Mount Sinai Beth Israel
Mount Sinai St. Luke’s
Mount Sinai Roosevelt
Planning Application Instructions for Regularly Scheduled Series
January 2015 – December 2015
Contact your CME Office RSS Coordinator with questionsMount Sinai Beth Israel / Mount Sinai St. Luke’s and Mount Sinai Roosevelt
Kiersten Smith-Gaston
212-420-4713
/ Annette Roman
212-523-2138
Submission of application does NOT represent an approval of your activity
INSTRUCTIONS
· Applications must be submitted before Monday, December 30th, 2014
· 2014 Semi-Annual RSS Evaluation must be submitted before Thursday, January 15th, 2015
· Application must be COMPLETE to be submitted to CME Review Committee for approval
· No CME Activity will be approved retroactively
CME ACTIVITY CHECKLIST
I. APPLICATION AND ENCLOSURES (MUST be included for activity to be approved)A. Agenda or Outline of Content for January – March 2015
B. Data Sources to Support Identified Gaps
C. Signed Disclosure Forms from all Planning Committee Members
D. Signed Letters of Agreement with Commercial Supporters (if applicable)
E. 2014 Semi-Annual RSS Evaluation (submit by Thursday January 15, 2015)
F. Activity Promotional Materials (Announcements, Flyers, Emails)
1. Correct Accreditation Statement
2. Correct Credit Designation Statement
3. Disclosure Statement
4. Objectives
5. Target Audience
6. Educational Grant Funding (if applicable)
Additional Comments:
0
Planning Application for Mount Sinai Health Systems:
Mount Sinai Beth Israel, Mount Sinai Roosevelt and Mount Sinai St. Luke’s
Credit Approval of a Regularly Scheduled Series
To be completed by the Course Director of the Activity
SECTION 1: GENERAL INFORMATION – January 2015 – December 2015
Name of RSS:Date of RSS: / Starting Date: / Ending Date:
Days of the Week:
(check all that apply) / Monday Tuesday Wednesday Thursday Friday
Time of Day:
(from-to) / to / AM/PM
/ Meeting
Location:
RSS Frequency: / Weekly Monthly Bi-Monthly Quarterly Other:
*Any changes or additions to the schedule must be communicated to the Office of CME as soon as possible.
Type of RSS:Please indicate the educational format you intend to use. Please select only 1 that best describes your series. / Grand Rounds/Lecture Series / Tumor Board
M&M / Journal Club
Case Conference / Other :
Sponsoring Department: / Institution:
(check) / Mount Sinai Beth Israel
Mount Sinai Beth Israel Brooklyn
Mount Sinai Roosevelt
Mount Sinai St. Luke’s
Division:
Will Sessions Be Video Conferenced in Real-Time (Webcast)? / YES NO
Location 1 / Institution: / Department:
Location 2 / Institution: / Department:
Location 3 / Institution: / Department:
CONTACT INFORMATION: (Activity Director must be a faculty member within Mount Sinai Health Systems)
Activity Director:Academic Title:
Phone: / Email:
RSS Coordinator:
Phone: / Email:
ACTIVITY SCHEDULE
Please attach a copy of the proposed RSS schedule. A partial schedule will suffice in cases where a complete schedule is not yet available (3 months minimum). Your planned activity agenda for the proposed activity should include:
· Date(s), Time(s) and Location
· Topics
· Speakers including their clinical title and their academic appointment to a medical school
PLANNING COMMITTEE
Planners: Include names and titles of those individuals directly involved in the planning and who influence the content of this activity.
Please submit a completed financial relationship reporting form for every planner. If necessary, attach additional list of planners.
Planning Committee Member:Academic Title:
Phone: / Email:
Planning Committee Member:
Academic Title:
Phone: / Email:
Planning Committee Member:
Academic Title:
Phone: / Email:
Planning Committee Member:
Academic Title:
Phone: / Email:
List of additional planning committee members attached
Faculty Disclosures: All faculty, even those on staff, who present/moderate/or author at any CME Activity must submit a completed Faculty Disclosure Form to the CME Office prior to their participation.The process will include:
· Completion of a Disclosure of Relevant Financial Relationships and Unapproved Product uses form signed and dated prior to the session with disclosure relevant to the content of the presentation
· Identification and resolution of conflict of interest prior to the session (when the presenter has disclosed relevant financial relationships)
· Disclosure of relevant financial relationships or the lack thereof to the learners immediately prior to the presentation on the CME handout
· Any individual who refuses to disclose will be disqualified
Failure to complete the entire relevant financial disclosure process may result in the appropriate session(s) not being certified for CME and participants not receiving credit.
PRINTED MATERIALS – ANNOUNCEMENT FLYERS
All promotional materials, including emails, flyers, web-posting, brochures, signs, etc. must comply with the Guidelines for Promotion of an RSS that is included in the attached template.
Failure to follow the Guidelines for Promotion of an RSS may result in the appropriate session(s) not being certified for CME and participants not receiving credit.
In order to obtain CME approval, you must complete all of the questions below.
Note the examples of clinical gaps, learning objective and outcome measures
PRACTICE GAPS/DATA SOURCES
The ACCME requires that all educational activities be based on an identified gap in practice. A gap represents the difference between a Best Practice and the Current Practice. It is the difference between what actually occurs and what is ideal or what evidence based practice should be. This is the method by which the learning objectives will be defined and measured.
1. Using the space below describe how you link the planning and development of your RSS to other departmental/institutional performance or quality improvement initiatives.
2. What has changed in the practice of your specialty over the past year, and would therefore merit educational interventions focused on that issue?
3. Is there breaking research in your specialty that physicians will find interesting and medically relevant to the quality of care for their patients? What are the educational strategies that will expedite the translation of the research to practice?
4. Are there traditional core performance areas in your specialty that are worth reinforcing and updating?
5. What gaps have you identified from your specialty's Maintenance of Certification (MOC) requirements that would merit a single RSS iteration or multiple iterations?
Summarize the educational or professional practice gaps that underlie the needs that the activity will address. The professional practice gap represents a deficit in knowledge, competence and/or performance among prospective participants.
The gap should be audience specific. Provide evidence (data sources) that you used to identify the professional practice gap of your audience (minimum of two).
Possible sources of evidence include: (Check which sources you are attaching – minimum of two)Clinical Practice Guidelines
Health Performance Data
AHRQ/Government/Snapshots
Local Data
Quality Improvement Data
Research/Peer-Reviewed Literature
Peer-Reviewed Scientific/Clinical Publications
Exam Performance Analysis
Epidemiology Data / Government Mandates/Legislation
Public Health Data
Survey of Targeted Learners
Expert Opinion
(Planning Committee, Course Faculty, Experts Consensus)
Evaluation Data/Gaps Identified by Target Audience (Previous CME Evaluations)
Requirements of State Licensing Board, Specialty Societies
New Medical Development/Technology
CLINICAL GAPS
EXAMPLES OF CLINICAL GAPS
Note: All specific references are professional clinical gaps of learners for illustration purposes
NEED IN GAP / GOOD EXAMPLE / EVIDENCE OF GAP / BAD EXAMPLEKnowledge
Competence
Performance / Referral patterns to orthopedists from PCPs greater than 80% / Data Source: as cited in JAMA (Dec 2011, pp. 240-251). / PCPs consult orthopedists inappropriately.
No data to support gap.
Knowledge
Competence
Performance / Inadequate recognition of and use of diagnostic testing for common musculoskeletal complaints / Data Source: Mount Sinai utilization data for 2010 <20%. / PCPs lack of training about common musculoskeletal disorders.
No data to support gap.
Knowledge
Competence
Performance / Underutilization and misinterpretation of cardiac ultrasound by Emergency Department physicians identified through 2011 quality improvement review / Data Source: Emergency Medicine College of Physician Guidelines. / Importance of cardiac ultrasound as a diagnostic procedure.
No data to support gap.
Please Complete:
NEED IN GAP / SPECIFIC CLINICAL GAP(Current Practice) / EVIDENCE OF GAP
Indicate Data Source
(copies of sources used must be attached)
Knowledge
Competence
Performance / GAP 1:
Knowledge
Competence
Performance / GAP 2:
Knowledge
Competence
Performance / GAP 3:
PERFORMANCE/LEARNING OBJECTIVES
Based on the gaps you have identified, what are your learning objectives? They must be measurable and action-based. For help selecting action based verbs, you can obtain a list of appropriate verbs from the CME office or website. If learning objectives are clearly articulated, they become valid means by which to measure educational outcomes.
