CONTINUING MEDICAL EDUCATION (Direct and Joint Providership) Central Michigan University College of Medicine (CMED) is accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. As an ACCME accredited provider, CMED adopts, adheres to and abides by all the ACCME s accreditation requirements, criteria, policies, procedures and Standards of Commercial Support. In addition, CMED is governed by the American Medical Association s (AMA) credit requirements. CMED is responsible for ensuring that all accredited activities, direct and jointly provided, meet ACCME and AMA requirements. Continuing medical education is defined as: educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships a physician uses to provide services for patients, the public, or the profession. CME represents 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, include all requested attachments and documentation (see last page checklist), and submit a pdf form via email to the (OCME) at CMEDCME@cmich.edu. For those seeking joint providership, a Joint Providership Agreement must be signed prior to beginning the application process. All applicants (direct and joint providers) need to understand and agree with the CME Content Development and Validation Policy and Disclosure to Learners Policy available at med.cmich.edu/cmeapplicationdocs. Completed applications are due 45 days in advance of the requested CME activity. Additional fees apply if the application is received 30 or 10 days in advance of the activity. Organization Name: APPLICANT INFORMATION Department: Address: Activity Director: Name Degree Title & Affiliation Email: Phone: Fax: Activity Coordinator: Name Title & Affiliation Email: Phone: Fax: Page 1 of 9 Revised November 2018
ACTIVITY INFORMATION Activity Title: Activity Date: Start Time: End Time: Activity Location: Number of AMA PRA Category 1 Credits TM requested (indicate to the quarter hour, i.e., 1.5, 3.25) Activity Type (providership): Direct Joint Commercial Support: Yes No (If yes, complete section on Commercial Support) Other accreditation: AOA Category 1-A Social Work (CE) Other: Additional fees apply (Specify) The ACCME is collaborating with an increasing number of medical specialty boards. Is this activity suitable for Maintenance of Certification or Continued Certification: Yes No If Yes, please select board: American Board of Anesthesiology (ABA) American Board of Internal Medicine (ABIM) American Board of Otolaryngology -- Head and Neck Surgery (ABOHNS) American Board of Pathology (ABPath) American Board of Pediatrics (ABP) Activity Format: Live activity Course/Seminar/Symposium Regularly Scheduled Series (RSS) (i.e., Grand Rounds, Tumor Boards, Morbidity & Mortality conferences) Enduring Material (Release date) Printed Recorded presentation Podcast Online platform name & contact Test item writing Manuscript review (for journals) Performance Improvement (PI) CME activity Internet point-of-care learning (PoC) Journal-based CME Other If RSS: How frequently will the CME activity occur: One time Weekly Monthly Other: Is this live activity/rss/special event appropriate for Internet live streaming: Yes No Activity target audience: MD/DO Nurse Pharmacist Social Worker Dentist Other If additional target audience, please specify: Educational/Teaching Format (select all that apply): Lecture/presentation Simulation Demonstration Other Case study Patient simulation Hands-on workshop Panel discussion Journal club/literature Abstracts/poster session Q & A session Morbidity & Mortality Audience response If other, describe: Page 2 of 9 Revised November 2018
Explain/describe why the educational formats selected are appropriate for this activity: Describe the professional practice gap(s) of your learners on which this activity is based (a gap is the problem this activity is designed to address; it is what the audience does not know/practice) 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, including the Activity Director, planning committee/faculty, presenters and coordinators. Planning Committee/Faculty: (use extra sheet if necessary) Presenter(s): (use extra sheet if necessary) Disclosures required for anyone in a position to control content. 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 3 of 9 Revised November 2018
A needs assessment defines educational practice gaps: the difference between the current and best or optimal practice: Current Current knowledge and practice Practice Gap Best/ideal practice What should be known and practiced What is the educational need that is the underlying cause of the professional practice gap(s): Knowledge need Competence need Performance need Describe each educational need (in terms of knowledge / competence / performance: Per the ACCME: knowledge consists of facts, data, information; competence means understanding how new knowledge fits with existing knowledge, development of strategies for turning what is known into what can/will be done; and performance or actual use/practice is implementation of the new knowledge and strategies into clinical practice or teaching. Describe what this CME activity is designed to change in terms of learners competence or performance or patient outcomes: Per the ACCME: patient outcomes means any potential impact on the patient: patient health, satisfaction or even engagement. OBJECTIVES (minimum of 3) What the learners will understand and be able to do upon completion of this educational activity. A well-written learning objective outlines the knowledge, skills and/or attitude the learners will gain from the educational activity and does so in a measurable way. What sources were used to support your gap(s)/need(s) assessment (please attach documentation): Expert Needs Participant Needs Observed Needs Clinical practice guidelines Needs Assessment Survey Medical records analyses New diagnoses / treatment methods Focus panel discussion/ interviews Database analyses QA audit data/analyses Professional society guidelines Previous related evaluation summary Morbidity & Mortality data Epidemiological data Peer-reviewed literature Other physician requests National clinical guidelines Research findings Environment Public health initiatives Government regulations/mandates Industry press Page 4 of 9 Revised November 2018
