Credit Request for Grand Rounds and Regularly

CREDIT REQUEST FOR GRAND ROUNDS AND REGULARLY

SCHEDULED CONTINUING MEDICAL EDUCATION ACTIVITIES

This document is for use by UCSF faculty to request AMA PRA category 1 CME credit for a Grand Rounds or other regularly scheduled continuing medical education activity sponsored by the UCSF School of Medicine. UCSF is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide CME for physicians. If you have questions regarding the completion of this form or its attachments, please contact the Office of Continuing Medical Education.

Course Number (OCME use only): / Today’s Date:10/15/2008
Activity Title:
Department/Division:
Repeat Activity? / No Yes / Previous Course #:
Activity Chair:
Mailing Address: / Phone:
Fax:
E-mail:
Administrative Contact:
Mailing Address: / Phone:
Fax:
E-mail:
Activity Site:
Type of Conference
Grand Rounds / Case Conference / Lecture Series
Mortality/Morbidity Conference / Tumor board / Other (describe):
Conference Schedule
Activity Will Be Presented (Frequency):
Daily Weekly Bi-weekly Monthly Other (describe):
Day 1: Day of Week Start Time: End Time: if bi-weekly; continue to Day 2
Day 2: Day of Week Start Time: End Time:
Date of First Meeting: / Date of Last Meeting:
Number of Sessions Anticipated: / Total Credit Hours Requested:

Departmental Approval and Financial Agreement

This course is submitted for CME credit review by the Department of (or if a Department of Medicine course, Division of) , UCSF School of Medicine, in full compliance with ACCME accreditation requirements, UCSF policies, and OCME business practices. The Department (or if DOM, Division) understands and agrees to pay OCME accreditation, registration, and event planning fees (when appropriate). The Department (or if DOM, Division) retains final financial responsibility for any course loss and will receive any course surplus.Departmental/Divisional NCA/Fund/DPA for payment to OCME:

If approved for CME credit, the financial obligations noted below will apply:

CME Accreditation and Oversight Fee$500

I concur:

Activity Chair(PRINT NAME & SIGN)Date

I concur:

UCSF Department Chair or Division Chief(PRINT NAME & SIGN)Date

I.CME ACTIVITY PLANNING

A.Planning Committee: Identify activity chair(s) and committee members.

Planning Committee Member’s Name / UCSFSchool of Medicine Faculty? Please indicate. / Academic Title / Akkkk
1. / Yes / No
2. / Yes / No
3. / Yes / No
4. / Yes / No
5. / Yes / No

Include additional planning committee members with their faculty affiliation and academic title below if necessary.

B. Planning Process:

1. This educational activity must address educational needs defined by a professional practice gap. A professional practice gap is the difference between health careprocesses or outcomes observed in practice, and those potentially achievable on the basis of current professional knowledge.This educational activity must also be designed to change physician competence, performance and/or patient outcomes. Please indicate the methods used to identify the educational need for this course. Please indicate each method used and describe how each method influenced your planning process in section2below.Include formal citations or attach copies of data used.

Demonstrated need:

Patient care indicators (cite in II.B or attach)

Quality assurance data (attach)

Federal or state legislation or other similar government directives (cite in II.B or attach)

Literature review (Cite in Section 2 or attach journal articles, Medline searches, etc.)

Public health data (cite in II.B)

Abstracts/presentations at national meetings (cite in II.B)

Other (describe):

Expressed need:

Previous evaluation summary (attach if repeat course)

Focus group survey (attach results if available)

Target audience survey (attach results if available)

Other (describe):

Presumed need:

New procedure (provide description of new procedure in II.B)

Opinion / experience of planning committee (describe in II.B)

Input from other experts (describe in II.B)

Other (describe):

2. Summarizethe needs assessment data obtained by methods designated above. Please cite/attach all relevant

primary data and/or citations with the credit request.

3.Describethe professional practice gap this activity is designed to address.

4.Indicate if the need, based on the gap, is a need in knowledge, competence and or performance (check all that

Apply)

Knowledge

Competence

Performance

Patient Health Outcomes

C.Learning Objectives:

1.Learning objectives should be written from the perspective of what the learner will apply in the practice setting

with the information gained through this educational intervention. Please list the learning objectives of the activity

below:

2. How will this activity’s purpose or objectives be communicated to the learner before participating in the activity

(Please check all that apply):

Brochure / Faxes / Other (describe):
Email Announcements / Flyers

D. Evaluation:Evaluations are used to determine if the result you intended for learners has actually been achieved.

Please describe how changes in learner’s competence, performance, or changes in patient outcomes will be evaluated:

E. Results Planned for this Activity

1.Describe the desired results of the activity i.e. changes in competence, performance or patient outcomes.

2.Describe one or more ACGME/ABMS or IOM competencies that will improve after participating in this activity.

F. System/Educational Barriers: Describe anticipated barriers that could limit implementation (e.g. formulary restrictions, time for implementation of new skills, insurance reimbursement restrictions, systems issues, resources, policy issues etc) and describe how these barriers will be addressed in the educational intervention:

G. Target Audience:

1.Define by medical specialty or sub-specialty; include related allied health professions as appropriate. Identify any special background requirements/prerequisites.

2. Describe how the activity matches the learner’s scope of practice:

H. Content:

1.Attach a course outline showing beginning and ending times for each educational session, as well as registration periods, breaks, meals, and time of adjournment. Indicate sessions qualifying for specialty or other mandated credits.

2.Please list issues of patient safety associated with theeducational interventions that will be addressed in this activity:

I. Cultural and Linguistic Competency: Cultural and linguistic competency is a set of integrated attitudes, knowledge and skills that enables health care professionals to care effectively for patients from diverse cultures, groups and communities. Please select one or more methods you will implement to address cultural competency.

1. Offer specifically designed and focused activities that include these four elements:

a. Applying linguistic skills to communicate effectively with the target population
b. Utilizing cultural information to establish therapeutic relationships
c. Eliciting and incorporating pertinent cultural data in diagnosis and treatment
d. Understanding and applying cultural and ethnic data to the process of clinical care

2. Incorporate translation/interpretation resources and/or integrate relevant strategies into materials for a CME activity.

3. Incorporate a review and explanation of relevant federal and state laws and regulations regarding linguistic access.

J. Educational Format

This activity must utilize an educational format that is appropriate for the attainment of the desired results.Select the educational format for this activity.

Course (live activity)

Internet Activity Live

Enduring Material

Internet Activity Enduring Material

Journal-based CME

Performance Improvement

Point-of-care Initiative

Grand Rounds/Case Conference

K. Educational Methods: Indicate the methods to be used (check all that apply):

Abstracts/posters / Group discussion / Panel discussion / UCTV or other television/ satellite broadcast
Audio/video presentation / Hands-on lab (animal)1 / Question & answer / Videotape (to internal UCSF providers)
Case presentations / Hands-on procedure (human)1 / Simulation / Videotape (to external non-UCSF providers)
Computer-assisted learning (CD-ROM, etc.) / Lecture / Syllabus/Handouts
Demonstration / Literature review (journal club) / Teleconference / Web-based Materials
Other (describe):

1 Attach current Institutional Animal Care and Use Committee letter or Committee on Human Research Letter/Patient Observation Consent Form.

PROGRAM ADMINISTRATION AND RESOURCES

A. Budget

1. Attach a preliminary budget. If this is a repeat activity, include a final financial statement from the most recent activity.Include estimated revenue from the following sources: enrollment or registration fees; commercial support including educational grants and in-kind contributions; and exhibit fees. If commercial supporters or exhibits are not yet confirmed,list projected funding sources and anticipated levels of support. Include estimated expenses for all relevant line items.

2. Commercial Support: Will the activity seek commercial support? Yes No

All commercial support in the form of educational grants and in-kind contributions of goods or services must be included in the budget. A completed, dated, signed letter of agreement for either a grant or an in-kind contribution must also be secured in advance of the activity. Include any completed letters of agreement for grants or in-kind contributions with the credit request. Describe how commercial support will be communicated to learners (check all that apply):

Syllabus

Brochure

Other (please describe)

3.Exhibits: Will the activity have on-site exhibits? Yes No If yes, please indicate the per table exhibit fee: $ A Exhibit Agreement is required for all activities with exhibits. Complete, dated, signed exhibit agreements must also be secured in advance of the activity. Include any completed exhibit agreements with the credit request.

B. Faculty Disclosure: Indicate how faculty disclosures will be communicated to the audience prior to the presentation (check all that apply):

Flier/Announcement

III.ENDURING MATERIALS

Will you be developing CME materials such as video, DVD/CD-Rom, web-based CME, audiotapes, etc. based on the content of this live activity that will be offered for CME credit?

No Yes (describe the format you plan to use and its anticipated release date):

If yes, contact OCME to request a required supplemental Enduring Material Credit Request and a copy of the Policy on Enduring Materials.

Submit the completed credit request no later than four to sixmonths before promotion begins for the proposed activity. Upon completion of the review by the UCSF CME Accreditation Review Committee, a letter with the Board’s decision will be sent to the Activity Chair.

CHECKLISTHave you included?

Departmental NCA/Fund/ DPA for payment of accreditation and registration fees

Signatures of activity and department chairs

Core Sheet

Planning documentation (meeting minutes, e-mail correspondence)

Needs assessment supporting documentation (articles, citations, surveys,)

Activity program/schedule indicating specialty or other mandated credits

Copy of prior year evaluation report (if repeat activity)

Evaluation tool including a bias question(if new activity)

Projected budget showing grantor names and amounts AND prior year’s financial statement (if repeat course)

Completed signed commercial support agreements (if support has been or will be sought)

Completed signed faculty disclosure forms for planning committee members.

Return the completed form with supporting documentation to:

Kolette Massy, CCMEP

Manager, Accreditation and Educational Development

Office of Continuing Medical Education

3333 California Street, Suite 450

San Francisco, CA 94143-0742

415.476.6124

CRDirect082108 V8.dot / Last printed 9/25/2008 11:16:00 AM