COMPETENCE: Ability to apply the knowledge to a practice-based situation, the degree to which participants show in an educational setting how to do what the CME activity intended them to be able to doPERFORMANCE: Skills, ability and strategies, learned during the activity that is subsequently implemented in practice; the degree to which participants have implemented changes to their professional practice that resulted (in whole or in part) from the CME activity
PATIENT OUTCOMES: A measured change in patient outcomes associated with the implementation of the knowledge and skills learning during the activity; the degree to which the health status of patients improves due to changes in the practice behavior of participants
LEARNING OBJECTIVES AND OUTCOME MEASURES
EXAMPLES OF LEARNING OBJECTIVES AND OUTCOME MEASURES
FOCUS OF OBJECTIVE / GOOD EXAMPLE OF OBJECTIVE / BAD EXAMPLE OF OBJECTIVECompetence / Describe recent innovations in XXX and when they should be appropriately utilized / List 2 recent innovations in XXX
Performance / Identify current barriers and an action plan to increase screening for and appropriate management of XXX / Increase knowledge of XXX
Patient Outcomes / Explain to patients and check for understanding about the reasons for and how to appropriately monitor HgbA1C levels to improve diabetic blood sugar control / Identify the guidelines for HgbA1C monitoring in patients with diabetes
LINK OBJECTIVES TO STATED CLINICAL GAPS
At the conclusion of this activity, participants will be able to: / DESIGNED TO CHANGE
Clinical Gap 1- Objective: / Competence
Performance
Patient Outcomes
Clinical Gap 2- Objective: / Competence
Performance
Patient Outcomes
Clinical Gap 3- Objective: / Competence
Performance
Patient Outcomes
a) TARGET AUDIENCE
Learners for this RSS: (select all that apply)Hospital-Based Physicians
Medical Students
Nurses
Fellows/Residents / Allied Health Professionals
Administrators
Other (Specify):
List Medical Specialties:
b) PROGRAM FORMAT
What learning formats and tools will be used in your activity to ensure that your objectives are achieved and the learner is engaged? We encourage that >25% of your activity will be interactive. (Check all that apply)
LecturePanel Discussion
Q/A Format
Case Based/Problem Solving Discussion
Small Group Discussion / Hand-On Practice Workshop
Simulation Training (including standardized patients)
Audience Response System
Other (Specify):
c) TOOLS/STRATEGIES that Reinforce Learning Results
Thoughtful tools that assist physician-learners in attaining intended results for this activity should be developed and encouraged. These tools/strategies might include treatment algorithms, patient compliance handouts, reference guides, flow charts and examples of procedures.
This activity will include these tools: (Check all that apply)There are no patient safety issues applicable to this activity
Patient Care Algorithms
Patient Compliance Handouts
Reference Guides
Flow Charts
Patient Feedback Tools / Learner Reminders (Emails, Newsletters)
Interactive Web Tools
Chart Audit Process
Other:
Please check:
Tool(s) may be found or downloaded / Source(s) of Tool(s):
Tool(s) to be provided to the CME Office
d) PROFESSIONAL COMPETENCIES
Core Competencies and Physician Attributes are national goals for physicians associated with the targeted specialty (ies) that should be addressed when planning a CME Activity.
What physician competencies/attributes will this educational activity address?IOM [Institute of Medicine], ABMS(MOC) [American Board of Medical Specialties(Maintenance of Certification)], ACGME/AAMC[Accreditation Council for Graduate Medical Education/Association for American Medical Colleges] Competencies:
Patient-Centered Care
Work in Interdisciplinary Teams
Employ Evidence-Based Medicine
Apply Quality Improvement
Utilize Informatics
Medical Knowledge
Practice-Based Learning and Improvement / Interdisciplinary & Communication Skills
Professionalism
Systems-Based Practice
Evidence of Professional Standing
Lifelong Learning
Cognitive Expertise (Examination)
Performance in Practice
PATIENT SAFETY CONSIDERATIONS
Planners should examine planned activities for patient safety concerns in accordance with the national public interest. Please list issues of patient safety associated with these educational interventions that need to be addressed in this activity.
There are no patient safety issues applicable to this activityThe following patient safety issues have been identified and will be addressed in this activity
IDENTIFIED PATIENT SAFETY ISSUES / PLANNED DISCUSSION IN ACTIVITY CONTENT
EVALUATION METHODS
Evaluations are tools that are used to determine if the result you intended for the learners has actually been achieved. What evaluation tools will you be using to measure activity outcomes?
Method Selected /Audience Response System / (Measures immediate learning and provides learning reinforcement.)
Pre-Test / (Measures current learning)
Post-Test / (Measures transfer of knowledge or new skills attained)
CME Immediate Activity Evaluation Form / (Measures impact of learner’s perceived change of practice for better patient care)
Case Discussion or Vignettes / (Measures application of knowledge to practice or competence)
SYSTEM BARRIERS AND OPPORTUNITIES
Barriers or potential barriers are factors affecting the learners that could impact the desired objectives of incorporating improvements in competence and/or performance and/or patient outcome into practice.
What factors outside your control or barriers can you identify that learners may encounter that will prevent them from applying the strategies and/or best practices taught in this activity?
EXAMPLE / Patient education requires time and giving patient education tools helps solve the problem.This activity has no relevant system barriers
The following system barriers have been identified and will be addressed in this activity:
IDENTIFIED SYSTEM BARRIERS / PLANNED DISCUSSION IN ACTIVITY CONTENT
The following barriers have been identified and will be addressed in this activity(check all that apply)
Lack of Time for Implementation of New Skills or Behaviors
Resistance to Change
Lack of Time to Assess/Counsel Patients
Technical Skills
Lack of Staff Support
Lack of Equipment
Formulary Restrictions / Lack of Health System Support
Lack of Consensus or Professional Guidelines
Insurance does not Reimburse for Treatments
Policy Issues within Institution
Other:
If barriers have been identified, will they be addressed in your activity? / YES NO
If yes, how will they be addressed:
If no, please indicate why they will not be address: