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pplication and Planning Document Form.doc

  1. 1. Office of Continuing Medical Education Formal Planning Guide and Application Form
  2. 2. Formal Planning Guide and Application Form Accreditation Statement The University of Arkansas for Medical Sciences College of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Mission Statement Mission Statement The mission of the UAMS College of Medicine Continuing Medical Education (CME) Program is to assist physicians in their pursuit of life-long learning for the purpose of providing high quality health care. This is accomplished by offering educational opportunities that support physicians' improvement in their competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Means and Purpose The University of Arkansas for Medical Sciences (UAMS) is the sole academic medical center in the state of Arkansas. It consists of five colleges and a graduate school sharing a common mission: to teach, to heal, to search, and to serve the healthcare needs of the people of Arkansas. The College of Medicine's CME Program is central to this broad mission. The major purpose of the CME Program is dissemination of state-of- the-art, evidence-based education that will allow practicing physicians opportunities to maintain and enhance their knowledge and skills, and in the process, reaffirm their professional commitment to the provision of excellent health care. Content Areas The content of CME activities produced by the UAMS College of Medicine (COM) is determined and initiated by the College of Medicine faculty and through joint sponsor relationships with other organizations including state health agencies, community and regional hospitals, and medical professional societies whose own missions are aligned with that of the UAMS College of Medicine. CME activities are developed based on needs assessment data to ensure that activities present current, state-of-the-art, evidence-based information in order to improve physician competence, performance and/or patient outcomes in Arkansas. Target Audience Educational activities are designed for practicing physicians whose work crosses the continuum of primary care, specialty care, and tertiary care. Other health care professionals are welcomed to activities appropriate to their needs for education at the physician level. These activities draw participants from local, regional, national and international geographic areas. Types of Activities Provided The CME Program offers a broad spectrum of educational activities using a range of instructional methods including didactic lectures, symposia, demonstrations, interactive workshops, case-based conferences, interactive video conferences, and self-directed learning materials (e.g., enduring materials such as Internet activities, instructional videotapes, CDs, and printed documents). The UAMS College of Medicine CME Program is committed to exploring new initiatives and opportunities in education to enhance the overall program and encourage development of Performance Improvement and other innovative approaches to physician CME learning activities. Expected Results of the Program The CME activities approved by the Office CME will contribute to improved physician competence, performance, and enhanced health care outcomes for Arkansans.
  3. 3. Formal CME Activity A Formal CME activity is considered to be one that is presented as a live conference or lecture. Instructions The purpose of this planning guide and application form is to document compliance with the requirements of the Accreditation Council for Continuing Medical Education (ACCME), the national organization that accredits the UAMS College of Medicine Office of Continuing Medical Education to provide CME for physicians. This interactive planning process is designed to assist you in planning a CME activity that meets the expectations of the ACCME and the OCME. The checklist and timeline will help you know when to submit the necessary forms and documentation for your event. You will need to use the <TAB> key to advance from field to field when completing this form. You will find within the form, explanations, examples, check boxes and text boxes in which to type. You will see the icon, , whenever documentation is required upon submission of the application. When you have completed the form, save, print, and submit it, along with the necessary documentation, to: UAMS OCME 4301 W. Markham St. Slot 525 Little Rock, AR 72205. If you have questions or need assistance, please feel free to contact us by calling 501-661-7962, faxing 501-661-7968 or emailing lamabry@uams.edu. Formal Planning Guide and Application Form
  4. 4. CHECKLIST AND TIMELINE Pre-activity materials - Submit with the application for preliminary approval Application/Planning Document 4-6 months before the activity Joint Sponsorship Agreement, if applicable 4-6 months before the activity Documentation of Planning (minutes, notes, etc.) 4-6 months before the activity Planning Committee Disclosure Forms 4-6 months before the activity Needs Assessment Documentation 4-6 months before the activity Preliminary agenda (proposed topics, speakers, timeline) 4-6 months before the activity Preliminary Budget 4-6 months before the activity Submit before the activity for final approval (if not included with initial application submission) Draft of faculty invitation letter (see faculty letter template) 2-4 Months before the activity List of faculty with credentials and topics 2-4 Months before the activity Faculty CVs (required for non-UAMS College of Medicine Faculty) 2-4 Months before the activity Final Agenda with speakers/topics/time slots 2-4 Month before the activity Draft of brochure, save the date and/or other announcements A draft copy of all printed materials including but not limited to: save the date, brochure, syllabus, evaluation, must be reviewed and approved by OCME prior to printing. 