Live Course/Class
CME Program Application
Please Note: Throughout this document, endnotes are used to provide you with additional
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information in the actual endnote.
Information available to person completing the application:
 Instructions:i
 Deadlines:ii
o Caution related to the months the Board does not meetiii
o Course/class for which Educational Grants are being soughtiv
 Contact Informationv
Activity Type
1. Type of Course/Class
A course/class which may be offered once or
more times during the year. Each time the
course is offered participants change, but not the
content. Example: ACLS, Fundamentals of Critical
Care
Other, please describe.
Course Information
2. Proposed Course/Class Name:
3. Brief description of proposed
course/classvi
4. Is this a course (in which the content is
offered during multiple sessions) or is
it class (in which all the content is
offered in one session)?
1
Course
How many sessions are there in one course?
How many hours of contact are there in each
session?
How many hours of contact are there in the
entire course?
Class
How many times in the next year to you
anticipate this class being offered?
How many hours of contact in the class?
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, April 2011
Please attach a schedule for the course/class for the application year, including number of times
it is offered, proposed dates, and start and end times,
5. Location: (city and facility)
6. This course/class is being planned by:
An Academic Medical College/Department
A hospital/healthcare network or it’s affiliated
Medical Staff Organization
Other: Please describe
7. Has this course/class been accredited
in the past by the ETSU Office of CME?
No
Yes. When?
Documenting the Need
8. What leads you to believe this
education is needed?vii
9. What data do you have that supports
this need? viii
10. How will this educational course/class
address this need? (Check all that
apply)
11. All Continuing Medical Education is
required to contribute to physician
competency. The following is a list of
ABMS/ACGME Physician
Competencies. Please check those
2
Quality improvement or performance data
Potential participant’s request
Organizational mandate or new initiative
Joint Commission or other accrediting body
requirement
Emerging clinical guidelines or new technology
Other. Please explain:
It will impart:
Knowledge: No course/class will be approved
that provides ONLY knowledge. While the
course/class can impart knowledge, it must also
address Competency or Performance
Competency: The course/class provides
knowledge AND the process, strategy, or tools to
apply that knowledgeix
Performance: The course/class arises out of
performance or quality improvement data,
examines current clinical practice performance
and measures it against established guidelines,
newly developed or adopted performance
standards, or previous performance data x
Patient carexi
Practice-based learning and improvementxii
Interpersonal and communication skillsxiii
Professionalismxiv
Medical knowledgexv
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, April 2011
Systems-based practicexvi
that would be addressed in this
course/class.
Course/Class Format
12. Is this program being offered in
No, we are developing the content and choosing
conjunction with a third party who
the instructor(s)
stipulates the content, instructor
Yes, the course/class specifics are stipulated by a
requirements, format, and stipulates
third party
the mode and/or content of testing?
Who is that third party?
What do they stipulate?
Content
Format
Schedule
Instructor qualifications
Testing process and execution
Hand out materials
Testing forms
Sign in Sheets
Evaluations forms
13. What format will be used to support
the learning?xvii
Case presentations
Clinical skills assessments
Computer assisted learning
Lecture
Hands on skills lab
Panel discussion
Self assessment
Simulation or standardized patients
Teleconferencing
Video or audio presentations
Workshops
Other. Please describe:
Learning Objectives
14. What will you look for (either in
clinical practice or patient outcomes)
that would indicate this course/class
has been successful?
15. How and when would you measure
that outcome?
16. Please translate these desired
outcomes into 2-5 learning objectives
for the course/class:
(For assistance in crafting your
objectives, hover you mouse over a
3
As a result of participating in this course/class, the
attendee will be able to…….
1
2
3
4
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, April 2011
footnote number to view examples of
verbs that convey “Knowledge”xviii ,
“Comprehension”xix, “Analysis”xx,
“Ability to Evaluate”xxi, “Application”xxii
“Skill demonstration”xxiii)
17. Who is your intended physician
audience?
5
Target Audience
Internal Medicine Physicians
Family Medicine Physicians
OB/GYN Physicians
Surgeons
Pediatricians
Psychiatrists
Emergency Medicine Physicians
Pathologists
Other Specialists – Please List:
18. Who is your intended non-physician
audience?
