Planning Application

Form A

PLANNING APPLICATION

FOR

LIVE ACTIVITY OR

ENDURING MATERIAL

CME CREDIT

APPROVAL

Contact Alfie Truchan, CME Director at

or 212-731-7936 if you have any questions.

Icahn School of Medicine at Mount Sinai (ISMMS)

Form A – Planning Application for CME Activity - CHECKLIST:

(To be completed after planning application is completed to ensure that all the components are attached)

INSTRUCTIONS

• Applications must be submitted and approved at least THREEmonths prior to the activity date.
• Submit an Original and One (1) Copy of this application.
• Application MUST be complete to be submitted to CME Review Committee for approval.
• Any involvement of a third-party company for production or logistics MUST abide by the Mount Sinai & ACCME policies and sign the Educational Collaborative Agreement form.
• BROCHURES AND PUBLICITY MAY NOT BE PRINTED PRIOR TO:

1)CME approval of the educational activity, and 2) CME approval of promotional material.

I. APPLICATION AND ENCLOSURES (MUST be included for activity to be approved)

II. APPLICATION

Yes / N/A / Pending
A. Identified Practice Gaps
B. Measureable Learning Objectives
C. Target Audience
D. Educational Format (didactic, case )
E. Evaluation (means of evaluating activity)
F. Budget
G. Joint Sponsorship Agreement (if applicable)
II. ENCLOSURES
A. Curriculum Plan
B. Signed Disclosure Forms for all Planner Committee Members
C. Data Sources to support Identified Practice Gaps (2 minimum)
D. Activity promotional material (flyers, emails, brochures) sample:

1. Correct Accreditation Statement
2. Correct Designation statement

1. Disclosure statement
2. Objectives

1. Target Audience
2. Educational Grant Funding (if applicable)

Additional Comments:

Planning Application for ISMMS Credit Approval of a CME

Live Activity or Enduring Material Activity

FORM A

Planning Application for CME Approval

To be completed by the Course Director of the Activity

Title of Activity:
Date(s) of Activity: / Starting: / Ending:
Location of Activity:
ISMMS Dept/Institution Sponsoring Activity:
Course Director* / Title:
Department: / Hospital:
Phone: / Fax:
Email:

*Director or Co-Director must be a Mount Sinai faculty member.

Co-Director*: / Title:
Phone: / Email:

*If applicable.

Contact*: / Email:
Phone: / Fax:

*Only needed if the contact person is not the Course Director

BRIEF ACTIVITY SUMMARY
Please use this box for the following information:
1. Give a brief overview of the proposed activity. (2 to 3 sentences)

1. TYPE OF ACTIVITY:(please check appropriate box)

1) What type of LIVE ACTIVITY are you planning? (if applicable)

Conference/Symposium

Live Internet (Webinar)

Other (please describe): ______

2) What type of ENDURING MATERIALS (with or without a live activity) are you planning?

Print (Newsletter, monograph)

Internet enduring (list all URLs)

Journal CME

PDA/Podcast

Other

None

NECESSARY DOCUMENTATION

LIVE ACTIVITY
Attach Appendix A / You must attach your planned activity agenda, including the following;

• Date(s), Time(s) and Location
• Topics
• Speakers, including their clinical title and their academic appointment to a medical school

ENDURING MATERIALS
Attach Form CME-2 / You must attach the following:

• Completed Enduring Material Application Form CME-2 (pages 14 & 15)
• Detailed outline or table of contents with a description of the media used to convey the information to learners

1. GENERAL INFORMATION

1)What is the estimated number of registrants? MDs______Non-MDs______

2)Will this activity be reviewed by other certifying organizations? Yes ______No ______

3)If yes, please complete this information:

Organization:
Contact person: / Title:
Address: / City/State: / Zip:
Phone: / Fax:
Email:

4)Will other meeting planners or logistical partners (i.e.3rd Party education/communication companies) be involved? YES* NO

*If yes, list name and anticipated role and attach signed ISMMS EDUCATIONAL COLLABORATIVE AGREEMENT

1. ACADEMIC PROVIDERSHIP

1. Type of sponsorship requested:
Solely ProvidedSMMS
Jointly Provided (non-accredited organization contributes with the planning of the CONTENT)
If jointly provided, please list Joint Sponsors and attach a signed Joint Providership Letter of Agreement (Form E) for each. Attach additional pages for more than 2 Joint Sponsors:
Name of Co- or Joint Provider(s):
Address:
Contact Person:
Phone:
Email:
Commercial supporters are not considered joint sponsors and therefore may not enter into a joint providership agreement with an accredited provider.

