Inova Health System Office of Continuing Medical Education Application for Awarding Continuing Medical Education Credit for Regularly Scheduled Series This application must be used to collect all of the information necessary to plan and develop the proposed CME series. Completion of all sections of this form is necessary to meet accreditation requirements. Please attach all required documentation. Applications without this information and signatures of course directors and the department chairperson will be returned. Program Identification: Activity Title: Affiliation: IFH IAH IFOH IMVH IHS Other (describe) Activity Date: Day(s) of Week Held: Sun Mon Tue Wed Thur Fri Sat Time(s): Start Time End Time. Number of Category 1 Credits: To be filled out by OCME Location: Sponsorship: (Note: a pharmaceutical company or medical device manufacturer is not a sponsor.) Place an X in the appropriate box. Directly Sponsored: Inova Department works with Inova OCME Jointly sponsored (OCME works with non-cme accredited provider) List Company Name(s): Co-sponsored (OCME works with another CME accredited provider) List Company Name(s): Section 1: Leadership and Administrative Staff Support Activity Director: The physician or scientist who has overall responsibility for planning, developing, implementing, and evaluating the content and logistics of a certified activity. Name: Degree: Office Address: Work #: Fax #: Email: Title: Affiliation: Department: Activity Co-Director: (optional) The individual who shares responsibility for planning the certified activity. Designating an Activity Co-Director is optional, but strongly encouraged, for a jointly sponsored or co-sponsored activity. Name: Degree(s): Office Address: Work #: Fax #: Email: Title: Affiliation: Department: 1
Administrative Coordinator: The individual responsible for the operational and administrative support of the activity. Name: Office Address: Work #: Fax #: Email: Section 2: Planning Program Planning Committee: In addition to the activity medical director or co-director, list the names, degrees, titles, affiliations and emails of persons chiefly responsible for the design and implementation of this activity. Use additional sheets if necessary. Please note all planning committee members must complete a Disclosure Form. Name: Degree(s): Title: Affiliation: Email: Name: Degree(s): Title: Affiliation: Email: Name: Title: Affiliation: Degree(s): Email: Planning Process: Place an X in the appropriate box. Who identified the speakers and topics? (select all that apply) Activity Medical Director Activity Co-Director Other (Provide names) What criteria were used in the selection of speakers? (select all that apply) Subject Matter Expert Other (please explain) Excellent Teaching Skills/Effective Communicator Experienced in CME Were any employees of a pharmaceutical company and/or medical device manufacturer involved with the identification of speakers and/or topics? No Yes (Please explain) 2
Target Audience: At least one box from geographic location, provider type and specialty must be selected. Select all that apply by placing an X in the box next to the item. Geographic Location Provider Type Specialty Internal only Primary Care Physicians All specialties OB/Gyn Local/regional Specialty physicians Anesthesiology Oncology National Pharmacists Cardiology Ortho International Physician Assistants Dermatology Pediatrics Nurses Emergency Psychiatry Med Nurse Practitioners Family Med Radiology Other (specify): General Med Surgery Other (specify): Section 3: Needs Assessment and Educational Design Alignment with Inova CME Mission Statement: CME activities should be designed to change competence, performance or patient outcomes as described in the CME mission statement. The activity director must initial the boxes below to verify the activity meets these guidelines. CME Mission: The purpose of Inova Health Systems Office of Continuing Medical Education (OCME) is to facilitate the highest quality of patient care by sponsoring and promoting high-quality, evidence-based educational opportunities that are designed to advance physician competence, enhance practice performance, promote patient safety and cultivate lifelong learning. This activity fits within the above CME Mission Statement This activity meets the standards for scientific validity and its content would be accepted by the profession as being within the basic medical sciences, the discipline of clinical medicine and the provision of health care to the public. Statement of Need: Please state below the overall need for this educational activity: Data and Sources: Please indicate the sources used to identify the deficiencies/quality gaps or need. The ACCME/MSV requires that you attach representative documentation of how needs were determined. If you cannot provide the documentation, do not indicate the use of the source. Select at least two of the following, over and above course evaluations (a): Previous Participant Evaluations (a) (if checked, need 2 more from list below) Expert Opinion (attach names, affiliations and summary of recommendations) Faculty/Clinical Staff Perception (attach names and summary/minutes/informal notes of planning meetings or discussions held to assess need) Literature Review, Consensus Reports (attach review articles, reports, or bibliography) Medical Audits/QI Reviews (attach audit report) Patient Survey; Clinical or Patient Care Indicators (attach results) Physician Survey (attach survey) 3
Industry Sources Recent Research; Data from public health sources/publications (attach description of research results) Self Assessment Tests (attach documentation) Other (Please specify and provide documentation) Learning Objectives: Please indicate how the identified needs cited on the previous page will be incorporated into the learning objectives of your program. What will the participant know or be able to do following completion of this program? [: Differentiate acute (simple) pain from chronic (complicated) pain.] Following this program, the participant should be able to: (please list objectives) (verb list attached): 1. 2. 3. 4. 5. Core Competencies: CME Activities should be developed in the context of desirable physician attributes. Please indicate which American Board of Medicine Specialties (ABMS) or Institute of Medicine (IOM) core competencies that will be addressed in this activity. Patient Care or Patient-Centered Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health Medical about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals Professionalism as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population System-Based Practice as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value Interdisciplinary Teams: cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable Quality Improvement: 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; design and test interventions to change processes and systems of care, with the objective of improving care Utilize Informatics: communicate, manage knowledge, mitigate error, and support decision making using information technology 4
Employ Evidence-Based Practice: integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible Identification of Professional Practice Gaps, Educational Needs, Learning Objectives, and Desired Results (minimum of 3 total must be identified for the overall activity) Professional Practice Gap HIV providers and patients are faced with a constantly evolving standard of care. This poses a challenge for assuring that HIV treatment is consistent with the most current guidelines Educational Need HIV providers need educational initiatives related to current HIV treatment guidelines. This is a gap/need of: (check all that apply) Learning Objective Identify current guidelines in order to provide optimal care to women with HIV. Desired Result Increased knowledge of current HIV treatment guidelines. Professional Practice Gap Educational Need This is a gap/need of: (check all that apply) Learning Objective Desired Result 1 A professional practice gap is defined as the difference between ACTUAL (what is) and IDEAL (what should be) in regards to performance and/or patient outcomes. 1 An educational need is defined as the need for education on a specific topic identified by a gap in professional practice. 1 Learning objectives are the take-home messages; what should the learner be able to accomplish after the activity? Objectives should bridge the gap between the identified need/gap and the desired result. 1 Desired results are what you expect the learner to do in his/her practice setting. How will the information presented impact the clinical practice and/or behavior of the learner? Indicate how this change could be reasonably measured. 1 is defined as the ability to apply knowledge, skills, and judgment in practice (knowing how to do something). 1 is defined as what one actual does, in practice. Identified Barriers: (Select 1 at minimum) What potential barriers do you anticipate attendees may have in incorporating new knowledge, competency, and/or performance objectives into practice? Select all that apply by placing an X in the appropriate box. Lack of time to assess or counsel Lack of consensus on professional guidelines patients Lack of administrative Cost support/resources Insurance/reimbursement issues Patient compliance issues No perceived barriers Other (specify) 5
Please describe how you will attempt to address these identified barriers in the educational activity. [: If the identified barrier is cost, you would attempt to address the barrier by stating, The agenda will allow for the discussion of cost effectiveness and new billing practices. ] Format 1. Attach a copy of the draft agenda(s) with proposed topics and speakers for the year. Educational Design/Methodology: Please indicate the educational method(s) that will be used to achieve the stated goals and objectives that is appropriate for the topic and intended audience s learning style. Select all that apply by placing an X in the appropriate box. Live course/lecture Audio Audio lecture teleconference Internet CME Case discussions CD-ROM Home study/individual Patient practicum study Demonstration of procedures/simulation/skills lab Other (specify) Activity/Post-Activity Evaluation: How will you measure if changes in competence, performance or patient outcomes have occurred? Place an X next to all that apply; note, you may be asked to provide summary data for the evaluation methods selected. The OCME will provide a standard evaluation tool. Participant post-activity evaluation must contain or measure the following standardized sections or statements in addition to any repeated questions. An evaluation/outcomes assessment and analysis must be completed at the conclusion of the CME activity/series and any follow up (long term) strategies for documenting changes in knowledge, skills and abilities and practice improvement must be included. / Evaluation tool for participants (required) Physician and/or patient surveys Audience Response System (ARS) Other (specify) Adherence to guidelines Case-based studies Customized pre and post test Chart audits Direct observations Customized follow-up survey/interview/focus Other (specify) group about actual change in practice at specified intervals Patient/Population Health Observe changes in health status measures Observe changes in quality/cost of care Other (specify) Obtain patient feedback and surveys Measure mortality and morbidity rates Section 4: Commercial Support and Exhibits Will this activity receive commercial support (financial or in-kind grants or donations) from a company such as a pharmaceutical or medical device manufacturer? Yes and I have read and agree to abide the ACCME Standards for Commercial Support Will vendor/exhibit tables be allowed at this activity? Yes No No 6
How will you communicate faculty disclosure to participants? In writing: will be handed out to participants Verbally when speaker is introduced or introduces themselves (documentation of announcement required) Important Note Regarding Commercial Support and Disclosures: Commercial support must be acknowledged on promotional and handout materials whenever possible. All commercial support MUST be by an educational grant to the IHS Foundation and must flow through OCME. Letters of Agreement MUST be signed by grantors/ocme office. Faculty expenses, lecture fees, etc. are NEVER to be paid directly to faculty by any commercial entity. Faculty disclosure is required, even if the CME activity does not receive commercial support. No matter how disclosure is accomplished (verbal or written), a written record of the disclosure must be kept for each speaker (physician, planning committee, guest faculty, fellows, residents, etc.) If using power point, we recommend that the first slide of the presentation be of the faculty disclosure. List Financial Support: Section 5: Signatures I have read the OCME application and filled it out completely. All required attachments are included with the application. Activity Director(s) (Print or Type Name) Department Chairperson (Print or Type Name) Signature Date Signature Date After completing this application, please return to: Office of Continuing Medical Education, Physicians Conference Center 3300 Gallows Road, Falls Church, VA 22042 Fax: 703-776-3961 FOR OCME USE ONLY New Program Repeat Program Approval Date: Activity Code: Credits Approved: Coordinator: Madeline Erario, MD, FACP Director, Continuing Medical Education 7
FORWARD ALL REPORTS NO LATER THAN 14 DAYS UPON COMPLETION OF EACH ACTIVITY DATE. The reports should include: 1. Summary Sheet 2. Attendance Sheets 3. Completed Speaker/Faculty Disclosure Statement for EVERY SPEAKER (including guest faculty, residents & fellows) 4. Copies of all marketing or promotional material: emails, announcements, brochures, fliers. 5. Copy of Letter of Agreement (Only if there is Commercial Support) 6. Session Handouts (if applicable) 7. Post Activity Evaluation Summary Report (quarterly evaluation) 8