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Rush University
Planning Form for Discipline Specific or Interprofessional Continuing Education (IPCE) Activities
ALLOW AT LEAST TEN (10) WORKING DAYS FOR PROCESSING
Demographic Data:
Title of Activity: Date Form Completed:
Is this activity a regularly scheduled series (RSS) such as grand rounds, case studies, journal club, tumor board, etc?
Yes
No
If “yes”, how often will the RSS be offered?
Weekly
Monthly
Quarterly
Other (Describe)
If this activity is a RSS, what type?
Grand rounds
Case reviews/studies
Journal club
Tumor board
Other(Describe)
If this activity is a RSS, what is the first date it will be offered?
Activity Type:
Provider-directed, provider-paced: Live (in person or webinar)
Date of live activity (if offered more than once, provide all anticipated dates):
Location of live activity. Venue:
City/state:
Provider-directed, learner-paced: Enduring material
Format: Online Website:
CD-ROM, DVD
Start date of enduring material:
Expiration/end date of enduring material:
Performance Improvement Project: Provider-directed, learner-paced PI project based on clinical data.
CONTACT IPCE OFFICE. This form is not intended for PI CE.
Course Director*for this activity.
Name and credentials:
Contact Information:
Does the content of the educational activity enable the learner to acquire or improve knowledge or skills beyond basic knowledge and enhance professional development or performance? Is the content of the educational activity generalizable regardless of the employer?
Yes No If no, the activity is not eligible for contact hours.
This activity is eligible for number of credits/contact hours. (For RSS, enter credit(s) for a single event.)
Assessment of Learner Needs:
Identify target audience (Check all that apply):
Physician Physical Therapist
Registered Nurse Occupational Therapist
Advance Practice Nurse Nutrition/Dietician
Physician Assistant Speech Therapist
Respiratory Therapist Psychologist
Social Worker Audiologist
Other - (Describe):
Specialty Areas (if applicable, specify- i.e. cardiology, palliative care, critical care):
What type of credit are you applying for (check all that apply
Continuing Medical Education (CME)
Continuing Nursing Education (CNE)
Continuing Education (CE)
Estimated Number of Participants:
Internal Users (Rush Employees)
External Users
If physicians are included in the target audience:Indicate fromthe list below which Accreditation Council for Graduate Medical Education (ACGME) Competency(s) most closely relate(s) to the intended learner outcome of this educational activity.Select all that apply.
Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.
Medical Knowledge 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.
Systems-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.
If MORE THAN ONE profession is included in the target audience (i.e. physicians, nurses and social workers):Indicate fromthe list below which Institute of Medicine (IOM) interprofessional Core Competency(s) most closely relate(s) to the intended learner outcome of this educational activity. Select all that apply.
Provide patient-centered careIdentify, respect, and care about patients’ differences, values,
preferences, and expressed needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health.
Work in interdisciplinary teams Cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable.
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.
Apply 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 quality.
Utilize informatics Communicate, manage knowledge, mitigate error, and support decision making using information technology.
Identify the appropriatepractice gap that this educational activity will address for the intended target audience (Select One):
Gap in Knowledge of the Target Audience (knows) Describe:
Gap in Skills of the Target Audience (performance) Describe:
Gap in Practice of the Target Audience (patient outcomes, faculty/student-related outcomes, professional development outcomes, etc) Describe:
Other - Describe:
Type of needs assessment method used to plan this event? The learning need is based on the identified gap. (Check all that apply)
Surveying stakeholders, target audience members, subject matter experts or similar
Requesting input from stakeholders such as learners, managers, or subject matter experts
Reviewing quality studies and/or performance improvement activities to identify opportunities for improvement
Reviewing evaluations of previous educational activities
Reviewing trends in literature, law and health care (i.e. Institutes of Medicine, National Institute of Nursing Research)
Other (Can include observation by subject matter experts) Describe:
Check if the needs assessment data is attached (e.g., survey data, reference in literature, QI data, etc.)Needs assessment data must beavailable upon request if the data does not accompany this planning form.
Effective Educational Design Principles
Purpose/Need.The purpose or learning need must be related to the identified gaps in the Assessment of LearnerNeeds section (knowledge, skills, practice, or other) for the target audience. The purpose should be stated in relation to the desired outcome of the educational activity as a result of the educational program. (i.e. The purpose of this activity is to ……….)
Content for this educational activity was chosen from:
Information available from organization/web site (organization/web site must use current available evidence within past 5 - 7 years as resource for readers; may be published or unpublished content; examples – Agency for Healthcare Research and Quality, Centers for Disease Control, National Institutes of Health)
Information available through peer-reviewed journal/resource (reference should be within past 5 – 7 years):
Clinical guidelines (i.e. -
Expert resource (individual, organization, educational institution) (book, article, web site)
Textbook reference
Other:
List the evidence-based references used for developing this activity:
Complete the Planning Table below for the activity.
For Live Event or Enduring Material:If you are planning a program that is three or more hours in length, please use global objectives for the event versus objectives for each speaker’s content area. Three to six global objectives are sufficient for three or more hours or multi-day programs. One to four objectives are sufficient for programs that are one to two hours in length.
Educational Objectives: Specificobjectives for the learning activityare developed collaboratively by the planners and Faculty/Presenters/Authors (if applicable) andmust relate to the purpose of the activity. Each objective should have only one measureable action verb andshould specify what the learner willdo once the objective has been completed (the outcome of attaining the objective). See Planning Table below.
Planning Table for Performance Improvement: This form is not intended for Performance Improvement CE projects. Please contact the IPCE Office for more information.
Objectives / Time / Presenter / Teaching method / Learner FeedbackList learner’s objectives in behavioral terms. (How will the learner change his/her practice after this course?) / State the time frame for each objective. (Total should be length of/credit for entire activity.) / List the faculty for the activity. / Describe the teaching methods, strategies, materials & resources (i.e. lecture, discussion, Q & A, handouts, case reviews, powerpoints, etc) / List or describe how learners will be provided feedback (i.e. Q & A, discussion, testing, return demonstration, role play, etc)
Content:
Description of the content of this activity that will be provided to meet each learning objective:
-OR-
Content of the activity is provided with this application (i.e. PowerPoint slides, monograph, etc.).
Successful Completiondocumented by(Consistent with the purpose, objectives and teaching/learning strategies. Check all that apply):
Attendance at entire event or session
Attendance for at least ____% of event
Attendance at 1 or more sessions
Completion/submission of evaluation form
Achieving passing score on post-test. (Passing score is: ____%)
Return demonstration
Other - Describe:
Partial Credit Awarded for Participation?
Yes, partial credit awarded based on time attendedand completion of evaluation.
No partial credit is awarded.
Verify Participation (Check all that apply):
Attendance/participation will be verified through sign in sheets/registration form.
Signed attestation statement by participant verifying completion of entire or part ofthe activity.
Collection of participation verification via computer log
Other - Describe:
Enduring material CE programs (print, CD, web-based, etc.): Contact Hour/Timeframe Calculation
What was the method for calculating the contact hours? (Select one)
Pilot Study
Historical Data
Complexity of content and data
Other - Describe:
Qualified Planners and Faculty/Presenters/Authors/Content Reviewers
Complete the table below for each person on the planning committee and include name, educational degree(s), credentials, and role on the planning committee. The Course Director is knowledgeable of continuing education accreditation standards and process and is responsible for adherence to the ANCC and/or ACCME criteria. One planner needs to have appropriate subject matter expertise for the educational activity being offered. The Course Director and content expert must be identified. All interprofessional activities need at least two planners,they must represent different professions, and the planners can also be course faculty.
For Continuing Nursing Education credit, planning committees must have a minimum of one registered nurse with a BSN or higher in nursing. For Continuing Medical Education credit, it is recommended that a planning committee have a minimum of one physician planner.
Employees or representatives of pharmaceutical or medical device companies are NOT permitted to plan or to act as faculty of any continuing education activities.
Planning Committee:
Committee Member Name / Credentials/Faculty Appointment / Degrees / Role on Committee(check all that apply)Course Director
Planner
Content Expert
Course Director
Planner
Content Expert
Course Director
Planner
Content Expert
Course Director
Planner
Content Expert
Course Director
Planner
Content Expert
Course Director
Planner
Content Expert
Course Director
Planner
Content Expert
A Disclosure Form for each planning committee member is attached.
Identification, evaluation and resolution of conflict of interest for planning committee members:
Course Director(s) name(s):
Does the Course Director(s) have a relationship with a commercial interest organization that is relevant to the content of this educational activity:
Yes* No
*Individual responsible for reviewing conflict of interest information for Course Director(s) (Course Director may not evaluate his/her own conflict of interest information. An IPCE office staff member or planning committee member can review the Course Director(s) for actual orpotential conflict of interest):
The Course Director(s) Disclosure Form(s) was reviewed for actual or potential conflict of interest: Yes No
All actual or potential conflicts of interest were resolved: Yes No
Faculty/Presenters/Authors
Faculty/Presenters/Authors must have documented qualifications that demonstrate their education and/or experience in the content area they are presenting. Expertise in subject matter can be evaluated based on education, professional achievements and credentials, work experience, honors, awards, professional publications, etc. The qualifications must address how the individual is knowledgeable about the topic and how expertise has been gained. Faculty/Presenters/Authors do not have to be nurses, physicians, or other licensed professionals but nurses should address nursing care and nursing implications per the ANCC guidelines, as applicable. Disclosure Forms must contain information specific to this activity. Faculty/Presenters/Authors may also be members of the planning committee.
