All Questions Require an Answer, Unless Otherwise Specified

CME Application 2017 – SAMPLE

This document is a sample for planning purposes only.
All applications must be submitted through the online application process

Applications must be completed in one sitting. You will not be able to save and return to an application at a later time. All applications must be submitted through this online system in order to be considered for approval. View a sample PDF of the application for preparation and planning purposes at

All questions require an answer, unless otherwise specified.

ACTIVITY INFORMATION

Please identify who is completing and submitting this application:

First Name
Last Name
Email

What type of event you are planning?

Each format selected is considered a separate offering.

-Course = Seminar, Conference, Workshop, etc.

-Regularly Scheduled Series = Grand Rounds, Tumor Board, M&M, Journal Club, Case Conference, etc.

-Internet Live = Web Stream

-Internet Archived = On Demand - available for long period of time at learner’s convenience

-Performance Improvement = 3-stage structured, long-term process

Course

Regularly Scheduled Series

Internet Live

Internet Archived

Performance Improvement

What is the title/name of your event? This title will be used for all documentation and marketing.

This question only applies to Internet Live (web stream) or Internet Archived events

State the URL where the internet event will be hosted. If unknown at the time of this application, enter TBD.

This question only applies to Course (symposium, workshop, conference) events

When is the meeting being held (select start date):

Will you be partnering with any external (non-Beaumont Health) organizations in the planning, development, implementation, or evaluation of this activity?

No

Yes

This question only applies if you will be partnering with any external organizations.

Please list all companies you are partnering with and state their primary involvement:

Company / Company Role
Company Name / Logistics / Content / Other
Company 1 /  /  / 
Company 2 /  /  / 
Company 3 /  /  / 

The next 2 questions only apply if you will NOT be partnering with any external organizations.

Please identify the PRIMARY Beaumont Health hospital that is "hosting" the event:

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Corporate Beaumont Health

OUWB

Royal Oak

Troy

Grosse Pointe

Dearborn

Taylor

Trenton

Wayne

Farmington Hills

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Please identify the Beaumont Health department/center taking the lead in this activity (i.e., Sponsoring Department): Select One

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Anesthesiology & Peri-Operative Medicine

Cardiovascular Medicine

Colon and Rectal Surgery

Diagnostic Radiology

Emergency Medicine

Family Medicine

General Surgery

Internal Medicine

Medical Oncology/Hematology

Obstetrics & Gynecology

Ophthalmology

Orthopaedic Surgery

Pathology & Laboratory Medicine

Pediatrics

Physical Medicine & Rehabilitation

Psychiatry

Radiation Oncology

Surgery

Urology

Oakland University William Beaumont School of Medicine

Medical Administration

Research Administration

Other ______

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Target Audience

Primary Geographic Reach Select One

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Internal Only (Beaumont Health/OUWB)

Local/Regional

National

International

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Profession(s) Select all that apply

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All Professions

Physicians

Physician Assistants

Residents

Fellows

Pharmacists

Nurse Practitioners

Nurses

Other, specify: ______

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Specialty Select all that apply

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All Specialties

Anesthesiology

Cardiology

Dermatology

Emergency Medicine

Family Medicine

General Medicine

Neurology

Ob/Gyn

Oncology

Ophthalmology

Orthopaedics

Pathology

Pediatrics

Psychiatry

Radiology

Radiation Oncology

Surgery

Urology

Other, specify ______

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Which credit type(s) are you applying for?

*Additional accreditation requirements and/or fee may apply.

AMA PRA Category 1 CME (Allopathic CME)

AOA CME (osteopathic CME)*

Trauma CME

OUWB Meaningful Participation credits

American Academy of Family Physicians CME credit*

Medical Specialty Board Maintenance of Certification credits*

This question only appears if AOA CME (osteopathic CME)* Is Selected

Which type of American Osteopathic Association credits are you applying for?

*Category 1-A: Formal osteopathic CME related to any of the seven osteopathic core competencies *Requires a minimum of 50% of the presenters be DOs or employed full time by a College of Osteopathic Medicine and the content presented must be osteopathic in nature.

Category 2-A: Formal educational programs that are AMA accredited, but do not qualify for Category 1-A

Category 1-A

Category 2-A

Where is the meeting being held?

Venue
(i.e., Troy Marriott, Beaumont Royal Oak)
Room (i.e., Banquet Hall, Auditorium)
City, State

Does this activity consist of a...

One-time event

Series of multiple events held on different dates - schedule required

Activity Description - Optional This description will be used for marketing purposes.

CME must review and provide final approval on all promotional and recruitment materials prior to printing or distributing. We strongly encourage you to submit all initial drafts to CME prior to the design and layout process. To view the CME advertising requirements/language, click here.

I attest that I have reviewed and agree to the CME Requirements for Event Marketing.

Would you like the CME Department to post this event on our public CME calendar (

Yes

No, this is by special invitation only

This question does not apply to Regularly Scheduled Series

Please identify which of the following optional services you would like the CME department to provide for your event (additional fees apply):

-Design a custom website - fee starts at $100

-Manage online registration - fee ranges from $0 to $1,000 (depends on complexity of registration)

-Apply for educational grants - fee starts at $100 per grant application submitted by CME

-Apply for additional credit types (i.e., AAFP) - fee starts at $100 per credit type + any application fee charged by the credit organization

-Print and assemble name badges - service only available if Beaumont is managing registration; fee ranges from $250 to $500

-Process/print CME handout - based on the number of copies required, fee starts at $100

-On-site support for audience response system or registration - for local meetings only and depends on availability of CME staff; fee starts at $250 per person + travel and is based on meeting location and length

No additional services are requested at this time

Design a custom conference website

Manage online registration

Apply for educational grants

Apply for additional credit types (i.e., AAFP)

Print and assemble name badges

Process/print CME handout

On-site support for audience response system or registration

The following questions only apply to Regularly Scheduled Series

Meeting Information

Start Time (i.e., 8:00 a.m.):

End Time (i.e., 9:00 a.m.):

How often is your meeting held? *Schedule required

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1/week

2/week

1/month

2/month

6/year*

4/year*

Varies*

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Please identify the day(s) of the week your meeting is held. This meeting is held every...

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Monday

Tuesday

Wednesday

Thursday

Friday

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Please identify when your meeting is held. This meeting is held every...

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1st

2nd

3rd

4th

5th

Monday

Tuesday

Wednesday

Thursday

Friday

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Will this meeting be broadcast to another audience?

No

Yes - specify location(s): ______

How will this meeting be broadcast to other audiences? Select all that apply

Video Conference

Internet

Conference Call

Other, specify: ______

PLANNING COMMITTEE/FACULTY

Important Information: All individuals responsible for the planning, design, implementation, and presentation of content must be listed. Employees of commercial interests are not eligible to serve as faculty (planner, speaker, moderator, author, etc.) of a CME-certified activity if the content of CME they are planning/developing/presenting relates to the business lines and products of their employer. If the spouse/significant other of a planner/presenter/moderator, etc is employed by a commercial interest that planner/presenter/moderator will not be eligible.Disclosures must be completed for all planning committee members and course directors before the CME application will be accepted. For more information about Beaumont’s disclosure process click here. Please include the individual’s Beaumont and OUWB titles when applicable.

Please list all Course Director(s)

This is the individual(s) with overall responsibility for the planning, development, and implementation of this meeting. It is preferred to have a physician serve in this role. An up-to-date disclosure of conflict of interest is required for all course director(s).

Name & Degree / Title & Affiliation / Email / Phone
Course Director
Co-Director (optional)

Please list all Department Coordinators

This is the individual(s) who are responsible for the operational and administrative support of this meeting.

Name / Title & Affiliation / Email / Phone
Primary Coordinator
Secondary Coordinator (optional)

Is the department coordinator(s) involved with selecting speakers, topics, or influencing content?

Yes - a CME disclosure is required

No - administrative coordinator is assisting with logistical aspects only

Other than the Course Director(s) and Department Coordinator(s) identified above, are there any additional individuals involved with selecting speakers, topics, or influencing content?

Yes

No

**If AOA Category 1-A credit is being requested, a CV/biosketch is required for all speakers.

EDUCATIONAL INFORMATION

Professional Practice Gaps and Educational Needs - The "What" and "Why"

A professional practice gap is the difference between a desirable or achievable state of practice (what should be happening) and current reality (what is happening). An educational need can be defined as the cause or reason for the practice gap. Gaps exist when providers are not doing everything they could, are not doing things correctly, and/or could improve what they are doing. Gaps can be in knowledge (providers don't know something), competence (provider's don't know how to do something, don't have methods or strategies), performance (providers are not doing something in their practice), or patient outcomes (the consequences of the performance).

Questions to ask when identifying the professional practice gaps and educational needs of this event:

• What questions does my target audience have and what does that reveal about their deficit(s) of knowledge, competence, or performance?
• What patient problems or professional challenges are they unable to address?
• Why does this problem exist?
• Is there a lack of knowledge, competence or performance that caused the problem?

Example Practice Gaps:

• Inappropriate technique and use of ultrasound is leading to complications and medical errors. Clinicians are applying incorrect ultrasound techniques (competence, performance).
• IBS continues to be a common condition encountered by healthcare professionals, but is often under recognized. Clinicians are not currently up-to-date on current evidence for best practices in the treatment of IBD (knowledge).
• 2/3 of eligible patients do not receive in-hospital VTE prophylaxis but should. Clinicians are unaware of benefits of prophylactic mechanical and pharmacologic interventions, which have been shown to decrease the rate of VTE (knowledge). Clinicians are unable to implement prophylaxis in different clinical settings or lack the ability to counsel patients (competence).

