New York City Health and Hospitals Corporation
Division of Medical and Professional Affairs
Office of Patient Centered Care
Continuing Medical Education
Activity Application
Instructions for Completing the Application for Accreditation of CME Program Activities
The complete application package must be submitted at least six (6) weeks before the planned program activity. Please submit one (1) copy of the completed application to the Office of Patient Centered Care at 346 Broadway 11th Floor, Suite 1136or a scanned copy of the application. There will be no retrospective approval or accreditation of any program activity; no credits may be awarded to programs conducted which had not been previously approved.
Only one application for a CME or CE activity that will be given multiple times (one program repeated in various facilities on different dates), or a series of learning sessions (grand rounds, etc.) needs to be completed.
1. Form 1: Provide a general description of the proposed CME or CE activity, including the intended audience; grant and other non-corporate sources of funds including commercial interests; presence of commercial exhibits, and amenities that will be made available to attendees.
Append a draft of the program announcement and program agenda with the appropriate CME or CE accreditation statement, learning objectives, financial disclosure from faculty, and financial support from other organizations. Brochures, program announcements, and publications used to promote or distributed at the program activity must include the following statements:
1.a. CME Accreditation Statement for direct sponsorship:
New York City Health and Hospitals Corporation is accredited by The Medical Society of the State of New York to provide continuing medical education for physicians. New York City Health and Hospitals Corporation designates this (enter type of learning activity) educational activity for a maximum of (number of credits) AMA PRA Category 1 Credit(s)TM. Physicians should claim only credit commensurate with the extent of their participation in the activity.
CME Accreditation Statement for joint sponsorship:
This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Medical Society of the State of New York (MSSNY) through the joint sponsorship of New York City Health and Hospitals Corporation (NYC HHC) and (Name the Non-Accredited Provider). New York City Health and Hospitals Corporation is accredited by MSSNY to provide continuing medical education for physicians. NYC HHC designates this (Type of Activity) for a maximum of (Number of Credits) AMA PRA Category 1 Credits™. Physicians should claim only credit commensurate with the extent of their participation in the activity.
1.b. Program Learning Objectives:
At the conclusion of the course, program participants are expected to:
1. (insert learning objectives)
1.c. Statement about the source of commercial funds, grants, and others, e.g.:
This activity is supported by an unrestricted educational grant from (insert source of fund).
1.d. Disclosure Statement
Policies and standards of the MSSNY, ACCME, AMA, and ADA require that faculty and planners for continuing medical education and continuing education activities disclose any relevant financial relationships they may have with commercial interests whose products, devices or services may be discussed in the content of a CME or CE activity.
The following faculty members and planners have no relevant financial relationships to disclose:
(insert names of faculty members and planners)
The following faculty members and planners asked to disclose information about their financial relationships:
(insert name of faculty members and planners along with name of commercial interest(s) and the nature of the relationship(s).
2. Form 2: Describe the educational needs (knowledge, competence, or performance) that underlie the professional practice gaps of the intended audience. Include the needs assessment data to plan CME or CE activity. Indicate participation of commercial interests in the planning process, if any.
3. Form 3: Provide the learning objectives of the proposed CME or CE program activity, and for each of the topics in the program activity. These learning objectives must also be on the formal printed CME or CE program or agenda distributed during the educational session(s). Please ensure that these learning objectives correspond to the ‘needs’ identified in needs assessment (Form 2).
4. Form 4. Provide the educational format of the proposed CME or CE program. Append an outline, brief description of the presentation, or the slides to be presented by each of the faculty. Ensure that learning objectives for the presentation(s) and the faculty disclosure of any potential conflict of interest are included in the presentation.
5. Form 4-A. Provide a list of the faculty and planning committee members. Append curriculum vitae or resume of the faculty member, program directors and planning committee members.
6. Form 4-B Provide Objectives: What the participant will learn; Content topics: What the learner will be taught; Time frames: Specified time in minutes to deliver the content; Presenters: Who will deliver the content; Teaching methods: Mode of content delivery. Objectives should be learner oriented outcomes that are expressed in measurable terms, identify observable actions and specify one action or outcome per objective. The number of objectives should be sufficient to accomplish the intended purpose of the activity
7. Form 5. Describe how the learning session will be evaluated for its effectiveness. Ensure that the evaluation of the educational sessions and any evaluation tools used by participants are submitted to the CME and CE Program office within one month after the conclusion of the educational session. In addition to the participants’ and program directors’ evaluation of the learning session, include at least one additional strategy to evaluate program effectiveness.
8. Form 5-A: Suggested model for participant’s evaluation and attendance attestation. If not using this format or if the program director wishes to separate the ‘program evaluation’ from the ‘attendance attestation’, append these forms to collect participant’s evaluation and attestation of attendance of the learning session. CME credits will only be provided to participants who complete and submit an evaluation and, or, attendance attestation form.
9. Form 5-B: The program director must complete this general evaluation of the learning session.
10. Form 6: Sample Participants Sign-in Sheet. If not using this format, append any other form that will be used to document attendance in the learning session.
11. Form 7: Budget for the proposed CME or CE activity. Provide all funding source(s) including commercial interests, and program participant fees when applicable.
12. Form 8: All members of the faculty including program moderators, program directors and members of the program planning committee must complete the conflict of interest and financial disclosure form.
Financial relationships to be disclosed include receiving salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefits. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.
Relevant financial relationships with commercial interests of any amount are those which exist in the 12-month period proceeding the time that the individual is being asked to assume a role controlling content of the CME or CE activity.
It is deemed a Conflict of Interest when an individual has an opportunity to affect CME or CE content about products or services of a commercial interest with which the individual has a financial relationship.
