CONTINUING PHARMACY EDUCATION (CPE) Project Planning Form for Live and Enduring Activities More information about this form may be found at http://cpe.pharmacy.ufl.edu. NOTE: Minimum time before activity date 30 days for general CE. If Florida State Board approval required 60 days. ACTIVITY INFORMATION Title of activity: Date of original release: Accreditation Desired: 1 Year; 2 years; 3 years; Other All Locations & Dates: Will any type of media be required: If so, what type: If home study, estimated time to complete: Credit hours requested: Institution or Department: ACTIVITY DIRECTOR OR PERSON IN CHARGE OF ACTIVITY Name: Mailing Address: Phone: Email: ACTIVITY PLANNING COMMITTEE (team members recommended that you have a minimum of three) Name Phone Email ADMINISTRATIVE CONTACT Name: Mailing Address: Phone: Fax: Email: SUBMISSION AND APPROVAL Submitted by Activity Director s Name Signature If program is sponsored by a college department, I approve the sponsorship of this CPE activity by my department. If not, ignore this signature. Accepted and approved by Department Chair Or Preceptor s Name Signature Page 1
FINANCIAL INFORMATION 1. This CPE activity will include discussion of off-label use.* Yes No Don t know 2. Financial support was obtained for this activity.* Yes No Pending 3. If you answered Yes to question #2 above, please check all that apply regarding this CPE activity: Financial support was provided by a commercial interest (i.e., pharmaceutical and/or device manufacturer) Financial support was provided by a non-commercial interest (i.e., foundation, government, etc.) Financial support was provided by only 1 grant supporter Financial support was provided by more than 1 grant supporter Fully supported (100%) by grant(s) Partially supported (<99.9%) by grant(s) Activity would be conducted despite receipt of grant support Activity would not be conducted if grant support was not received 4. Is there a participant registration fee for this activity?* Yes No Items with a * must have a response before proceeding. NEEDS ASSESSMENT DATA AND SOURCES Describe the educational need or clinical practice gap that will be addressed by this activity. For example, activity may focus on providing learners with up to date knowledge in a rapidly changing area of pharmacy practice or provide strategies for improving performance in areas where clinical performance is known to be less than optimal. Other programs may aim to improve performance on a clinical, communication, professionalism or system based practice. (Attach additional pages if necessary.) If requesting pharmacist and pharmacy technician accreditation the needs assessment for technicians cannot be the same as for pharmacist. It must be specific for technician responsibilities. Use additional space to complete needs assessment if needed. Provide at least two data sources used to identify the educational need or clinical practice gap described above. For the data source chosen, provide a brief description of the source and the data. Expert faculty opinion (provide names and description of their input) Literature review (provide summary) National or local clinical quality, safety or performance data (describe) Survey of target audience (provide survey results) Prior program evaluations (provide or describe) New medical information (describe source of information) External requirements such as: National Committee for Quality Assurance (NCQA), Joint Commission on Accreditation of Healthcare (JCAHO), CMS, Professional Society, Licensure or MOC requirements (describe) Legislative, regulatory or organizational changes effecting patient care Other: Page 2
Continuing Pharmacy Education (CPE) activities should be developed to address competencies for the practice of pharmacy as described by the CAPE Outcomes. Please indicate which competencies will be addressed in this activity. Foundational Knowledge Learner (Learner) - Develop, integrate, and apply knowledge from the foundational disciplines (i.e., pharmaceutical, social/behavioral/administrative, and clinical sciences) to evaluate the scientific literature, explain drug action, assess and solve therapeutic problems, and advance population health and patientcentered care. Essentials for Practice and Care Patient-centered care (Caregiver) - Provide patient-centered care as the medication expert (collect and interpret evidence, prioritize patient needs, formulate assessments and recommendations, implement, monitor and adjust plans, and document activities). Medication use systems management (Manager) - Manage patient healthcare needs using human, financial, technological, and physical resources to optimize the safety and efficacy of medication use systems. Health and wellness (Promoter) - Design prevention, intervention, and educational strategies for individuals and communities to manage chronic disease and improve health and wellness. Population-based care (Provider) - Discuss how population-based care influences patient-centered care and influences the development of practice guidelines and evidence-based best practices. Approach to Practice and Care Problem Solving (Problem Solver) Identify and assess problems; explore and prioritize potential strategies; and design, implement, and