check ALL that apply and ATTACH supporting documentation. Charlotte AHEC requires at least two [2] supporting documents be submitted with your application. Expert Needs Research findings Institutional or national core measures Required by Government Regulation/Law Medical audits/ Other patient care reviews Participant Needs Target Audience Needs Assessment Survey Previously related Evaluations Summary Professional/ ABMS requirements Requests from physicians or physician groups Focus panel discussion /Interviews [provide summary] NCQA data / Quality committee recommendations Current literature / Expert opinion/ New advances Joint Commission Patient safety goal/ Competency Observed Needs M&M data Hospital admissions and diagnosis data Data from outside sources/ Public health statistics Clinical practice data DESIRED CREDIT[S] Indicate which credits you would be interested in offering, if the event qualifies. Credit is not guaranteed approval. American Medical Association AMA PRA Category 1 Credits / CEU Contact Hours

3 OBJECTIVES List at least three [3] measurable and specific objectives that the participants should be able to address and improve as a result of their participation in this activity as a whole. These objectives are to be stated in measureable terms of what the participant will take away from the activity. Please use verbs such as identify, discuss, analyze, apply Add more rows as needed. After this educational activity, the participant will be able to: Competence: knowing how to do something, the ability to apply knowledge, skills, and judgment in practice Performance: what a physician or health care provider actually does in practice Patient Outcomes: actual outcomes in individual patients and/or patient population data ACGME/ABMS COMPETENCIES Level of Desired Outcomes Competence Performance Patient Outcomes Competence Performance Patient Outcomes Competence Performance Patient Outcomes CME activities should be developed in the context of desirable physician attributes. Indicate which American Board of Medical Specialties [ABMS]/Accreditation Council for Graduate Medical Education [ACGME] and Institute of Medicine competencies will be addressed in this activity related to the identified gaps. Patient Care Medical Knowledge Interpersonal and Communication Skills Professionalism Systems Based Practice Practice Based Learning and Improvement INSTITUTE OF MEDICINE COMPETENCIES Provide patient centered care Apply quality improvement Employ evidence based practice Utilize informatics Work in interdisciplinary teams EDUCATIONAL DESIGN Instructional Formats: What methods will you use to achieve your intended results? Lecture [knowledge] Self Directed Learning [knowledge/competence] Q&A Session [knowledge/competence] Panel Discussion [knowledge/competence] Simulations [competence/performance] Flipped Classroom [competence/performance] Roundtable [knowledge/competence] Case Studies [competence] Small Group Work [knowledge/ competence] Skilled demonstrations [competence/performance] Educational Strategies: What educational strategies will be used that could enhance change in your learners as an adjunct to this activity? Wall Charts Posters, safety flip charts Post activity follow up with key points from the lecture[s] Reminder systems, checklists Interactive web based tools Algorithms, clinical protocols Pocket card guidelines Tool kits Patient educational materials Newsletters, booklets Patient assessment tools Links to social networks Instructional Formats: What methods will you use to achieve your intended results? No perceived barriers Patient compliance issues Lack of time to assess/counsel patients Lack of administrative support/resources Lack of consensus on professional guidelines Cost Insurance/ reimbursement issues Will you try to address any of these barriers in this CME activity? No Yes N/A Explain:

4 DISCLOSURES List all individuals involved with the planning and development of this course. Faculty, Physician Course Director, CME Activity Coordinator, planning committee members and anyone else involved in, or who could have control over the content of the activity. Each MUST complete and sign a disclosure statement. All disclosures for planning committee members and the Physician Course Director MUST be submitted with this application. List addtional persons on a seperate sheet. Planning Committee Name Michael Ruhlen, MD, MHCM, FAAP, FACHE Christie Carpenter, MS Margo Ross Activity Role Review/Planning Committee: Vice President, Division of Medical Education, Carolinas HealthCare System Director, Charlotte AHEC Planning Committee: Director, Charlotte AHEC, CME Education Planning Committee List all known Speakers, Moderators, Authors, Panelists, Reviewers, or other members]. All MUST complete and sign a disclosure form. First Last Credentials EVALUATION What changes to your activity do you intend to implement based on previous years evaluation results? [If applicable] Explain: Select which method[s] of evaluation will be used from the list below. The method of evaluation should match the level of desired outcomes of your objectives. Charlotte AHEC CME activities must be evaluated upon conclusion of the activity and 3 months after the activity in order to assess how effectively the course objectives were linked to the desired results. Measuring Knowledge/Competence Post Program Survey required Please indicate frequency: Weekly Monthly Quarterly Quality Data Submitted with Year End Conference Evaluation required Audience Response System Pre and/or Post Tests Collect and analyze learner s intended practice change Measuring Performance Request description of new protocols or tools developed Small group work in practice redesign or quality initiative Case Based Studies/ Chart Audits/ Registry Direct Observations/ Simulations Measuring Patient Outcomes Observed change in health status measure/outcomes data/ quality data Obtain patient feedback

