5/4/2016

Live Activity

CME Program Application

Thank you for considering us to support you in your continuing medical education activity plans. Completing this application is one of the earliest steps in working with us to achieve your education goals. Should you wish, you may call us before you begin the application so we can have a preliminary discussion on your plans. That should make the application process easier for you. We can be reached at 423 439 8081.

For information that can provide a resourceas you complete the application, hover your mouse over the footnotes both here and throughout this document:

  • Application instructions:[i]
  • Deadlines:[ii]
  • Important information related to the months the Board does not meet[iii]
  • Live programs for which Educational Grants are being sought[iv]
  • Live programs for which brochures must be developed[v]
  • Contact Information[vi]

Activity Type / Office Use Only
  1. What type of activityare you proposing?
/ A live, one-time activity, conference, symposium, or seminar
Other. Please call us at 423 439 8081 to determine which application you should be using. / Additional Planner Comments
Activity Information / Office Use Only
  1. Proposed Activity Name:
/ Additional Planner Comments[vii]
  1. Has this activity been accredited in the past by the ETSU Office of CME?
/ No
Yes. When? / Additional Planner Comments[viii]
  1. Brief description of proposed activity[ix]
/ Additional Planner Comments
  1. Proposed Date:
/ Additional Planner Comments
  1. Activity proposed beginning and ending time:
/ Additional Planner Comments
  1. Proposed number of education hours for the activity:
/ Additional Planner Comments[x]
  1. Location: (city and facility)
/ Facility:
City: / Additional Planner Comments
  1. This activity is being planned by:
/ An Academic Medical College/Department
A hospital/healthcare network or it’s affiliated Medical Staff Organization
Other: Please describe / Additional Planner Comments
  1. What is the name of the sponsoringcollege, departmentor organization?
/ Additional Planner Comments
Documenting the Need / Office Use Only
  1. What leads you to believe this education is needed?
/ Additional Planner Comments[xi]
  1. Why do you believe your learners need this education?
(Please note: no education will be approved that imparts only knowledge. All educational activities must also address either competency or performance.) / Learners need additional knowledge(A Knowledgeneed)
They have the knowledge, but need additional tools, processes or skills to act on that knowledge (A Competencyneed)
They have the knowledge and skills, but need support in performing at a consistent level (A Performanceneed) / Additional Planner Comments[xii]
Planner Note: For PARS DATA, this activity is considered
A Competency Activity
A Performance Activity
A Patient Outcome Activity
  1. What data do you have that supports this need? [xiii]
/ Requests by participants in previous education activities
Organizational mandate or new initiative
Emerging clinical guidelines or new technology
Focused discussion with the physicians who would potentially attend the seminar
Quality improvement or performance data
Primary research on physicians in the targeted communities
Other. Please explain: / Additional Planner Comment[xiv]
  1. All continuing medical education must contribute to physician competency. The following is a list of ABMS/ACGME Physician Competencies. Please check those that would be addressed in this activity.
/ Patient care[xv]
Practice-based learning and improvement[xvi]
Interpersonal and communication skills[xvii]
Professionalism[xviii]
Medical knowledge[xix]
Systems-based practice[xx]
  1. What barriers to learning do you believe might exist in your target audience?[xxi]
/ Additional Planner Comments
  1. How will you design your activity to help break down those barriers?
/ Additional Planner Comments[xxii]
Program Format / Office Use Only
  1. Please describe the program format for the activity (check any that apply)
/ Case-based presentations
Lecture
Panel discussion
Simulation
Skills-based training
Small group discussion
Other. Please describe: / AdditionalPlanner Comments
Planner Note: For PARS DATA, this conference is categorized as
Case-based presentations
Lecture
Panel discussion
Simulation
Skills-based training
Small group discussion
Other. Please describe:
Learning Objectives / Office Use Only
  1. What will you look for (in learner competency, performance or patient outcomes) that will indicate this activity has been successful?[xxiii]
/ Additional Planner Comments[xxiv]
  1. How and when will you measure this expected outcome?
/ Additional Planner Comments[xxv]
  1. Please translate these desired outcomes into 2-5 learning objectives for the activity:
(For assistance in crafting your objectives, hover you mouse over a footnote number to view examples of verbs that convey “Knowledge”[xxvi] , “Comprehension”[xxvii], “Analysis”[xxviii], “Ability to Evaluate”[xxix], “Application”[xxx] “Skill demonstration”[xxxi]) / As a result of participating in this activity, the attendee should be able to……. / Additional Planner Comments[xxxii]
Target Audience / Office Use Only
  1. Who is your intended physician audience?
/ Family Medicine Physicians
Internal Medicine Physicians
OB/GYN Physicians
Pediatricians
Psychiatrists
Surgeons
Emergency Medicine
Other Specialists – Please List: / Additional Planner Comments
  1. Who is your intended non-physician audience?
/ Advanced Practice Nurses
Physician Assistants
Pharmacists
Psychologists
Nurses
Medical or Nursing Students
Other Specialists – Please List: / Additional Planner Comments
  1. From what college, department, community, region, or organization do you expect your attendees to come?
/ ETSU
NE TN Region
Knoxville Region
SW VA Region
State of Tennessee
National
An Organization’s Medical Staff – Please list:
Other– Please List: / Additional Planner Comments
  1. Target Audience Size
/ Physicians : (excluding residents)
NP/PAs:
Non Physicians: (including residents) / Additional Planner Comments
Commercial Financial Support / Office Use Only
  1. Do you intend to seek commercial support for this activity?
/ Yes
No / Additional Planner Comments[xxxiii]
Additional Planner Comment for PARS Data
Anticipating:
Grants
Exhibits
Activity Director Information
  1. Name of Activity Director[xxxiv]

  1. Title

  1. Specialty

  1. Organization Name / College / Department

  1. Address

  1. E-mail Address

  1. Phone

  1. Fax

Planning Committee[xxxv]
Name and Title / Specialty / Phone Number / E-mail Address
Contact Information
Contact Person Name
Title
Organization
Address
Phone Number
Fax Number
E-Mail
Is this the person who is responsible for the day to day support of this activity? / Yes
No. If no, please detail below:
Responsible individual’sname
Department
Position
Phone number
Fax number
Email address

(more)

Next Steps

You may call the Office of Continuing Medical Education during business hours to receive assistance with completing this application, or to discuss anything related to your potential activity. Our number is 423-439-8081.

Save this as a Word document,and email it to.Within a few days one of our educational planners will give you a call. BECAUSE WE WILL BE ADDING ADDITIONAL COMMENTS TO THE DOCUMENT, WE MUST RECEIVE IT IN ITS ELECTRONIC FORMAT.

Submit Required Attachments

Below is the list of additional required attachments. Your application cannot be processed without the following. All required attachments can be sent electronically or faxed. Our fax number is 423 439 8040. Our application e-mail address is .

Action / Activity
Director / Contact Person / All Planning Committee Members / Academic Department Chair or Healthcare Executive / Instructions
Provide CV or Resume / Required / Required only if he/she participates on Planning Committee / Required / Not required / Please see instructions below to include your CV
Complete Conflict of Interest Disclosure / Required / Required only if he/she participates on Planning Committee. / Required / Not required / Go to this link to complete. Please copy and send this link to all that need to complete a conflict of interest.Please note, you must have your CV ready to attach to your conflict of interest disclosure
Sign Required Signatures Form / Signature Required / Not Required / Not Required / Sign Required Signatures Form / Required Signature Form can be obtained at this link: It can be copied and given to the Activity Director and the Chair/Healthcare Executive for signatures. They do not both need to sign the SAME form. We will accept either electronic or faxed copies.

-End of Document -

Footnotes

1 / Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016

[i] Instructions:

  • This application is in MS Word, and is a form. To complete, put your cursor in a grey shadowed area and start typing. It is difficult to spell check in a Word Form, so be aware that this is not a problem to us if your spelling is not perfect. If you are the person completing this application, it is important that you have significant information on the need, focus and expected outcomes of the proposed activity.
  • If this is the first time you have completed one of our applications, we do not expect you to complete this application flawlessly. Once we have received it, our planners will assist you in further refining your application until it is ready for the Advisory Board’s review. This consultation process is what makes it necessary for the application to be submitted according to the deadlines.
  • You may contact us at any time if you need clarification on the application or the process.
  • Once the application is complete, you may either e-mail it to or call the Office of Continuing Medical Education at (423)439-8081. The contact information is listed at the end of the application.

[ii] Deadlines:

  • All applications and their supporting documentation receive a thorough internal review before they are submitted to the Advisory Board. Deadlines are set to accommodate that internal review, and to provide the best opportunity for the activity to be approved.
  • Advisory Board meetings are the first week of the month. Applications for live conferences must be received by the 10th day of the month preceding the next Advisory Board meeting. For example, an application that is going to be reviewed by the board the first week of May must be submitted to the Office of Continuing Medical Education by April 10.

[iii] The Advisory Board does not meet in December or July. Applications which would ordinarily be submitted for December or July review, will need to be reviewed at the November or June meetings respectively.

[iv] Add an additional 90 days of planning time to the above application deadlines if your organization would like assistance in securing educational grants to support the program. PLEASE NOTE THAT NO COMMERCIAL SUPPORT CAN BE REQUESTED OR RECEIVED BY ANY PARTY TO THE ACTIVITY EXCEPT THE OFFICE OF CONTINUING MEDICAL EDUCATION FOR ANY PROGRAMS ACCREDITED BY THE OFFICE OF CME AT ETSU.

[v] If the applicant would like a brochure developed for the program, add 60 days to the application deadline, to assure that adequate planning is underway to have the speaker information available for brochure development. WHILE A BROCHURE OR “SAVE THE DATE” CARD COULD BE MAILED PRIOR TO RECEIVING APPLICATION APPROVAL, NO STATEMENT OF ANY KIND CAN BE INCLUDED RELATED TO CME CREDIT PENDING OR AVAILABLE.

[vi] Office of Continuing Medical Education

James H. Quillen College of Medicine

East Tennessee State University

Box 70572

Johnson City, TN 37614-1708

Phone: 423-439-8081

Fax: 423-439-8040

Email: .
Website:

[vii]Planner Notes: If this is a Joint Providership, please add the entity name to the front of the program name.

[viii]Planner Notes: Please notate the program number from when it was previously held

[ix] EXAMPLE A one day conference for pediatricians and family medicine physicians on the developmental problems most frequently encountered in children under the age of 20 in Appalachia.

[x]Planner Notes: Please adjust hours if needed and attach documentation, if available

[xi]Planner Notes: Please translate the need into the “Learning Gap”

[xii]Planner Notes: Please accept or modify as appropriate, assuring the need matches the format and objectives. Also notate if the activity as envisioned by the applicant is designed to address competency or performance, and not impart only knowledge.

[xiii]Examples of data that demonstrates need:

  • Continuous quality improvement data;
  • Accreditation site visit reports;
  • Accreditation requirements;
  • Health policy studies;
  • Incident reports/Sentinel events;
  • Patient records and databases;
  • Professional review organization studies;
  • Government reports on health statistics, technology developments, etc.;
  • Practice audits and reviews;
  • Recent research articles describing the need;
  • New techniques, protocols, clinical pathways or guidelines;
  • Organizational policy or board mandates;
  • Consensus reports from workshops and committees;
  • Primary research;
  • Published expert opinions;
  • Outcomes of physician surveys;
  • Evaluation summaries from previous CME activities;
  • Written faculty perceptions and recommendations;
  • Committee notes;
  • Focus groups;
  • Informal discussions with peers;

[xiv]Planner Notes: Please comment if the data is adequate as is or if you are supplying additional data (and attach or note the citation where it can be accessed)

[xv]Patient care that is compassionate, appropriate, and effective for the treatment of health.

[xvi]Practice-based learning and improvementrequires investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and documented improvements in patient care.

[xvii] Interpersonal and communication skill results in effective information exchange and team interaction with patients, their families, and other health professionals.

[xviii]Professionalism ismanifest by a commitment to carryout professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.

[xix]Medical knowledge demonstrates established and evolving biomedical, clinical and cognate (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.

[xx]System-based practice is manifest by actions that demonstrate an awareness of and responsiveness to the larger context and system for health care and the ability to effectively call on system resources to provide care that is of optimal value.

[xxi]Examples of barriers to learning might include such issues as beliefs and attitudes, technology, schedules, organizational dynamics

[xxii]Planner Notes: Please comment on whether or not the barriers have been adequately addressed

[xxiii] An example would be an observed improvement in the type and timing of diagnostic testing on potential stroke patients after physician education on the new evidence based guidelines on Acute Stroke.

[xxiv] Planner Notes: Please accept or modify as appropriate

[xxv] Planner Notes: Please accept or modify as appropriate

[xxvi]Verbs that inform: Cite, Define, Describe, Identify, List, Name, Recite, Record, Recognize, Select, State, Summarize, Update, Write

[xxvii] Verbs that denote comprehension: assess,associate, classify, compare, contrast, demonstrate, describe, differentiate, distinguish, estimate, explain, locate, identify, interpret, predict, report, review

[xxviii] Verbs that indicate analysis: analyze, appraise, contrast, criticize, detect, differentiate, distinguish, evaluate, infer, measure, question, summarize

[xxix]Verbs used to evaluate: assess, choose, compare, critique, decide, determine, estimate, evaluate, measure, rate, recommend, select

[xxx] Verbs that demonstrate application: apply, calculate, choose, demonstrate, develop, examine, illustrate, interpret, locate, operate, practice, predict, report, review, select, treat, use, utilize

[xxxi] Verbs that demonstrate skills: demonstrate, diagnose, integrate, manage, measure, operate, perform, record

[xxxii]Planner Notes: Please refine and format as required

[xxxiii] Planner Notes: If commercial support will be sought, please define what kind of support

[xxxiv] The Activity Director must be a physician or nurse practitioner. The Activity Director must have direct involvement in the planning of the activity, and will need to be in a position to collaborate with the Office of Continuing Medical Education as the planning unfolds.

[xxxv]EXAMPLES: Multidisciplinary (Team) Conference in Geriatrics, e.g.:

  • Activity Director – Physician (Geriatrician)
  • Community Physician with interest in geriatrics
  • Clinical Pharmacist
  • APN with interest/specialty in geriatrics
  • Physical Therapist with interest/specialty in geriatrics
  • Clinical Social Worker or Representative from long-term care facility

EXAMPLES: Pediatric Specialty Conference, e.g.:

  • Activity Director – Physician (Pediatrician with interest in topic)
  • Family Medicine Physician
  • Pediatric Resident/Fellow
  • FNP Representative from practice site
  • Public Health Representative