evaluate the most viable solution. Educator (Educator) Educate all audiences by determining the most effective and enduring ways to impart information and assess understanding. Patient Advocacy (Advocate) - Assure that patients best interests are represented. Interprofessional collaboration (Collaborator) Actively participate and engage as a healthcare team member by demonstrating mutual respect, understanding, and values to meet patient care needs. Social & Cultural Sensitivity (Includer) - Recognize social determinants of health in order to diminish disparities and inequities in access to quality care. Communication (Communicator) Effectively communicate verbally and nonverbally when interacting with an individual, group, or organization. Personal and Professional Development Self-awareness (Self-aware) Examine and reflect on personal knowledge, skills, abilities, attitudes, beliefs, biases, motivation, and emotions that could enhance or limit personal and professional growth. Leadership (Leader) - Demonstrate responsibility for creating and achieving shared goals, regardless of position. Innovation and Entrepreneurship (Innovator) - Engage in innovative activities by using creative thinking to envision better ways of accomplishing professional goals. Professionalism (Professional) - Exhibit behaviors and values (e.g., UF PHARMD CORES) that are consistent with the trust given to the profession by patients, other healthcare providers, and society. TARGET AUDIENCE Please select the audience for whom the activity is being planned. Pharmacists Pharmacy Technicians Other (specify) EDUCATIONAL OBJECTIVES Note: If requesting pharmacist and pharmacy technician accreditation the learning objectives for technicians cannot be the same as for pharmacist. They must be specific for technician responsibilities. As a result of participation in this activity, participants will be able to: 1. 2. 3. 4. 5. 6. Use additional paper if needed Page 3
DESIGNATOR: TYPE OF ACTIVITY (01-Drug Therapy; 02-AIDS; 03-Law; 04-General Pharmacy; 05-Patient Safety [Medication Errors] Knowledge-Based (Intent is to acquire factual knowledge) Application-Based (Intent is to apply information learned during immediate activity Practice-Based (Intent is to systematically acquire specific knowledge, skills, attitudes and performance behaviors that expand or enhance practice competencies) ACTIVITY FORMAT: Live Activity Internet Enduring Material Other type of activity; please specify: Please identify the instructional formats of this activity. Lecture Case studies Workshop Small group discussion Other: What instructional format was used in creating this activity? Please describe the form of active learning to be used. PLANNING PROCESS Please describe the process you used to develop this activity. For example, if the planning committee met face to face or electronically to plan the meeting, describe those interactions. Meeting minutes or emails can be helpful in documenting the activity planning process. (Use additional pages as necessary.) EVALUATION This activity is designed to accomplish which of the following outcomes? (Check all that apply.) Improved learner competence Improved learner performance in practice Improved patient outcomes Indicate the evaluation method you plan to use. Note the activity evaluation plans should match the activity goals described earlier. Evaluation for pharmacists and technicians must be separate and must focus on specific objectives. If using evaluation form other than standard CPE evaluation form please provide example. CPE evaluation form - Note: This form must be included. Upon approval, will be provided. Group problem-solving exercises live activity only - (please describe) Performance evaluation (such as direct performance evaluation or assessment on case based problem before and after the activity) live activity only. Other : How do you expect that this activity will impact pharmacy practice? CONFLICT DISCLOSURE FORMS **ALL DISCLOSURE FORMS MUST BE SIGNED AND SUBMITTED WITH THIS APPLICATION** Forms must be completed by the Activity Director, each member of the Planning Committee, and each Speaker. Identify the number of forms attached for each group: Planning committee members Activity Director Speakers Page 4
Include any activity planning advertisements/announcements/brochures for CPE Staff review Announcements or program brochures may not be distributed until they are approved by CPE Staff. WAIT! Before you submit your application, are the following attached? Return application to: The following items are required for approval: Completed and signed application Needs assessment description, gap analysis and supporting documentation Planning process documentation Proposed agenda for activity Copy of Activity Announcement/Brochure/Flyer Curriculum Vitae for each presenter Disclosure forms for activity director, planning committee, speakers Power Point Slides (if used) Letter of Agreement (if other than UFCOP) If home study, knowledge check questions for pharmacists and/or technicians. Director of Continuing Pharmacy Education Megan Murphy-Menezes murphymenezes@ufl.edu Contact us: 352-273-6275 cesupport@ahc.ufl.edu Visit our website: http://cpe.pharmacy.ufl.edu Page 5