4/11/2016
Regularly Scheduled Series
CME Program Series Application
Quillen College of Medicine, East Tennessee State University, Office of Continuing Medical Education
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 meet iii
o Regularly Scheduled Series for which Educational Grants are being soughtiv
 Contact Informationv
Activity Type
1. What type of series are
you proposing?
Grand rounds
Journal club
M&M, or Case Conference
(except cancer case conferences,
which have their own
application)
Medical staff lecture series
Clinical guideline or pathway
development
Other. Please call us at 423 439
8081 to determine which
application you should be using.
Series Information
2. Proposed Series Name:
3. Has this activity been
accredited in the past by the
ETSU Office of CME?
4. Brief description of
1
Office Use Only
Additional Planner
Comments
Office Use Only
Additional Planner
Commentsvi
No
Yes. When?
Additional Planner
Commentsvii
Additional Planner
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
4/11/2016
proposed seriesviii
Comments
5. Proposed Start Date:
Additional Planner
Comments
(If approved, accreditation of this
series will expire 364 days from
when it was approved)
6. Frequency of the program:
Frequency
Semi Annually
Quarterly
Bi monthly (6 meetings
per year)
Monthly
Bi-weekly (25 meetings
per year)
Weekly
Additional Planner
Comments
Day of the Week
Monday
Tuesday
Wednesday
Thursday
Friday
Week of the Month
First Week
Second Week
Third Week
Fourth Week
Other:
7. Beginning and ending time
of the session:
Additional Planner
Comments
8. Proposed number of
education hours for each
session in the series:
9. Location:
Additional Planner
Comments
Facility/Building:
City:
10. This series is being planned
by:
11. What is the name of the
sponsoring organization?
2
Medical school/department
A hospital/healthcare network
or its affiliated medical staff
organization
Other: Please describe
Additional Planner
Comments
Additional Planner
Comments
Additional Planner
Comments
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
4/11/2016
Documenting the Need
12. What leads you to believe
this education is needed?
13. What data do you have
that supports this need?
14. Why do you believe your
learners need this
education?
(Please note: no education
will be approved that
imparts only knowledge.
All educational activities
must also address either
competency or
performance.)
15. What barriers to learning
do you believe might exist
in your potential
learners?xii
16. How will you design your
activity to help break down
those barriers?
17. All Continuing Medical
Education is required to
contribute to physician
competency. The
following is a list of
ABMS/ACGME Physician
Competencies. Please
check those that would be
addressed in this series.
3
Quality improvement or
performance data
Potential participant’s request
Organizational mandate or new
initiative
Emerging clinical guidelines or
new technology
ABMS/ACGME competencies
that need to be addressed
Other. Please explain:
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)
Office Use Only
Additional Planner
Commentsix
Additional Planner
Commentsx
Additional Planner
Commentsxi
Planner Note: For PARS
DATA, this activity is
considered
A Competency
Activity
A Performance
Activity
A Patient Outcome
Activity
Additional Planner
Comments
Additional Planner
Commentsxiii
Patient carexiv
Practice-based learning and
improvementxv
Interpersonal and
communication skillsxvi
Professionalismxvii
Medical knowledgexviii
Systems-based practicexix
Additional Planner
Comments
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
4/11/2016
Program Format
18. Please describe the
program format for the
series
19. Note: Applies to Casebased conferences only:
Do you have plans to video
conference this case
conference to a remote
site?
Case-based discussion
Lecture
Panel discussion
Simulation
Small group discussion
Skill-based training
Other. Please describe:
Additional Planner
Comments
Does not apply
No, do not intend to video
conference this case conference
Yes, we would like to video
conference this activity
1. To what site(s)?
2. Will the technology allow for
real-time discussion
between both sites?
No
Yes. If yes, applicant
must list the name and
contact information for the
person at the remote site
that will be accountable for
management of the learning
activity while it is occurring.
ETSU will confer with that
individual for training and to
review accountabilities.
Please list individual’s name
and contact information
here:
Additional Planner
Comments:xx
Learning Objectives
4
Office Use Only
Planner Note: For PARS
DATA, this conference is
categorized as
Case-based
presentations
Lecture
Panel discussion
Simulation
Skills-based training
Small group
discussion
Other. Please
describe:
Office Use Only
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
4/11/2016
20. What will you look for (in
learner competency,
performance or patient
outcomes) that will
indicate this activity has
been successful?xxi
21. How and when will you
measure this expected
outcome?
22. Please translate these
desired outcomes into 1-3
learning objectives for the
activity:
(For assistance in crafting
your objectives, hover you
mouse over a footnote
number to view examples
of verbs that convey
“Knowledge”xxiv ,
“Comprehension”xxv,
“Analysis”xxvi, “Ability to
Evaluate”xxvii,
“Application”xxviii “Skill
demonstration”xxix)
Additional Planner
Commentsxxii
Additional Planner
Commentsxxiii
As a result of participating in this
activity, the attendee should be able
to…….
1
2
3
Target Audience
Additional Planner
Commentsxxx
Office Use Only
23. Who is your intended
physician audience?
Family Medicine Physicians
Internal Medicine Physicians
OB/GYN Physicians
Pediatricians
Psychiatrists
Surgeons
Emergency Medicine Physicians
Other Specialists – Please List:
Additional Planner
Comments
24. Who is your intended nonphysician audience?
Advanced Practice Nurses
Physician Assistants
Pharmacists
Psychologists
Nurses
Medical or Nursing Students
Other Specialists – Please List:
Additional Planner
Comments
5
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
4/11/2016
25. From what department,
community, region, or
organization do you expect
your attendees to come?
ETSU
College of Medicine
Department:
Health Science College:
Additional Planner
Comments
Tri-Cities
NE TN Region
Knoxville Region
SW VA Region
State of Tennessee
National
An Organization’s Medical Staff
– Please list:
Other– Please List:
26. Target Audience Size
Physicians (excluding
residents)
Physician Residents
APNS/PAs
Other Non-Physicians
Commercial Financial Support
27. Do you intend to seek
commercial support for
this activity? xxxi
Yes
No
Additional Planner
Comments
Office Use Only
Additional Planner
Commentsxxxii
Additional Planner
Comment for PARS Data
Anticipating:
Grants
Exhibits
Activity Director Information
28. Name of Activity
Directorxxxiii
29. Title
30. Specialty
6
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
4/11/2016
31. Department / College /
Organization
32. Address
33. E-mail Address
34. Phone
35. Fax
Planning Committeexxxiv
Name and Title
Specialty
Phone Number
E-mail Address
Contact Information
36. Contact Person
Name
37. Title
38. Organization
39. Address
40. Phone Number
41. Fax Number
42. E-Mail
43. Is this the person
who is responsible
for the day to day
support of this
series?
7
Yes
No. If no, please provide details below:
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
4/11/2016
On-site Coordinator Information
44. On-site coordinator
Name
45. Title
46. Organization
47. Address
48. Phone Number
49. Fax Number
50. E-Mail
(More)
8
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
4/11/2016
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 johnsonc@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
1) 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 johnsonc@etsu.edu.
Action
Activity
Director
Provide CV
or Resume
Required
Complete
Conflict of
Interest
Disclosure
Required,
and is
embedded
in the
Required
Signatures
Form. No
need for
Activity
Director to
go to web
link to
complete.
Signature
Required
Sign
Required
Signatures
Form
Contact
Person
All Planning
Committee
Members
Academic
Department
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
We will accept either electronic or faxed
copies
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, with the
exception of the Activity Director, who
will complete his/her conflict of interest
on Required Signatures Form.
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 9
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
4/11/2016
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.
Commercial support is rarely sought for Regularly Scheduled Series. Please discuss this with your CME Planner,
and be aware that NO commercial support can be requested or received by any party to the series except by the
Office of Continuing Medical Education.
iv
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: johnsonc@etsu.edu
Website: www.etsu.edu/cme
vi
Planner Notes: If this is a Joint Sponsorship, please add the entity name to the front of the program name.
Planner Notes: Please notate the program number from when it was previously held. Please also notate the number
of time the program met last year/the number of times it was approved to meet.
vii
viii
ix
EXAMPLE “Monthly lecture series for faculty and residents focused on emerging technology in cardiology”
Planner Notes: Please translate the need into the “Learning Gap”
Planner 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)
x
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.
xi
xii
Examples of barriers to learning might include such issues as beliefs and attitudes, technology, schedules, organizational dynamics
10
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
4/11/2016
xiii
Planner Notes: Please comment on whether or not the barriers have been adequately addressed
xiv
Patient care that is compassionate, appropriate, and effective for the treatment of health.
xv
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.
xvi
Interpersonal and communication skill results in effective information exchange and teaming with patients, their
families, and other health professionals.
xvii
Professionalism is manifest by commitment to carryout professional responsibilities, adherence to ethical principles,
and sensitivity to a diverse patient population.
xviii
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.
xix
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.
With Joint Sponsorships, only case-based conferences can be video conferenced, and then only if the technology
allows for real time discussion and participation at each site. The planner will need to discuss with the applicant
that before approval, the Joint Sponsor will need to designate an onsite contact person at the remote participating
site, and that they will need to be educated by ETSU on the process and use of the forms, including deadlines.
Planner needs to comment on this discussion in the application.
xx
xxi
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.
xxii
Planner Notes: Please accept or modify as appropriate
xxiii
Planner Notes: Please accept or modify as appropriate
xxiv
Verbs that inform: Cite, Define, Describe, Identify, List, Name, Recite, Record, Recognize, Select, State, Summarize, Update, Write
xxv
Verbs that denote comprehension: assess, associate, classify, compare, contrast, demonstrate, describe, differentiate, distinguish,
estimate, explain, locate, identify, interpret, predict, report, review
xxvi
Verbs that indicate analysis: analyze, appraise, contrast, criticize, detect, differentiate, distinguish, evaluate, infer, measure,
question, summarize
xxvii
Verbs used to evaluate: assess, choose, compare, critique, decide, determine, estimate, evaluate, measure, rate, recommend,
select
xxviii
Verbs that demonstrate application: apply, calculate, choose, demonstrate, develop, examine, illustrate, interpret, locate,
operate, practice, predict, report, review, select, treat, use, utilize
xxix
Verbs that demonstrate skills: demonstrate, diagnose, integrate, manage, measure, operate, perform, record
xxx
Planner Notes: Please refine and format as required
xxxi
Commercial support is rarely sought for Regularly Scheduled Series. Please discuss this with your CME Planner, and
be aware that NO commercial support can be requested or received by any party to the series except by the Office of
Continuing Medical Education.
xxxii
Planner Notes: If commercial support will be sought, please define what kind of support
11
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education
4/11/2016
xxxiii
The Activity Director must be a physician or nurse practitioner. The Activity Director must have direct involvement
in the planning of the series, and will need to be in a position to collaborate with the Office of Continuing Medical
Education as the planning unfolds.
xxxiv EXAMPLE: Medical Staff Grand Rounds e.g.:
 Activity Director (former Chief of Staff or Director of Med Ed)
 Members of the Medical Executive Committee
 VP Medical Affairs or Chief Operating Office
 QI Representative
12
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education