VENTURA COUNTY MEDICAL CENTER
SANTA PAULA HOSPITAL
Associated with the UCLA School of Medicine
ADMINISTRATIVE POLICY
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PROCEDURE:
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VCMC CONTINUING MEDICAL EDUCATION
CME PLANNING, DOCUMENTATION AND SUBMISSION FOR
CME APPROVAL
SUBJECT: PURPOSE OF DEPARTMENT
DEPARTMENT:
AFFECTS:
APPROVED BY:
OFFICE OF MEDICAL EDUCATION
EFFECTIVE DATE:
REVISION DATES:
5/15/2013
9/25/2013; 12/5/2013
ALL DEPARTMENTS
Cheryl Lambing, M.D., FAAFP, CME Director
Medical Director, Professional Education, Ventura County Health Care Agency
REVIEW DATES:
9/25/2013; 12/5/2013
Renee Higgins, M.D.
Chief Operations Officer, Ventura County Health Care Agency
Continuing Medical Education Committee Medical Staff, Staff and Members
PURPOSE
The purpose of the Continuing Medical Education (CME) Program is to assess the educational needs of
Ventura County Medical Center (VCMC) Medical Staff and, as determined by those needs, to provide
broad educational programs of excellence that will enhance optimal patient care.
The Ventura County Medical Center, Department of CME will make available to the Activity Medical
Directors the CME Application and Planning Worksheet. The worksheet can serve as a useful tool to
guide the planning of CME activities and to help document the process.
Protocol for CME Planning
In general, the process of planning a CME program should begin 2-12 months in advance, with the
application submitted for review to the CME Department 2-6 weeks prior to activity date. While there are
common components, a worksheet should fit the unique aspect of each qualified CME program. Attach
extra sheets to document the planning stages.
Review 2013 IMQ/CMA Accreditation Criteria and Policies for Continuing Medical Education effective
September 1, 2013 on file in the Medical Education office. This provides the information for the CME
activity planning committee.
Common Components required for Accredited CME:
1) Documentation of Needs Assessment
For example, Adverse Events from Committees, Department Meetings, Performance Improvement
Committee, Chart Review, Committee Reports--committees which recommended CME topic for
inclusion in the overall VCMC CME program.
2) Required Disclosure Form
All committee members, planning members, staff, and speakers must submit a CME disclosure form
which covers each 12-month period and must include their spouse/partner. For regular Ventura
County Health Care Agency Medical Staff and CME support staff, this disclosure may be submitted
once a year to be updated if circumstances change. All disclosures are reviewed by the CME
Director or designee annually. The Documentation of Needs Assessment Data should include, for
instance, summary from committee or department meetings, summary of a patient care item or
diagnosis. If a committee refers a CME topic, the specific date and committee should be noted such
that disclosures for the committee members can be matched to the CME Application.
3) Needs Assessment Documentation
a. Where did the recommendation come from? What is the evidence that this CME topic is
necessary and will meet the Definition of Continuing Medical Education as defined by the
State of California Legislature (see page 7 of the IMQ/CMA Document). Indicate areas on
Needs Assessment Data and Sources (page 4 of the planning document) and submit
supporting documentation. If no documentation is submitted for the activity, the activity will
not be considered for CME.
b. Document with written notes, email, minutes, committee meetings (live or conference call),
the names of participants who planned the CME activity with the submission of an application
for CME credit.
c. Document the analysis of the Needs Assessment that led to the planning of the proposed
CME activity. Research and include the Cultural and Linguistic Components (minimum of 2
required for any medical practice program). Document the required elements (educational
need/Cultural and Linguistic Components) that you will require the presentation(s) to address.
d. Provide documentation of preliminary invitation to potential speakers. The letter should
include the unmet need that the planning committee would like to be addressed and at
minimum 2 Cultural and Linguistic areas that have already been researched by the planning
committee. The invitation should also reference the date that all materials are due to the
CME provider (VCMC) in order for the program to be considered for CME (the speaker’s CV,
the PowerPoint or other handout for review, objectives as determined by the committee in
working with the desired presenter). The invitation should note attachments including but not
limited to disclosure form, which covers the last 12 months and includes the spouse/partner.
e. Submit application and all required documents to the VCMC Medical Education Office no
later than 2 weeks prior to the desired program date to ensure there is adequate time for
review and to resolve any conflicts. Applications are accepted at any time and the CME
committee meets monthly. Each step needs to be carefully documented/on file. Please call
the Medical Education Office at 652-6228 for the next scheduled Committee Meeting.
Presenter CV and PowerPoint or handout will need to be submitted for review and approval.
f.
No publicity for the activity may be distributed until CME is approved. All publicity and flyers
must be submitted for review and approved before distributing. No publicity may indicate that
“CME is pending”. Once CME is approved, all publicity, flyers, disclosure, handouts (learner
activity materials), and/or materials listing faculty or objectives must include the appropriate
Accreditation Statement shown below. Italics must be used where designated AT ALL
TIMES along with the required trademark where indicated. There are NO EXCEPTIONS TO
THIS REQUIREMENT.
Approved Accreditation Statement for VCMC directly-sponsored activities:
VCMC is accredited by the Institute for Medical Quality/California Medical Association (IMQ/CMA)
to provide continuing medical education for physicians.
Approved AMA Credit Designation Statement
CME MUST consistently use the appropriate accreditation statement(s) on all publicity and learner
materials for educational activities. The following complete, italicized, trademarked AMA Credit
Designation Statement must be written without paraphrasing and be listed separately from accreditation
or other statements and included in relevant announcement and activity materials:
VCMC designates this [learning format is inserted here] for a maximum of [number of credits is
inserted] AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit
commensurate with the extent of their participation in the activity.
The accreditation statement, the credit designation statement, and the CME Certification statement
should all be on separate lines.
Conflict of Interest
If conflicts of interest or content cannot be resolved, there are 3 options available for the planning group:
a) cancel the program, b) reschedule for a future date, or c) provide the program without CME.
Evaluation
Work with the Department of CME to prepare the Evaluation Form as required for all accredited
activities. Objectives for the CME program must be outcome based. (See Attachment B - IMQ Tips to
Writing Learning Objectives for CME Activities, Copyright 2011) The CME Committee will periodically
assess the target audience using survey methodology for self-reported change.
Disclosures
Disclosures (and any conflicts that have been resolved by the VCMC policy) must be provided to the
participants BEFORE the program begins. This will be accomplished verbally, by slide introduction and
by inclusion in written materials.
Compliance Monitor
Establish a monitor who will verify that all requirements are met on the day of the program. This person
cannot be the Activity Medical Director or the speaker (cannot monitor self). This individual will provide a
report of compliance for the CME activity to Medical Education for the Activity file.