MissouriState Medical Association
Joint Providership Application
Name of Organization:Name, Address, and Phone of Individual Completing this Form:
Title of Proposed Offering:
Location:
Date(s)
Category 1 hours requested
Intended audience: / To qualify for Category 1 credit, the program must be designed by physicians for physicians.
Other health professionals to be invited:
Educational Design: (e.g. lecture, panel, discussion groups, workshops, etc.) /
Series of lectures, with break out sessions and small group discussion activities tailored to each of the 3 topics.
Provide copies of: /- A copy of the evaluation instrument
- A list of the offering planning committee members.
- A list of proposed offering faculty, including their titles and academic affiliations. Briefly indicate why each was selected.
- A copy of signed disclosure forms for all speakers
- A copy of the mechanism that will be used to disseminate disclosure information to the learner
Joint Providership Application
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Activity Development Worksheet
As a possible starting point to connect our activities to patient care, let us consider what quality gap(s)(e.g., the difference between healthcare processes or outcomes observed in practice and those that are potentially/optimally achievable) might be addressed by education.Who is involved in the system or practice environment that produces the quality gap? What role does each person potentially play in the outcome? Which of the health professionals in this milieu are our learners?
ACCME/MSMA’sAccreditation Criteria
Important Note!! We should remember to integrate the ACCME/MSMA Standards for Commercial SupportSM into our planning processesat every step.For every activity/education intervention, we must ensure that:
- All planning is done INDEPENDENT OF COMMERCIAL INTERESTS.
- Everyone who is in a position to control content DISCLOSES ALL RELEVANT FINANCIAL RELATIONSHIPS with a commercial interest.
- We implement a mechanism(s) to IDENTIFY AND RESOLVE ALL CONFLICTS OF INTEREST before the education activity is delivered to learners.
- What is/are the professional practice gap(s) — the difference between current practice and optimal practice — that we wish to address with education?
- What educational needs(e.g., knowledge, competence, performance) should be addressed in order to close the professional practice gap(s) [See Question 1 (Q1)]?
- This activity is designed to change competence, performance, or patient outcomes—individually, or in some combination. Please check all that apply:
Performance
Patient Outcomes / C3
- Please list the learning objectives for your presentation (see Addendum How to Write CME Objectives)
- What are the potential barriers, whether perceived or real, that may prevent our learners from achieving the expected change [Q3] in competence, performance, or patient outcomes? How might we address or overcome these barriers?
- What educational method/format will help us facilitate this change [Q3] in competence, performance, or patient outcomes in our learners?
- How will we measure the changes [Q3] in competence, performance, or patient outcomes that are the expected results of this activity? What analysis of this data will allow us to determine if the activity has been effective in changing learner competence or performance, or patient outcomes?
- Are there non-educational strategies that are currently being used to enhance this change [Q3] in our learners? If not, what adjunctive approaches (e.g., reminders, flagging charts, feedback systems) could we use to promote change—beyond the CME activity alone?
- What desirable physician attributes(e.g. professional competencies) set forth by national organizations of medicine(e.g., IOM, ACGME, ABMS) does this activity address?
Provide patient-centered care / Patient care / Professional standing
Work in interdisciplinary teams / Medical knowledge / Commitment to lifelong learning
Employ evidence-based practice / Practice-based learning and improvement / Cognitive expertise
Apply quality improvement / Interpersonal and communication skills / Performance in practice
Utilize informatics / Professionalism
Systems-based practice
/ C6
- How can we improve the impact of this activity through collaboration and cooperation? Are there other initiatives within our institution that are also working to address the professional practice gaps[Q1] or quality gaps we have identified? Are there other organizations we could partner with?
- In what ways could we include these internal or external groups in our CME activity to help us address or remove barriers [Q4] to learner change identified above? How might these collaborations improve the effectiveness of this activity, or our entire program of CME, beyond the performance of our learners to address patient outcomes?
- What are we doing to ensure that the content of the activity promotes improvements in healthcare and not proprietary interests of a commercial interest? (e.g., clinical recommendations supported by evidence, cited research conforms to accepted standards of experimental design, balanced view of therapeutic options).
- Based on the format and method we have chosen, what attributes and skills will we expect of planners, teachers, and authors to help ensure that the learners achieve the change [Q3] we expect to occur?
- What financial relationships does each person who will control the content of this activity (teachers, authors, planners) possess with ACCME/MSMA defined commercial interests? How do we determine whether these financial relationships are relevant to the content of this activity, such that they create a conflict of interest? How will we manage and resolve the conflict(s) that we identify?
Joint Providership Application
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Signature of the activity director responsible for the educational content of this activity and for making certain the activity complies with the MSMA Joint Providership policy.
Signature
Administrative Fee: Sponsors of Continuing Medical Education offerings jointly sponsor by the MSMA will be assessed a non-refundable activity administration fee of $1,000. A check in the appropriate amount, payable to the Missouri State Medical Association must be submitted upon receipt of invoice.
Application Deadlines: The completed application must be received by the MSMA at least 6 months prior to the activity.
Notification: The MSMA will respond to your application within 30 working days.
NEITHER APPROVAL OF JOINT PROVIDERSHIP NOR DESIGNATION OF CME CREDIT MAY BE GIVEN RETROACTIVELY.
Mail your application to:Missouri State Medical Association
113 Madison Street
P. O. Box 1028
Jefferson City, MO65102
For Questions: (573)636-5151, Benita Stennis
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For use by the MSMA CME Commission
Application Received: By:
Date:
ApprovedNot Approved
Signature of CME Commission Chair
Joint Providership – Page 1