Advanced Practice Nurses
Physician Assistants
Pharmacists
Psychologists
Nurses
Medical or Nursing Students
Other Specialists – Please List:
19. From what community, region, or
organization do you expect your
attendees to come?
ETSU
NE TN Region
Knoxville Region
SW VA Region
State of Tennessee
National
An Organization’s Medical Staff – Please list:
Other– Please List:
28. Target Audience Size per course/class
Physicians
Nurse Practitioners and PAs
Other clinical and support staff:
Activity Director Information
20. Activity Director
namexxiv
21. Title
22. Specialty
4
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, April 2011
23. Organization Name / College /
Department
24. Address
25. E-mail Address
26. Phone
27. Fax
Name and Title
Planning Committeexxv
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 course/class?
5
Yes
No. If no, please detail below:
Responsible individual’s name
Department
Position
Phone number
Fax number
Email address
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, April 2011
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 423-439-8081.
Return this form (In its electronic version) via e-mail to dougherty@etsu.edu. Within a few days one of our educational
planners will give you a call.
Required Attachments
1) You must provide the following documents with your application:
a) A “Required Signatures Form” that has imbedded in it the Activity Director’s Conflict of Interest Disclosure and
his or her signature accepting responsibility for the program. Click this link to access this form: Required
Signature Form
b) The Activity Director’s CV/Resume
c)
A copy of any data you may have that demonstrates the need for this program, as addressed in Question 9.
2) Additional documents required before the Advisory Board Meeting (1st Thursday of each month) are:
a) A “Conflict of Interest Disclosure” completed by each member of the Planning Committee. This takes no more
than 1 minute, and can be accomplished by sending this link to each member of the planning committee:
http://com.etsu.edu/esurvey/Survey.aspx?surveyid=1405
b) The CV/resume of each member of the Planning Committee
3) All required attachments can be sent by fax or scanned and returned to us via email. Our fax number is 423 439
8040. Our application e-mail address is dougherty@etsu.edu.
Person
Activity Director
Contact Person
Planning Committee
Members
Department Chair or
Healthcare Executive
Instructions:
6
CV
Conflict of
Interest
Disclosure
X
Required
Signature
Form
X
X
X
X
X
Comments
Activity Director’s COI disclosure is
embedded in the Required Signature Form
CV and Conflict of Interest Disclosure
required of Contact Person only if they
participate on the planning committee.
Send COI link to all members of the planning
committee: Planning Committee Member
Conflict of Interest Disclosure Statement
X
Send to
CME via
fax or email
Send this
link to all
planning
committee
members
Planning
Committee
Member
Conflict of
Interest
Disclosure
Statement
To obtain
form, follow
this link
Required
Signature
Form
Contact information
Phone Number: 423-439-8081
Fax Number: 423 439 8040
E-mail address for applications and
attachments: JohnsonC@etsu.edu
Send
completed
form to CME
via fax or email
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, April 2011
- End of Document -
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 course/class.
 If this is the first time you have completed one of our applications, we do not expect you to complete this
application flawlessly. However, you must complete it thoughtfully. 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, please e-mail in its current electronic format to the Office of Continuing Medical
Education. 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 course/class to be approved.
 Advisory Board meetings are the first week of the month. Applications for a Course/class must be received by the
10th day of the month that PRECEEDS submission to the Advisory Board. 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 January or July. Applications which would ordinarily be submitted for January or
July review, will need to be reviewed at the December or June meetings respectively. This shortens your application
deadline by an additional month. Contact us by phone if you are caught by this unawares.
iv
Commercial support is rarely sought for Course/class. Please discuss this with your CME Planner, and be aware that
NO commercial support can be requested or received by any party to the course/class except by the Office of Continuing
Medical Education.
v
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: dougherty@etsu.edu
Website: http://www.etsu.edu/com/cme/
Example: A four week course, 3 hours each week, teaching the fundamentals of critical care for physicians,
nurses, nurse practitioners, PAs and EMTs who work for or are under hospitalist contract with Smith-Wilson
Memorial Hospital
vii Consider: Without “X” (Where “X” describes knowledge, skills and abilities provided in this activity),
PHYSICIANS (Cannot, will not, may not, do not, etc.) “Y” (where “Y” is a description of the desired clinical practice
or patient outcome). Example: Without yearly certification in pediatric life support, physicians in the Emergency
Department may not adequately perform infant cardiac resuscitation.
viii
Examples of data that demonstrates need:
 Continuous quality improvement data;
 Accreditation site visit reports;
 Accreditation requirements;
vi
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, April 2011
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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 ;
ix
Competency: Examples of activities that achieve competency are those that have a skill or knowledge achievement
that is measured by testing or observation (Such as ACLS, NCC Certification Testing). Other examples of competency
related activities are those in which the participant leaves the course/class with tools, e.g. flow diagrams, clinical
guidelines, or chart forms which he/she can incorporate immediately in clinical practice, thus implementing the newly
acquired knowledge.
OUTCOME MEASUREMENT OF COMPETENCY includes pretest/post test, case presentation with audience Q & A and self
reported changes in practice, measured after the fact.
x
Performance: Activities include those in which QI or process improvement is used to identify a problem, a change is
identified and implemented, and the same process is used to identify the (+/-) change in the practice performance or
patient outcomes. Examples include activities where physicians, in conjunction with a healthcare organization, and
based on some QI, sentinel event, or other objective data, examine the appropriateness of their clinical practice
guidelines, study the evidence as to the best guidelines to choose or incorporate into practice, educate the medical staff
on the newly established guidelines, and re-measure the same data or performance after the guidelines have been
implemented.
Another example is when a physician audits his/her own practice against established evidence based guidelines for a
specific patient population, making a change in process or policy, and after a time, re-auditing the practice against the
same guidelines. The performance outcome is achieved when the later audit is measured against (+/-) the previous one.
OUTCOME MEASUREMENT OF PERFORMANCE includes objective data such as percent of change in practice
performance or patient outcomes measured over time.
xi
Patient care that is compassionate, appropriate, and effective for the treatment of health.
xii
Practice-based learning and improvement involves investigation and evaluation of their own patient care, appraisal
and assimilation of scientific evidence, and improvement in patient care.
xiii
Interpersonal and communication skill results in effective information exchange and teaming with patients, their
families, and other health professionals.
xiv
Professionalism is manifest by commitment to carryout professional responsibilities, adherence to ethical principles,
and sensitivity to a diverse patient population.
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, April 2011
xv
Medical knowledge demonstrates established and evolving biomedical, clinical and cognate (e.g., epidemiological and
social-behavioral) sciences and the application of this knowledge to patient care.
xvi
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.
xvii
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Examples of Educational Format:
Case presentations;
Clinical skills assessments;
Computer assisted learning;
Lecture; Hands on skills lab;
Panel discussion; Self assessment;
Simulation or standardized patients;
Teleconferencing;
Video or audio presentations;
Workshops;
Other.
xviii
Verbs that inform: Cite, Define, Describe, Identify, List, Name, Recite, Record, Recognize, Select, State, Summarize,
Update, Write
xix
Verbs that denote comprehension: assess, associate, classify, compare, contrast, demonstrate, describe,
differentiate, distinguish, estimate, explain, locate, identify, interpret, predict, report, review
xx
Verbs that indicate analysis: analyze, appraise, contrast, criticize, detect, differentiate, distinguish, evaluate, infer,
measure, question, summarize
xxi
Verbs used to evaluate: assess, choose, compare, critique, decide, determine, estimate, evaluate, measure, rate,
recommend, select
xxii
Verbs that demonstrate application: apply, calculate, choose, demonstrate, develop, examine, illustrate, interpret,
locate, operate, practice, predict, report, review, select, treat, use, utilize
xxiii
Verbs that demonstrate skills: demonstrate, diagnose, integrate, manage, measure, operate, perform, record
xxiv
The Activity Director must be a physician or nurse practitioner. The Activity Director must have direct involvement in
the planning of the course/class, and will need to be in a position to collaborate with the Office of Continuing Medical
Education as the planning unfolds.
xxv
EXAMPLE: Specialty Speaker (same curriculum, various locations), e.g.:
 Activity Director (Physician speaker)
 Primary Care Physician (representing target audience)
 Rural Physician (representing target audience)
(Committee must have contact with a representative from each site/location that speaker intends to present at, to
determine needs of target audience at that site.)
EXAMPLE: Quality Improvement Course, e.g.:
 Activity Director – Physician who sits on QI or Peer Review Committee of that institution.
 Physician(s) from medical staff
 QI Representative (from institution(s))
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, April 2011