CONTINUING EDUCATION ACTIVITY PLANNING WORKSHEET Rutgers Biomedical and Health Sciences is accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing education for the healthcare team. This CE Planning Process has been designed based on the Criteria for Joint Accreditation for Interprofessional Continuing Education and accepted adult learning principles. For this educational activity to be approved for AMA, ANCC or ACPE credit/contact hours, the planning process outlined in this document is required. This CE Activity Planning Worksheet with all supporting forms and documents must be completed and submitted at least 90 days in advance of the proposed activity date. Incomplete worksheets will be returned. Required Attachments: Preliminary agenda (live event) Supporting needs assessment sources (see page 4) Signed Disclosure Forms for all individuals involved in the development and/or implementation of the activity. If not all disclosure forms are available at the time this worksheet is completed, they must be submitted to the CE unit in a timely manner in order to identify and resolve conflicts of interest. Budget summary indicating anticipated income (including grants) and expenditures Marketing PLEASE NOTE: The CE unit is required to review all marketing materials before they are made available to prospective participants. If any of the below methods will be used to generate an audience, please forward the draft versions to the CE unit for review. Invitation/brochure/letter (mail, fax, email) Web based announcements Advertisements/journal announcements Posters Save the Date card (Note: A Save the Date card cannot be used as the only method to generate an audience.) Title: General Activity Information Date(s): Location(s): Activity/Delivery Type Live Event Enduring Material Journal based Performance/Quality Improvement If live event, anticipated number of minutes of instruction (excludes meals, breaks, introductions): Page 1 of 16
Format Audioconference Case Study Conference/Symposium DVD Journal Meeting Monograph Newsletter Podcast Satellite Webcast/Webinar Target Audience Physicians Nurses Advanced Practice Pharmacists Pharmacy Technicians Physician Assistants Fellows Psychologists Social Workers Dentists Podiatrists Other Healthcare Professional(s): Other Non healthcare Stakeholder(s): Content Focus All specialties Cardiology Dermatology Emergency Medicine Infectious Disease Internal Medicine Family Medicine Neurology OB/GYN Oncology Orthopaedics Pain Pathology Pediatrics Pharmacology Management Psychiatry Public Health Radiology Radiation Surgery Oncology Geographic Area of Target Audience Internal Local/Regional National International Sponsoring School/Unit: NJMS RWJMS SN PHARM UBHC Sponsoring Department: Is the activity being jointly provided (planned and implemented with a non accredited organization)? Yes No If yes, joint provider(s): Credits Requested Physician (AMA PRA) Nurse (ANCC) Pharmacist (ACPE) Pharmacy Technician (ACPE) Note: Planning committee must include professionals who are reflective of the target audience. Page 2 of 16
Activity Description (one paragraph description of overall purpose and goal of this activity) Pharmacy (ACPE) Activity Type (select one) FOR PHARMACY ONLY Knowledge based (designed to acquire factual knowledge; minimum 0.25 contact hour) Application based (designed to apply information learned in time frame allotted; minimum 1 contact hour) Practice based (designed to acquire specific knowledge, skills, attitudes, and performance behaviors with didactic and practice components; minimum 15 contact hours) Pharmacy (ACPE) Topic Designator FOR PHARMACY ONLY 01: Drug Therapy Related (addresses drugs, drug therapy, and/or disease states) 02: AIDS Therapy Related (addresses therapeutic, legal, social, ethical, or psychological issues related to understanding and treatment of patients with AIDS) 03: Law (addresses federal, state, or local laws and/or regulations affecting the practice of pharmacy) 04: General Pharmacy Topics (addresses topics relevant to the practice of pharmacy other than those included in the classifications of drug therapy related, AIDS therapy related and law) 05: Patient Safety (addresses prevention of healthcare errors and the elimination or mitigation of patient injury caused by healthcare errors) Page 3 of 16
Verification of Identified Learner Needs INSTRUCTIONS: Learner needs will be identified through an analysis of a variety of sources. There are many sources of information that can be used for conducting a needs assessment and the table below is intended to guide you in the needs assessment process. Select at least two sources by which you identified the need for the activity. You must submit documentation that supports each of the selections. Only select those sources for which you can provide documentation. You will be asked to interpret the information gleaned from the sources on the following page. NOTE: Documentation is required for each selection made. For larger documents, please highlight the section(s) that specifically identifies the need. Learner Identified Needs Evaluation results from previous activities Needs assessment survey Focus group/ discussion Request from relevant healthcare professionals Other, please specify: National guidelines (NIH, CDC, AHRQ, etc.) Specialty society guidelines Peer reviewed literature Regulatory requirements (Joint Commission, MOC, etc.) Expert Identified Needs Other, please specify: Planning/Advisory Committee members Department Chair/ leadership Requested by institution(s) or health care professional group(s) Current research Data based Observations QA/QI data or dashboards Departmental quality metrics Publicly reported performance data Database analyses (utilization, practice management, medication Rx, etc.) Department/specialty case reviews that highlight potential problems Other, please specify: NOTE: A summary description of the data should be submitted in lieu of the actual data. Page 4 of 16
