Application Must Be Submitted at Least 45Business Days Prior to the Activity Date

VCU
Pharmacy CE Application Form

Application must be submitted at least 45business days prior to the activity date.

Activity Information

Activity Title: Anticipated # of Attendees: Organization/Department:

Activity Director Name and Credentials(must be a pharmacist): Email address:
Activity Coordinator: Email address: Phone number: Fax number:

Date Planning Started:

Sponsorship/Providership:

Directly sponsored (For ACPE credit, only programs managed by the VCU SOP are considered directly sponsored)

Jointly Provided Activity (external partner) List organization name(s):

Activity Information:

Live activity (in person or live webinar)
Date of live activity (if offered more than once, provide all anticipated dates):
Venue of live activity:
City/State:
Home Study
Format:
Online, Website:
Print
Start date of home study:
Expiration/end date of home study:
Maximum approval is three years
Where will the enduring material/home study content be housed?
__ VCU Health CME CloudCME Platform
__ Other, please specify

CE Application 1 | Page

Requested Number of Credits/Contact Hours:

(1 credit = 60 minutes of content participation – does not include breaks, meals, etc)

Activity Type:

Knowledge – minimum of 15 minutes in duration, designed for participants to acquire factual knowledge

Application – minimum of 60 minutes in duration, designed for participants to apply information learned in allotted timeframe

Practice-based – minimum of 15 hours in duration, designed for participants to systematically acquire specific knowledge, skills, attitudes, and practice behaviors that expand or enhance practice competencies; include a didactic and practice component

Attach AGENDA including topics, speakers with credentials, presentation start/end times, breaks/meals, etc.(can be a draft)

CE Application 1 | Page

Needs Assessment #1

Please provide a specific educational need of the learners that this activity will address related to a specific practice gap in learner knowledge/competence, skills/strategy, and/or performance.

Current Practice / Describe the current practice issue/problem/practice gap (limited to 100 words max):
How do you know this issue/problem/practice gap exists?
Select the source(s) you used to identify this practice gap:
Survey data from stakeholders, target audience members, subject matter experts or similar
Input from stakeholders such as advisory/education committees, learners, managers, or subject matter experts
Evidence from quality studies and/or performance improvement activities to identify opportunities for improvement
Evaluation data from previous education activities
Morbidity and Mortality Data
Legislative/regulatory changes
Trends in literature, law and health care
Direct observation
Advice from authorities in the field/relevant accrediting bodies, medical societies, new regulations or practice guidelines
Public health data
Other—Describe:
Please provide a brief summary of data gathered (250 words or less):
Please include a bibliography of references consulted as an attachment.
Best Practice / Describe the quality and/or performance and/or standards of care measures that highlight optimal expectations related to this practice gap (limited to 100 words max):
List the specific source(s) that supports this standard of care:
Learning Objective
Please ensure measureable verbs align with the activity type.
For activities serving both Pharmacists and Pharmacy Technicians, please be sure to include appropriate objectives for each audience type. / What will the learners be expected to do differently as a result of their participation in this activity that addresses the practice gap above?
Desired Result(s) & Intended Outcome(s) / What change do you plan to measure as a result of this activity?
Knowledge/Competence (ex. Evaluation form, audience response system, case-based test, customized pre/post-test)
Application/Skills (ex. audience response system, case-based test, simulation, role-play)
Practice/Performance (ex. demonstration of adherence to guidelines, chart audits)
Patient Outcomes (ex. patient feedback/surveys, measurement of mortality and morbidity rates, observed changes in quality of care)

Needs Assessment #2

Please provide a specific educational need of the learners that this activity will address related to a specific practice gap in learner knowledge/competence, skills/strategy, and/or performance.

Needs Assessment #3

Please provide a specific educational need of the learners that this activity will address related to a specific practice gap in learner knowledge/competence, skills/strategy, and/or performance.

Topic Identifier:

Please select ONE of the following topic identifiers that best describes the content of your activity. This will be used in the UAN number provided to ACPE/CPE Monitor.
01: Disease State Management/Drug Therapy – activities that address drugs, drug therapy, and/or disease states.

02: AIDS Therapy - activities that address therapeutic, legal, societal, ethical, or psychological issues related to the understanding and treatment of patients with HIV/AIDS.

03: Law Related to Pharmacy Related Practice – activities that address federal, state, or local laws and/or regulations affecting the practice of pharmacy.

04: General Pharmacy – activities that address topics relevant to practice of pharmacy other than those included in the classification of drug/disease therapy related, HIV/AIDS therapy related, and law.

05: Patient Safety – activities that address topics relevant to the prevention of healthcare errors and the elimination or mitigation of patient injury caused by healthcare errors.

06: Immunizations – activities related to the provision of immunizations, i.e., recommend immunization schedull.es, administration procedures, proper storage and disposal, and record keeping. This also includes review for appropriateness or contraindication and identifying and reporting adverse drug events and providing necessary first aid.

07: Compounding – activities related to sterile, nonsterile, and hazardous drug compounding for humans and animals. This includes best practices and USP quality assurance standards, environmental testing and control, record keeping, error detection and reporting, and continuous quality improvement processes.

Learner engagement strategies:

Integrating opportunities for dialogue or question/answer

Including time for self-check or reflection

Analyzing case studies with interactive discussion

Use of audience response system

Providing opportunities for problem-based learning

Games and Quizzes to practice recall

Demonstration

Example withpractice

Role play

Application exercises

Practice exercises

Other:

Criteria for Awarding Credit

Criteria for awarding contact hours for live and home study activities in addition to mandatory completion of evaluation form include:

(Check all that apply)

Attendance at entire activity

Credit awarded commensurate with participation

Attendance at 1 or more sessions

Successful completion of a post-test (e.g., attendee must score % or higher)

Successful completion of a return demonstration

Other - Describe:

Engage in active case discussions

Participate in audience response system (ARS) polls

Demonstrate skills through simulation exercises

What assessment and feedback techniques will be utilized for this activity?

Learning assessments are required for each CPE activity to allow participant to assess achievement of learned content. This can be informal or formal, but must be consistent with the activity type.

Individuals in a Position to Control Content

Complete the table below for each person in a position to control content of the educational activity and include name, credentials, educational degree(s), role on the planning committee, and expertise that substantiates their role.

There must be one Pharmacist serving as the Activity Director for each educational activity. I

Who identified the speakers and topics? (Select all that apply.)

Activity Director / Planning Committee / Other

Credit cannot be granted if employees of a pharmaceutical or medical device manufacturer were involved with the identification of speakers and/or topics.

What criteria will be or was used in the selection of speaker(s)?

Subject Matter Expert

Teaching/Communication Skills

CE Experience

Other: ______

If a Pharmacy Resident is a speaker/faculty for this event, please include his/her mentor who oversaw content development. A conflict of interest disclosure form must be completed from both the resident and mentor.

Name of individual and credentials / Individual’s role in activity / Planning committee member? (Yes/No) / Name of commercial interest / Nature of relationship
Example: Sue Brown, PharmD / Activity Director / Yes / None / ---
Example: John Doe, PhD / Presenter / No / Pfizer / Speakers Bureau

Identified Barriers
What potential barriers do you anticipate attendees may have in incorporating new knowledge, competency, and/or performance objectives into practice?

Select all that apply, one (1) at minimum

Limited time / Lack of consensus on professional guidelines
Lack of administrative support/resources / Cost Fiscal constraints
Insurance/reimbursement issues / Other, specify:
Policy/organizational resistance / No perceived barriers
Patient compliance issues

Please provide an answer for EACH question below:

Indicate N/A for those that do not apply to activity.

Please describe how you will attempt to address these identified barriers in the educational activity:

What other organizations within or outside the institution are working on the issue you are addressing?

Factors outside provider’s control that impact patient outcomes.

Activity Funding (select all that apply):
Please contact your CE representative if planning to seek independent medical education grants or in-kind donations from pharmaceutical and/or device manufacturers.

Independent medical education grants

Exhibit Fees

Registration Fees

Department/Hospital/Foundation/Organization/Professional Society Funds

In-kind donations – Describe:

Other – Describe:

As Activity Director and Coordinator, we attest that all content presented during this activity will be in compliance with the ACPE Policy on Content Validation, and Standards for Commercial Support.
Signature of Activity Director / Date
Signature of Activity Coordinator / Date
TO BE COMPLETED BY SOP:
All documents have been received and this activity:
aligns with the Mission of VCU School of Pharmacy, Continuing Education, and
is Approved for ACPE Credit Hours
is Not approved Reason:
______
Evan Sisson, PharmD Date
Director, Continuing Pharmacy Education

CE Application 1 | Page