Form B
Jan 2009 – Dec 2010
PLANNING APPLICATION FOR
Regularly Scheduled Series
CME CREDIT APPROVAL
Contact Alfie Truchan, ...
CME Course Director Date
Mount Sinai Medical Center The Page and William Black Post-Graduate School
Mount Sinai Hospital M...
FACULTY DISCLOSURE (“Appendix B”)
Planners: Include names and titles of those individuals directly involved in the plannin...
All the recommendations involving clinical medicine in a CME activity must be based on
evidence that is accepted within th...
Identify these gaps, the planning committee has utilized the following resources/methods. Choose as many need
sources as a...
SAMPLE EDUCATIONAL DESIGN RATIONALE
What is the Need? What is the Learning Method? Expected Results?
Need for enhanced kno...
PATIENT SAFETY CONSIDERATIONS
Planners should examine planned activities for patient safety concerns in accordance with th...
Communication skills
Professionalism
Systems-based practice
Lifelong learning
Cognitive expertise (examination)
Performanc...
STANDARDS FOR COMMERCIAL SUPPORT AND EDUCATIONAL GRANTS
Mount Sinai School of Medicine’s Office of Continuing Medical Educ...
FINAL GRAND ROUNDS DOCUMENTATION (DUE BY 10TH
OF EACH FOLLOWING MONTH)
Attn: Maria Olivo, RSC Coordinator, Office of CME, ...
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Form B: Application for Regularly Scheduled Conference (i.e ...

  1. 1. Form B Jan 2009 – Dec 2010 PLANNING APPLICATION FOR Regularly Scheduled Series CME CREDIT APPROVAL Contact Alfie Truchan, CME Director at alfie.truchan@mssm.edu or 212-731-7936 if you have any questions. Submission of application does not represent an approval of your activity INSTRUCTIONS • Applications require a minimum of three weeks for internal review by the CME Committee. • Application must be COMPLETE to be submitted to CME Review Committee for approval. • No CME Activity will be approved retroactively. • Any involvement of a third-party company for production or logistics MUST abide by the MSSM & 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 2) CME approval of promotional material. CME ACTIVITY CHECKLIST (To be completed by Course Director after planning application is completed to ensure that all the components are attached) I. APPLICATION AND ENCLOSURES (MUST be included for activity to be approved) A. Agenda or outline of content B. Needs Assessments and 2 Forms of Documentation C. Signed disclosure forms from all planners D. Signed letters of agreement with commercial supporters E. Evaluation F. Activity promotional pieces (brochure, Internet listing, journal ad, etc) 1. Correct accreditation statement 2. Correct CME Designation statement 3. Disclosure statement 4. Objectives 5. Educational Grant Funding (if applicable) 6. Targeted Audience Additional Comments:       CLICK HERE TO ENTER A DATE. 2009 1
  2. 2. CME Course Director Date Mount Sinai Medical Center The Page and William Black Post-Graduate School Mount Sinai Hospital Mount Sinai School of Medicine Mount Sinai School of Medicine One Gustave L. Levy Place New York, NY 10029-6574 Box 1193 Tel: (212) 731-7950 Fax: (212) 731-7930 FORM B Planning Application for MSSM Credit Approval of a CME Activity To be completed by the Course Director of the Activity GENERAL INFORMATION – January 2009 – December 2010 Title of Activity:       Date(s) of Activity: Starting Date:Click to enter date Ending Date: Click to enter date Estimated number of registrants: MDs     Non-MDs     MSSM Dept/Institution Sponsoring Activity:       (Course Director or Co-Director must be a Mount Sinai faculty member.) Course Director:       Title:       Department:       Hospital:       Address:       City/State:       Zip:       Phone:       Fax:       Email:       Contact Person:       Email:       Phone:       Fax:       SCREENING CRITERIA (Check all that apply) Content is based on evidence that constitutes “best practices” Gap between current and best practices differs significantly Closing the gap will result in improvement in the health and/or outcomes of patients The proposed educational intervention will result in significant changes in current practice There is funding available to support this educational intervention ACTIVITY AGENDA (“Appendix A”) Please attach an outline of topic areas for period of January 2009 to December 2009 (or minimum of 6 months). Although specific lecture topics may not as yet be determined, submission of expected curriculum is required. An actual schedule of 2009 conferences must be submitted to the CME Office. Your planned activity agenda for the proposed activity include: • Date(s), Time(s) and Location • Topics • Speakers including their clinical title and their academic appointment to a medical school 2009 2
  3. 3. FACULTY DISCLOSURE (“Appendix B”) Planners: Include names and titles of those individuals directly involved in the planning of the content of this activity. Please attach a completed signed disclosure form for every planner. Attach additional list of planners if necessary. Name       Academic Title       Dept/Institution       E-mail       Name       Academic Title       Dept/Institution       E-mail       Name       Academic Title       Dept/Institution       E-mail       Name       Academic Title       Dept/Institution       E-mail       Faculty: All faculty, even those on staff, who present/moderate/or author at any CME Activity must submit a signed and completed Faculty Disclosure Form to the Course Director prior to their participation. • If the speaker has nothing to disclose, this information must also be communicated to the audience. • Any individual who refuses to disclose will be disqualified. • 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. • MSSM must ensure that Content Validation is preformed by a reviewer 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 MSSM Policy on Identifying and Resolving Conflicts of Interest before you 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: www.mssm.edu/cme/forms Please attest that this activity will adhere to the following ACCME Policy on Validating the Clinical Content of CME activities: 2009 3
  4. 4. All the recommendations involving clinical medicine in a CME activity must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported or used in CME in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection and analysis. PRINTED MATERIALS – ANNOUNCEMENT FLYERS/BROCHURE (“Appendix C”) MODE OF ADVERTISING: Classified Advertising (Publication titled) Announcement Fliers E-Mail Letter of Invitation Other Direct Mail Brochure (AMA Specialties / Geographic Target / Specialty Societies) Announcement flyers/Brochures may not be printed without prior approval of the Office of CME THE FOLLOWING 6 ITEMS MUST APPEAR IN YOUR BROCHURE/FLYER: 1. MOUNT SINAI SCHOOL OF MEDICINE LOGO (A camera-ready logo is available online at www.mssm.edu/cm/logos) 2. CME ACCREDITATION STATEMENT The following two required ACCME Accreditation Statements must appear exactly as written: • The Mount Sinai School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. • The Mount Sinai School of Medicine designates this educational activity for a maximum of __ AMA PRA Category 1 Credit(s)TM . Physicians should only claim credit commensurate with the extent of their participation in the activity. 3. DISCLOSURE POLICY STATEMENT The following statement must appear exactly as written: • It is the policy of Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. This information will be available as part of the course material. 4. RSC OBJECTIVES (refer to item V-2.3 of this application) •The Objectives should be measurable and are derived from the program goal. • Each lecture should have specific objectives (except for Tumor Boards, M&M, Journal Club & Case Conferences, which may state a general overall objective for the series. 5. TARGET AUDIENCE • Who will be invited to this activity? 6. ACKNOWLEDGMENT OF COMMERCIAL SUPPORT The following statement must appear in brochures/flyers for RSS’s if there is are any educational grants: • This activity has been made possible in part by educational grants from <Insert Name of Company> NEEDS ASSESSMENT/PRACTICE GAPS (“Appendix D”) Identifying Gaps in Physician Knowledge and/or Performance In accordance with our CME Mission, this educational intervention will address 1) physician competencies (changes in knowledge, skills or attitudes), as determined by national or specialty society guidelines, specialty credentialing boards, or other sources of national priority such as the Institute of Medicine and the US Surgeon General; 2) physician performance-in-practice (changes in abilities or strategies); and/or 3) patient outcomes (changes in patient healthcare outcomes). 2009 4
  5. 5. Identify these gaps, the planning committee has utilized the following resources/methods. Choose as many need sources as applicable and ATTACH DOCUMENTATION (minimum of TWO). Expert Opinion Environmental Scanning Guidelines Hospital Quality Analyses Peer Reviewed Literature Focus Panels Survey of Targeted Learners Epidemiological Data Findings Required by Governmental Authority/regulation/law Other       2009 5
  6. 6. SAMPLE EDUCATIONAL DESIGN RATIONALE What is the Need? What is the Learning Method? Expected Results? Need for enhanced knowledge Didactic CME Improvement in knowledge level Skill-Relevance to the learner target Analysis of practice profile Appropriate application of new knowledge More experience Practice experience with new skill Technical competence, dexterity, comfort Change in attitude, confidence, beliefs Peer discussion, casework New way of looking at problem, new ways of measuring success or failure Systems barriers and obstacles Group discussion, sharing of best practices that illustrate ways to change the system or overcome the barriers Barriers are resolved COMPLETE THIS GRID (Check All That Apply and Add Lines as Needed) IDENTIFIED GAP WHAT IS THE NEED? LEARNING METHOD EXPECTED RESULTS INTERVENTION TYPE       Didactic Case based discussion Debate Q/A format &/or Panel Chart Review Other             Knowledge Competency Performance Patient outcome       Didactic Case based discussion Debate Q/A format Chart Review Other             Knowledge Competency Performance Patient outcome       Didactic Case based discussion Debate Q/A format Chart Review Other             Knowledge Competency Performance Patient outcome 1. What has changed in the practice of your specialty over the past year, and would therefore merit educational interventions focused on that issue?       