5/4/2016 Live Activity CME Program Application Thank you for considering us to support you in your continuing medical education activity plans. Completing this application is one of the earliest steps in working with us to achieve your education goals. Should you wish, you may call us before you begin the application so we can have a preliminary discussion on your plans. That should make the application process easier for you. We can be reached at 423 439 8081. For information that can provide a resource as you complete the application, hover your mouse over the footnotes both here and throughout this document: Application instructions:i Deadlines:ii o Important information related to the months the Board does not meetiii o Live programs for which Educational Grants are being soughtiv o Live programs for which brochures must be developedv Contact Informationvi Office Use Only Activity Type 1. What type of activity are you proposing? A live, one-time activity, conference, symposium, or seminar Other. Please call us at 423 439 8081 to determine which application you should be using. Activity Information 2. Proposed Activity Name: 3. Has this activity been accredited in the past by the ETSU Office of CME? 4. Brief description of proposed 1 Additional Planner Comments Office Use Only Additional Planner Commentsvii No Yes. When? Additional Planner Commentsviii Additional Planner Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016 5/4/2016 activityix Comments 5. Proposed Date: Additional Planner Comments 6. Activity proposed beginning and ending time: Additional Planner Comments 7. Proposed number of education hours for the activity: Additional Planner Commentsx 8. Location: (city and facility) Facility: City: 9. This activity is being planned by: An Academic Medical College/Department A hospital/healthcare network or it’s affiliated Medical Staff Organization Other: Please describe 10. What is the name of the sponsoring college, department or organization? (Please note: no education will be approved that imparts only knowledge. All educational activities must also address either competency or performance.) 13. What data do you have that 2 Additional Planner Comments Additional Planner Comments Documenting the Need 11. What leads you to believe this education is needed? 12. Why do you believe your learners need this education? Additional Planner Comments Learners need additional knowledge (A Knowledge need) They have the knowledge, but need additional tools, processes or skills to act on that knowledge (A Competency need) They have the knowledge and skills, but need support in performing at a consistent level (A Performance need) Requests by participants in previous Office Use Only Additional Planner Commentsxi Additional Planner Commentsxii Planner Note: For PARS DATA, this activity is considered A Competency Activity A Performance Activity A Patient Outcome Activity Additional Planner Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016 5/4/2016 supports this need? xiii education activities Organizational mandate or new initiative Emerging clinical guidelines or new technology Focused discussion with the physicians who would potentially attend the seminar Quality improvement or performance data Primary research on physicians in the targeted communities Other. Please explain: 14. All continuing medical education must contribute to physician competency. The following is a list of ABMS/ACGME Physician Competencies. Please check those that would be addressed in this activity. Patient carexv Practice-based learning and improvementxvi Interpersonal and communication skillsxvii Professionalismxviii Medical knowledgexix Systems-based practicexx 15. What barriers to learning do you believe might exist in your target audience?xxi 16. How will you design your activity to help break down those barriers? Additional Planner Comments Additional Planner Commentsxxii Program Format 17. Please describe the program format for the activity (check any that apply) 3 Commentxiv Case-based presentations Lecture Panel discussion Simulation Skills-based training Small group discussion Other. Please describe: Office Use Only Additional Planner Comments Planner Note: For PARS DATA, this conference is categorized as Case-based presentations Lecture Panel discussion Simulation Skills-based Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016 5/4/2016 training Small group discussion Other. Please describe: Learning Objectives 18. What will you look for (in learner competency, performance or patient outcomes) that will indicate this activity has been successful?xxiii 19. How and when will you measure this expected outcome? 20. Please translate these desired outcomes into 2-5 learning objectives for the activity: Office Use Only Additional Planner Commentsxxiv Additional Planner Commentsxxv As a result of participating in this activity, the attendee should be able to……. 