A satisfactory resolution of any conflict of interest must be achieved before the individual could continue to participate in anyway in the proposed CME or CE activity.
13. Form 9: Financial Disclosure for the Presenting Organization. Provide all information on external support, financial or ‘in-kind,’ for this CME or CE activity. Commercial Support must be in the form of unrestricted educational grants to the sponsoring organization to ensure independence from commercial interest and that the educational program is free of commercial bias.
ACCME defines ‘Commercial Interest’ as any proprietary entity producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies.
The ADA defines ‘Commercial Support as financial support, products, and other resources to support or offset expenses and/or needs associated with a provider’s continuing dental education activity’ and ‘Commercial Supporter as entities which contribute financial support, products, and other resources to support or offset expenses and/or needs associated with a provider’s continuing dental education activity.’
14. Form 10: Written Agreement for Commercial Support to ensure independence of educational activities from commercial bias between the organizational director offering the CME or CE activity and the commercial donor, if any. Complete one written agreement for each source of commercial support. Indicate ‘No Commercial Donor’ on this form if there is no such sponsorship.
15. Form 11: CME Program Committee Review and Approval.
FORM 1 GENERAL DESCRIPTION OF CME PROGRAM ACTIVITY
I Title: ______
II Presenting Organization: ______
III. Location of Educational Activity: ______
IV Course Director(s):
Name: ______Name: ______
Address: ______Address: ______
Email: ______Email: ______
Telephone: ______Telephone: ______
Fax: ______Fax: ______
V. Date(s) for activity (For regularly scheduled series please include documentation of scheduled dates):
VI. Screening Criteria (Note: If none of the following apply, please reconsider the need for this educational intervention)
[ ] Content is based on evidence that constitutes ‘best practices’
[ ] Gap exists between current and best practices
[ ] Closing the gap will result in improvement in the health and, or, outcome of patients
[ ] The proposed educational intervention will result in change in practice
VII. Intended Audience:______
A. Will this program be open to non-corporate providers? [ ] No [ ] Yes
B. Will fees be charged for participation in this program? [ ] No [ ] Yes
VIII. Number of AMA PRA Category 1 Credit(s)TM requested: ______
IX Will there be commercial sponsors or external funding source for this program? [ ] Yes [ ] No
If yes, please identify funding source:
(Commercial support may only be accepted as unrestricted funds)
X. Promotional Activities
Will there be commercial exhibits and, or, items from commercial interest for participants in this program activity?
[ ] Yes [ ] No
(Commercial exhibits are not permitted at the entrance to, or on a direct or unavoidable path to the educational program activity, or in the same room where program activities will be provided.)
[ ] Yes [ ] No
Will there be meals served supported by commercial interests? [ ] Yes [ ] No
If yes, provide statement to disclose this matter: ______
XI. Attach proposed/draft of Program Announcement and Program Agenda to include the following information: Must be included to complete application
A. Program Learning Objectives (minimum of three)
B. CME accreditation statement:
The New York City Health and Hospitals Corporation is accredited by the Medical Society of the State of New York to sponsor continuing medical education for physicians.
The New York City Health and Hospitals Corporation designates this educational activity for a maximum of (number of credits) AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.
C. Financial disclosure and conflict of interest statement:
Participating faculty members and planners have no relevant financial relationships to disclose: (insert names of faculty members and planners)
Or
The following faculty members and planners asked to disclose information about their financial relationships:
· Insert name of faculty members and planners
· Name of commercial interest(s) and the
· Nature of the relationship(s)
D. Financial support from any organization:
This activity is supported by an unrestricted educational grant from: ______
XII. Educational Activity Overview
Use Attached Educational Activity Table to Supply Items 1-5
1. Objectives:
Indicate what the participant will be able to do at the conclusion of the activity. Objectives should be written in measurable terms given the time frame and teaching method. An average of 1-2 objectives per hour is realistic.
2. Content:
Itemize key points that will be addressed with each objective. Content must be more than a restatement of the objective and must be related to the objective.
3. Time Frame:
Indicate the number of minutes for each objective for live presentations.
4. Presenter:
List the faculty who will be addressing each objective (this is not applicable for content specialists).
5. Teaching Methods:
List the methods, strategies, materials, and resources to be used by faculty to cover each objective.
FORM 2 NEEDS ASSESSMENT FOR THE CME or CE ACTIVITY
I. Why is this learning session necessary?
This learning session has been designed to meet identified gaps in knowledge and competence of providers on:
12
3
4
5
6
7
8
9
10
and/or to address the following specific performance measures:
12
3
4
5
6
7
8
9
10
II. How was the gap in knowledge, competence, or performance measure determined or identified?
(Append measurement tools, if appropriate)
III. Has there been any participation by a commercial interest in the needs assessment and/or planning for this learning activity? [ ] No [ ] Yes.
If YES, please identify commercial interest: ______
FORM 3 LEARNING OBJECTIVES OF THE CME or CE ACTIVITY
I. State Learning Objectives for the CME or CE program activity.
Please ensure that the learning objectives are designed to meet the identified gaps in knowledge and skills, or performance measures identified in Form 2: Needs Assessment.
At the conclusion of the course, the participants should be able to:
1. ______
2. ______
3. ______
4. ______
5. ______
II. Append the specific learning objectives for each topic or presentation in the CME or CE learning session.
1. ______
2. ______
3. ______
4. ______
5. ______
Revised June 2011
FORM 4 EDUCATIONAL METHODS TO ACHIEVE LEARNING OBJECTIVES
I. Indicate the educational methods that will be used to achieve aforementioned objectives for this CME or CE program activity.