OFFICE OF CONTINUING MEDICAL EDUCATION. Application for Continuing Medical Education (Direct and Joint Providership)

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1 OFFICE OF CONTINUING MEDICAL EDUCATION (Direct and Joint Providership) Central Michigan University College of Medicine Office of Continuing Medical Education (CMU COM OCME) is accredited by the Michigan State Medical Society (MSMS) to provide continuing medical education for physicians. CMU Medical Education Partners administers the Office of Continuing Medical Education for CMU College of Medicine. CMU COM OCME has adopted the current Accreditation Council for Continuing Medical Education (ACCME) accreditation requirements, policies and procedures and Standards of Commercial Support. CME activity content as defined by the American Medical Association (AMA) and the ACCME is: Continuing medical education consists of educational activities which serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession. The content of CME is that body of knowledge and skills generally recognized and accepted by the profession as within the basic medical sciences, the discipline of clinical medicine, and the provision of health care to the public. If your planned CME activity meets the above definition, please complete this application in its entirety and include all requested attachments and documentation. For those seeking joint providership, please complete and sign the Joint Providership Agreement and Acknowledgment. All planners, speakers and anyone in a position to control content of the CME activity must sign a Disclosure of Relevant Relationships. Completed applications should be submitted no later than days in advance of the requested CME activity. Organization Name: Department: APPLICANT INFORMATION Address: 0 Activity Director: Name Degree Title & Affiliation Phone: Fax: Activity Coordinator: Name Title & Affiliation Phone: Fax: Page 1 of 8 Revised November 2017

2 ACTIVITY INFORMATION Activity Title: Activity Date: End Time: Start Time: End Time: Activity Location: Number of AMA PRA Category 1 Credit(s) TM requested (indicate to the quarter hour) (If yes, please Activity Type (providership): Direct Joint Commercial Support: Yes No complete section on Commercial Support.) MOC: American Board of Anesthesiology (ABA) American Board of Internal Medicine (ABIM) Activity Format: Live activity American Board of Pediatrics (ABP) Test item writing Course/Seminar/Symposium Manuscript review (for journals) Regularly Scheduled Series (RSS)/Grand Rounds Performance Improvement (PI) CME activity (Tumor Board, Morbidity & Mortality, Journal Internet point-of-care learning (PoC) Club, case conferences) Enduring Material Journal-based CME Other Is this live activity/rss/special event appropriate for Internet live streaming: Yes No If RSS: How frequently will the CME activity occur: One time Weekly Monthly Other: Activity target audience: MD/DO Dentist Pharmacist Nurse Social Worker Other If additional target audience, please specify: Educational/Teaching Format (select all that apply): Lecture/presentation Q&A session Simulation Case study Journal club/literature Patient simulation Panel discussion Morbidity & Mortality Demonstration Abstracts/poster session Hands-on workshop Explain why the educational formats selected above are appropriate for this activity: Describe the overall professional practice gap(s) of your learners on which this activity is based* (maximum 100 words): *See definitions on page 3 and ACCME examples (separate document). Page 2 of 8 Revised November 2017

3 ACCME Definitions: Gap: The difference between actual and ideal performance and/or patient outcomes. In patient care, the quality gap is the difference between present treatment success rates and those thought to be achievable using best practice guidelines. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Fact Sheet. AHRQ Publication No. 04-P014, March Agency for Healthcare Research and Quality, Rockville, MD. Since CME content is meant to address the needs of all physicians, it includes direct and indirect patient care. Therefore, the ACCME is using professional practice gap to refer to a quality gap in areas that include but also can go beyond patient care (e.g., systems base practice, informatics, leadership and administration). Need: The identified professional practice gap of the learner can be based on a range of needs. One such need includes knowledge that is the range of one s information or understanding, the sum of what is known. A physician s knowledge comes from previous education, experiences, and is also obtained through sources such as the medical literature, lectures, and conversations with peers. For example, understanding the various classes of antibiotics, the names within each drug class, and those organism for which a particular antibiotic is or isn t effective is knowledge. How is knowledge measured? For further clarification, please see the ACCME article, Defining Knowledge, Competence, Performance, and Patient Outcomes, on the Continuing Medical Education website, med.cmich.edu/cme under CME Application Documents - Reference Materials. What is the educational need that you determined to be the underlying cause of the professional practice gap(s): Knowledge need Competence need Performance need Based on the educational needs selected above, describe/define each gap: Describe what this CME activity is designed to change in terms of learners' knowledge, competence, and/or performance: What sources were used to support the gap(s) / need(s) assessment (please attach documentation): Expert Needs Participant Needs Observed Needs Environment Clinical practice guidelines Needs Assessment Survey Medical records analyses Public health initiatives New diagnoses / treatment methods Focus panel discussion/ interviews Database analyses QA audit data/analyses Government regulations/mandates Professional society guidelines Previous related evaluation Morbidity & Mortality data Industry press summary Epidemiological data Peer-reviewed literature Other physician requests National clinical guidelines Research findings Which of the following competencies are applicable to this CME activity: ACGME/ABMS Competencies Institute of Medicine Competencies Interprofessional Education Collaborative Competencies Patient Care and Procedural Skills Provide patient-centered care Values/Ethics for Interprofessional Practice Medical Knowledge Work in interdisciplinary teams Roles/Responsibilities Practice-based Learning and Improvement Interprofessional Communication Employ evidence-based practice Interpersonal and Communication Skills Apply quality improvement Teams and Teamwork Professionalism Utilize informatics Systems-based Practice Page 3 of 8 Revised November 2017

