CHRISTUS Trinity Mother Frances Health System CME Application for Courses Paperwork for proposed CME course must be submitted to the CME committee for approval at least six months prior to the planned activity s date. Submission Date: 1. Administrative Information Program or Activity Title: Date: Location: Time: Estimated # AMA PRA Category 1 CME Credit(s) : Does the content qualify for Ethics credit? Yes No Sponsoring Organization: CSRHC Other (list): Sponsoring Department: Program Planner and/or Physician Leader: Phone, Email: Administrative Coordinator: Additional Planning Committee Members: The planning committee must include a minimum of two physicians, one of which represents the target audience. Disclosure form required from each planner. Name/Degree Title/Position Email address 2. Target Audience: Describe the intended target audience for this program (medical specialties, roles, geographic locations, etc.): Indicate the approximate number of each type of clinician: The audience must include a majority of physician participants. #MD/DO #PA/NP/RN #Other #Total CME Application Conference Rev 02/2017 Page 1
3. Gap Analysis and Needs Assessment: State the professional practice gap(s) of your learners on which the activity was based (maximum 100 words). (C2) Knowledge need and/or State the educational need(s) that you determined to be the cause of the professional practice gap(s) (maximum 50 words each). (C2) Competence need and/or Performance need 4. Desired Result: State what this CME activity was designed to change in terms of learners competence or performance or patient outcomes (maximum 50 words). (C3) 5. Educational Format: (ücheck all that apply) Lectures followed by question periods Panel discussions Video presentation with discussion Workshop performance of manipulative skills under supervision Group discussion Demonstration of procedures Case presentation and discussion Webinar presentation with discussion Patient simulation Other (specify): CME Application Conference Rev 02/2017 Page 2
Explain why this educational format is appropriate for this activity (maximum 25 words). (C5) 6. Which ACGME core competencies are being addressed by this educational activity? (C6) (ücheck all that apply) Patient Care and Procedural Skills (treatment of health problems and the promotion of health) Medical Knowledge (application of established and evolving scientific research to patient care) Practice-based Learning and Improvement (involving evaluation of their own patient care; appraisal/assimilation of scientific evidence; improvements in patient care) Interpersonal and Communication Skills (resulting in effective information exchange and teaming with patients, families, and other health professionals) Professionalism (commitment to professional responsibilities, adherence to ethical principles, sensitivity to diverse patient populations) Systems-based Practice (awareness of and responsiveness to the larger context of health care; ability to call on system resources to provide optimal care) 7. Select which of the following criteria will be addressed through this activity? Must include at least one of these items in order to be considered for CME credit. (ücheck all that apply) This activity engages members of interprofessional teams in the planning and delivery of interprofessional continuing education. (C23) If so, list team members with the planning committee members on page 1. This activity engages residents or health professions students in the planning and delivery of continuing education. (C25) If so, list residents or students names with the planning committee members on page 1. This activity addresses factors beyond clinical care that affect the health of populations. (C27) If so, describe the strategy or strategies used to achieve improvements in population health. This activity is a collaboration with another organization to address population health issues. (C28) If so, list the organization and describe how this collaboration will augment the ability to address population health issues. This activity is designed to optimize technical and procedural skills of learners. (C30) If so, describe the elements of the activity that address technical or procedural skills. Describe how you will evaluate the observed technical or procedural skills of the learners. You must include an example of how you will deliver formative feedback to learners about communication skills. This activity utilizes support strategies to enhance change as an adjunct to CME. (C32) If so, describe the support strategy that you plan to use. This activity demonstrates creativity and innovation in CME. (C35) If so, describe the educational innovation. CME Application Conference Rev 02/2017 Page 3
8. Learning Objectives: The objectives must be measurable and describe a potential impact on physician competence, performance, and/or patient outcomes. AVOID use of the following words when creating learning objectives: Know Understand Approach Grow Learn Thinks critically Appreciate Improve Increase Expands horizons Become Grasp the significance of Behavioral Verbs that may be used in writing learning objectives: Knowledge Comprehension Application Analysis Synthesis Evaluation Define Discuss Compute Distinguish Diagnose Evaluate List Describe Demonstrate Analyze Propose Compare Recall Explain Illustrate Differentiate Design Assess Name Identify Operate Compare Manage Justify Recognize Translate Perform Contrast Hypothesize Judge State Restate Interpret Categorize Summarize Appraise Repeat Express Apply Appraise Plan Rate Record Convert Use Classify Formulate Choose Label Estimate Practice Outline Organize Decide What are the specific learning objectives for this activity? (List) 9. Content Outline: Attach the proposed program agenda to include timeframes. 10. Program Faculty (For activities with multiple presenters, no more than 50% can be from any single outside institution.) How did you determine the faculty for this activity? List all speaker/presenter names with their affiliations and contact information. Attach a signed disclosure form and CV for each faculty member. If honorarium is to be paid, indicate the amount. Name/Degree Title/Position Affiliation Email address Honorarium Faculty Letters: The following must be communicated in writing to all faculty members: Target audience Objectives of the presentation Honorarium/expense reimbursement if applicable All the recommendations involving clinical medicine in the activity must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported or used in the activity in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection and analysis. CME Application Conference Rev 02/2017 Page 4
CME must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If CME educational content includes trade names, trade names from several companies should be used where available, not just the names from a single company. 11. Outcomes Measurement: a. What evaluation methods will you use to know if the activity was effective at meeting the need and creating change in competence, performance, or patient outcomes? b. This activity will be measured to determine changes in: Competence (change in participant skills, knowledge, or intent to change clinical practice) Performance (self-reported or objectively measured change in clinician practice) Patient Outcomes (measured patient health outcomes) 12. Commercial Support It is the policy of CHRISTUS Santa Rosa Health Care not to utilize commercial support for its CME activities. 13. Budget How will this program be funded? (ücheck all that apply) Please note that any budgetary losses will be charged to the sponsoring department. Sponsoring department s funds Exhibitor fees Registration fees Other funding (describe): 14. Promotion: How will you publicize this activity? (ücheck all that apply) Hard copy mailing of flyer/brochure Email How will you obtain the mailing list of addresses or emails for the target audience? ATTACHMENTS Final agenda Disclosures all planning committee members Disclosures all faculty Faculty CVs Faculty letters Estimated budget CME Approval AMA PRA Category 1 CME Credit(s) : Signature of CME Committee Chair: Approval Date: CME Application Conference Rev 02/2017 Page 5