CME Application 2016 – SAMPLE
This document is a sample for planning purposes only.
All applications must be submitted through the online application process
http://meded.beaumont.edu/cme-application
Applications must be completed in one sitting. You will not be able to save and return to an application at a later time. All
applications must be submitted through this online system in order to be considered for approval. View a sample PDF of the
application for preparation and planning purposes at http://meded.beaumont.edu/cme-application
All questions require an answer, unless otherwise specified.
ACTIVITY INFORMATION
Please identify who is completing and submitting this application:
First Name
Last Name
Email
What type of event you are planning?
Each format selected is considered a separate offering.
- Course = Seminar, Conference, Workshop, etc.
- Regularly Scheduled Series = Grand Rounds, Tumor Board, M&M, Journal Club, Case Conference, etc.
- Internet Live = Web Stream
- Internet Archived = On Demand - available for long period of time at learner’s convenience
- Performance Improvement = 3-stage structured, long-term process
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Course
Regularly Scheduled Series
Internet Live
Internet Archived
Performance Improvement
What is the title/name of your event? This title will be used for all documentation and marketing.
This question only applies to Internet Live (web stream) or Internet Archived events
State the URL where the internet event will be hosted. If unknown at the time of this
application, enter TBD.
This question only applies to Course (symposium, workshop, conference) events
When is the meeting being held (select start date):
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Will you be partnering with any external (non-Beaumont Health) organizations in the planning,
development, implementation, or evaluation of this activity?
 No
 Yes
This question only applies if you will be partnering with any external organizations.
Please list all companies you are partnering with and state their primary involvement:
Company
Company Name
Company Role
Logistics
Content
Other
Company 1
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Company 2
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Company 3
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The next 2 questions only apply if you will NOT be partnering with any external organizations.
Please identify the PRIMARY Beaumont Health hospital that is "hosting" the event:
 Corporate Beaumont Health
 Dearborn
 OUWB
 Taylor
 Royal Oak
 Trenton
 Troy
 Wayne
 Grosse Pointe
 Farmington Hills
Please identify the Beaumont Health department/center taking the lead in this activity (i.e.,
Sponsoring Department): Select One
 Anesthesiology & Peri-Operative Medicine  Pathology & Laboratory Medicine
 Cardiovascular Medicine
 Pediatrics
 Colon and Rectal Surgery
 Physical Medicine & Rehabilitation
 Diagnostic Radiology
 Psychiatry
 Emergency Medicine
 Radiation Oncology
 Family Medicine
 Surgery
 General Surgery
 Urology
 Internal Medicine
 Oakland University William Beaumont School
 Medical Oncology/Hematology
of Medicine
 Obstetrics & Gynecology
 Medical Administration
 Ophthalmology
 Research Administration
 Orthopaedic Surgery
 Other ____________________
Target Audience
Primary Geographic Reach Select One
 Internal Only (Beaumont Health/OUWB)
 Local/Regional
Profession(s) Select all that apply
 All Professions
 Residents
 Physicians
 Fellows
 Physician Assistants
 Pharmacists
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 National
 International
 Nurse Practitioners
 Nurses
 Other, specify: ________
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Specialty Select all that apply
 All Specialties
 Anesthesiology
 Cardiology
 Dermatology
 Emergency Medicine
 Family Medicine
 General Medicine
 Neurology
 Ob/Gyn
 Oncology
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Ophthalmology
Orthopaedics
Pathology
Pediatrics
Psychiatry
Radiology
Radiation Oncology
Surgery
Urology
Other, specify ____________________
Which credit type(s) are you applying for?
*Additional accreditation requirements and/or fee may apply.
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AMA PRA Category 1 CME (Allopathic CME)
AOA CME (osteopathic CME)*
Trauma CME
OUWB Meaningful Participation credits
American Academy of Family Physicians CME credit*
Medical Specialty Board Maintenance of Certification credits*
This question only appears if AOA CME (osteopathic CME)* Is Selected
Which type of American Osteopathic Association credits are you applying for?
*Category 1-A: Formal osteopathic CME related to any of the seven osteopathic core competencies *Requires a minimum of
50% of the presenters be DOs or employed full time by a College of Osteopathic Medicine and the content presented must
be osteopathic in nature.
Category 2-A: Formal educational programs that are AMA accredited, but do not qualify for Category 1-A
 Category 1-A
 Category 2-A
Where is the meeting being held?
Venue
(i.e., Troy Marriott, Beaumont Royal Oak)
Room (i.e., Banquet Hall, Auditorium)
City, State
Does this activity consist of a...
 One-time event
 Series of multiple events held on different dates - schedule required
Activity Description - Optional This description will be used for marketing purposes.
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CME must review and provide final approval on all promotional and recruitment materials prior
to printing or distributing. We strongly encourage you to submit all initial drafts to CME prior
to the design and layout process. To view the CME advertising requirements/language, click
here.
 I attest that I have reviewed and agree to the CME Requirements for Event Marketing.
Would you like the CME Department to post this event on our public CME calendar
(http://meded.beaumont.edu/cme-calendar)?
 Yes
 No, this is by special invitation only
This question does not apply to Regularly Scheduled Series
Please identify which of the following optional services you would like the CME department to
provide for your event (additional fees apply):
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Design a custom website - fee starts at $100
Manage online registration - fee ranges from $0 to $1,000 (depends on complexity of registration)
Apply for educational grants - fee starts at $100 per grant application submitted by CME
Apply for additional credit types (i.e., AAFP) - fee starts at $100 per credit type + any application fee charged by the
credit organization
Print and assemble name badges - service only available if Beaumont is managing registration; fee ranges from
$250 to $500
Process/print CME handout - based on the number of copies required, fee starts at $100
On-site support for audience response system or registration - for local meetings only and depends on availability of
CME staff; fee starts at $250 per person + travel and is based on meeting location and length
No additional services are requested at this time
Design a custom conference website
Manage online registration
Apply for educational grants
Apply for additional credit types (i.e., AAFP)
Print and assemble name badges
Process/print CME handout
On-site support for audience response system or registration
The following questions only apply to Regularly Scheduled Series
Meeting Information
Start Time (i.e., 8:00 a.m.):
End Time (i.e., 9:00 a.m.):
How often is your meeting held? *Schedule required
 1/week
 2/week
 1/month
 2/month
 6/year*
 4/year*
 Varies*
Please identify the day(s) of the week your meeting is held. This meeting is held every...
 Monday
 Tuesday
 Wednesday
 Thursday
 Friday
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Please identify when your meeting is held. This meeting is held every...
 1st
 Monday
 2nd
 Tuesday
 3rd
 Wednesday
 4th
 Thursday
 5th
 Friday
Will this meeting be broadcast to another audience?
 No
 Yes - specify location(s): ____________________
How will this meeting be broadcast to other audiences? Select all that apply
 Video Conference
 Internet
 Conference Call
 Other, specify: ____________________
PLANNING COMMITTEE/FACULTY
Important Information: All individuals responsible for the planning, design, implementation, and presentation of content must
be listed. Employees of commercial interests are not eligible to serve as faculty (planner, speaker, moderator, author, etc.)
of a CME-certified activity if the content of CME they are planning/developing/presenting relates to the business lines and
products of their employer. If the spouse/significant other of a planner/presenter/moderator, etc is employed by a
commercial interest that planner/presenter/moderator will not be eligible. Disclosures must be completed for all planning
committee members and course directors before the CME application will be accepted. For more information about
Beaumont’s disclosure process click here. Please include the individual’s Beaumont and OUWB titles when applicable.
Please list all Course Director(s)
This is the individual(s) with overall responsibility for the planning, development, and implementation of this meeting. It is
preferred to have a physician serve in this role. An up-to-date disclosure of conflict of interest is required for all course
director(s).
Name & Degree
Title & Affiliation
Email
Phone
Course Director
Co-Director
(optional)
Please list all Department Coordinators
This is the individual(s) who are responsible for the operational and administrative support of this meeting.
Name
Title & Affiliation
Email
Phone
Primary Coordinator
Secondary Coordinator
(optional)
Is the department coordinator(s) involved with selecting speakers, topics, or influencing content?
 Yes - a CME disclosure is required
 No - administrative coordinator is assisting with logistical aspects only
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Other than the Course Director(s) and Department Coordinator(s) identified above, are there
any additional individuals involved with selecting speakers, topics, or influencing content?
 Yes
 No
This question appears if Yes Is Selected above
Please list all Planning Committee Members
These are the individuals (in addition to the course director, co-director, and/or department coordinator identified above) who
are involved with the planning, design, and implementation of this meeting - including the identification and selection of
presenters and topics. An up-to-date disclosure of conflict of interest is required for all planning committee members. If
more planning members are involved than space allows below, please submit a completed Faculty List Template with this
application.
Name & Degree
Title & Affiliation
Email
Planning Member 1
Planning Member 2
**If AOA Category 1-A credit is being requested, a CV/biosketch is required for all speakers.
EDUCATIONAL INFORMATION
Professional Practice Gaps and Educational Needs - The "What" and "Why"
A professional practice gap is the difference between a desirable or achievable state of practice (what should be
happening) and current reality (what is happening). An educational need can be defined as the cause or reason
for the practice gap. Gaps exist when providers are not doing everything they could, are not doing things
correctly, and/or could improve what they are doing. Gaps can be in knowledge (providers don't know
something), competence (provider's don't know how to do something, don't have methods or strategies),
performance (providers are not doing something in their practice), or patient outcomes (the consequences of the
performance).
Questions to ask when identifying the professional practice gaps and educational needs of this event:
 What questions does my target audience have and what does that reveal about their deficit(s) of
knowledge, competence, or performance?
 What patient problems or professional challenges are they unable to address?
 Why does this problem exist?
 Is there a lack of knowledge, competence or performance that caused the problem?
Example Practice Gaps:
 Inappropriate technique and use of ultrasound is leading to complications and medical errors. Clinicians
are applying incorrect ultrasound techniques (competence, performance).
 IBS continues to be a common condition encountered by healthcare professionals, but is often under
recognized. Clinicians are not currently up-to-date on current evidence for best practices in the
treatment of IBD (knowledge).
 2/3 of eligible patients do not receive in-hospital VTE prophylaxis but should. Clinicians are unaware of
benefits of prophylactic mechanical and pharmacologic interventions, which have been shown to
decrease the rate of VTE (knowledge). Clinicians are unable to implement prophylaxis in different
clinical settings or lack the ability to counsel patients (competence).
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What are the professional practice gaps and educational needs that you have identified for this
event (i.e., what problems are you trying to address)?
What source(s) did you utilize to identify your professional practice gaps and educational
needs? Sources identified with an * require submission of additional documentation.
 Medical audit, patient-care review
 Problem and/or uncommon case(s)
 National, regional, local QI data*
 Publication(s)/scientific literature*
 Survey of target audience (must be more than just list of topics)*
 Issue identified by colleagues
 Referral patterns
 Other, specify: ____________________
Learning Objectives - The "How"
The objectives are the solution to address the need and help close the gap. Objectives show what
changes are anticipated (in knowledge, competence, performance or patient outcomes) as a result of
the activity. Questions to ask when identifying the learning objectives for this event:
- What should the learner be able to accomplish as a result of attending this activity?
- What should the learner be better able to do as a result of attending this activity?
Examples:
- Apply correct techniques...
- Recognize X more promptly...
- Treat patients with X in a more timely manner...
- Describe and implement current guidelines for VTE prophylaxis.
- Perform an effective problem-focused history and physical examination for evaluation of eligibility for
VTE prophylaxis.
A minimum of 3 objectives are required. Objectives for individual presentation topics are not required
UNLESS AOA Category 1-A credit is being requested; global objectives, if used, must relate to at
least 90% of presentation topics.
What are the learning objectives that have been identified for this event? Objectives must relate
back to the professional practice gaps and educational needs previously identified. Learning
objectives must start with an action verb - do not use understand, improve, gain, etc.
Learning Objective #1
Learning Objective #2
Learning Objective #3
Additional Objectives (optional)
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Desired Outcome(s) - The “Result”
All CME activities should strive to increase competence, improve physician behavior and/or improve
patient outcomes. The purpose of CME activities should be to close the gaps of your learners. The
activity’s outcomes/desired results should directly link back to the cause of the practice gaps.
Questions to ask when identifying the outcomes/desired results for this event:
- What new abilities/strategies do we want learners to gain?
- How can we help learners modify their practice?
- How can we help learners improve their patient outcomes?
Examples:
 Increased Competence = Give physicians new abilities/strategies – “The ability to identify patients
eligible for prophylaxis, the ability to counsel patients.”
 Increased Performance = Helping physicians modify their practice – “Screening more eligible patients
and administering prophylactic treatments.”
 Increased Patient Outcomes = Providing tangible improvements in overall health and patient outcomes
as measured by reviews of clinician practices - “Decreased rates of VTE or death.”
What are the desired outcome(s) for this event? A minimum of 1 category must be answered (i.e.,
if you are only trying to change competence, then you only need to complete the competence
section). Only include desired outcomes that you actually plan to evaluate and monitor.
 Increased Competence ____________________
 Improved Performance ____________________
 Improved Patient Outcomes ____________________
This question only appears if Increased Competence Is Selected
Evaluating Your Outcomes/Results: How will you measure if the COMPETENCE-based
changes/outcomes you identified above have occurred? Select all that apply. You will be asked
to provide summary data for each evaluation method selected at the conclusion of the event.
 CME Evaluation
 Audience Response System
 Pre/post-test
This question only appears if Improved Performance Is Selected
Evaluating Your Outcomes/Results: How will you measure if the PERFORMANCE-based
changes/outcomes you identified above have occurred? Select all that apply. You will be asked
to provide summary data for each evaluation method selected at the conclusion of the event.
 Adherence to Guidelines
 Chart Audits
 Focus Group
 I am not able to measure changes in performance
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This question only appears if Improved Patient Outcomes Is Selected
Evaluating Your Outcomes/Results: How will you measure if the PATIENT OUTCOMES-based
changes/outcomes you identified above have occurred? Select all that apply. You will be asked
to provide summary data for each evaluation method selected at the conclusion of the event.
 Measure M&M rates or other QI data
 Obtain patient feedback
 Observe changes in quality/health status measures
 I am not able to measure changes in patient outcomes
Educational Design/Methodology
Indicate the educational method(s) that will be used to achieve the stated goals and objectives. Select all that
apply.
 Didactic lecture with Q&A
 Case-based discussion
 Small group discussion
 Panel discussion
 Simulation
 Skill-based training
Tools to Support Learners in Achieving Results
Previous activity evaluation comments reveal that participants place great value on additional resources or tools
that they can use within their practice and that these resources can help participants achieve the desired
outcomes of the event. Note, these are supplemental materials and not materials already presented at the
event (i.e., presentation slides). Are there additional resources such as the ones listed here that could be
provided to participants to help reinforce or extend their learning experience? Select all that apply. Note, you
will be required to submit copies of all materials selected below following the conference to the CME department
for our files.
 Not at this time
 Post-activity follow-up with key points from the
 Reminder systems, checklists
lecture(s)
 Newsletters, booklets
 Algorithms, clinical protocols
 Posters, safety flip charts
 Pocket card guidelines
 Patient assessment tools
 Patient educational materials
 Other, specify: ____________________
Competencies
CME activities should be developed in the context of competencies. Select all that apply.
Patient care/patient-centered care: Identify, respect, and care about patients’ differences, values, preferences, and
expressed needs; clearly inform, communicate with, and educate patients; continuously advocate disease prevention,
wellness, and promotion.
Medical knowledge: Established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social behavioral)
sciences and the application of this knowledge to patient care.
Practice-based learning and improvement: Investigation and evaluation of patient care, appraisal and assimilation of
scientific evidence, and improvements in patient care.
Interpersonal and communication skills: Effective information exchange and teaming with patients, their families and other
health professionals.
Professionalism: Commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to a
diverse patient population.
System-based practice: Actions that demonstrate an awareness of and responsiveness to the larger context and system of
health care and the ability to effectively call on system resources to provide care that is of optimal value.
Interdisciplinary teams: Cooperate, collaborate, communicate and integrate care teams to ensure that care is continuous and
reliable.
Quality improvement: Identify errors and hazards in care: understand and implement basic safety design principles such as
standardization and implications; continually understand and measure quality of care in terms of structure, process and
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outcomes in needs; and design and test interventions to change processes and systems of care, with the objective of
improving quality.
Utilize informatics: Communicate, manage knowledge, mitigate error, and support decision-making using information
technology.
Employ evidence-based practice: Integrate best research with clinical expertise and patient values for optimum care, and
participate in learning and research activities to the extent feasible.
Osteopathic Philosophy and Osteopathic Manipulative Medicine: Demonstrate and apply knowledge of accepted standards
in Osteopathic Manipulative Treatment (OMT) appropriate to their specialty; and remain dedicated to life-long learning and to
practice habits in osteopathic philosophy and manipulative medicine.
Please identify which competencies this activity is designed to address.
 Patient care/patient-centered care
 Interdisciplinary teams
 Medical knowledge
 Quality improvement
 Practice-based learning and improvement
 Utilize informatics
 Interpersonal and communication skills
 Employ evidence-based practice
 Professionalism
 Osteopathic Philosophy and OMM
 System-based practice
 Other competency, specify: __________
Patient Safety Considerations/Institutional or System Framework
CME should be focused on integrating and contributing to healthcare quality improvement (QI) so that the education
provided becomes integral to institutional or system QI efforts. Are you using this event as a strategy to meet any patient
safety and/or quality metrics at the health system, hospital, and/or department level?
 Yes
 No
The next questions are directly related to patient safety considerations
Please identify the global metrics you are trying to meet/improve.
 AHRQ Indicators
 HCAHPS
o Prevention Quality
o Communication with Nurses
o Pediatric
o Communication about
o Patient Safety
Medications
o Adult
o Communication with Doctors
o Pain Control
 Core Measures
o Discharge
o Acute Myocardial Infarction
o Care Transitions
o Surgical Care Improvement
o Respect of Staff
o Length of Stay
o Environment
o Outpatient Measures
o Patient Satisfaction
 Joint Commission
o Pneumonia Care
o Hip/Knee Replacement
o Venous Thromboembolism
o Transplant Care
o Immunization
o Pain Management
o Heart Failure
o Chest Pain
o Mortality
o Stroke
o Stroke
o Bariatric Care
o Diabetes
 Other, specify: _________________
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Identified Barriers
What potential system and/or physician barriers do you anticipate attendees may have that will prevent
them from incorporating new knowledge, competence, and/or performance objectives into
practice? Select all that apply.
 None
 Lack of time
 Formulary restrictions
 Cost
 Lack of administrative support/resources
 Patient compliance issues
 Insurance/reimbursement issues
 Other, specify: ____________________
 Lack of consensus on professional
guidelines
FINANCIAL INFORMATION
Will your event have any expenses in the form of food, honorarium, marketing, etcetera?
 Yes
 No
Will your event receive any income from registration fees, educational grants, or exhibits?
Select all that apply
 Registration Fees
 Educational Grants
 Promotional Exhibits
 No Income
If your event will receive income from educational grants or exhibits:
Due to the Physician Payment Sunshine Act reporting requirements that went into effect August 2013,
food-related expenses should not be paid for using educational grant or exhibit income. Food should
be purchased using registration fees or department income.
If your event will receive income from promotional exhibits:
Have potential vendors/exhibitors already been contacted about exhibiting?
Specific rules apply for vendors/exhibitors. The CME department must approve all exhibitor
opportunities to ensure compliance with CME regulations and policies. An exhibitor agreement is
required from all exhibitors.
 Yes, potential exhibitors have already been contacted
 No, potential exhibitors have not yet been contacted
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