FORM CMERSS-2
END OF YEAR REPORT AND CHECKLIST
RSS ACTIVITIES
(July 1, 2015 – June 30, 2016)
(This report is due in the CME office no later thanJuly 18, 2016)
Please submit one hard copy of the report (with attachments) to the CME Office and email one electronic copy of the report (only the report, not the attachments) in word format to
Department:
Title of Activity:
Course Director:/ e-mail
Coordinator: / e-mail
Location:
The following are required documentation for all WCMC RSS Activities:
Attached?
- Attendance Summary (7/1/2015-6/30/2016) Yes No
- Full List of Sessions (7/1/2015-6/30/2016) Yes No
- Budget Summary (7/1/2015-6/30/2016) Yes No
4.Renewal Application – Form CMERSS-3(7/1/2016-6/30/2017) Yes No
Course Director SectionI understand that I must retain activity records/files for all sessions for at least six years.
I have shared evaluation data with faculty for this activity.
I attest that sessions related to QA/UR issues were included in this RSS during this reporting period. I verify that an assessment of Quality and Patient safety needs has been performed and that the curriculum for this activity includes activities aimed at addressing deficiencies and closing quality gaps.
COURSE DIRECTOR’S Signature:
Print Name / DateSignature
(By signing, you verify that you have reviewed and approved this CME report.)
Core Competencies (select 1 at minimum)CME activities should be developed in the context of desirable physician attributes. Please indicate which American Board of Medical Specialties (ABMS)/Accreditation Council for Graduate Medical Education (ACGME), Institute of Medicine (IOM) core competencies (as of July 2010) or Interprofessional Education Collaborativewere addressed in this activity.
Patient Careand Procedural Skills:Provide care that is compassionate, appropriate, and effective treatment for health problems and to promote health.
Medical Knowledge:Demonstrate knowledge aboutestablished and evolving biomedical, clinical, and cognate (e.g. epidemiological and social behavioral) sciences and the application of this knowledge to patient care.
Practice-Based Learning and Improvement:involves investigation and evaluation of their own patient care practices, appraisal and assimilation of scientific evidence, and improvements in patient care.
Interpersonal and Communication Skills:Demonstrate skills that result in effective information exchange and teaming with patients, their families and professional associates.
Professionalism: Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population.
System-Based Practice:actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.
Provide Patient-centered care:Identify, respect, and care about patients’ differences, values, preferences, and expressed needs; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health.
Work in Interdisciplinary Teams:Cooperate, collaborate, communicate and integrate care teams to ensure that care is continuous and reliable.
Employ evidence-based practice:Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible.
Apply Quality Improvement: Identify errors and hazards in care: understand and implement basic safety design principles such as standardization and implications; continually understand and measure quality of care in terms of structure, process and outcomes in needs; and design and test interventions to change processes and systems of care, with the objective of improving quality.
Utilize Informatics: Communicate, manage knowledge, mitigate error, and support decisions making using information technology.
Values/Ethics for Interprofessional Practice:Work with individuals of other professions to maintain a climate of mutual respect and shared values.
Roles/Responsibilities:Use the knowledge of one’s own role and those of other professions to appropriately assess and address the healthcare needs of the patients and populations served.
Interprofessional Communication:Communicate with patients, families, communities, and other health professionals in a responsive and responsible manner that supports a team approach to the maintenance of health and the treatment of disease.
Teams and Teamwork:Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan and deliver patient-/population-centered care that is safe, timely, efficient, effective, and equitable.
ATTENDANCE SUMMARY
July 1, 2015 – June 30, 2016
A. Total # of sessions
B. Total # credits approved per session (e.g. 1, 1.5)
C. Total hours of instruction (A x B)
D. Total # of MD hours
Miultiply the number of MDs attending by the number of sessions attended.
(e.g. Dr. X attended 12 sessions for one hour each. This equals 12 attendee hours. Add totals for all MD’s.)
E. Total # of NonMD hours
Multiply the number of nonMDs attending by the number of sessions attended.
(e.g. Dr. X attended 12 sessions for one hour each. This equals 12 attendee hours. Add totals for all nonMD’s.)
Please attach a spreadsheet documenting the names of attendees, dates of attendance and total hours of attendance for this activity for July 1, 2015 to June 30, 2016.
- Spreadsheet attached? Yes No
Reviewed and approved by OCME: ______
APPENDIX A
Attendance Spreadsheet
Please attach here
FULL LIST OF SESSIONS
July 1, 2015 – June 30, 2016
Total # of Sessions:
Date / Speaker / TopicBUDGET SUMMARY
July 1, 2015 – June 30, 2016
1. TOTAL REVENUE (INCOME)
Sources of Revenue/Income:
A.Departmental Funding$
B.Other Support$
TOTAL REVENUE/INCOME$
2. TOTAL EXPENSES
A.Speaker Honoraria (list each speaker):
$
$
$
$
$
TOTAL HONORARIA$
B.Faculty housing, travel, meals, misc.$
C.Meals/Coffee Breaks$
D.Other Expenses: (please list)$
TOTAL EXPENSES$ *
NET INCOME/LOSS...... $ *
(Calculation: income minus expenses)
* Expense must be offset by either Departmental or other income.
* Negative balances are not acceptable.
APPENDIX B
Renewal Application (Form CMERSS-3)
Please attach here
1
Revised June 15, 2016