2-4 Months before the activity Proposed evaluation tool, if not using OCME standard forms 2-4 Months before the activity Faculty disclosure forms All faculty and planning committee members must complete and appropriately sign a Disclosure Form prior to the activity. Conflicts of Interest (COI) must be resolved by the Course Director. 1 Month before the activity Written disclosure method Disclosure of financial relationships must be communicated to the participants prior to the activity. It is required that you submit your slides, signs, or whatever written method you plan to use for disclosure to the OCME for approval prior to the event. 1 Month before the activity Commercial Support Agreement (LOAs) All educational grants must be documented by an appropriately signed LOA for commercial support. 1 Month before the activity Proof of payment for CME approval 1 Month before the activity Post-activity materials - Submit within 30 days of the activity’s completion CME Formal Activity Closing Report - (Form available on the OCME Website) Participant evaluation summary including comments Sign-in sheets Final budget - Must include a breakdown of All income sources and all expenditures. Attendee roster or excel data file with/name, degree, address, last 4-digits SSN & email Final syllabus/handout (1 copy) Verification of disclosure - Must send a copy of 1) slides, handouts, and 2) verification of disclosure attestation statement Final brochure (5 copies) Verification of acknowledgement of commercial support, if applicable Copy of certificate (For MDs and Non-MDs)
  5. 5. APPLICATION FOR SPONSORSHIP OF A FORMAL CME CONFERENCE www.uams.edu/cme Revised 09/17//2009 ACTIVITY TITLE       START DATE       END DATE       START TIME       END TIME       LOCATION (Hotel or other, etc.)       CITY, STATE       SPONSORSHIP AND COURSE MANAGEMENT SPONSOR Must be a UAMS College of Medicine Department or AHEC Office UAMS College of Medicine, Department of:       Area Health Education Center (AHEC), Location:       JOINT SPONSOR(S) are organizations or entities external to UAMS College of Medicine who are not accredited by the ACCME Required Attach signed Joint Sponsorship Agreement Yes…..If yes, complete the Joint Sponsorship Agreement and include it with this application. List the organization(s) or outside entities involved in planning this activity below. ORGANIZATION CONTACT NAME PHONE #                                                                         Is a member of the UAMS College of Medicine Faculty involved in the planning and/or organization of this activity? YES NO If yes, Faculty member’s name:       Course Director (Planner)       CME Associate (Coordinator)       Title       Title       Address/City/St       Address/City/St       Telephone       Telephone       Fax       Fax       Email       Email       ACTIVITY MANAGEMENT: Who will have primary responsibility for managing this CME activity? UAMS College of Medicine department/AHEC Office, please specify:       Joint Sponsor/Educational Partner, please specify:       The OCME. DEPARTMENTAL/DIVISIONAL/ORGANIZATIONAL APPROVALS Course Director: Date:
  6. 6. Chairman/Division Head/CEO: Date: PLANNING INFORMATION TYPE OF ACTIVITY ACTIVITY IS: Formal Activity (symposium, course, conference) Short Activity or lecture 1-2 hrs in length. Live interactive/compressed video conference Live web cast Series (same content presented multiple times) (Not considered as an Regularly scheduled series) NEW REQUEST ANNUAL ACTIVITY DESIRED CREDITS AMA Category 1 COMMERCIAL SUPPORT – INDEPENDENCE OF THE PLANNING PROCESS The ACCME requires the following decisions in planning a CME activity be made free of control by a commercial interest (refer to and policies). These decisions include: 1) Identification of needs 2) Determination of objectives 3) Selection and/or presentation of content 4) Selection of personnel and organizations who would be in a position to control the content 5) Selection of educational methodology 6) Evaluation of the activity 1. PLANNING PROCESS Attach planning meeting minutes, emails, or other documentation of the planning process Describe the planning process for the content (not the meeting logistics).       2. TARGET AUDIENCE Check all that apply. Who is the target audience? Physicians: Specialties (specify):       Physician Assistants Nurses Pharmacists Dietitians Social Workers Health care administrators Other (specify):       Local State Regional National International Estimated Attendance: Physicians       Other       NEEDS ASSESSMENT Needs Assessment is defined as "any systematic approach to collecting and analyzing information about the educational needs of individuals or organizations." Educational needs may be perceived, desired or thought to be important. The needs assessment data is the basis for developing learning objectives for a CME activity. A needs assessment is a tool to identify a gap, the difference or distance between what is occurring in practice and what is expected (the desired outcome), or, the difference between what is and what should be. For more information about conducting a needs assessment refer to the Needs Assessment Guidelines and the Types of Needs Assessment Data Sources guide.
  7. 7. 3. NEEDS ASSESSMENT DATA DOCUMENTATION ACCME Requires Documentation Supporting documents MUST be included with the application. Check all methods that apply. For more information about needs assessment refer to the following: Needs Assessment Guidelines and the Types of Needs Assessment Data Sources guide Watch the ACCME Video about needs assessment compliant data (2 min.): http://education.accme.or g/video/accme-video- faq/documenting- professional-practice- gaps A needs assessment that meets ACCME compliance must go beyond identifying the perceived need of a professional performance gap. Additional data that is evidence-based must also be provided in support of the identified learning needs. Needs perceived by clinical experts Clinical expert opinion (activity faculty, planning committee members, department chair, etc.) Please list the names of those giving expert opinion and their credentials:       Needs perceived by targeted participants (provide summary for each method indicated) Needs Assessment survey of target audience Previous evaluation summary* (Required for renewal applications.) Focus group discussion/interviews Requests by affiliated institutions Requests from other physicians Other, please specify      Clinical expert opinion and/or participant needs are perceptions that must be supported by at least one evidence-based data source for each identified need. Choose at the minimum one source from the categories below for each performance gap this CME activity will address: Evidence-based information (provide copy of summary or source) Peer-reviewed literature (provide summary)       Research findings, please specify       Medical School requirements, please specify       Government laws/regulations, please specify       National guidelines (NIH, NCI, AHRQ, etc.) please specify       Specialty society guidelines, please specify       Other, please specify      Observed Needs (provide summary or copy of data for each of the selected) Adverse drug events Database analysis (e.g., RX changes, diagnosis trends, etc.) Epidemiological data Hospital/Clinic Quality Assurance data Pharmacy & Therapeutic or Quality Improvement data/guidelines Morbidity & Mortality data Other clinical observations Referral data Other, please specify      Environmental Needs (provide a copy of the standard/law/etc.) Joint Commission Standards/Core Measures
  8. 8. Laws/Regulations Lay Press (specify):       Other societal trends (specify):       4. After analyzing the data obtained from the sources on the previous page, please summarize the process of analyzing the data and explain why these professional performance gaps were selected.       Now, outline the professional performance gap(s) identified during the needs assessment. Explain the desired result of the CME activity for reducing or removing the identified gap. In other words, what will the learners be able to apply in their practice based on the knowledge and implementation strategies addressed in this activity? Add more lines or provide information on a separate page, if necessary. Identified GAP/Learners’ Needs What was identified as missing or deficient (the professional performance gap) in what the targeted learners know and/or can do in their healthcare practice or in their care of patients? Desired Result After the CME activity, what would indicate a reduction or elimination of the gap? Content Focus Where do you need to focus the content? The objectives and instructional methods will be determined by the content focus of the CME activity.             Knowledge (do not know) Competence (know but unable to apply if needed) Performance (able to do) Patient Outcome (demonstrated changes in patient outcome indicators)             Knowledge Competence Performance Patient Outcome             Knowledge Competence Performance Patient Outcome             Knowledge Competence Performance Patient Outcome
  9. 9.             Knowledge Competence Performance Patient Outcome
  10. 10. Physician Competencies and Attributes The Maintenance of Certification (MOC) competencies designated by the American Board of Medical Specialties (ABMS) and Accreditation Council of Graduate Medical Education (ACGME), and the Attributes identified by the Institute of Medicine (IOM) are national goals for physicians and, when possible, should be addressed in CME planning. Patient Care or Patient-Centered Care: identify, respect, and care about patients’ differences, values, preferences, and expressed needs; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health. Medical Knowledge: established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social behavioral) sciences and the application of this knowledge to patient care. Practice-Based Learning and Improvement: involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. Interpersonal and Communication Skills: that result in effective information exchange and teaming with patients, their families and other health professionals. Professionalism: commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a diverse patient population. System-Based Practice: actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Interdisciplinary Teams: cooperate, collaborate, communicate and integrate care teams to ensure that care is continuous and reliable. Quality Improvement: identify errors and hazards in care; understand and implement basic safety design principles such as standardization and implications; continually understand and measure quality of care in terms of structure, process and outcomes in needs; and design and test interventions to change processes and systems of care, with the objective of improving quality. Utilize Informatics: communicate, manage knowledge, mitigate error, and support decisions making using information technology. Employ evidence-based practice: integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible. 5. PHYSICIAN COMPETENCIES AND ATTRIBUTES Indicate physician competencies and attributes that will be addressed in the curriculum of this CME Activity. Please check all that apply: Competencies Attributes Patient/Clinical care Patient-centered care Medical knowledge Interdisciplinary team work Practice-based improvement Evidence-based practice Communication skills Quality improvement practices Professionalism Utilization of informatics System-based practice
  11. 11. OBJECTIVES Now, review your identified professional performance gaps, the desired results (what will indicate that the gaps have been reduced or eliminated), and what content focus (knowledge, competence, performance and/or patient outcomes) that the CME activity is designed to address. Your objectives should be based on the identified professional practice gaps you identified from your needs assessment. Terminology for educational objectives usually begins with, "Following this activity, the participant should be able to . . ." followed by phrases that communicate a measurable performance capability, by the participant. Think of performance as the action of doing something. Whenever possible, think in terms of improving patient care outcomes. Use verbs that convey doing such as: describe, analyze, discuss, compare, differentiate, examine, formulate, propose, evaluate, assess, measure, select, and choose when writing your objectives. Write objectives that are parallel to the level of learning you are attempting to accomplish. Knowledge, competence, performance, and patient outcomes objectives require different objectives. Avoid verbs that are not easily measured such as understand, appreciate, and know. For more information about writing measurable, performance-based objectives refer to Guidelines for Writing Objectives. 6. OBJECTIVES ACCME Requirement: The audience must be provided information about the activity’s goals and/or objectives before activity occurs. For more information about notifying the participants see: Guidelines for Brochures and Promotional Materials Based on what you hope to accomplish, list three or four objectives that reflect what you would like for the participants to be able to do as a result of participation in this CME activity. These are objectives for the entire activity. If there is not enough room here, please use a separate page and submit as an attachment.            
  12. 12. 7. EDUCATIONAL FORMAT Consider what will be the most effective method(s) for achieving your objectives to eliminate or reduce the educational gap. What instructional methods will be used? (Check all that apply) Live lecture presentation (knowledge) Panel discussions (knowledge) Case studies (competence) Interactive workshops (competence) Interactive telecommunication (knowledge, competence) Live demonstration of procedure (competence) Video demonstration of procedure (competence) Skills workshop (competence, performance) Individual study assignment (knowledge, competence) Other, please describe.       8. FACULTY SELECTION (speakers, moderators, panelists) Please tell us why and how the speakers were selected and who was involved in the decision to select the speakers?      9. ACTIVITY AGENDA ACCME Requires Documentation Attach a copy of the agenda A copy of the proposed schedule is attached. Yes No It must include specific time schedule, speakers, and topics. Approval cannot be granted until the final agenda is received. If no, please explain.      
  13. 13. DISCLOSURE OF FINANCIAL RELATIONSHIPS REQUIRED BY THE ACCME Refer to the Policy for Disclosure of Financial Relationships and Resolution of Conflicts of Interest UAMS CME DISCLOSURE POLICY It is the policy of the University of Arkansas for Medical Sciences (UAMS) College of Medicine to ensure balance, independence, objectivity, and scientific rigor in all sponsored or jointly sponsored educational activities. All individuals who are in a position to control the content of the educational activity are required to disclose all relevant financial relationships they have with any commercial interest(s). These individuals include course/activity directors, planning committee members, staff, teachers, or authors of CME. The ACCME defines relevant financial relationships as those in any amount occurring within the past 12 months that create a conflict of interest. Individuals who refuse to disclose MUST BE disqualified from participation in the development, management, presentation, or evaluation of the CME activity. • The “Disclosure and Attestation Statement” (disclosure form) is the mechanism used by the OCME to gather information about relevant financial relationships with commercial interests. • This form must be completed by EVERYONE who has the opportunity to influence the content of the CME activity, including the course director, CME Associate, planning committee members, speakers, authors, moderators, etc. • Individuals refusing to disclose MUST NOT be allowed to participate in the CME activity. Failure to return a disclosure form is equal to refusing to disclose. • Conflicts of Interest (COI) must be resolved BEFORE the activity occurs, preferably during the early planning stages. • It is the responsibility of the Course Director to make certain that all of the disclosure forms are collected, reviewed for relevant financial relationships with commercial interests and all conflicts of interest resolved. Disclosure forms and documentation of how relevant financial relationships were explored and any conflicts of interest were resolved must be submitted to the OCME well before the activity begins. 10. DISCLOSURE PLAN Refer to ACCME Requires Documentation Attach copies of letters, memos, emails, etc. How were planners and faculty informed about disclosure?       11. DISCLOSURE FORMS and RESOLUTION OF CONFLICTS OF INTEREST (COI) Refer to the Disclosure Form Faculty disclosure forms must be submitted with this application or prior to the activity, see checklist and timeline below. Yes, disclosure forms are attached for everyone who has the opportunity to influence the content of the CME activity. No, all disclosure forms are not attached. Please explain      
  14. 14. Planners All planners must complete UAMS College of Medicine’s Disclosure and Attestation Statement ACCME Requires Documentation These disclosure forms MUST be attached to this application. Refer to UAMS Policy on Disclosure and Resolution of Conflicts of Interest Attach a separate page if there is not enough room here. List all individuals who are involved in planning. Name Affiliation Disclosure Forms Attached                                                                                                 Faculty/Speaker/Moderator/Author ACCME Requires Documentation. Complete the form below OR provide the information on a separate sheet as an attachment. 1) Please attach a copy of a curriculum vitae or biological sketch for each course faculty (speaker/moderator/author) who is not on the UAMS College of Medicine faculty. (Attach separate sheet if necessary.) 2) Disclosure form for each speaker/moderator/author 3) Review all disclosures of relevant financial relationships with commercial interests and resolve any conflicts of interest. Document how any conflicts of interest were resolved and submit that information to the OCME prior to the activity. Speaker/Moderator/Author Academic/Professional Titles Institution or Affiliation Disclosures Attached                                                                                                                                                 12. PROVIDE DISCLOSURE TO PARTICIPANTS A copy of the written method AND a verification of disclosure attestation form will be required to be submitted with closing report after CME event. How will the audience be given disclosure information gathered from the above planners, faculty, speakers, etc.? Written (preferred): Handouts Slides Other,       Verbal by: Speaker Moderator
  15. 15. 13. COMMERCIAL SUPPORT Required by the ACCME, if there is commercial support Refer to the Standards for Commercial Support 1) Acknowledgement - The audience must be informed about commercial support. 2) Letters of Agreement for Commercial Support (LOA) must be executed for ALL educational grants. The LOA is between the accredited provider (UAMS COM) and the company. They must be signed by both the company’s representative and the accredited CME provider’s representative. 3) The LOAs should be submitted prior to the activity if possible and if not received prior to the activity, they must be included in the closing report. 4) An exhibitor form must be completed for each exhibitor. Will this activity receive support from Educational grants? Yes No Will there be exhibits? Yes No If yes, how will commercial support for this activity be acknowledged to the participants? Brochures Handouts/syllabus Verbally Other, please describe.       Management of Commercial Support The Course Director and CME Associate have read the ACCME’s Standards for Commercial Support of CME and understand the guidelines for management of commercial funds. Yes No A complete accounting of the commercial support must be submitted with the closing report at the conclusion of the activity. 14. MARKETING AND ADVERTISING The ACCME requires certain information be included on promotional materials: • target audience • purpose and/or objectives, • faculty • topics • sponsorship • accreditation statement • AMA PRA Category 1 Credit™ designation statement The OCME must approve promotional materials before they are printed. Refer to Guidelines for Brochures and Promotional Materials How will notification of this educational activity be distributed to the participants prior to the activity? Brochure Email Website: URL site:       Journal Fax Other, identify:       A copy of the promotional material is attached. A copy of the promotional material will be sent later.
  16. 16. EVALUATION There are some important areas that need to be addressed by the evaluation of the program. Participants should have the opportunity to: 1. rate the overall quality of activity 2. assess the extent that the objectives were met 3. rate the extent that their professional effectiveness will be enhanced 4. incorporate an outcomes question 5. assess if bias or the appearance of bias existed in the instructional process 6. rate the quality of the faculty 7. confirm that disclosures were made known to the audience at the beginning of the activity 8. confirm that commercial support was acknowledged, if applicable 9. rate the learner satisfaction ACCME Requirement: (see essential area 3) All CME activities MUST be evaluated to determine the effectiveness of meeting the identified educational needs. Plan an evaluation method that corresponds with the outcome. For example, if you are planning to have performance as an outcome, then how are you going to measure that the learner can now perform the task or skill? If you plan to have an outcome to change patient outcomes, what is your evaluation plan for determining the change in patient outcomes? There must be a plan to measure this change. Standard evaluation forms are posted on the OCME Website: Overall Evaluation Individual Speaker 15. EVALUATION ACCME Requirement Please attach a copy of the form you plan to use or explanation of evaluation method. A copy of the summarized results MUST be submitted with the final “Activity Closing Report”. What method(s) will be used to assess what the participants have learned as a result of attending this educational activity? Please select all that apply: Post-activity evaluation (measures perceptions of knowledge acquisition and satisfaction) OCME standard post-evaluation form Other evaluation form (attach a copy, must be approved in advance). Pre-Post test (measures immediate learning) (attach a copy). Learning Contract (commitment to change) questions (attach a copy) Audience Response (identifies if learners understand content and provides learning reinforcement) Focus Groups (qualitative measurement to explore more in-depth information) Post-conference follow-up (3-6 months post-conference to measure for performance change) (attach a copy of follow- up plan) Or, describe alternative evaluation method      
  17. 17. 16. BUDGET INFORMATION ACCME Requirement Attach a preliminary budget (rough estimates are acceptable) including all projected revenue and expenses. A final income and expense report is required with the activity closing report. Refer to the budget template How will activity expenses be paid? (check all that apply) Internal department funds Participant registration fees Commercial Support State or Federal Grant Other, identify:       17. CME ADMINISTRATIVE FEES Attach a check or copy of IDT or other transaction. Please include payment with the application. Method of payment: Check (attached) IDT (include a copy or other proof of transaction) Please indicate the activity title in the text fields to assure proper posting. Credit to: 118-600001-1006376 Debit to: xxx-631600-xxxxxxx If payment is not included, please explain.      

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