Faculty/Presenter/AuthorName / Credentials/Faculty Appointment / DegreesDisclosure Formfor each Faculty/Presenter/Author is attached.
Planning committee assures the qualifications of the Faculty/Presenters/Authors are appropriate and adequate by(Check all that apply):
Review of resume/CV of faculty/presenter/author.
Recommendation by colleagues.
Review of literature written by faculty/presenter/author.
Observation of previous presentation by faculty/presenter/author.
New faculty/presenter/author being mentored by:
Other - Describe:
Identification, evaluation and resolution of conflict of interest for Faculty/Presenters/Authors:
The Course Director(s) is responsible for evaluating whether any Faculty/Presenter/Author has a relationship with a commercial interest organization. Refer to the Disclosure Form forinformation to assist with identifying and resolving conflicts of interest.
All Disclosure Forms were reviewed for actual or potential conflict of interest: YesNo
All actual or potential conflicts of interest were resolved: Yes No
Evaluation
Check or describe the methods of evaluation to be used: (Check all that apply)
Evaluation Form
Pre- and/or Post-test (Attach a copy if testing is to be used)
Return Demonstration
Case Study Analysis
Longitudinal study with self-reported change in practice (long term method)
Data collection related to quality outcome measure (long term method)
Observation of performance in practice (long term method)
Other - Describe: (Attach a copy if appropriate)
Upon completion of the activity, a summative evaluation is generated.
The Course Director or planning committee will review the summative evaluation to assess the activity's effectiveness and to identify how results may be used to guide future educational activities.
Accreditation
All communications, marketing materials, certificates, and other documents that refer to awarding contact hours or continuing education credit for an individual educational activity must include the accreditation statement(s) of the Accredited Provider.
The accreditation statement(s) must be displayed clearly to the learner and must be worded correctly according to the most current Accreditation Manual(s). Each accreditation statement must stand alone on its own line of text. IPCE will provide correct accreditation statement(s) upon qualification of the activity.
Type of advertising to be used (please note that the advertising material should contain the program purpose and objectives):
Flyer/brochure
Memo/Letter
Meeting Notice
Web site
Social Media
Other - Describe
Copies of advertising materials are attached and available upon request.
Correct Accredited Provider accreditation statements will be provided by IPCE upon approval of this activity.
Commercial Support and Sponsorship
A commercial interest is defined by ACCME and ANCC as any entity either producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients or an entity that is owned or controlled by an entity that produces, markets, re-sells or distributes health care goods or services consumed by, or used on, patients. Exceptions are made for non-profit or government organizations and non-health care related companies.
Commercial support is financial, or in-kind, contributions given by a commercial interest, which is used to pay all or part of the costs of a CME or CNE activity. Providers of commercial support may not be providers or co-providers of an educational activity.
A sponsor is identified as an organization that does not meet the definition of commercial interest. Sponsorship is financial, or in-kind, contributions given by an entity that is not a commercial interest, which is used to pay all or part of the costs of a CME or CNE activity.
If no commercial support or sponsorship received, select the box below and proceed to “Disclosures” section.
If commercial support or sponsorship is received, complete table and items below, and attach the signed and dated agreement(s).
This activity has no commercial support or sponsorship. (Proceed to “Disclosures Provided to Participants”.)
Commercial support/sponsorship has been provided by the following: (List name of organization(s) providing commercial support or sponsorship.)
Name of Organization / Funding or In-Kind Donation / Type of Organization (commercial interest ornon-commercial interest)
Content integritywill be maintained by (Check all that apply):
The commercial support/sponsorship policy/procedure has been discussed with those providing commercial support or sponsorship.
The commercial support/sponsorship policy/procedure has been shared in writing with those providing commercial support/sponsorship.
Signed commercial support or sponsor agreement provided by IPCE is attached.
In conjunction with above, the session will be monitored and violators of policy will not be asked to present again.
Other - Describe:
The following precautions will be taken to prevent bias in the educational content (Check all that apply):
Commercial support/sponsorship and bias has been discussed with each presenter.
Each Faculty/Presenter/Author has signed a statement that says s/he will present information fairly and without bias.