Program No: 2016 - ______CME Office, Department of Medical Education

St Luke’s University Health Network Estes Building, 800 Ostrum Street, Bethlehem, PA 18015

V-484-526-2483 Fax-484-526-6450

Continuing Medical Education

Application for AMA PRA Category 1 Credits(s)

I.  DEMOGRAPHICS

Application Submission Date / Start Date
Sponsoring Department(s) / End Date
Day(s) of Week / Time (ex. 8-9am)
CME Credit Hrs Requested (per event) / Primary Location
Program Title:
Frequency: / Once Repeated Monthly Weekly Quarterly Other:

*If requested credit is greater than 2.00 hours, please attach an agenda that lists activity objectives, topic, time schedules, and faculty.

II.  TYPE OF ACTIVITY

Regularly Scheduled Series – activities that occur on a regular basis
Grand Rounds Tumor Board M&M Case Review PI/Safety
Live Activity – single or mulit-day meeting presented once or repeated.
Enduring Materials - a non-live, printed, recorded, or computer-based CME activity that “endures” over time.

III.  PLANNING COMMITTEE – individuals involved in planning the activity, completing all pre/during/post CME paperwork, and in control of content. A signed disclosure form is required . Note: interprofessional collabortation in planning and/or delivering CME activities are encouraged.

Full Name (MD/DO, RN, ACP, etc) / Role (e.g. leader, planner, patient, student, public rep, etc) / Disclosure Form
Physician Activity Leader / Completed
Completed
Completed
Completed
Completed

IV.  TEACHING STAFF – complete the grid below for all individuals who will serve as faculty for this activity.

Faculty Name / Address/City/State/Zip / Phone / Email / Tax ID or SS# / Honorarium / Expenses

V.  TARGET AUDIENCE – This CME activity is designed to match the current or potential scope of practice of the following learners who are experiencing the gap/need identified above. Check all that apply.

Our Departmental Staff Physicians / General Medical Staff
Primary Care Physicians / Residents/Fellows
Specialists/Subspecialists (specify): / Other Healthcare Professionals (specify):

VI.  GAPS / NEEDS / OBJECTIVES - Samples for how to write professional practice gaps and instructional objectives are located at: http://medaffairs.slhn.org/manny/cme/cmeframe.htm.

§  Knowledge = Learners need to know about something (gain new knowledge)

§  Competence = Learners need to learn how to do something (gain new abilities and skill)

§  Performance = Learners need to change something they do in their practice (modify their practice / improve patient care)

Professional Practice Gaps /

Instructional Objectives

What are the problems/issues occurring in practice that you want to affect/change with this activity? / What should your learners be able to demonstrate as a result of participating in this activity?
1.
2.
3.
4.
5.

VII.  NEEDS ASSESSMENT DATA SOURCES – Please indicate any data sources that helped determine that your learners are experiencing the gap/need(s) identified above. Check all that apply.

Request from Medical Staff or Administration / Medical Specialty Association Recommendations
Evaluation Data from Prior CME Activities / Medical Specialty Board – Maintenance of Certification
Recent Literature Search by Medical Staff / Recommendation of Experts
Quality Measures, Protocol Changes, or Patient Care Issue / Advances in Technology or Medical Research
Hospital or Performance Improvement Initiative / Regulatory Requirements
Formal Survey, Assessment, or Internal Research Studies / Public Health Data (aka health informatics)
Other (specify):

VIII.  ACTIVITY GOALS – As a result of participating in this activity to help address the identified practice gaps, the target audience should see improvement in the following competencies. Check 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 sciences and the application of knowledge.
Practice-based learning that involves evaluation of physician’s own patient care and appraisal/assimilation of scientific evidence.
Interpersonal/communication skills that result in effective exchanges and teaming with patients, families, & health professionals.
Professionalism carry out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse population.
Systems-based awareness of the larger system for health care and ability to effectively call on system resources to provide care.

IX.  FORMAT - We chose the following format for this CME activity as the best way to transmit the material to our learners and meet our learning objectives. Check all that apply..

Conference/Lecture/Workshop / Journal Club or Literature Review
Case Studies / Round Table or Small Group Learning
Panel Discussion / Role Playing
Simulation or Standardized Patients / E-learning module
Enduring Material (e.g. print, video, podcasts, etc) / Other (specify):

X.  EVALUATION - How will you determine if your activity made a difference? What mechanism will you use to measure the effectiveness of the expected outcomes? All CME activity require a performance or outcomes measure.

Measure Knowledge & Competence / Measure Performance / Measure Outcomes
Post Activity Evaluation / Performance Improvements / Patient Surveys (e.g. HCAHPS)
Pre/Post Tests / Chart Audits / Growth
Follow-up Check-In Test / Direct Observation Study / Quality
Follow-up Skills Survey / Interviews or Focus Groups / Financial
Other (specify): / Other (specify): / Other (specify):

XI.  PERFORMANCE SUPPORT MECHANISMS

1.  What barriers do you anticipate the learner will face when trying to make the changes this activity is designed to address?