4 OBJECTIVES (minimum of 3): Will this activity charge a fee: Yes No If Yes, how much Does this activity require conference support services of the CME Department: Yes No If yes, please contact the Office of Continuing Medical Education. Is application fee attached for jointly provided activities/events: Yes No N/A AGENDA / PROGRAM / BROCHURE: Agenda Attached: Yes No Please explain: Attach preliminary and/or final agenda, program or brochure (as applicable). All promotional materials must be approved by the Office of Continuing Medical Education prior to distribution. Prior to accreditation approval, only a Save the Date flyer may be disseminated with the event title, location, date, time. No speaker names, number of credits or that accreditation is pending. PLANNING COMMITTEE AND SPEAKER INFORMATION List (or attach list of) all individuals involved in planning this CME activity. Anyone in a position to control the content of an accredited CME activity is required to disclose* all relevant financial relationships with any commercial interest. Planning Committee/Faculty: (use extra sheet if necessary) Speaker(s): (use extra sheet if necessary) Attach CV for each speaker/moderator. * Please read the Glossary of Terms provided by the ACCME on the Disclosure Form. The ACCME considers relationships of the person involved in the CME activity to include financial relations of a spouse or partner. If a conflict of interest (COI) is determined, it will be resolved per the policy and procedure for identification and resolution of COI. Page 4 of 8 Revised November 2017

5 COMMERCIAL SUPPORT Will this activity accept commercial support* (educational grant, in kind): Yes No If yes, applicant agrees to abide by the ACCME Standards for Commercial Support** and all CMU CME Policies and Procedures. All commercial support associated with a CME activity must be pre-approved by the Office of Continuing Medical Education. Notification of commercial support and copies of grant application(s) are required. A Letter of Agreement (LOA) for Commercial Support is required for each funding source. CMU College of Medicine Office of Continuing Medical Education must be listed on all LOAs as the accredited provider and must sign the agreement. Will this activity have exhibitors or displays: [Note: Exhibitors are not commercial support.] Yes No If yes, the please complete the Vendor Display Exhibitor Form for each exhibitor. Specific requirements for appropriate management of associated commercial promotion are outlined in ACCME Standard 4**. An estimated budget is required with application; final budget/financial report is required within 30 days postevent. The Physician Payments Sunshine Act requires manufacturers of drugs, medical devices and biologicals that participate in U.S. federal health care programs to report certain payments and items of value given to physicians and teaching hospitals. The Centers for Medicare & Medicaid Services (CMS) has been charged with implementing the Sunshine Act and has called it the Open Payments Program. As part of this program, manufacturers now are required to submit annual data on payment and other transfers of value that they make to covered recipients. Please demonstrate a mechanism/process to capture the required information, if applicable. *ACCME Definitions: Commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by or used on, patients. The ACCME does not consider providers of clinical service directly to patients to be commercial interests. Commercial support for a CME activity is monetary or in-kind contributions given by a commercial interest that is used to pay all or part of the costs of a CME activity. The requirements for receiving and managing commercial support are explain in the ACCME Standards for Commercial Support. Advertising and exhibit income is not considered commercial support. **Please read the ACCME Standards for Commercial Support on our website under CME Application Documents: CMU CME Application Documents. Describe how you will inform learners that anyone in a position to control content has disclosed they have no or any conflicts of interest or relevant financial relationship(s) with commercial interests (i.e., PowerPoint slide(s), handout, verbal, other). Page 5 of 8 Revised November 2017

6 Accreditation Statement: ACCREDITATION STATEMENT For directly sponsored activities: Central Michigan University College of Medicine Office of Continuing Medical Education is accredited by the Michigan State Medical Society to provide continuing medical education for physicians. For jointly sponsored activities: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Michigan State Medical Society (MSMS) through the joint providership of Central Michigan University College of Medicine Office of Continuing Medical Education and [name of non-accredited provider]. Office of Continuing Medical Education is accredited by the MSMS to provide continuing medical education for physicians. Designation Statement: Central Michigan University College of Medicine Office of Continuing Medical Education designates this (insert type of activity) activity for a maximum of (number of credits) AMA PRA Category 1 Credit(s) TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Types of activities that can earn AMA PRA Category 1 Credit(s) TM : Live activities Enduring materials Journal-based CME learning Test item writing Manuscript review (for journals) Performance Improvement (PI) learning Internet point of care learning (POC) Other NOTES: 1. Both the Accreditation and Designation statements must be used and in the order above: Accreditation first, then the Designation statement you do not have to use the words Accreditation and Designation they are used to here distinguish each and to advise that both are required. 2. Per the AMA s pamphlet, The Physician s Recognition Award and credit system, 2017, page 7: a. The AMA Credit Designation Statement must be written without paraphrasing and be listed separately from accreditation or other statements. b. The phrase AMA PRA Category 1 Credit" is a trademark of the American Medical Association. Accredited CME providers must always use the complete italicized, trademarked phrase. The phrase Category 1 Credit cannot be used when referring to AMA PRA Category 1 Credit TM. 3. Most of the activity formats accredited by CMU COM OCME are live activities (Grand Rounds/RSS, special CME events). Please be sure to select the correct activity format. EXAMPLES: Direct Providership Central Michigan University College of Medicine Office of Continuing Medical Education is accredited by the Michigan State Medical Society to provide continuing medical education for physicians. Central Michigan University College of Medicine Office of Continuing Medical Education designates this live activity for a maximum of 1.00 AMA PRA Category 1 Credit(s) TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Joint Providership This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Michigan State Medical Society (MSMS) through the joint providership of Central Michigan University College of Medicine Office of Continuing Medical Education and XYZ Community Hospital. Office of Continuing Medical Education is accredited by the MSMS to provide continuing medical education for physicians. Central Michigan University College of Medicine Office of Continuing Medical Education designates this live activity for a maximum of 2.50 AMA PRA Category 1 Credit(s) TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Page 6 of 8 Revised November 2017

7 EVALUATION How do you plan to evaluate/assess changes in learners competence, strategies, performance and/or patient outcomes? How do you determine objectives were met? Evaluation Form Pre and Post Test Post Test Survey Other (required for MOC) If Other, describe how you will measure performance changes and/or improvements in patient outcomes: OPTIONAL Does this activity utilize non-education strategies to enhance change as an adjunct to its activities/educational interventions (e.g., reminders, posters, signs, patient feedback)? Yes No If yes, briefly describe: Does this activity address strategies to remove or overcome barriers to change? Yes No If yes, briefly describe: Does this activity address quality improvement strategies or patient safety issues? Yes No If yes, briefly describe: Page 7 of 8 Revised November 2017

8 POST EVENT DOCUMENTATION Within 30 days of the activity, please submit the following documentation: N/A YES Signed attendance sheet (or electronic equivalent) designating MDs/DOs and non-physicians Completed evaluation forms (or electronic equivalent/summary) Evidence of disclosure to learners Copies of all handouts Final list of exhibitors and copies of Vendor Display Exhibitor Forms. Final budget, financial report PLANNING COMMITTEE FEES Joint Providership Application fee: $ / per credit hour: $ if received 45 days in advance of event date If 30 days, fee: $ / per credit hour: $ If 10 days, fee: $ / per credit hour: $ Conference/Event Planning & Production Services: Please contact the Office of Continuing Medical Education FINAL CHECKLIST WAIT!!! Before you submit your application, are the following attached? All boxes must be checked. N/A YES Supporting documentation of the needs/gaps source Signed Disclosure Form for anyone in a position to influence content (Planners/Speakers). Speaker CVs Preliminary promotional material(s), brochure, flyer, etc. Notification of Commercial Support (with copies of grant requests attached) Letter(s) of Agreement for each source of commercial support/educational grant Preliminary list of exhibitors W-9 Forms for each speaker receiving financial remuneration/expense reimbursement Preliminary budget Payment for fees for Joint Providership and/or conference planning services I have reviewed this application in its entirety and to the best of my knowledge it meets all requirements for designation of CME credit. Signature of Requestor Date FOR OFFICE OF CME USE ONLY: Completed Application Received on: Approved for Category 1 Credits Approved by: Disapproved Date: Office of Continuing Medical Education 1632 Stone St., Saginaw MI or 7602 CME Administrator: Fax CMEDCME@cmich.edu Website: med.cmich.edu/cme Page 8 of 8 Revised November 2017

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