Needs Assessment and Intended Outcomes INSTRUCTIONS: Please complete the table below in order to identify the specific educational needs of learners that this activity will address related to the specific practice gaps in learner knowledge and/or competence and/or performance. Current Practice Indicate the issues, problems, and/or practice gaps you want to address (Check all that apply) Learners are not aware of new methods for diagnosis and treatment Learners do not know how to apply the new information into practice Learners are not applying evidence based guidelines into practice Learners are having difficulty managing patient care scenarios Patient problems or challenges that have not been adequately addressed Areas of patient care within the department or institution in need of improvement Gap identified by PI/QI process Broad variations of patient care among colleagues Issues reported by patients that need more attention Describe the specific issues, problems, and /or practice gaps indicated above Page 5 of 16
List the specific sources you used to identify the practice gaps and provide documentation to support the existence of the gaps (list the specific sources selected on page 4) Best Practice Describe the quality, performance, and/or standards of care measures that highlight optimal expectations related to the practice gaps Page 6 of 16
List the specific sources that support these standards of care and provide documentation to support it (list the specific sources selected on page 4) Educational Need(s) Desired Result(s) & Intended Outcome(s) Indicate the reason(s) the practice gaps exists related to the gap analysis above Knowledge (learners lack of understanding) Skills/Strategy (learners difficulty or inability to apply strategy) Performance (practice not meeting standard of care) What will the learners be expected to do differently as a result of their participation in this activity that addresses the practice gaps above? Classify the expected change(s) of the learners behavior as a result of their participation in this activity Skills/Strategy (gain new abilities/strategies to apply to practice) Performance (practice modification as a result of application learned) Patient Outcomes (change in health status of patients due to change in practice behavior) Page 7 of 16
Learning Objectives INSTRUCTIONS: Please check off the area(s) of improvement that this activity will address and provide a minimum of two (2) overall learning objectives. If you would like to use measureable action verbs not listed below, please write it in the text box. Area(s) of Improvement Knowledge (what learners need to know) Skills/Strategy (what learners need to know how to do) As a result of this educational activity, learners should be better able to: Learning Objectives As a result of this educational activity, learners should be better able to: Performance (what learners need to do) As a result of this educational activity, learners should be better able to: Choose one measurable verb below: Choose one measurable verb below: Choose one measurable verb below: Define List Recognize Assess Integrate Outline Develop Apply Perform Name Cite State Evaluate Distinguish Select Interpret Show Diagnose Choose Compare Explain Implement Use Practice Choose one measurable verb below: Choose one measurable verb below: Choose one measurable verb below: Define List Recognize Assess Integrate Outline Develop Apply Perform Name Cite State Evaluate Distinguish Select Interpret Show Diagnose Choose Compare Explain Implement Use Practice Page 8 of 16
Choose one measurable verb below: Choose one measurable verb below: Choose one measurable verb below: Define List Recognize Assess Integrate Outline Develop Apply Perform Name Cite State Evaluate Distinguish Select Interpret Show Diagnose Choose Compare Explain Implement Use Practice Choose one measurable verb below: Choose one measurable verb below: Choose one measurable verb below: Define List Recognize Assess Integrate Outline Develop Apply Perform Name Cite State Evaluate Distinguish Select Interpret Show Diagnose Choose Compare Explain Implement Use Practice Choose one measurable verb below: Choose one measurable verb below: Choose one measurable verb below: Define List Recognize Assess Integrate Outline Develop Apply Perform Name Cite State Evaluate Distinguish Select Interpret Show Diagnose Choose Compare Explain Implement Use Practice Page 9 of 16
Outcomes Assessment INSTRUCTIONS: Please identify how you plan to assess the relevance and impact of the activity on practice application, clinician performance, and/or health outcomes. Check all that apply. Post activity evaluation (required) Pre/post assessments Skills/Strategy Report of skills/strategy changes Performance Report of performance or practice changes Track and identify new practices or policies as a result of activity Chart audits with analysis of results Participant focus group about actual change in practice Patient Outcomes Report of patient outcome changes Patient satisfaction survey Quality assessment data/review (departmental, institutional, external) Claims data/review with analysis of results Morbidity/Mortality data with analysis of results Scope of Professional Activities INSTRUCTIONS: Activity content must match the healthcare team or individual members of the healthcare team s current or potential scope of professional activities. Please briefly describe below how the activity content will be relevant to each profession selected in the Target Audience section on page 2. In relation to the content focus, consider the daily practice of the profession, relevant practice parameters and practice guidelines, and how the profession participates as a member of the healthcare team. Physicians Nurses Advanced Practice Nurses Pharmacists Page 10 of 16
Pharmacy Technicians Physician Assistants Fellows Psychologists Social Workers Dentists Podiatrists Page 11 of 16
Format and Design Related to Sustaining Results INSTRUCTIONS: The purpose of continuing education is change in behavior or validation that changes already made are consistent with best practices. In the table below, indicate your choices for each element and the rationale for that choice: A. VENUE AND/OR MODE OF EDUCATIONAL INTERVENTION APPROPRIATE TO THE TARGET AUDIENCE TO ACHIEVE DESIRED RESULTS Live symposium Print enduring material Journal supplement Internet based activity Electronic enduring material RATIONALE APPROPRIATE TO OBJECTIVES/RESULTS: B. METHODS TO ENGAGE LEARNERS (Click all that apply, but at least one): RATIONALE APPROPRIATE TO Case studies Audience response system OBJECTIVES/RESULTS: Reflection worksheet Small group work Panel Discussion Role play Question/Answer Return demonstration C. ANCILLARY TOOLS TO REINFORCE AND SUSTAIN LEARNING GOALS: RATIONALE APPROPRIATE TO OBJECTIVES/RESULTS: Email reminder Pocket guide Patient reminder Algorithm worksheet None Page 12 of 16
Competencies INSTRUCTIONS: Identify the competencies that this activity is designed to address. Patient Care Including: compassionate, appropriate and effective treatment of health problems and/or health promotion Medical/Clinical Knowledge Including: established and/or evolving biomedical, epidemiological, socialbehavioral knowledge as it applies to clinical medicine Practice Based Learning and Improvement Including: appraisal of one s own care patterns, knowledge, expertise and gaps; setting goals and addressing gaps in one s own practice and implementing changes with the goal of practice improvement; locating appraising, and assimilating evidence from scientific studies to apply in own practice Interpersonal and Communication Skills Including: effective communication with patients, families, other health professionals; effective collaboration leadership in a healthcare team Professionalism Including: adherence to ethical principles; integrity; respect for others; responsiveness to patient needs; sensitivity and responsiveness to diverse populations Systems Based Practice Including: coordination of patient care within a healthcare system with appropriate and effective use of system resources; system based quality assessment and improvement INSTRUCTIONS: Check below if this activity will focus on any of the following Core Competencies for Interprofessional Collaborative Practice: Values/Ethics for Interprofessional Practice Work with individuals of other professions to maintain a climate of mutual respect and shared values Roles/ Responsibilities Use the knowledge of one s own role and those of other professions to appropriately assess and address the healthcare needs of the patients and to promote and advance the health of populations Interprofessional Communication Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease Teams and Teamwork Apply relationship building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient /population centered care and population health programs and policies that are safe, timely, efficient, effective and equitable INSTRUCTIONS: Check below if this activity will focus on any of the following National Academy of Medicine competencies: Provide patient centered care Work in interdisciplinary teams Employ evidence based practice Apply quality improvement Utilize informatics Page 13 of 16
Identified Barriers and Strategies to Address Them INSTRUCTIONS: Planners are encouraged to give consideration to the system of care in which the learner will incorporate new or validate existing learned behaviors. Planners must be sure to (a) identify barriers that could block implementation and (b) attempt to apply strategies to address, discuss strategies to overcome or remove those barriers (if possible) in the content of the activity. Please indicate below the barrier(s) you have identified: Lack of time to assess or counsel patients Lack of consensus on professional guidelines Clinician Barriers Patient Based Barriers Insufficient adherence to treatment plan Communication/language barriers Institutional Barriers Institutional policies Insufficient administrative support/resources Insufficient clinical staff Insufficient technical resources Organizational culture System Barriers Insurance/reimbursement issues Cost of treatment Insufficient accessibility/availability of treatment No perceived barriers If applicable, describe the strategies that will be employed in this activity to address or remove the identified barriers: Planning Committee INSTRUCTIONS: Please complete the table below for each planning committee member. When developing an interprofessional continuing education activity, the planning process must include health care professionals from two or more professions and include professionals who are reflective of the target audience members. COMMITTEE MEMBER NAME DEGREES/ CREDENTIALS TITLE AND AFFILIATION ROLE ON COMMITTEE Activity Director Activity Director Activity Director Page 14 of 16
Activity Director Activity Director Activity Director Activity Director Activity Director Attach additional sheets if necessary Faculty/Presenters/Authors INSTRUCTIONS: Please complete the table below for each faculty/presenter/author. FACULTY/AUTHOR/PRESENTER NAME DEGREES/ CREDENTIALS TITLE AND AFFILIATION Attach additional sheets if necessary Page 15 of 16
Successful Completion of the Activity INSTRUCTIONS: Indicate the criteria for verifying participation in and successful completion of the activity Criteria for successful completion of the activity include: (Check all that apply) Attendance at entire event or session Attendance for at least % of event Attendance at 1 of more sessions Completion/submission of evaluation form Achieving a passing score of % on post test How will attendance be verified? Sign in sheets/registration form Signed attestation by participant verifying completion of entire or part of activity Collection of participation verification via computer log Attestation I hereby certify that this worksheet was completed accurately and attest to the validity of the information contained within. I agree to collaborate with RBHS to ensure that the planning and implementation of the series are consistent with the continuing education policies of RBHS other agencies that regulate continuing education. Name (Please Print ) Signature Date ADMINISTRATIVE REVIEWER, IF APPLICABLE Name (Please Print ) Signature Date Page 16 of 16