What are the professional practice gaps and educational needs that you have identified for this event (i.e., what problems are you trying to address)?

What source(s) did you utilize to identify your professional practice gaps and educational needs? Sources identified with an * require submission of additional documentation.

Medical audit, patient-care review

Problem and/or uncommon case(s)

National, regional, local QI data*

Publication(s)/scientific literature*

Survey of target audience (must be more than just list of topics)*

Issue identified by colleagues

Referral patterns

Other, specify: ______

Learning Objectives - The "How"

The objectives are the solution to address the need and help close the gap. Objectives show what changes are anticipated (in knowledge, competence, performance or patient outcomes) as a result of the activity. Questions to ask when identifying the learning objectives for this event:

-What should the learner be able to accomplish as a result of attending this activity?

-What should the learner be better able to do as a result of attending this activity?

Examples:

-Apply correct techniques...

-Recognize X more promptly...

-Treat patients with X in a more timely manner...

-Describe and implement current guidelines for VTE prophylaxis.

-Perform an effective problem-focused history and physical examination for evaluation of eligibility for VTE prophylaxis.

A minimum of 3 objectives are required. Objectives for individual presentation topics are not required UNLESS AOA Category 1-A credit is being requested; global objectives, if used, must relate to at least 90% of presentation topics.

What are the learning objectives that have been identified for this event? Objectives must relate back to the professional practice gaps and educational needs previously identified. Learning objectives must start with an action verb - do not useunderstand, improve, gain, etc.

Learning Objective #1
Learning Objective #2
Learning Objective #3
Additional Objectives (optional)

Desired Outcome(s) - The “Result”

All CME activities should strive to increase competence, improve physician behavior and/or improve patient outcomes. The purpose of CME activities should be to close the gaps of your learners. The activity’s outcomes/desired results should directly link back to the cause of the practice gaps. Questions to ask when identifying the outcomes/desired results for this event:

-What new abilities/strategies do we want learners to gain?

-How can we help learners modify their practice?

-How can we help learners improve their patient outcomes?

Examples:

• Increased Competence = Give physicians new abilities/strategies –“The ability to identify patients eligible for prophylaxis, the ability to counsel patients.”
• Increased Performance = Helping physicians modify their practice –“Screening more eligible patients and administering prophylactic treatments.”
• Increased Patient Outcomes = Providing tangible improvements in overall health and patient outcomes as measured by reviews of clinician practices - “Decreased rates of VTE or death.”

What are the desired outcome(s) for this event? A minimum of 1 category must be answered (i.e., if you are only trying to change competence, then you only need to complete the competence section). Only include desired outcomes that you actually plan to evaluate and monitor.

Increased Competence ______

Improved Performance ______

Improved Patient Outcomes ______

This question only appears if Increased Competence Is Selected

Evaluating Your Outcomes/Results: How will you measure if the COMPETENCE-based changes/outcomes you identified above have occurred? Select all that apply. You will be asked to provide summary data for each evaluation method selected at the conclusion of the event.

CME Evaluation

Audience Response System

Pre/post-test

This question only appears if Improved Performance Is Selected

Evaluating Your Outcomes/Results: How will you measure if the PERFORMANCE-based changes/outcomes you identified above have occurred? Select all that apply. You will be asked to provide summary data for each evaluation method selected at the conclusion of the event.

Adherence to Guidelines

Chart Audits

Focus Group

I am not able to measure changes in performance

This question only appears if Improved Patient Outcomes Is Selected

Evaluating Your Outcomes/Results: How will you measure if the PATIENT OUTCOMES-based changes/outcomes you identified above have occurred? Select all that apply. You will be asked to provide summary data for each evaluation method selected at the conclusion of the event.

Measure M&M rates or other QI data

Obtain patient feedback

Observe changes in quality/health status measures

I am not able to measure changes in patient outcomes

Educational Design/Methodology

Indicate the educational method(s) that will be used to achieve the stated goals and objectives. Select all that apply.

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Didactic lecture with Q&A

Case-based discussion

Small group discussion

Panel discussion

Simulation

Skill-based training

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Tools to Support Learners in Achieving Results

Previous activity evaluation comments reveal that participants place great value on additional resources or tools that they can use within their practice and that these resources can help participants achieve the desired outcomes of the event. Note, these are supplemental materials and not materials already presented at the event (i.e., presentation slides). Are there additional resources such as the ones listed here that could be provided to participants to help reinforce or extend their learning experience? Select all that apply. Note, you will be required to submit copies of all materials selected below following the conference to the CME department for our files.

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Not at this time

Reminder systems, checklists

Newsletters, booklets

Posters, safety flip charts

Patient assessment tools

Post-activity follow-up with key points from the lecture(s)

Algorithms, clinical protocols

Pocket card guidelines

Patient educational materials

Other, specify: ______

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