Cme Joint Providership Application

CME JOINT PROVIDERSHIP APPLICATION

Applications must be received at least 4 months prior to your event/activity.

Please allow 2 weeks from receipt of your application for our response.

Applications received < 4 months from the start date will incur a rush fee of $1000.

1. JOINT PROVIDER NAME (As the organization hosting the conference, you are the Joint Provider)

II. ACTIVITY DETAILS

III.FACULTY: List all individuals in control of the content of your CME activity and specify their role (eg, Activity Director, planning committee member, speaker, author, reviewer, etc.)

IV. BRIEF ACTIVITY OVERVIEW

V. GOAL: The goal states the broad purpose of the activity.

VI. TARGET AUDIENCE: Who will be invited to this activity? What specialties and degrees should the audience members have?

VII. FORMAT: What is the format of this activity?

Live activity (please also check all of the following that apply):

Case-based discussion

Lecture

Panel

Simulation

Skill-based training

Small-group discussion

Other (please give brief description): ______

Podcast/audio or video conference/webinar

Journal

Other (please give brief description): ______

How did you determine that the format of this activity was appropriate?

VIII. SCOPE: How does this activity correspond with your learners’ scope of practice (research, administrative, or clinical)?

IX. PHYSICIAN ATTRIBUTES: What are the desirable physician attributes associated with this activity? (Examples are available at: Please choose from this list.)

X. PROFESSIONAL PRACTICE GAPS:

Professional Practice Gap Q&A:

What is a professional practice gap?

The Agency for Healthcare Research and Quality (AHRQ) defines a gap in the quality of patient care where the gap is "the difference between healthcare processes or outcomes observed in practice, and those potentially achievable on the basis of current professional knowledge."

A “professional practice gap” is a description of a problem in research, clinical, educational, or administrative practice. The professional practice gap is the gap that physician(s) themselves tell you they have or that you (as the CME provider) deduce based on data/information from your research. Professional practice gaps arise due to a lack of understanding, knowledge, strategies, etc.

Why do we need to identify practice gaps?

The identification of practice gaps should be used to guide the planning of the CME activity and direct the learning objectives. This will aid in enhancing the learning experience, knowledge base, and competency of the learners.

How do you identify the professional practice gap?

There are many ways to identify professional practice gaps. One way is by looking at a list of articles that describe case studies of a certain clinical problem; from that, you might identify that the cause of the problem is from a lack of knowledge of ______and physicians lacking a strategy for a certain intervention in certain situations.

Additional ways to identify professional practice gaps include: discussing problems with physicians/colleagues, conducting a retrospective analysis of trial data, reviewing institutional / specialty society requirements, reviewing recertification requirements, and comparing pre- and post-test results of your other / previous CME activities.

What is not a professional practice gap?

• A guideline is not a professional practice gap. Instead, the professional practice gap is: “This guideline was published last week, no one has seen it, and therefore no one knows how to manage this condition.”
• A list of topics that learners want you to cover is not a professional practice gap; you have to either ask them what problems or issues in their practice they would like your CME activity to address or identify it on your own through your research.

Please review the following questions, and then fill in the template on the next page. An example is provided on the following. This must be filled out for EACH module/session/category.

1. What is the practice gap being addressed?
2. What are the changes in competence, performance, or patient outcomes that will be addressed by this article?
3. What are the expected results of this module?

Professional Practice Gap Template:

For each professional practice gap, complete the form below. (Copy and paste the template below for your additional practice gaps.)

Please see the next page for an example.

Example:

• Survey of > 5000 physicians at previous conferences on their ability to use ECPR in their Emergency Dept or ICU. Only 3 were capable.
• Bellezzo JM, Shinar Z, Davis DP, et al. Emergency physician-initiated extracorporeal cardiopulmonary resuscitation. Resuscitation. 2012;83:966-970.
• Sakamoto T, Morimura N, Nagao K, et al. Extracorporeal cardiopulmonary resuscitation versus conventional cardiopulmonary resuscitation in adults with out-of-hospital cardiac arrest: a prospective observational study. Resuscitation. 2014.
• Stub D, Bernard S, Pellegrino V, et al. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation. 2015;86:88-94.

XI. DESIRED RESULTS: The ACCME requires accredited providers to understand the issues with knowledge, competence, or performance that underlie a professional practice gap; to design an educational activity to intervene; and to measure in terms of changes in competence, performance, or patient outcomes.

1. This activity is designed to change:

_____ Competence (what you know and what you would do because of it)

_____ Performance (competence in action, what you actually do in practice)

_____ Patient outcomes (consequences of actual performance in practice)

1. How will you measure whether or not the activity has changed the option(s) you chose above (ie, competence, performance and/or patient outcomes)?

XII. PLANNING PROCESS: Describe the activity planning process. How did you link the identified needs (the practice gaps) with the desired results?

XIII. COMMERCIAL SUPPORT: Will this activity receive commercial support? YES NO

Important Note: The ACCME defines commercial support as “financial, or in-kind (non-monetary), contributions given by a commercial interest which is used to pay all or part of the costs of a CME activity.” If equipment, machine, or other materials will be donated/used as part of your CME activity, then it is considered commercial support and must be included on this application.

1. If yes, list the names of all commercial supporters here:

1. If yes, how will you disclose the commercial support to learners? And how will you ensure that this activity was not biased by commercial support in the planning or final stages?

1. If yes, submit a completed copy of the Letter Of Agreement For Commercial Support form with your application. A blank copy of this form can be downloaded at All activities must comply with the ACCME’s Standards for Commercial Support.

XIV. Do your faculty/authors/contributors/speakers receive an honorarium, reimbursement for travel or other expenses, or complimentary rooms or other comps? If yes, what are your procedures for payment/ reimbursement? (Note that honoraria must comply with our Policy & Procedures For Honoraria, which can be viewed at .)

XV. ADDITIONAL SERVICES: Do you need EB Medicine to provide any additional services? Please check the services you need below, and include the applicable fee in your application fee payment.

Sending CME certificates to participants ($500)

Handling registrations ($2000)

Other (please describe): ______(Cost to be determined on a case-by-case basis)

Please review the Marketing Services available through EB Medicine (see next page) and check below which level you have chosen for your activity.

Right-bar ad on EB Medicine home page (free)

Level 1 ($2500)

Level 2 ($5000)

Level 3 ($7500)

Option add-ons (please note your choices): ______

______

(Cost to be determined on a case-by-case basis)

Other (please describe): ______

______

(Cost to be determined on a case-by-case basis)

• Sidebar ad to run on all pages of EBM website (1 month)
• 1 Back of issue on-page ad in one of our journals

• Sidebar ad to run on all pages of EBM website (2 months)
• 2 Back of issue on-page ads in one of our journals

XVI. APPLICATION AND JOINT PROVIDERSHIP FEE:

• $300 per activity, non-refundable, must be submitted with the application. Remit payment with your application and corresponding attachments. Please request an invoice if needed. Payment can be made via credit card (noted on invoice) or check (made out to EB Medicine and mailed to Attn: Erica Scott, EB Medicine, 5550 Triangle Pkwy, Suite 150, Norcross, GA 30092).
• If the activity is approved, a separate invoice will be sent for the balance of the joint providership fee ($4700) in addition to any requested additional services or marketing services.

In addition to the joint providersip fee, you also agree to:

• Prominently display the statement, “Brought to you by EB Medicine,” and on all promotional and conference materials
• Provide a copy of Emergency Medicine Practice, Pediatric Emergency Medicine Practice, and/or EM Critical Care on relevant topics to all conference attendees (either on a USB drive or via a password-protected weblink sent in the registration email or in an email after the conference).
• Provide attendee names and email addresses, so that EB Medicine can send an “affinity” email to attendees after the conference (the email will include the name of the conference, the name of the conference chair, the conference logo, and market copy provided by EB Medicine).

XVII. CONTACT INFORMATION: Please complete the fields below for the contact person for this application.

XVIII. ACTIVITY DIRECTOR SIGNATURE: Provide signature(s) below indicating acceptance of the following terms and conditions for sponsorship by EB Medicine.

To ensure final designation of credit, I agree to collaborate with EB Medicine to ensure that the planning and implementation of the proposed CME activity are consistent with the policies and procedures of the ACCME. I have read and agree to abide by the ACCME’s Policy for Identifying and Resolving Conflicts of Interest in CME and Standards for Commercial Support. I hereby certify that this application was completed accurately and attest to the validity of the information contained within.