Cost / Patient Compliance Issues
Lack of Time to Assess or Counsel Patients / Lack of Consensus on Clinical Practice Guidelines
Lack of Resources / No Relevant Barriers
Insurance or Reimbursement Issues / Other (specify):

2.  What “non-CME strategies” will you utilize to address these barriers and/or to support the goals of your CME activity?

Physician Incentives / Reminders to patients, staff, or learners following CME activity
Changes in Hospital Policy or Clinical Practice Guideline / Embed Reminders into Electronic Medical Record
Posters, Signs, Stickers, Pocket Guides, or Newsletters / Regular Reporting of Quality and/or Performance Data
Follow-up Coaching Sessions / Changes in Rounding
Managing-Up / Nothing Planned at this Time (but interested in exploring)
Feedback from Patients / Other (specify):

XII.  BUDGET – Please list all revenues and expenses associated with this CME activity. A CME processing fee of $100 is charged for each commercial support grant. If no budget for this event, please leave blank. Note: Alcoholic beverages will NOT be reimbursed.

Program Revenue / Amount / Program Expenses / Amount
Registration or Fees / Honorarium
Commercial Supporters (Specify) / Travel and Hotel Expenses
Exhibitor Fees (Specify) / Food & Beverage Expenses (no alcohol)
Hospital Support / Room Rental
Medical Staff Contribution / Supplies & Equipment
Other Gifts or Grants (Specify ) / Advertising
Total Revenue / Total Expenses

XIII.  COMMERCIAL SUPPORT – Will this CME activity receive financial support from a pa pharmaceutical, medical device or other commercial entity? Support includes financial and in-kind grants and donations. Exhibit fees are NOT considered commercial support. All financial support given from a commercial interest to fund a Category 1 CME activity must comply with the ACGME Standards for Commercial Support and must be paid in the form of an educational grant to St. Luke’s University Health Network.

Are you applying for commercial support for this educational activity? Yes No

Are there exhibits or advertisements associated with this activity? Yes No

If yes, list specifics below:

Company / Amount / Description / Company Rep Name / Address/City/State/Zip / Phone / Email

XIV.  ACTIVITY LEADER AGREEMENT – I understand and will follow these guidelines to the best of my ability.

Upon CME Committee APPROVAL and AFTER each activity:
§  Any speaker who HAS NOT signed a disclosure form within the calendar year, or who has new financial relationships to disclosure (that are relevant to a topic), must sign and submit a Disclosure Form to the CME Office 7 days (1 week) prior to the event when a speaker is on St. Luke’s Medical Staff, and 14 days (2 weeks) if a speaker is NOT on St. Luke's Medical Staff. In addition, the CV is required for all speakers NOT on St. Luke's Medical Staff.
§  Resolve all declared speaker conflicts prior to an activity by following the “Conflict Resolution Policy and Form” found at http://medaffairs.slhn.org/manny/cme/cmeframe.htm
§  After each activity, all evaluations, attendance sheets, learning objectives, and speaker introduction forms must be submitted to the CME Office within 14 days (2 weeks) in order for attendees to be awarded CME credit. If you are using an online evaluation, please distribute to the participants who attended each activity. CME credit will NOT be awarded if submitted after this period.
§  After each activity, send all CME paperwork to Delrose Livermore via email at or fax at 484-526-6450 or call at 484-526-2483 to make arrangements to drop off at Estes Building, 800 Ostrum Street, Bethlehem, PA.
§  All CME activities require a progress report to the CME Committee on the impact of your program.
If you anticipate Commercial Support or Exhibitor Payments:
§  If a company is supporting your event with an educational grant, the complete name of the company, address, representative’s name, telephone number and email must be provided. ONLY, the CME office or CME designee will contact the representative to complete a “Commercial Support Letter of Agreement” .
§  If a company wants to purchase exhibit space during your event, the complete name of the company, address, representative’s name, telephone number and email must be provided. ONLY, the CME office or CME designee will contact the representative to complete a “Exhibitor Letter of Agreement”. Note: exhibitor payments are NOT considered commercial support.
§  ALL agreements with companies must be signed by the CME office or CME designee .
§  ALL agreements must be fully executed at least ONE WEEK prior to the activity.
§  ALL educational grants and exhibitor payments will be deposited in (and expenses paid out of) St. Luke’s CME Account.
§  ALL educational grants or department funds earmarked to pay CME Speakers must be deposited or transferred into St. Luke’s CME Account, so that ALL honorarium and expenses can be paid directly to speakers by the CME Office.
§  ALL brochures and advertising must be received and approved by the CME office at least 14 days (2 weeks) PRIOR to publication launch date. They must contain the approved Pennsylvania Medical Society Statements..
Agree Do Not Agree

Physician Activity Leader or Designee Who Agrees to the Terms of this CME Application:

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