5 COMMERICAL SUPPORT What revenue source[s] will pay for the expenses of the CME activity? [Check all that apply]. Participant registration fees Commercial support/exhibitor fees Internal department funds Government or foundation grant NOTE: If yes, Charlotte AHEC staff must be notified for each commercially supported program at least 30 days in advance in order to ensure compliance. A commercial interest is any entity producing, marketing, re selling, or distributing health care goods or services consumed by, or used on, patients. Commercial interests cannot be a joint providership. The ACCME does not consider providers of clinical service directly to patients to be commercial interests. Within the context of this definition and limitation, the ACCME considers the following types of organizations to be eligible for accreditation and free to control the content of CME: 501 C Non profit organizations [Note, ACCME screens 501c organizations for eligibility. Those that advocate for commercial interests as a 501c organization are not eligible for accreditation in the ACCME system. They cannot serve in the role of joint providership, but they can be a commercial supporter.] Government organizations Non health care related companies Liability insurance providers Health insurance providers Group medical practices For profit hospitals For profit rehabilitation centers For profit nursing homes Blood banks AUDIO VISUAL Charlotte AHEC s offers many services such as event photography, webinar capabilities, AV equipment rental, setup, and/or operation by our audiovisual specialist staff. Please go to the following website to submit a request for service. [The Medical Media team will contact you upon receiving your request via the website]: MARKETING AND ADVERTISING Charlotte AHEC MUST approve all promotional materials BEFORE they are distributed. The Charlotte AHEC logo MUST be included on promotional material. Check all that apply E Card Printed Brochure Physician Connect [CHS Programs Only] Website / URL Note: Please include any marketing materials that are already developed or marketing drafts that are being developed. As well, throughout the program year, it is required that a copy of newly developed marketing materials be submitted to Charlotte AHEC CME before they are distributed. ]

6 CHARLOTTE AHEC CME INDEPENDENCE STANDARDS Please read the following. The course director s signature in the Application Submission section will serve as consent that you comply with Charlotte AHEC CME independence standards. Best Available Evidence Recommendations involving clinical medicine in this CME series will be based on the best available evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. Peer Reviewed Sources To the extent practical, recommendations involving clinical medicine in this CME series will be substantiated by peer reviewed sources. Scientific Integrity All scientific research referred to, reported or used in support of justification of a patient care recommendation will conform to generally accepted standards of experimental design, data collection, and analysis. Free of Commercial Bias CME content presented to learners will be free of commercial bias. No product, service or therapeutic option will be over represented when comparing competing products, services and therapeutic options. When appropriate, generic trade names or trade names from several companies will be used. If a representative from a commercial interest attends an RSS session, I will ensure that representative does not promote their company, product, device, etc. in any way so as to keep the education free from commercial bias. Serve the Public Interest Any selection of topics, instructional content, and personnel I made for this CME activity was done to serve the public interest by improving the quality of healthcare. To the best of my ability, I did not let any personal financial relations influence this selection process. Disclosure to Provider All persons who have control of CME content [including planning committee members, speakers, authors and evaluators] will disclose relevant financial relationships [such as stock ownership, consulting, etc.] to the Physician Course Director. This will be done using the CME Faculty Disclosure form available at Resolution of Conflicts of Interest I will appoint an appropriate content expert to review for bias the content produced by any speakers, authors or editors who have a conflict of interest. The appointed content expert will not have a conflict of interest. [The Physician Course Director may serve as the reviewer.] Disclosure to Learners All persons who have control of CME content [including planning committee members, speakers, authors, and evaluator] will disclose to learners relevant financial relationships [such as stock ownership, consulting, etc.]. This will be done both verbally and through any printed or projected material [such as syllabus, PowerPoint presentation, slide show, etc.] that will be used to deliver the CME content. Disclosure to learners will also occur via the activity evaluations which must be distributed before the activity. Honorarium Policy Any payments to faculty will be made in compliance with CHS Charlotte AHEC s Honorarium Policy. Faculty honorariums are not to exceed $2, unless pre approved by the Charlotte AHEC CME staff. Administrative Support In addition to a Physician Course Director who oversees the completion of the RSS application, activity planning, and content, each series is required to have a CME Activity Coordinator who is responsible for managing clerical aspects of the series. Administrative duties include, but are not limited to, generating activity promotional materials, activity set, oversight of E TRAC registration, managing faculty disclosures, making speaker arrangements, processing commercial support requests, assisting in COI resolution, serving as a point of contact for the Charlotte AHEC CME staff, and attending the CME Annual Updates workshop. The Charlotte AHEC CME staff is available to orient Physician Course Directors and CME Activity Coordinators to CME policy and procedures [a consultation fee may apply]. Charlotte AHEC CME also reserves the right to deny or suspend CME credit from a series that does not demonstrate compliance with the ACCME Standards, Charlotte AHEC Policies and Procedures, submission of required RSS session checklist materials, or provision of adequate administrative support. APPLICATION SUBMISSION I, the Physician Course Director, approve the partnership/sponsorship of this activity by my department or organization and accept the financial responsibility on behalf of my department or division for the financial outcomes of this CME activity as outlined in the budget for this activity, including the Charlotte AHEC CME fees. I, the Physician Course Director, attest that I, as well as the CME Activity Coordinator, planning committee members, and faculty, have been informed of the Charlotte AHEC CME Disclosure Policy [see attached Instructions and Examples for additional details] and have agreed to comply with this policy. I, the Physician Course Director, have read Charlotte AHEC's Policies and Procedures and the ACCME Standards for Commercial Support of CME and understand the guidelines for management of commercial funds, if applicable. I, the Physician Course Director, will ensure all required session materials are turned in to the AHEC CME RSS Coordinator throughout the year on a timely basis. I, the Physician Course Director, attest to incorporating at least one Quality Session in the 2015 cycle. I, the Physician Course Director, am aware that if the required documentation is not submitted as requested, credit may be withheld. Type or sign your name below. Physician Course Director Signature: CME Director Signature: Date: Approval Date:

7 APPLICATION FEE $ Application Fee [Non Refundable] $ Scanner Fee Fee MUST accompany the application prior to approval or denial. Invoices are available on request. NOTE: $50.00 per hour of education fee will be charged to your department bi annually. Please contact your Charlotte AHEC representative if you would like to be provided with a detailed invoice. Check the method of payment: Check CHS Interdepartmental Transfer B/U#: Department #: Credit Card American Express Visa MasterCard Card #: Expiration Date: Name as it appears on the credit card: INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED FOR ACCREDITATION. Two [2] Supporting Documents for Needs Assessments Include with application submission Completed Disclosure Forms for all planning committee members and the Physician Course Director RSS Sessions Schedule for the Calendar Year Proposed Marketing [if applicable] ** IN ORDER FOR YOUR PROGRAM TO BE IN COMPLIANCE, PLEASE REMEMBER TO USE THE ACCREDITATION STATEMENT AND CREDIT DESIGNATION STATEMENT IN ALL YOUR MARKETING MATERIALS** Please type this application and a completed and signed copy to: Christie Carpenter, Director, Continuing Medical Education [CME] Christie.Carpenter@carolinashealthcare.org Carolinas HealthCare System / Charlotte AHEC CME Phone: [704] You will be notified via within 10 business days as to the status of your application.