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

Transcription

1 CME Activity Application Carolinas HealthCare System/Charlotte AHEC Office of Continuing Medical Education For additional guidance on completing this application, reference the Application Guide. Activity Title: ACTIVITY INFOMATION Date[s]: Time[s]: Organization[s]/Department[s] Sponsoring: Venue: [Address/ P.O Box, City, ST ZIP Code] Type of Activity: One Time Event [Conference, Symposium, Workshop] Multiple Events [Same course repeated throughout a year] Multiple Events [Lecture series focused on a specific topic] Internet Live [Webinar] Enduring Material [Module, Recorded Event] Other [Describe]: 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 ACTIVITY OVERVIEW Give a brief overview of the main goal[s] or desired outcome[s] of this activity as a whole. This information will be used on the registration website and/or in marketing materials.

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 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

3 Instructional Formats: What methods will you use to achieve your intended results? EDUCATIONAL DESIGN Lecture [knowledge] Panel Discussion [knowledge/competence] Roundtable [knowledge/competence] Q&A Session [knowledge/competence] Flipped Classroom [competence/performance] Self Directed Learning [knowledge/competence] Simulations [competence/performance] Case Studies [competence] Skilled demonstrations [competence/performance] Small Group Work [knowledge/ competence] Educational Strategies: What educational strategies will be used that could enhance change in your learners as an adjunct to this activity? Wall Charts Reminder systems, checklists Pocket card guidelines Newsletters, booklets Posters, safety flip charts Interactive web based tools Post activity follow up with key points from the lecture[s] Algorithms, clinical protocols Patient educational materials Patient assessment tools Links to social networks Tool kits Instructional Formats: What methods will you use to achieve your intended results? No perceived barriers Lack of administrative support/resources Insurance/ reimbursement issues Lack of consensus on professional guidelines Cost Lack of time to assess/counsel patients Patient compliance issues Will you try to address any of these barriers in this CME activity? No Yes N/A Explain: 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 American Academy of Physician Assistants [AAPA] American College of Pharmacy Education [ACPE] International Association for Continuing Education & Training [IACET ] ACHE Qualified Education Contact Hours (Leadership) National Board for Certified Counselors [NBCC] ADG PACE [Dental] American Nurses Credentialing Center Contact Hours [ANCC] Separate fee required: American Academy of Family Practice [AAFP] American Association for Respiratory Care [ AARC] American Registry of Radiologic Technologists [AART] American Society of Radiologic Technologists [ASRT]

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 additional persons on a seperate sheet. Planning Committee Name Michael Ruhlen, MD, MHCM, FAAP, FACHE Christie Carpenter, MS Activity Role Review/Planning Committee: Vice President, Division of Medical Education, Carolinas HealthCare System Director, Charlotte AHEC Planning Committee: Director, Charlotte AHEC, CME Education 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 [Charlotte AHEC will also conduct a follow up survey 3 6 months following the program to assess the program's effectiveness in achieving desired outcomes] 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 REGISTRATION FEE STRUCTURE Physician [MD, DO]: Or provide your own structure: Advanced Clinical Practitioners [NP, PA, PharmD]: Interns/Residents: Other:[Specify] 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 Are you receiving educational grants? Yes No If Charlotte AHEC is applying for grants, provide the following: Organization Tax ID Number: Course Director s NPI Number: If Charlotte AHEC is applying for grants, provide companies and websites Company Grant Website Are you receiving exhibitor funding? Yes No If Charlotte AHEC is reaching out to exhibitors, provide company names, representative name and Company Name Rep Name 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]:

6 MARKETING AND ADVERSTING 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] AHEC Catalog AHEC Website Website / URL Poster [Additional Charge] Check the markets you wish to target: Adolescent Health [13 18] Gynecology/Obstetrics Otolaryngology Adult Health Hematology Pain Management Allergies Hepatology Pathology Anesthesiology Imaging Technology Pediatrics Bariatrics Immunology Pharmacy Services Cardiovascular Diseases Infant Health [0 2] Plastic Surgery Critical Care Medicine Infectious Diseases Podiatry Cultural Diversity Internal Medicine Practice Management Dermatology Internship & Residency Psychiatry Developmental Disabilities Long Term Care Psychology Dietetics and Nutrition Neonatology Psychotherapy Emergency Medicine/Services Nephrology Pulmonary Medicine Endocrinology Neurology Quality Assurance / Improvement ENT [Otorhinolaryngology] Nuclear Medicine Radiology Epidemiology Oncology Rehabilitation Ethics Ophthalmology Respiratory Care Family Medicine/Practice Optometry Rheumatology Gastroenterology Orthopaedics Sleep Medicine Genetics Orthotics / Prosthetics Surgery Geriatrics Osteopathic Medicine Urology APPLICATION SUBMISSION As the Physician Course Director attests that he/she, as well as the CME Activity Coordinator, planning committee members, and faculty have been informed of the Charlotte AHEC CME Disclosure Policy [see attached Application Guide 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. Type or sign your name below. Physician Course Director Signature: CME Director Signature: Date: Approval Date:

7 APPLICATION FEE $ Application Fee [Non Refundable] Fee MUST accompany the application prior to approval or denial. Invoices are available on request. Note: Additional fees will be discussed after the approval process is complete. The planning fee is dependent on Charlotte AHEC services requested and a per participant fee is based on number of credit hours awarded. A Memorandum of Understanding [MOU] will be signed by both parties to agree to these responsibilities and terms.. 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. Include with application submission Completed Disclosure Forms for all planning committee members and the Two [2] Supporting Documents for Needs Assessments Physician Course Director Proposed Marketing [if applicable] Proposed Agenda W9 [If Charlotte AHEC is applying for grants] Proposed Budget Application must be reviewed and approved prior to registration, marketing, application of educational grants, contact with exhibitors, etc. 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.