Competencies All CME activities must be developed in the context of desirable physician attributes as those designated by the Institution of Medicine (IOM) and American Board of Medical Specialties (ABMS)/Accreditation Council of Continuing Graduate Medical Education (ACGME) Competencies. Select all that apply to this activity: ABMS/ACGME Competencies Patient Care Medical Knowledge Interpersonal and Communication Skills Professionalism Systems-based Practice Practice-based Learning and Improvement Provide care that is compassionate, appropriate and effective treatment for health problems and to promote health. Demonstrate knowledge about established and evolving biomedical, clinical and cognate sciences and their application in patient care. Demonstrate skills that result in effective information exchange and teaming with patients, their families and professional associates (e.g. fostering a therapeutic relationship that is ethically sounds, uses effective listening skills with non-verbal and verbal communication; working as both a team member and at times as a leader). Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations. Demonstrate awareness of and responsibility to larger context and systems of healthcare. Be able to call on system resources to provide optimal care (e.g. coordinating care across sites or serving as the primary case manager when care involves multiple specialties, professions or sites). Able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence and improve their practice of medicine. IOM Competencies Provide patient-centered care Work in interdisciplinary teams Employ evidence-based practice Apply quality improvement Utilize informatics Identify, respect, and care about patients' differences, values, preferences, and expressed needs; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health. Cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable. Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible. Identify errors and hazards in care; understand and implement basic safety design principles, such as standardization and simplification; continually understand and measure quality of care in terms of structure, process, and outcomes in relation to patient and community needs; and design and test interventions to change processes and systems of care, with the objective of improving quality. Communicate, manage knowledge, mitigate error, and support decision making using information technology. Page 5 of 9 Revised November 2018
Will this activity charge a fee: Yes No If Yes, how much: Does this activity require event production / conference support services Yes No If yes, please contact the. 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 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. 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 CMED 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 must be listed on all LOAs as the accredited provider and must sign the agreement. Will this activity have exhibitors or displays: Yes No [Note: Exhibitors are not commercial support.] 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. *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 at CMED Application Documents. Page 6 of 9 Revised November 2018
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 Pre and Post Test Audience Response Survey Post Test Other If Other, describe how you will measure performance changes and/or improvements in patient outcomes: OPTIONAL Does this activity promote team-based education: (Criteria 23-25) Yes No Engages interprofessional teams; patients/public, students of health professions. Does this activity address public health priorities: (Criteria 26-28) Yes No Incorporates health practice date; addresses population health; collaborates effectively. Does this activity enhance skills? (Criteria 29-32) Yes No Optimizes learners communication skills; optimizes learners technical/procedural skills; creates individualized learning plans; utilizes support strategies. Does this activity demonstrate educational leadership? (Criteria 33-35) Yes No Engages in research/scholarship; supports CPD for CME team; demonstrates creativity/innovation. Does this activity achieve outcomes? (Criteria 36-38) Yes No Improves performance; improves healthcare quality; improves patient/community health Page 7 of 9 Revised November 2018
Does this activity meet the Mission of CMU College of Medicine? Mission Statement: CMED Mission Statement Central Michigan University College of Medicine (CMED) is committed to fostering an environment rich in professional development opportunities for physicians and inter-professional healthcare teams. Through integrating new technologies, identifying and overcoming barriers to change, providing state-of-the-art health care information and research, we strive to improve physician knowledge, competence, performance and patient outcomes for all populations throughout the State of Michigan. Yes If yes or no, briefly describe: No 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 Affiliates are defined as organizations (hospitals, private practices) where our students and residents are taught and practice or have been associated with our organization for a number of years. Non-Affiliates are organizations outside of our medical educational network and can be local, regional or national. AFFILIATE FEES Application Per Credit 45 days 30 days 10 days 45 days 30 days 10 days $200.00 $250.00 $300.00 $150.00 $175.00 $200.00 NON-AFFILIATE FEES Application Per Credit 45 days 30 days 10 days 45 days 30 days 10 days $400.00 $450.00 $500.00 $200.00 $300.00 $400.00 Conference/event planning services: Please contact the. Page 8 of 9 Revised November 2018
FINAL CHECKLIST WAIT!!! Before you submit your application, are the following attached? N/A YES Supporting documentation of the needs/gaps source Signed Disclosure Form for everyone in a position to influence content (Planners/Speakers). CVs for all speakers/presenters Preliminary and/or final 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 (if applicable) Payment for fees for Joint Providership and/or conference event planning/staffing services usually billed after the activity date unless otherwise agreed. 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 Disapproved AMA PRA Category 1 Credit TM AOA Category 1-A ACPE (Pharmacy) ANCC (Nursing) Social Work CE AAFP (American Academy of Family Physicians) Other Approved by: Date: 1632 Stone St., Saginaw MI 48602 Ph: 989-746-7602 or 989-746-7555 Email: CMEDCME@cmich.edu Website: med.cmich.edu/cme Page 9 of 9 Revised November 2018