IXX. Financial Responsibility Letter

Joint Provider Name: ______

Joint Provider Address: ______

EB Medicine and ______ have entered into an educational partnership in order to develop the CME activity titled ______. It is the CME policy of EB Medicine to delegate full responsibility for managing all income and expenses related to a CME activity to the educational partner. This purpose of this letter is to delegate ______ with the responsibility of financial management for the above mentioned activity. By doing so, EB Medicine takes no financial responsibility for any surplus or loss this program might incur.

______ agrees to follow the budgetary criteria outlined by EB Medicine. This criterion is based on the Accreditation Council for Continuing Medical Education’s (ACCME) Accreditation Policy, which states “The accredited provider may delegate the responsibility for receiving and disbursing funds from educational grants to an educational partner. However, the letter of agreement regarding the grant must be between the accredited provider and the commercial supporter, and the accredited provider must maintain and be able to produce as documentation a full accounting of the funds.”

Please use the following list as a guide when preparing your budget for submission. (Your budget must be submitted with your application.)

• Expenses:
• Faculty honoraria and travel. Under no circumstance can the commercial supporter pay a faculty/honorarium directly
• Instructional supplies
• Facilities and A/V
• CME accreditation fee
• Promotion and mailing expenses
• Other
• Income:
• Registration fees
• Unrestricted grant revenue**
• Exhibitor revenue**
• Other sources** (be specific)

** Commercial support letter of agreement must be between EB Medicine and the commercial supporter.

EB Medicine recognizes your outstanding effort to design and produce a quality CME activity. The submission of your application and budget will bring you one step closer to meeting the ACCME criteria for a CME activity.

Please sign here if you accept the financial responsibility of this activity:

Printed Name:

Signature:

Date:

XX. CHECKLIST: All items above must be completed, and the supporting documents listed below must be submitted with your application; incomplete applications will not be reviewed.

CME application

Practice gaps/Needs assessment for each module/session (template included within the application)

Proposed budget

Commercial interest attestation form

Financial disclosure forms for each member of the planning committee and each speaker (all persons in a position to control the content, including the planning committee, faculty, speakers, authors, contributors, etc.)

Commercial support agreements from all commercial supporters

CME application fee of $300 (please request an invoice if needed – payment can be made via credit card [noted on invoice] or check [made out to EB Medicine and mailed to Attn: Erica Scott, EB Medicine, 5550 Triangle Pkwy, Suite 150, Norcross, GA 30092]) – A separate invoice will be sent for the balance of the CME fee and any Marketing services needed.

1

5550 Triangle Pkwy, Ste 150 / Norcross, GA 30092  Phone: 1-800-249-5770 or 678-366-7933

Fax: 770-500-1316  Email:  Web:

SEND THE APPLICATION TO:

Erica Scott

Email:

SEND QUESTIONS TO:

Phone: 678-366-7933 x.125

Fax: 770-500-1316

1

5550 Triangle Pkwy, Ste 150 / Norcross, GA 30092  Phone: 1-800-249-5770 or 678-366-7933

Fax: 770-500-1316  Email:  Web:

Upon receipt of your application, you will receive an email confirmation and your application will be reviewed within 2 weeks. If we want to proceed, you will be sent notification of preliminary approval as well as a checklist of additional items and a timeline. Upon completion of the additional items, full approval of your application will be issued, you will be emailed a Joint Sponsorship Letter of Agreement, which must be reviewed and signed by the Activity Director prior to the activity. If your application is denied, you will receive a notification by email.

For Internal Use Only:

CME Director: Please initial one of the following:

______This activity will have commercial support (requires prior approval by our CME Director and CEO; initial here: ______)

______This activity will not have commercial support

CME Director: Please initial one of the following:

______This activity is in compliance with all ACCME and EB Medicine guidelines and is approved for ____ AMA PRA Category 1 CreditsTM.

______This activity is not in compliance with all ACCME and/or EB Medicine guidelines and is not approved.

1

5550 Triangle Pkwy, Ste 150 / Norcross, GA 30092  Phone: 1-800-249-5770 or 678-366-7933

Fax: 770-500-1316  Email:  Web: