1 A5_CME-CE_Course_Planning_Application_ doc. Instructions Page

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1 1 Winthrop University Hospital Continuing Professional Education (CME-CE) Live, Simulation-based and Enduring Activity Planning Document Instructions Page Dear CE/CME Activity Planner: It is the goal of the Winthrop Continuing Professional Education Committee (formerly the CME Committee) to promote the development of inter-professional education activities at the institution. To achieve this goal, Winthrop is an accredited provider of both ACCME-CME credits and ANCC- nurse contact hours. Live activities sponsored by Winthrop are typically dual-accredited for physicians and nurses. As such, there is alignment of our accreditation and planning requirements for both accrediting bodies, the ACCME and ANCC, making it possible to complete a combined planning document eliminating separate documents as in the past. The instructions to complete this document are: A. Complete all required areas of the document B. Attach the following: 1. Final course agenda with the time, topics and speakers listed for the duration of the course 2. CV s (do not include research or publications list) for the activity director(s), all planning committee members, confirmed faculty and/or authors of content 3. Disclosure forms for activity director(s), all planning committee members, and all confirmed faculty. For Winthrop faculty, the CME Office should have a current, annual form on file 4. Educational Planning Table (Note: Once the speaker is confirmed, this information will be requested from the speaker directly via the speaker confirmation letter to be sent by either the CME-CE Office staff, OR sent directly by the sponsoring department staff.) Once all information is collected and the planning document is finalized, it will be scheduled for review by the CPE Committee. The Committee meets quarterly in July, October, January and April on the 4 th Tuesday of these months. Please submit your document at least 45 days in advance of a Committee meeting to assure approval prior to your activity date. If you require explanation, clarification or assistance with completing this planning document, we encourage you to call either Rob Martin, MBA, CHCP, Director of CME at x 3784 or Christine Marsiello, Director of Professional Nursing Practice and Education at x Thank you for your cooperation and work in the development of this educational event for our learners. 1 A5_CME-CE_Course_Planning_Application_ doc

2 2 Activity Title Section A - General Information Activity Location: Activity Date: Activity Coordinator/Administrator: Name and Credentials: Mailing Address: Telephone: Fax: Course Content Director: Name and Credentials: Mailing Address: Telephone: Fax: Nurse Planner: Name and Credentials: Mailing Address: Telephone: Fax: List Program Planning Program Members: * Attach CV s / Faculty Disclosure Forms Committee Member Name Credentials Degree Role on Committee Section B - Activity Details For nursing programs only: Will you utilize CME Office Online Registration System? Yes No (If no, see Director of Nursing Education to registration format.) Anticipated # Participants: Will there be a registration fee? Yes No If yes, registration fee will be based on approved CME-CE fee schedule to assure all meetings are selfsupporting. 2 A5_CME-CE_Course_Planning_Application_ doc

3 3 Section C: Specify your Target Audience (select all that apply at least 1 box from profession, specialty and geographic location must be selected) Physicians Surgeons Physician Assistants Nurse Practitioners Adv. Practice RN's Fellows Residents Target Specialties:(Please List) Registered Nurses Dieticians Social Workers Respiratory Therapists Physical Therapists Occupational Therapists Athletic Trainers Diabetes Educators Nassau County Speech/ Language Pathologists Pathology Scientists Patient/Family Caregiver Other (specify below) 5 Boroughs Section D: Identify Speakers, Authors, Faculty Faculty/Presenter/Author Name Credentials Degrees Qualifications (ie Content expertise, presentation skills, familiarity with target audience and/or teaching methodology) *Please Attach CV s and Faculty Disclosure Forms for EACH Planning committee member 3 A5_CME-CE_Course_Planning_Application_ doc

4 4 Section E: Type of Activity Live Activity Learner-directed/Enduring Material If so, what kind? Performance Improvement- CME for MOC or Specialty Recertification: Simulation-based Scenario with High/Low Fidelity and/or Standardized Patients Print Monograph Internetbased Other- please specify Live Webinar recorded for Online Archive Is this activity being co-provided/jointly sponsored/co-sponsored with an external organization? Yes No If yes, name of partnering organization: Please specify CME/CE accreditation status: Accredited Non-accredited Will this activity be applying for commercial support? Yes No Will you be seeking in-kind support from a commercial interest? Yes No If yes, indicate type of in-kind support requested of the commercial interest: Durable medical equipment Facilities/Space Disposable supplies (Non-biological) Animal parts or tissue Human parts of tissue Other please describe: If yes to either of the above, please schedule an appointment with the CME/CE Office staff to discuss process and compliance. CREDITS Calculate the number and select all credit types that you are seeking for this program. Other than CME, ANCC and AAPT accreditation, the department is responsible for submitting application and payment of fees for all other accrediting organizations. The CME Office will validate and determine total course credits. Number of Credits Requested: Type of Credit Requested: CME AMA PRA Category 1 Credit(s) AAP Nurse Contact Hours (ANCC) AAPT BOC (Athletic Trainers) ASTN CST Social Work AART AADE 4 A5_CME-CE_Course_Planning_Application_ doc

5 5 Section F: Needs Assessment Data: What sources and kinds of information (i.e. needs assessment data) did you use to identify the practice gap(s) described above and addressed in your curriculum? REQUIRED: At least one specific data source must be listed below in the development of your needs assessment. Your planning document will be automatically rejected if this is not indicated. Expert Sources Planning Committee/Expert Panel Departmental chair Activity faculty Peer-reviewed literature (attach references) Research findings Learner Sources Evaluation data from previous education activities Formal or informal clinician requests Objective Local Data Sources Case data from Medical Records Chart audit or patient care review Local or regional practice-based statistics Evidence from local quality studies and/or performance improvement activities Hospital/Clinic Outcomes Data Environmental Scanning Sources Direct observation Industry Press Lay press Direct-to-consumer Ads Trends in literature, law and health care Objective National Data Sources CMS/NCQA/AHRQ Data National Task force reports Epidemiological data Specialty Board's published practice guidelines Other Evidence Sources for Needs Assessment Institution-Collaborative QI data, admission/discharge, core measures Other Describe: 5 A5_CME-CE_Course_Planning_Application_ doc