1. Additional Planner Commentsxxxii (For assistance in crafting your objectives, hover you mouse over a footnote number to view examples of verbs that convey “Knowledge”xxvi , “Comprehension”xxvii, “Analysis”xxviii, “Ability to Evaluate”xxix, “Application”xxx “Skill demonstration”xxxi) Target Audience Office Use Only 21. Who is your intended physician audience? Family Medicine Physicians Internal Medicine Physicians OB/GYN Physicians Pediatricians Psychiatrists Surgeons Emergency Medicine Other Specialists – Please List: Additional Planner Comments 22. Who is your intended nonphysician audience? Advanced Practice Nurses Physician Assistants Pharmacists Additional Planner Comments 4 Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016 5/4/2016 Psychologists Nurses Medical or Nursing Students Other Specialists – Please List: 23. From what college, department, community, region, or organization do you expect your attendees to come? 28. Target Audience Size ETSU NE TN Region Knoxville Region SW VA Region State of Tennessee National An Organization’s Medical Staff – Please list: Other– Please List: Physicians : NP/PAs: Non Physicians: residents) (excluding residents) Additional Planner Comments (including Commercial Financial Support 24. Do you intend to seek commercial support for this activity? Additional Planner Comments Yes No Office Use Only Additional Planner Commentsxxxiii Additional Planner Comment for PARS Data Anticipating: Grants Exhibits Activity Director Information 25. Name of Activity Directorxxxiv 26. Title 27. Specialty 28. Organization Name / College / Department 29. Address 5 Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016 5/4/2016 30. E-mail Address 31. Phone 32. Fax Planning Committeexxxv Name and Title Specialty Phone Number E-mail Address Contact Information Contact Person Name Title Organization Address Phone Number Fax Number E-Mail Is this the person who is responsible for the day to day support of this activity? Yes No. If no, please detail below: Responsible individual’s name Department Position Phone number Fax number Email address (more) 6 Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016 5/4/2016 Next Steps You may call the Office of Continuing Medical Education during business hours to receive assistance with completing this application, or to discuss anything related to your potential activity. Our number is 423-4398081. Save this as a Word document, and email it to nolandm1@etsu.edu. Within a few days one of our educational planners will give you a call. BECAUSE WE WILL BE ADDING ADDITIONAL COMMENTS TO THE DOCUMENT, WE MUST RECEIVE IT IN ITS ELECTRONIC FORMAT. Submit Required Attachments Below is the list of additional required attachments. Your application cannot be processed without the following. All required attachments can be sent electronically or faxed. Our fax number is 423 439 8040. Our application e-mail address is nolandm1@etsu.edu. Action Activity Director Provide CV or Resume Required Complete Conflict of Interest Disclosure Required Sign Required Signatures Form Signature Required Contact Person All Planning Academic Committee Department Members Chair or Healthcare Executive Instructions Required only if he/she participates on Planning Committee Required only if he/she participates on Planning Committee. Required Not required Please see instructions below to include your CV Required Not required Go to this link to complete. Please copy and send this link to all that need to complete a conflict of interest. Please note, you must have your CV ready to attach to your conflict of interest disclosure Not Required Not Required Sign Required Signatures Form Required Signature Form can be obtained at this link: It can be copied and given to the Activity Director and the Chair/Healthcare Executive for signatures. They do not both need to sign the SAME form. We will accept either electronic or faxed copies. - End of Document - 7 Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016 5/4/2016 Footnotes i Instructions: This application is in MS Word, and is a form. To complete, put your cursor in a grey shadowed area and start typing. It is difficult to spell check in a Word Form, so be aware that this is not a problem to us if your spelling is not perfect. If you are the person completing this application, it is important that you have significant information on the need, focus and expected outcomes of the proposed activity. If this is the first time you have completed one of our applications, we do not expect you to complete this application flawlessly. Once we have received it, our planners will assist you in further refining your application until it is ready for the Advisory Board’s review. This consultation process is what makes it necessary for the application to be submitted according to the deadlines. You may contact us at any time if you need clarification on the application or the process. Once the application is complete, you may either e-mail it to cmeadean@etsu.edu or call the Office of Continuing Medical Education at (423)439-8081. The contact information is listed at the end of the application. ii Deadlines: All applications and their supporting documentation receive a thorough internal review before they are submitted to the Advisory Board. Deadlines are set to accommodate that internal review, and to provide the best opportunity for the activity to be approved. Advisory Board meetings are the first week of the month. Applications for live conferences must be received by the 10th day of the month preceding the next Advisory Board meeting. For example, an application that is going to be reviewed by the board the first week of May must be submitted to the Office of Continuing Medical Education by April 10. iii The Advisory Board does not meet in December or July. Applications which would ordinarily be submitted for December or July review, will need to be reviewed at the November or June meetings respectively. iv Add an additional 90 days of planning time to the above application deadlines if your organization would like assistance in securing educational grants to support the program. PLEASE NOTE THAT NO COMMERCIAL SUPPORT CAN BE REQUESTED OR RECEIVED BY ANY PARTY TO THE ACTIVITY EXCEPT THE OFFICE OF CONTINUING MEDICAL EDUCATION FOR ANY PROGRAMS ACCREDITED BY THE OFFICE OF CME AT ETSU. v If the applicant would like a brochure developed for the program, add 60 days to the application deadline, to assure that adequate planning is underway to have the speaker information available for brochure development. WHILE A BROCHURE OR “SAVE THE DATE” CARD COULD BE MAILED PRIOR TO RECEIVING APPLICATION APPROVAL, NO STATEMENT OF ANY KIND CAN BE INCLUDED RELATED TO CME CREDIT PENDING OR AVAILABLE. vi Office of Continuing Medical Education James H. Quillen College of Medicine East Tennessee State University Box 70572 Johnson City, TN 37614-1708 Phone: 423-439-8081 Fax: 423-439-8040 Email: dnolandm1@etsu.edu. Website: www.etsu.edu/cme vii Planner Notes: If this is a Joint Providership, please add the entity name to the front of the program name. viii Planner Notes: Please notate the program number from when it was previously held ix EXAMPLE A one day conference for pediatricians and family medicine physicians on the developmental problems most frequently encountered in children under the age of 20 in Appalachia. x Planner Notes: Please adjust hours if needed and attach documentation, if available xi Planner Notes: Please translate the need into the “Learning Gap” 8 Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016 5/4/2016 Planner Notes: Please accept or modify as appropriate, assuring the need matches the format and objectives. Also notate if the activity as envisioned by the applicant is designed to address competency or performance, and not impart only knowledge. xii xiii Examples of data that demonstrates need: Continuous quality improvement data; Accreditation site visit reports; Accreditation requirements; Health policy studies; Incident reports/Sentinel events; Patient records and databases; Professional review organization studies; Government reports on health statistics, technology developments, etc.; Practice audits and reviews; Recent research articles describing the need; New techniques, protocols, clinical pathways or guidelines; Organizational policy or board mandates; Consensus reports from workshops and committees; Primary research; Published expert opinions; Outcomes of physician surveys; Evaluation summaries from previous CME activities; Written faculty perceptions and recommendations; Committee notes; Focus groups; Informal discussions with peers; xivPlanner Notes: Please comment if the data is adequate as is or if you are supplying additional data (and attach or note the citation where it can be accessed) xv Patient care that is compassionate, appropriate, and effective for the treatment of health. xvi Practice-based learning and improvement requires investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and documented improvements in patient care. xvii Interpersonal and communication skill results in effective information exchange and team interaction with patients, their families, and other health professionals. xviii Professionalism is manifest by a commitment to carryout professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. xix Medical knowledge demonstrates established and evolving biomedical, clinical and cognate (e.g., epidemiological and socialbehavioral) sciences and the application of this knowledge to patient care. xx System-based practice is manifest 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. xxi Examples of barriers to learning might include such issues as beliefs and attitudes, technology, schedules, organizational dynamics xxii Planner Notes: Please comment on whether or not the barriers have been adequately addressed xxiii An example would be an observed improvement in the type and timing of diagnostic testing on potential stroke patients after physician education on the new evidence based guidelines on Acute Stroke. xxiv Planner Notes: Please accept or modify as appropriate xxv Planner Notes: Please accept or modify as appropriate 9 Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016 5/4/2016 xxvi Verbs that inform: Cite, Define, Describe, Identify, List, Name, Recite, Record, Recognize, Select, State, Summarize, Update, Write xxvii Verbs that denote comprehension: assess, associate, classify, compare, contrast, demonstrate, describe, differentiate, distinguish, estimate, explain, locate, identify, interpret, predict, report, review xxviii Verbs that indicate analysis: analyze, appraise, contrast, criticize, detect, differentiate, distinguish, evaluate, infer, measure, question, summarize xxix Verbs used to evaluate: assess, choose, compare, critique, decide, determine, estimate, evaluate, measure, rate, recommend, select xxx Verbs that demonstrate application: apply, calculate, choose, demonstrate, develop, examine, illustrate, interpret, locate, operate, practice, predict, report, review, select, treat, use, utilize xxxi Verbs that demonstrate skills: demonstrate, diagnose, integrate, manage, measure, operate, perform, record xxxii Planner Notes: Please refine and format as required xxxiii Planner Notes: If commercial support will be sought, please define what kind of support xxxiv The Activity Director must be a physician or nurse practitioner. The Activity Director must have direct involvement in the planning of the activity, and will need to be in a position to collaborate with the Office of Continuing Medical Education as the planning unfolds. xxxv EXAMPLES: Multidisciplinary (Team) Conference in Geriatrics, e.g.: Activity Director – Physician (Geriatrician) Community Physician with interest in geriatrics Clinical Pharmacist APN with interest/specialty in geriatrics Physical Therapist with interest/specialty in geriatrics Clinical Social Worker or Representative from long-term care facility EXAMPLES: Pediatric Specialty Conference, e.g.: Activity Director – Physician (Pediatrician with interest in topic) Family Medicine Physician Pediatric Resident/Fellow FNP Representative from practice site Public Health Representative 10 Office of Continuing Medical Education, Quillen College of Medicine, East Tennessee State University, May 2016