2. Have there been areas where quality indicators suggest a focused departmental improvement is appropriate?       3. Is there breaking research in your specialty that physicians will find interesting and medically relevant to the quality of their care for patients? What are the educational strategies that will expedite the translation of the research to practice?       2009 6
  7. 7. 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                                     LEARNING OBJECTIVES • Learning objectives, constructed properly, should bridge the gap between an identified need (whether the learning domain is cognitive/knowledge, skill, attitude or behavioral) and the desired result. • Learning objectives should be written from the perspective of what the learner will apply in the practice setting with the information gained through this educational intervention (NOT from the perspective of what the faculty wants to talk about). • Please review the attached list of verbs that can be used in writing measurable objectives. They are divided into three learning domains mentioned above: those used for interventions that offer cognitive (knowledge) objectives, those with psychomotor (skill) objectives, and those for affective (attitudinal) objectives. EXAMPLES OF A CONDITION, CONTENT STATED IN TERMS OF PERFORMANCE, AND A STANDARD DOMAIN EXAMPLE Knowledge “Evaluate treatment options for an adolescent patient with depression so that suicidal ideation is eliminated ” Skill “Obtain a 3 second rhythm strip from an attached esophageal ECG lead with minimal electrical interference.” Attitude “Counsel a 16 year old female-who has had 3 abortions but doesn’t want to have children—about birth control options” CONTENT STATED IN TERMS OF PERFORMANCE THE CONDITION THE STANDARD USING THE OBJECTIVES WORKSHEET ABOVE, PLEASE JOIN THE PARTS TOGETHER INTO FINALIZED LEARNING OBJECTIVES FOR THIS ACTIVITY (USE AS MANY LINES AS NECESSARY): At the conclusion of this activity, participants will be able to: Objective 1:       Objective 2:       Objective 3:       PROFESSIONAL COMPETENCIES: Competencies and Attributes are national goals for physicians associated with the targeted specialty (ies) that should be addressed whenever possible in planning CME. Based on the Maintenance of Certification (MOC) competencies designated by the American Board of Medical Specialties (ABMS), which competency areas will you address in this CME activity? Check all that apply. • See the appropriate specialty board’s criteria for each area as they are additional needs to include in your planning for this activity (http://www.abms.org/About_ABMS/member_boards.aspx). Select the desired physician attribute(s) that will be addressed by this activity: Patient-centered care Interdisciplinary teams Evidence/practice-based medicine Quality improvement Informatics Medical knowledge 2009 7
  8. 8. Communication skills Professionalism Systems-based practice Lifelong learning Cognitive expertise (examination) Performance in practice 2008 REGULARLY SCHEDULED SERIES EVALUATION (“Appendix E”) EVALUATION attach as “Appendix E” Every meeting and speaker must be evaluated by a questionnaire or other methods. a. Attach a sample copy of the evaluation form that is distributed at the activity. Evaluation measures overall success of your activity, how well the needs/ objectives were met. Evaluations also provide information that helps us to determine if improvements need to be made in the series or that expected outcomes, in terms of changed physician knowledge, skills, performance in practice and/or patient health status have been applied. The questions below should be based on tyour overall activity evaluation for the past calendar year (2008). 1. Did your planning committee identify educational or practice gaps that were successfully addressed in your grand round series (RSS)? Yes If yes, please describe:       No If no, will these topics be addressed in future activities?       2. Please tell us how your attendees have applied the knowledge, skills or competencies learned to their practice of medicine.       3. Were your 2008 objectives met? Were there any changes in practice as a result?       4. Did your series address physician competencies? Yes No If yes, please list the competency areas in your series       5. If, by attending your series, there has been an improvement in patient outcomes, please provide evidence or examples.       6. Have the learners perceived any bias in these presentations? Yes No If yes, what have you done to address the conflict of interest?       7. After evaluating your 2008 Regularly Scheduled Series, what improvements do you plan to your program in 2009/mnt/temp/unoconv/20150128120344/form-b-application-for-regularly-scheduled-conference- ie2136.doc/mnt/temp/unoconv/20150128120344/form-b-application-for-regularly-scheduled- conference-ie2136.doc?       2009 8
  9. 9. STANDARDS FOR COMMERCIAL SUPPORT AND EDUCATIONAL GRANTS Mount Sinai School of Medicine’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. • Attach completed and signed Letters of Agreement for Commercial supporter. (“Appendix F”) • A signed LOA between the grantor, accredited provider is necessary for each grant. • MSSM must be listed as the Accredited Provider on EVERY Letter of Agreement. • ALL commercial support for an activity must be documented by a fully executed and signed letter of agreement and the grant received by Mount Sinai BEFORE the start of the activity or it will not be recognized as support for that activity. No retroactive acknowledgments will be made for any funds not provided before an activity. • The Director of CME as the designated institutional signatory must sign ALL LOAs. • Acknowledgement of each company providing an educational grant for the activity. • Attach documentation that acknowledgment and faculty disclosure was made to the audience prior to each activity. (Submit to CME after the activity.) Pharmaceutical companies MAY NOT pay speakers, or any other expenses directly. FINANCIAL STATEMENT –Regularly Scheduled Series Budget Estimate (The Office of CME will assist you in developing a more comprehensive budget) Industry (pharmaceutical and device companies): 1. May NOT pay speakers directly. 2. May NOT pay for catering directly. 3. Must give all funds in the form of an educational grant to the department sponsoring the activity and the department may use the funds for paying speakers and catering. U Complete Budget Below DMPANY APPLICAION Please list the anticipated income: 1. Statement of Income: a. Departmental Donation $       b. Commercial Support (Pharmaceutical)* $       c. Other supporters and grants (i.e. memorial lectureships) $       Specify:       $       TOTAL INCOME: $       *A signed Commercial Support Letter of Agreement is necessary for each grant. 2. Statement of Expenses a. # of speakers       x honoraria $       = $       b. Estimated travel expenses $       c. Food Costs $       d. Printing and Postage $       TOTAL INCOME: $       2009 9
  10. 10. FINAL GRAND ROUNDS DOCUMENTATION (DUE BY 10TH OF EACH FOLLOWING MONTH) Attn: Maria Olivo, RSC Coordinator, Office of CME, Box 1193 It is the responsibility of the Course Director to assure that this RSS activity meets the criteria set forth by the Accreditation Council for Continuing Medical Education (ACCME). The following documentation must be forwarded to the Office of Continuing Medical Education (OCME). Transcripts of credits earned will not be released to the department or to the participant until all of the required documentation is received by the OCME by the deadline above. • Attendance Form (Sign in Sheet). All changes to attendance forms MUST be submitted in writing. • Summary of evaluations must be done by individual departments and submitted to the OCME. • Fully completed and Signed Faculty Disclosure Form for ALL speakers (even those on staff and residents). • Commercial Support Letters of Agreement signed for each company providing educational grants. • Announcement Flyer listing the Objectives, Target Audience, Faculty Disclosure and Acknowledgement of Commercial Support was made to the audience PRIOR to the educational activity. • Final Financial Summary Report requested by OCME (at the end of calendar year). • Renewal: a renewal form will be distributed December 1, 2009 to ensure that the regularly Scheduled Series will continue for the following year. SIGNATURES Please provide signatures below indicating acceptance of the following terms and conditions for sponsorship by Mount Sinai School of Medicine. • To ensure final designation of credit, each Activity Director agrees to collaborate with the Office of CME to ensure that the planning and implementation of the proposed CME activity are consistent with the policies and procedures of the ACCME. • I have read and agree to abide by the MSSM Policy for Identifying and Resolving Conflicts of Interest in CME and the ACCME Standards for Commercial Support. Application reviewed and approved by: Department Chairperson: Click here to enter a date. Signature Date I hereby certify that this application was completed accurately and attest to the validity of the information contained within: Course Director: Click here to enter a date. Signature Date FOR OFFICE USE ONLY, PLEASE DO NOT WRITE BELOW THIS LINE Date Received ______________ CME Office Reviewer ______________ CME Reviewer ____________________________# Category I Credit Hours Approved__________ Approval Date___________________ Course Director Notified__________ 2009 10

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