1. PLANNING COMMITTEE

LTY DISCLOSURE (“Appendix B”)

Planners:: Include names and titles of those individuals directly involved in the planning and who influence the content of this activity. Please attach a completed signed disclosure form for every planner. (Appendix B)

If necessary, attach additional list of planners.

Course Director
Academic Title
Dept/Institution
E-mail
Name
Academic Title
Dept/Institution
E-mail
Name
Academic Title
Dept/Institution
E-mail

Additional planning committee members attached.

In order to obtain CME approval, you must:

1. Identify the area(s) that require improvement and provide specific evidence that substantiates the need (PRACTICE GAPS/NEEDS ASSESSMENT);
2. Identify specific learning objectives (LEARNING OBJECTIVES) and describe the program;
3. Specify how you will evaluate the effectiveness of your program (PREPARATION OF OUTCOMES QUESTIONS).

PRACTICE GAPS/NEEDS ASSESSMENT

The ACCME requires that all educational activities be based on an identified gap in practice. A gap represents the difference between a Best Practice and the Current Practice. It is the difference between what actually occurs and what is ideal or what evidence based practice should be. This is the method by which the learning objectives will be defined and measured.

Summarize the educational or professional practice gap(s)that underlies the need(s) that the activity will address. The professional practice gap represents a deficit in knowledge, competence and/or performance among prospective participants. The gap should be audience specific. Provide evidence (data sources) that you used to identify the professional practice gap of your audience (minimum of two).

Possible sources of evidence include: (Check which sources you are attaching –minimum of two)

Clinical practice guidelines

Health Performance Data

AHRQ/Government/Snapshots

Local Data

Quality Improvement Data

Research/Peer-reviewed literature

Peer-reviewed scientific/clinical publications

Exam performance analysis

Epidemiology data

Government mandates/legislation

Public Health Data

Survey of Targeted Learners

Expert opinion (Planning Committee, Course Faculty, Consensus of Experts)

Evaluation data/gaps identified by target audience (previous CME evaluations)

Requirements of State licensing board, Specialty Societies

New medical development/technology

EXAMPLES OF PRACTICE GAPS

Note: All specific references are professional practice gaps of learners for illustration purposes

FOCUS OF GAP / GOOD EXAMPLE / EVIDENCE OF GAP / BAD EXAMPLE
Knowledge
Competence
Performance / Referral patterns to orthopedists from PCPs greater than 80%, / Data Source: as cited in JAMA (Dec 2011, pp. 240-251). / PCPs consult orthopedists inappropriately.
No data to support gap.
Knowledge
Competence
Performance / Inadequate recognition of and use of diagnostic testing for common musculoskeletal complaints. / Data Source:Mount Sinai utilization data for 2010 <20%. / PCPs lack of training about common musculoskeletal disorders.
No data to support gap.
Knowledge
Competence
Performance / Underutilization and misinterpretation of cardiac ultrasound by Emergency Department physicians identified through 2011 quality improvement review. / Data Source:Emergency Medicine College of Physician Guidelines. / Importance of cardiac ultrasound as a diagnostic procedure.
No data to support gap.

Please Complete:

FOCUS OF GAP / SPECIFIC PRACTICE GAP
(Current Practice) / EVIDENCE OF GAP
Indicate Data Source
(copies of sources used must be attached)
Knowledge
Competence
Performance
Knowledge
Competence
Performance
Knowledge
Competence
Performance

PERFORMANCE/LEARNING OBJECTIVES

Based on the gaps you have identified, what are your learning objectives? They must be measurable and action-based. For help selecting action based verbs, you can obtain a list of appropriate verbs from the CME office or website. If learning objectives are clearly articulated, they become valid means by which to measure educational outcomes

Competence = knowing how to do something.
Performance = what a physician does in practice
Patient Outcomes = goal is to improve patient outcomes
EXAMPLES OF LEARNING OBJECTIVES AND OUTCOME MEASURES
FOCUS OF OBJECTIVE / GOOD EXAMPLE OF OBJECTIVE / BAD EXAMPLE OF OBJECTIVE
Competence / Describe recent innovations in XXX and when they should be appropriately utilized. / List 2 recent innovations in XXX.
Performance / Identifycurrent barriers and an actionplan to increase screening for and appropriate management of XXX. / Increase knowledge of XXX
Patient
Outcomes / Explain to patients and check for understanding about the reasons for and how to appropriately monitor HgbA1C levels to improve diabetic blood sugar control / Identify the guidelines for HgbA1C monitoring in patients with diabetes
OBJECTIVES
At the conclusion of this activity, participants will be able to: / Designed to Change:
Objective 1: / Competence
Performance
Patient Outcomes
Objective 2: / Competence
Performance
Patient Outcomes
Objective 3: / Competence
Performance
Patient Outcomes
Objective 4: / Competence
Performance
Patient Outcomes

a) TARGET AUDIENCE

Who is your target audience? List the physician and other health care professionals audience for which this activity is primarily intended.

Tri-State Regional National International

b) PROGRAM FORMAT

What learning formats and tools will be used in your activity to ensure that your objectives are achieved and the learner is engaged? We encourage that >25% of your activity will be interactive. Check all that apply).

1

1/2013

Lecture

Panel Discussion

Q/A format

Case based/problem solving discussion

Small group discussion

Hand-on practice workshop

Simulation training (including standardized patients)

Role Modeling

Audience Response System

Pre-test/Post-Test

Other ______

c) TOOLS/STRATEGIESthat Reinforce Learning Results

Thoughtful tools that assist physician-learners in attaining intended results for this activity should be developed and encouraged. These tools/strategies might include treatment algorithms, patient compliance handouts, reference guides, flow charts and examples of procedures.

This Activity will include these tools: Yes* No

*If you indicated yes, check the tools/strategies that will be distributed to your learners

Form CME-1 – CME Application 1

Patient Care Algorithms

Patient compliance handouts

Reference guides

Flow charts

Patient feedback tools

Learner reminders (emails, newsletters)

Interactive web tools

Chart audit process

Other:

Form CME-1 – CME Application 1

Please check:

Tool may be found or downloaded: ______

Tool to be provided to the CME Office.

d) PROFESSIONAL COMPETENCIES

Core Competencies and Physician Attributes are national goals for physicians associated with the targeted specialty (ies) that should be addressed when planning a CME Activity.

What physician competencies/attributes will this educational activity address?

IOM, ABMS(MOC)/ACGME, AAMC Competencies:

Form CME-1 – CME Application 1

Patient-centered care

Work in interdisciplinary teams

Employ evidence-based medicine

Apply quality improvement

Utilize informatics

Medical knowledge

Practice-based learning and improvement

Interdisciplinary & communication skills

Professionalism

Systems-based practice

Evidence of Professional Standing

Lifelong learning

Cognitive expertise (examination)

Performance in practice

Form CME-1 – CME Application 1

PATIENT SAFETY CONSIDERATIONS

Planners should examine planned activities for patient safety concerns in accordance with the national public interest. Please list issues of patient safety associated with these educational interventions that need to be addressed in this activity:

There are no patient safety issues applicable to this activity.

The following patient safety issues have been identified and will be addressed in this activity:

Identified
Patient Safety Issues / Planned Discussion in
Activity Content

EVALUATION METHODS

Evaluations are tools that are used to determine if the result you intended for the learners has actually been achieved.

What evaluation tools will you be using to measure activity outcomes?

Method Selected
Audience Response System (measures immediate learning and provides learning reinforcement.)
Pre-Test (measures current learning)
Post-Test (measures transfer of knowledge or new skills attained)
CMEImmediate Activity Evaluation Form (measures impact of learner’s perceived change of practice
for better patient care)
Case discussion or vignettes (measures application of knowledge to practice or competence)

b) The OCME will conduct the Outcome survey using a STANDARDIZED SURVEY which will be sent to learners several months post-activity (3 – 6 months). Based upon your stated objectives, what outcomes questions should be included in the survey?

EXAMPLES OF OUTCOMES STATEMENTS

OUTCOMES QUESTION / THIS OUTCOME RELATES TO . . .
I am able to interpret skin tests and serum IgE test results for foods in the context of the history to accurately diagnose food allergy. / Increased Knowledge
Improvement in Competency
Enhanced Performance
A Better Patient outcome
I am able to identify symptoms of anaphylaxis, know when to use epinephrine, and convey this to my patients. / Increased Knowledge
Improvement in Competency
Enhanced Performance
A Better Patient outcome
I am able to develop management plans and individualize health plans for my patients to minimize risk of allergic reactions. / Increased Knowledge
Improvement in Competency
Enhanced Performance
A Better Patient outcome
OUTCOMES QUESTION / THIS OUTCOME RELATES TO . . .
Increased Knowledge
Improvement in Competency
Enhanced Performance
A Better Patient outcome
Increased Knowledge
Improvement in Competency
Enhanced Performance
A Better Patient outcome
Increased Knowledge
Improvement in Competency
Enhanced Performance
A Better Patient outcome

If you will be using an additional outcomes tool (case vignettes), please list below:

1. ______
2. ______
3. ______

c) System Barriers and Opportunities

Barriers or potential barriers are factors affecting the learners that could impact the desired objectives of incorporating improvements in competence and/or performance and/or patient outcome into practice.

What factors outside your control or barriers can you identify that learners may encounter that will prevent them from applying the strategies and/or best practices taught in this activity?

Example: Patient education requires time and giving patient education tools helps solve the problem.

This activity has no relevant system barriers.

The following barriers have been identified and will be addressed in this activity (check all that apply)

Lack of time for implementation
of new skills or behaviors / Resistance to Change / Lack of time to assess/counsel
patients
Technical Skills / Lack of Staff Support / Lack of Equipment
Formulary restrictions / Lack of Health System
Support / Lack of consensus or professional
guidelines
Insurance does not reimburse for treatments / Policy issues within institution / Other, Please Specify: ______

If barriers have been identified, will they be addressed in your activity?Yes No

If yes, how will they be addressed: ______

If no, please indicate why they will not be address: ______

STANDARDS FOR COMMERICAL SUPPORT AND EDUCATIONAL GRANTS

Icahn School of Medicine at Mount Sinai’s Office of Continuing Medical Education fully supports and adopts the ACCME Standards for Commercial Support of Continuing Medical Education as its basis for relating to organizations that provide commercial support for CME activities or the overall CME Program.Pharmaceutical companies MAY NOT pay speakers, or any other expenses directly.

FINANCIAL STATEMENT – Conference Budget Estimate

What is the expected financial source for the activity? Check all that apply.ANYAPPLICATION

Educational Grant(s) / Exhibit Fees / Registration
Fees / Department / Other (specify)

Budget

• A comprehensive budget must be attached detailing income and expenses.
• Contact the CME Office for the CME Budget Template.
• CME Staff must be present at all off-site meetings (include travel & hotel costs in your budget)
• Include CME Fees in your budget

• Standard CME Fees: $3,200 for application, $25 per registrant and 20% of educational grants.

• For Enduing Material Activities and Jointly Sponsored activities, please contact the CME Office.
• Please note that in the event the conference is cancelled after the CME Application has been approved a $3,200 application fee will be charged

(The Office of CME will assist you in developing a more comprehensive budget)

Will there be meals? receptions? etc.** / YesNo
Will there be other “social events?”** / YesNo
Describe:
** In accordance with ACCME’s Standards for Commercial Support (SCS Section 8a), ISMMS will use funds originating from the commercial supporter to support the educational activity. As such, commercial support may not be used to defray costs of any kind for guests of the primary registrant or faculty.

GENERAL GUIDELINES (Initial each section)

FACULTY CONFLICT OF INTEREST:

If the speaker has nothing to disclose, this information must also be communicated to the audience.

The Course Director is responsible for identifying, managing and resolving any Conflicts of Interests and reporting the disclosure information to the audience prior to the activity. Resolution of COI must be performed by a non-conflicted individual, if the course director has conflicts, an independent reviewer must review speaker presentations and validate the content to ensure fair balance and objectivity exists within the presentations.

ISMMS must ensure that Content Validation is performed by a review whose responsibility is to review course materials for scientific objectivity, fair balance and of appropriateness of patient care recommendations when there is a potential for a Conflict of Interest. Please read the ISMMSPolicy on Identifying and Resolving Conflict of Interest before your start this process. Once you have reviewed the disclosure forms and materials, please complete the Conflict of Interest Resolution Form. These forms may be found on our website:

Please attest that this activity will adhere to the following ACCME Policy on Validating the Clinical Content of CME activities: