Application for CME Credit (SYMPOSIUM)

Are you willing to determine and document the need for this activity using multiple data sources including physician performance and/or patient health data; and to link identified educat

Novant Health Office of CME

Novant Health Forsyth Medical Center

3333 Silas Creek Parkway, Mailbox 48,

Winston Salem, NC, 27103 Phone: 336-718-5987 Email: kagaydos@novanthealth.org

CONTINUING MEDICAL EDUCATION APPLICATION FOR

CREDIT SYMPOSIUM/CONFERENCE

Please Note:

• ACCME Criteria: Novant Health is accredited by the North Carolina Medical Society

to provide CME credit It is the responsibility of the CME Department to document compliance with NCMS and ACCME criteria before approving educational programs for CME credit

• Application: This application must be submitted for your program to be considered

for CME credit Submission of this application does not constitute approval

Approvals for symposium/conference programs are awarded for one calendar year

Applications should be submitted at least three (3) months prior to the intended

start date in order for CME Committee review and approval

Application for AMA PRA Category 1 Credit™

Title of CME Symposium/Conference:

Day/Times of Activity:

Activity Location:

Target Audience:

Course Director (include name, affiliation, phone, email address):

Activity Coordinator (include name, affiliation, phone, email address):

Attendance Taker (include name, affiliation, phone, email address):

Planning Committee Members/Planning Partners (include name, affiliation, phone, email address):

INSTRUCTIONS: Check the appropriate answer

1 Our conference can be described as:

Multi-hour Conference/Symposium Case Conference

Morbidity/Mortality Conference Other:

2 Are you willing to determine and document the need for this activity using multiple data sources including physician performance and/or patient health data; and to link identified educational needs with a desired result?

YES: Go to # 3 NO: Discontinue request for Category 1 credit

3 Are you willing to develop and provide the CME Office with your objectives for this activity? YES: Go to # 4 NO: Discontinue Request for Category 1 Credit

4 Are you willing to consistently communicate the learning objectives of the activity describing learning outcomes in terms of physician performance or patient health?

YES: Go to # 5 NO: Discontinue Request for Category 1 Credit

5 Are you willing to evaluate the activity for effectiveness in meeting identified educational needs,

as measured by practice application and/or health status improvement?

YES: Go to # 6 NO: Discontinue Request for Category 1 Credit

6 Are you willing to use the evaluation data to plan further offerings of this activity?

YES: Go to # 7 NO: Discontinue Request for Category 1 Credit

7 Are you willing to verify that all the recommendations involving clinical medicine in a CME activity will 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?

YES: Go to # 8 NO: Discontinue Request for Category 1 Credit

8 Are you willing to verify that 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

YES: Go to # 9 NO: Discontinue Request for Category 1 Credit

9 Will you request financial support from commercial interests (pharmaceutical manufacturers or medical device companies) for this activity?

YES: Go to # 10 NO: Go to # 11

10 Will you comply with the ACCME Standards for Commercial Support?

YES: Go to #11 NO: Discontinue Request for Category 1 Credit

11 Will you comply with the ACCME recommendation to followup changes in physician competence,

performance and patient outcomes by utilizing the Novant Health OCME Post Activity Follow-up Form? – NOT REQUIRED FOR CREDIT (contact NHOCME for follow-up form template)

NEEDS ASSESSMENT

C2

Rationale: The purpose of a needs assessment is to identify the learning needs of a target audience and to secure information as to how those needs were identified.

SOURCES OF DATA Types of Gaps (K=Knowledge; C=Competence; P=Performance)

Please identify at least two resources used in the needs assessment process (Check all that

apply)

Expert Needs

Planning committee (K)

Departmental chair (K)

Activity faculty (K)

Expert panels (K)

Peer-reviewed literature

(K)

Research (K)

Chart Reviews (K)

Legal or regulatory

requirements (OSHA,

JCAHO, IRB) (C)

Minutes from any

committee meeting in

which an educational need

is identified (K)

Other (please specify):

Participant Needs

Previous related evaluation summary (K) Focus

groups/interviews (K) Needs

survey/questionnaire (K) Implementation of new clinical practice guidelines

or clinical pathway (K) Other requests from physicians (K)

Other (please specify):

Observed Needs

QA analyses (C,P) Mortality/Morbidity data (C,P) Epidemiological data (C,P) National clinical guidelines (NIH, etc) (C,P)

Specialty society guidelines (C,P) Database analyses (Rx changes, diagnosis)

(C,P) Other (please specify):

Document the needs assessment process by answering the following questions:

What professional practice gap(s) and/or quality gap(s) is this activity addressing (i.e difference between actual and ideal performance and/or patient outcomes)?

Describe in detail how the needs assessment information (as noted above) was utilized in determining the overall goals of this proposed CME activity

Is the need a knowledge, competence or performance need? For example, does the physician need to know something, learn how to do something, develop a strategy for doing something, or need to change something in their practice?

How will the design of this activity promote changes in physician competence, performance, or patient outcomes?

PLANNING PROCESS – Content Development and Instructional Method(s)

Briefly describe the planning process used for this CME activity & answer the following questions:

C1,

C3

The Novant CME Mission Statement is attached at the end of this application How does

this activity fit within the mission of the Novant CME Department?

When planning this activity did you consider any non-educational strategies to support changes that your CME activity is promoting (e.g patient surveys, learner surveys, sending reminders about

information discussed at the CME activity, etc)

C6 ACGME Core Competencies in Medical Education

Will you address patient care that is compassionate, appropriate, and effective for the treatment of

health problems and the promotion of health in this activity? Yes No

Will you address medical knowledge about established and evolving biomedical, clinical, and

cognate sciences and the application of this knowledge to patient care in this activity? Yes No

Will you address practice-based learning and improvement that involves investigation and

evaluation of ones own patient care, appraisal and assimilation of scientific evidence, and

improvements in patient care in this activity?

Yes No

Will you address interpersonal and communication skills that result in effective information

exchange and teaming with patients, their families, and other health professionals in this activity? Yes No

Will you address systems-based practice, as manifested by actions that demonstrate an

awareness of and responsiveness to the larger context and system for health care and the ability to

effectively call on system resources to provide care that is of optimal value in this activity? Yes

No

Will you address professionalism, as manifested through a commitment to carrying out

professional responsibilities, adherence to ethical principles, and sensitivity to a diverse

patient population in this activity?

Yes No

C19 Please address barriers to physician change that your activity hopes to

overcome:

Does your planning process consider barriers that physicians may encounter when trying to make the change your CME activity is designed to promote? Check all that apply

No barriers Insurance/reimbursement issues Cost Patient compliance Lack of time to assess/counsel patients

Lack of administrative support/resources Lack of consensus on professional guidelines Other:

Will you incorporate a discussion of the barriers and strategies to remove or overcome the barriers in the CME activity?

EDUCATIONAL OBJECTIVES

Learning objectives must be written from the learner’s perspective of what you

expect the learner to do in the practice setting with the information you are teaching

All specific and general course objectives must be approved by the Novant

Health Office of CME in advance, and must be included in promotional

materials, instructional materials provided at the activity, and reiterated

on the evaluation instrument

You must express all objectives in measurable, behavioral terms, and demonstrate

the connection between identified needs and the desired results Please

provide at least 3 – 4 objectives for the activity.

Learning Objectives

For example, a good learning objective will be to “implement”, “demonstrate”,

“apply”, “exhibit”, “identify”, or other words that are oriented to the learner’s

performance (i.e What should the learners be able to apply to their profession after

they participate in the educational activity?)

Gap Identified

K=Knowledge C=Competency P=Performance

Knowledge Competence Performance

Knowledge

Competence Performance

Knowledge Competence Performance

Knowledge Competence Performance

Knowledge Competence Performance

How do you intend to make these objectives known to the prospective participants and faculty?

Check all that apply

Letters to faculty informing them of the course objectives

Brochure/promotional literature (pre-approved by the NH OCME before publishing)

Syllabus (pre-approved by the NH OCME before publishing)

Announcement prior to the beginning of the activity

Other:

INSTRUCTIONAL METHOD(S) – Types of Gaps (K=knowledge; C=competence; P=performance)

How will the learners receive the information being presented during this activity? What methods of instruction will be utilized? Check all that apply

Case presentation(s) (K,C)

Skills demonstration(s) (C,P)

Lecture(s) (K)

Panel discussion(s) (K)

Small group discussion(s) (K)

Question & answer session(s) (K)

Interactive response system (K) Simulated patient(s) (C,P) Laboratory session(s) (C,P) Mentoring/coaching (K,C,P) Remote site teleconference(s) (K) Videoconference(s) (K)

Other (please specify): _

If available, please list on a separate attachment all proposed speakers, their credentials, and affiliations (CVs must be provided once speakers are finalized)

Rationale for selection of this faculty: (select all that apply)

Subject matter expert Excellent teaching skills/effective communicator Experience in CME Other:

Resolving Conflicts of Interest IMPORTANT: All presenting faculty (speakers, moderators, conveners, authors, etc.) must complete a Conflict of Interest Disclosure Form, and all reported conflicts must be resolved, PRIOR to the CME activity For more information on Novant Health Conflict of Interest

policy and forms, please call 336-718-5987

ANY FACULTY MEMBER WHO REFUSES TO SUBMIT A CONFLICT OF INTEREST DISCLOSURE

MUST BE BARRED FROM PARTICIPATION IN THE ACTIVITY.

COMMERCIAL SUPPORT

If you do not anticipate receiving any commercial support for this activity, please check here:

Novant Health OCME adheres to the Standards for Commercial Support for Continuing Medical Education of the ACCME

(www.accme.org ) All commercial support to an activity designated for CME credit must be

documented by a signed Letter of Agreement for Commercial Support of CME Exhibit fees are not

considered commercial support by the ACCME However, potential exhibitors should be noted as such and listed below

If available, please complete the following information for each commercial supporter expected (attach a separate sheet as required):

Company: Disease state:

Rep’s Name/Email:

Company: Disease state:

Rep’s Name/Email:

Company: Disease state:

Rep’s Name/Email:

Company: Disease state:

Rep’s Name/Email:

ANNOUNCEMENT OF COMMERCIAL SUPPORT TO THE AUDIENCE

All commercial support must be provided/announced to the learner audience PRIOR TO the start of the activity How will commercial support be provided/announced to the audience?

Written announcement in instructional materials Slide Other: _

Verbally from the podium/lectern (must complete an Audience Disclosure form) N/A

INSTRUCTIONAL MATERIALS

Participants may receive instructional materials submitted by the presenters Check all instructional materials prior to submitting to the NHOCME for any promotional materials or references to product trade names for

commercial goods and services Prior to duplication, all instructional material must be approved by

the NHOCME.

EVALUATION

Each CME activity must be evaluated for its effectiveness in meeting its identified educational need(s) How

do you plan to determine the effectiveness of this activity? All evaluation methods must be approved by

the NHOCME Types of Gaps (K=knowledge; C=competence; P=performance) Check all that apply:

Post activity evaluation form (K, C)

Pre- and post-tests of knowledge (K, C)

Self-reported increase in practitioner confidence survey (K, C)

Intent to change survey (C)

Participant self-report of implementing knowledge or skill into practice survey (P)

Skills assessment survey (K)

Describe:

Knowledge assessment survey (K, C)

Describe:

PRELIMINARY ESTIMATED BUDGET

Will participants be charged a fee? Yes No

Proposed fees: Physicians NPs/PAs RNs _ Others _

Expected number of participants: Number of MDs/DOs:

Number of Others:

If this activity was implemented in the previous year, or

is a repeat in any way, please provide a copy of the most

recent reconciled Financial Summary for that activity REVENUE

Anticipated revenue from registration fees:

Anticipated revenue from educational grants and commercial

support:

Anticipated revenue from exhibitors:

Other anticipated revenue:

Please describe:

TOTAL EXPECTED REVENUE:

EXPENSES Honoraria – all speaker honoraria must be paid directly

by the sponsor or educational partner; no funds may

flow directly from commercial supporters to presenters.

Est # of speakers: @ $ _ per speaker Total

honoraria:  Speaker reimbursement (or program budget) for travel, lodging,

meals, & ground transportation, etc :

Food & beverage expenses (inc bkfst, lunch, breaks, receptions,

etc – inc tax & gratuity):

Hotel/conference center or other venue meeting room charges:

Audio-visual equipment/labor/set-up:

Instructional materials (syllabi, handouts, CDs, etc.):

Registration brochure (design, printing, postage),

advertising & marketing expenses:

Miscellaneous expenses (e.g., other contractual services, etc.):

NHOCM Credit Designation, recordkeeping and/or conference

management fees:

TOTAL EXPECTED EXPENSES:

PROJECTED BALANCE:

OUTCOMES MEASUREMENT

How will you measure the effectiveness of the CME activity in meeting identified needs in terms of practice

application and/or patient health status? All outcomes measurement methods must be approved by

the NHOCME Types of Gaps (K=knowledge; C=competence; P=performance) Check all that apply:

No outcomes measurement to be performed

Post activity participant survey (K) Peer-review (C,P)

Chart audits for physician behavioral change (P) Focus group (discussion group of attendees) (K,C,P)

Other patient data review for changes in physician practice/behavior (P)

Other health indicators (describe)

How soon after the activity will the outcomes measurement take place?

1 month 3 months 6 months Other _ N/A

PHYSICIAN PARTICIPATION AND AFFIRMATION – The Novant Health Office of CME requires

physician input into the planning and implementation of each activity designated for credit Your signature serves to verify that involvement An activity coordinator/ planner’s signature is also required Our signatures below confirm that to the best of our ability this activity has been planned and implemented in accordance with all Novant Health OCME policies and procedures and the ACCME Essential Areas and Standards for

Commercial Support of CME:

_

Signature of Physician (Course Director) Date:

_

Signature of Activity Coordinator/Planner Date:

_

Signature of the NH OCME Representative Date:

The Novant Health Office of CME APPROVES or DOES NOT APPROVE this educational

activity for a total of _ AMA PRA Category 1 Credits TM

Novant Health Continuing Medical Education

Mission Statement

Purpose

Novant Health’s core mission is to provide quality healthcare services to the

communities served by Novant Health facilities, as well as their contiguous