6 6 Section G: What sort of Outcomes/Changes will this activity produce? Knowledge and Attitudes: Facts and information acquired by a person through experience or education. Example: Reading a book on how to fly an airplane Competence: Having the ability to apply knowledge, skills, or judgment in practice if called upon to do so. Example: The knowledge from reading a book on how to fly an airplane is used to demonstrate flying an airplane in a flight simulator. Performance: What a clinician actually does in practice. Example: The knowledge from reading a book on how to fly an airplane combined with the competence from demonstrating how to fly in a flight simulator are used to actually fly an airplane. Patient Outcomes: Actual outcomes in individual patients and/or patient populations. Your Outcomes Measurement Strategy: What type(s) of evaluation method(s) will you use to determine if the activity was effective at meeting the needs of participants and creating the desired changes in knowledge, competence, performance, or patient outcomes listed above? Select the most appropriate method for assessing the educational outcomes of this activity from the options below: Knowledge and Attitude: CME-CE Office Standard Online Evaluation Pre/Post Tests Other Competence Post Session Test using Case -based Questions Pre/Post Tests using Case -based Questions Simulation-based Activities Faculty/Expert Observation Performance Commitment to Change Contract with Follow-up Individual Performance Data (i.e., chart audit) Hands-on Skill(s) Workshops Other Patient Outcomes Chart Audit Analysis of Local Clinical or Quality Data Other Please describe in detail AT LEAST ONE specific example of a change in knowledge, competence or performance that you intend this education to accomplish. 6 A5_CME-CE_Course_Planning_Application_ doc

7 7 Section H: Competencies What competencies of the ABMS/ACGME, Institute of Medicine(IOM), and Interprofessional Education Collaborative(IPEC) will be addressed in this series? (you must address AT LEAST ONE competency) 1. Patient care/procedural skills (ABMS/ACGME) 2.Medical knowledge (ABMS/ACGME) 3. Practice-based learning and improvement (ABMS/ACGME) 4. Interpersonal & communication skills (ABMS/ACGME) 5. Professionalism (ABMS/ACGME) 6.Systems-based practice (ABMS/ACGME) 7. Provide patient-centered care (IOM) 8. Work in interdisciplinary teams (IOM) 9. Employ evidence-based practice (IOM) 10. Apply Quality Improvement (IOM) 11. Utilize informatics (IOM) 12. Values/Ethics for Interprofessional Practice(IPEC) 13. Roles/Responsibilities(IPEC) 14. Interprofessional Communication (IPEC) 15. Teams and Teamwork (IPEC) 16. Other Competencies Each accredited CME-CE program is required to identify at least one existing and/or develop at least one new supportive/supplemental educational strategy (e.g. patient reminders, order sets, computer decision support systems, guidelines etc.) that is currently being used or could be used to close the identified practice gap(s) and to improve learner behaviors. (Required) 7 A5_CME-CE_Course_Planning_Application_ doc

8 8 Section J. Certification CME-CE Activity Director I hereby certify that this document was completed accurately and attest to the validity of the information contained within. I agree to collaborate with the Department of Continuing Medical Education and the Continuing Nursing Education Provider Unit to ensure that the planning and implementation of the proposed CME activity are consistent with the policies and procedures of the ANCC. Course Director Signature Date As Department Chair, I agree to cover any course deficit if this activity is not self-supporting via registration income and/or commercial support. Department Budget Will Not Cover Any Course Deficit Describe alternative plan for funding of deficit: Department Chair Signature: Date Certification Nurse Planner I attest that I am knowledgeable about the current ANCC criteria for educational design, and accept the responsibilities of the designated nurse planner for this activity. Designated Nurse Planner Signature Date I attest that I am knowledgeable about the current ANCC criteria for educational design, and accept the responsibilities of the lead designated nurse planner for this activity. Primary Nurse Planner of the Provider Unit Signature: Date 8 A5_CME-CE_Course_Planning_Application_ doc

9 9 Educational Planning Table Live and Enduring Courses (2013 Criteria) (Use multiple pages of this form to fully document your curriculum.) Course Title: Course Overview Statement/Summary (This will appear in the course brochure.) Step 1: Briefly identify and describe the professional practice gaps (behaviors) that you have identified and wish to change below. For example, Physicians are not prescribing available adjuvant therapies for patients with atrial fibrillation. OR Nurses are not conducting accuratge assessments of patients for possible stroke at triage. Step 2: Briefly described the desired results, i.e. changes in behaviors and practice that you expect learners to adopt after this course, below. Also include a specific outcomes measure(s) that you have established for this course and that you will plan to measure via a pre- and post- test evaluation process. 9 A5_CME-CE_Course_Planning_Application_ doc

10 LEARNING & PERFORMANCE OBJECTIVES CONTENT (Topics) TIME FRAME PRESENTER TEACHING METHODS/LEARNER ENGAGEMENT STRATEGIES 10 List learning objectives in behavioral terms aligned to the gaps and desired results stated above. Provide an outline of the content for each objective. It must be more than a restatement of the objective. State the time allotted for each objective Step 3: Complete the planning table below. Use additional pages as necessary. Use a bullet point format. List the speaker assigned to address each objective. Describe the teaching methods, strategies, materials & resources for each objective 10 A5_CME-CE_Course_Planning_Application_ doc

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