CME ACTIVITY PLANNING WORKSHEET
Title:
Type of Activity
Live Event
Enduring Material
Date:
Location:
Educational Partner
Jointly Sponsored with a non-accredited entity:
Co Sponsored with an accredited entity:
Educational Partner Contact
Name:
Title:
Address:
Telephone:
Fax:
E-mail:
Educational Partner Questionnaire completed and EP is not a Commercial Interest:
Credits requested:
AMA PRA
Nursing*
Yes
No
Pharmacy*
Required Attachments:
Preliminary agenda (live event)
Complete needs assessment, including supporting documentation clearly defining the gap to be addressed
Signed Disclosure Forms for all individuals involved in the development and/or implementation of the
activity
Budget summary indicating anticipated income and expenditures
This CME Planning Process has been designed based on the Criteria for Accreditation of the Accreditation
Council for Continuing Medical Education (ACCME) and accepted adult learning principles. For this
educational activity to be approved for AMA PRA Category 1 Credit™, the planning process outlined in this
document is required.
This CME Activity Planning Worksheet with all supporting forms and documents must be completed and
submitted to CCOE at least 90 days in advance of the proposed activity date. Incomplete worksheets will be
returned.
*If continuing nursing and/or pharmacy education credit is being requested in addition to CME credit, CCOE
will provide you with supplemental forms that must be completed.
For CCOE Staff Use Only
Date received: ________________ Date reviewed: ________________ Approved by: ________________
Approved for: _______ AMA PRA Category 1 Credit(s)™
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Course Code: __________________
SECTION 1: Gap AnalysisOutcomes DesignationLearning Objectives
Instructions for completing the grid on the following page
1. State the best practice under “Key Point.” A best practice may be from a national guideline or consensus
statement from a credible organization, from peer-reviewed medical literature where more than one
source agree on the practice, or from the considered opinion of the expert-planner in the case when no
published guideline exists. This becomes the end-goal for the activity.
2. State the source used that provided you with the best practice (i.e., article from peer reviewed journal,
name of consensus statement or clinical guideline, etc.).
3. State the current practice of the cohort of learners to which your educational activity is targeted. You can
determine this based on interviews (formal or informal) with members of the target audience, a
questionnaire, or a published article that reports on findings from learners. THE KEY IS TO GO BEYOND
EXPERT PERCEPTION OF THE GAP AND TO INCLUDE THE PERCEPTION OF THE LEARNER.
4. State the source used that provided you with current practice (i.e., from questionnaire of membership,
interviews with 6 family physicians, etc.).
5. State the gap based on the difference between best practice and current practice. This “resulting gap” will
define the learning objectives you will develop, which in turn leads to the content of the activity. Indicate
the “root cause” or reason for the gap [i.e., did the gap you isolated indicate learners lacked knowledge
(K), competence (i.e., ability to apply the knowledge to a practice-based situation) (C), or that
implementing it in practice or performance (P) was the issue]. Use those codes to indicate Root Cause in
the chart that follows.
6. The gap should inform you of the type of outcomes that are appropriate for this activity (i.e., does the gap
indicate a need to improve learner competence and/or performance-in-practice). The outcomes are
NOTE: Once designated, this will define your choice of evaluation (outcome) measurement tools.
7. Prepare a learning objective for each identified gap. Each objective should include a verb that is chosen to
describe something a physician will do in practice (and not what the teacher will teach). For example, do
not use verbs such as “discuss” or “describe, learn or understand.” Use words such as “apply, develop a
strategy to…, etc.” Ensure that the objective clearly states a standard against which one can judge the
success in achieving the objective. The ‘standard’ helps inform the outcomes questions you will prepare.
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GAP ANALYSIS—OUTCOMES DESIGNATION—LEARNING OBJECTIVES LINKAGE WORKSHEET
BEST PRACTICE
CURRENT PRACTICE
RESULTING GAPS
OUTCOME INDICATED
(What should be)
(What is)
(What interventions are
indicated?)
(Improvement in . . .)
Key Point:
Key Point:
Source:
Source:
Key Point:
Key Point:
Source:
Source:
Key Point:
Key Point:
Source:
Source:
Key Point:
Key Point:
Source:
Source:
Key Point:
Key Point:
Source:
Source:
Root Cause:
K
C
Root Cause:
K
C
Root Cause:
K
C
Root Cause:
K
C
Root Cause:
K
C
P
P
P
P
P
LEARNING OBJECTIVE
Competence
Performance
Patient Outcomes
Competence
Performance
Patient Outcomes
Competence
Performance
Patient Outcomes
Competence
Performance
Patient Outcomes
Competence
Performance
Patient Outcomes
<Insert or delete rows as needed>
LEGEND:
(1) SOURCE—Include journal references, name of survey, or other identifiers of the source from which you determined “key point” information.
(2) ROOT CAUSE—After stating the “resulting gap” above, indicate what you have determined to be the root cause or the reason for the gap by inserting
one or more of the following codes: Lack of Knowledge (K), Lack of Competence(C), and/or Failure to Perform in Practice (P).
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SECTION 2: Analysis of Current or Potential Scope of Practice
INSTRUCTIONS: Prior to writing learning objectives, which are the basis for the content of the CME activity, it is important to
assess the scope of practice of the targeted learners. The scope of practice may be a combination of current and potential
performance standards that are influenced by environment of the practice (e.g., is the practice environment of the learners an
urban area with cultural diversities that influence the scope of practice?), whether the practice is in an academic center, the
patient demographics, etc. The scope of practice also represents the vision of the specialty board as it impacts recertification in
the relevant specialty as well as the norms and guidelines developed by the national specialty society associated with the
specialty. All of this should be taken into consideration, together with the results of the gap analysis, as content is developed.
CURRENT SCOPE OF PRACTICE
What is the clinical specialty of the targeted
learners?
Describe the patient demographics associated
with learners’ practices?
Describe the daily practice of these learners.
POTENTIAL SCOPE OF PRACTICE
Ideal practice parameters expressed by the
relevant specialty board
Relevant practice guidelines from the relevant
national specialty society
MATCHING THE CONTENT OF THIS ACTIVITY TO THE CURRENT OR POTENTIAL SCOPE OF PRACTICE
Indicate how the above analysis will be
reflected in the content of this activity.
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SECTION 3: Application of Desirable Physician Attributes to CME Content
INSTRUCTIONS: Planners are required to address nationally-established goals for physician core competencies as developed by the Institute of Medicine (IOM), Accreditation
Council on Graduate Medical Education (ACGME), and the American Board of Medical Specialties (ABMS) related to specialty maintenance of certification. Based on the
following chart that lists all of these related national and prioritized competencies please indicate in the 4th column specific areas of content (and the competency number
identifier) in your planned CME activity that will address those national competencies:
IOM Core Competencies
1. Provide patient-centered care –
identify, respect, and care about patients’
differences, values, preferences, and expressed
needs; relieve pain and suffering; coordinate
continuous care; listen to, clearly inform,
communicate with, and educated patients; share
decision making and management; and
continuously advocate disease prevention,
wellness, and promotion of health lifestyles,
including a focus on population health.
ABMS (MOC)/ACGME Competencies
ABMS Maintenance of
Certification
6. Patient care that is compassionate,
appropriate, and effective for the treatment
of health problems and the promotion of
health
12. Evidence of professional standing,
such as an unrestricted license, a
license that has no limitations on the
practice of medicine and surgery in that
jurisdiction.
7. Medical knowledge about established
and evolving biomedical, clinical, and
cognate (e.g., epidemiological and socialbehavioral) sciences and the application of
this knowledge to patient care
2. Work in interdisciplinary teams–
cooperate, collaborate, communicate, and
integrate care in teams to ensure that care is
continuous and reliable.
8. Practice-based learning and
improvement that involves investigation
and evaluation of their own patient care,
appraisal and assimilation of scientific
evidence, and improvements in patient care
3. 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.
9. Interpersonal and communication
skills that result in effective information
exchange and teaming with patients, their
families, and other health professionals
4. Apply quality improvement – identify
errors and hazards in care; understand and
implement basic safety design principles, such as
standardization and simplification; continually
understand and measure quality of care in terms of
structure, process, and outcomes in relation to
patient and community needs; and design and test
interventions to change processes and systems of
care, with the objective of improving quality.
5. Utilize informatics – communicate,
manage, knowledge, mitigate error, and support
decision making using information technology.
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10. Professionalism, as manifested
through a commitment to carrying out
professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse
patient population
11. Systems-based practice, as
manifested 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.
13. Evidence of a commitment to
lifelong learning and involvement in a
periodic self-assessment process to
guide continuing learning.
14. Evidence of cognitive expertise
based on performance on an
examination. That exam should be
secure, reliable and valid. It must
contain questions on fundamental
knowledge, up-to-date practice- related
knowledge, and other issues such as
ethics and professionalism.
15. Evidence of evaluation of
performance in practice, including the
medical care provided for
common/major health problems (e.g.,
asthma, diabetes, heart disease, hernia,
hip surgery) and physicians behaviors,
such as communication and
professionalism, as they relate to
patient care.
Content Reflecting These
Competencies in Your CME Activity
INSTRUCTION: ENTER APPLICABLE
NUMBER(S) IN BOX FOLLOWED BY
DESCRIPTION OF CONTENT YOU PLAN TO
ADDRESS :




SECTION 4: Barriers to Achieving Results and Strategies to Address Them
INSTRUCTIONS: Planners are encouraged to give consideration to the system of care in which the learner will incorporate
new or validate existing learned behaviors. Planners must be sure to (a) identify barriers that could block implementation (e.g.,
formulary restrictions, time not allotted for implementation of new skills, or performance behaviors, insurance doesn’t
reimburse for treatments, organization doesn’t support educational efforts, lack of resources, policy issues within organization,
etc.) and (b) apply strategies to address, discuss strategies to overcome or remove those barriers (if possible) in the content of
the CME activity. Please indicate below the barrier(s) you have identified and the strategies you will employ in this activity to
address or remove them:
Identified System Barrier:
Strategy to Address or Remove the Identified Barrier:
Identified System Barrier:
Strategy to Address or Remove the Identified Barrier:
<Insert or delete rows as needed>
SECTION 5: Format and Design Related to Sustaining Results
INSTRUCTIONS: The purpose of CME is change in behavior or validation that changes already made are consistent with best
practices. Format decisions include (a) venue appropriate to your target audience and to achieve best practices (desired
results), (b) methods used to engage learners in the educational process—especially those that serve to demonstrate
application of knowledge to performance, and (3) ancillary processes and tools that sustain learning goals. NOTE: Refer to
Appendix A for guidance on format choices. In the table below, indicate your choices for each element above and the rationale
for that choice:
A. VENUE AND/OR MODE OF EDUCATIONAL INTERVENTION (HINT:
use of multiple interventions serve to reinforce new behaviors):
Live symposium
Internet-based activity
Print enduring material
Electronic enduring material
Journal supplement
Other
B. METHODS TO ENGAGE LEARNERS (HINT: Click all that apply, but
at least one):
Case studies
Audience response system
Reflection worksheet
Small group work
Panel Discussion
Debate
Question/Answer
Other:
C. PROCESSES AND ANCILLARY TOOLS TO REINFORCE AND
SUSTAIN LEARNING GOALS:
Email reminder
Ancillary case study online
Patient reminder
RATIONALE APPROPRIATE TO
OBJECTIVES/RESULTS:
Algorithm Worksheet
Other
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RATIONALE APPROPRIATE TO
OBJECTIVES/RESULTS:
RATIONALE APPROPRIATE TO
OBJECTIVES/RESULTS:
SECTION 6: Faculty/Planner Selection
INSTRUCTIONS: Faculty and activity planners that are selected should have a demonstrated expertise in the therapeutic
field, strong presentation and communication skills (if presenting), and ability to address the gaps and learning objectives
expressed in this planning document. It is advisable to select faculty with the most expertise and teaching skills and the least
amount of conflicts of interest. List the faculty and planners and their qualifications:
Name:
Title and Affiliation:
Role:
Planner
Speaker
Author
Editor
Peer Reviewer
Other:
Speaker
Author
Editor
Peer Reviewer
Other:
Speaker
Author
Editor
Peer Reviewer
Other:
Speaker
Author
Editor
Peer Reviewer
Other:
Speaker
Author
Editor
Peer Reviewer
Other:
Qualifications:
Name:
Title and Affiliation:
Role:
Planner
Qualifications:
Name:
Title and Affiliation:
Role:
Planner
Qualifications:
Name:
Title and Affiliation:
Role:
Planner
Qualifications:
Name:
Title and Affiliation:
Role:
Planner
Qualifications:
<Insert or delete rows as needed or attach additional sheets>
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SECTION 7: Marketing
INSTRUCTIONS: Indicate how this activity will be publicized to prospective participants and what materials will be developed
to promote this activity.
A. METHODS TO RECRUIT THE IDENTIFIED AUDIENCE Select all that apply.
Previous participants from another activity (please specify):
Society membership list (please specify):
Random list selected by: List mailing list sources(s) (AMA, medical assoc/society, etc.)
Geographic area (please specify):
Incidence of the disease (please specify):
Practice Patterns (please specify):
Expressed interest in CME courses
Other:
B. METHODS TO GENERATE AN AUDIENCE Select all that apply.
Direct mail, fax, email of invitation/brochure/letter
Posters placed in hospitals/clinics
Faculty distribution of invitation/brochure/letter
Web-based announcements
Advertisements/journal announcements
Save-the-Date card (Note: A Save-the-Date card cannot be used as the only method to generate an
audience.)
Assistance from grantor’s sales force (Note: A commercial interest can assist in the distribution of
promotional materials for CME activities, but not be used as the only method for audience generation.)
Other:
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SECTION 8: Budget
INSTRUCTIONS: In addition to providing an attached budget of anticipated income and expenditures, please indicate the
sources of expected financial support.
Sources of Expected Financial Support
Check all that apply and complete that specific section.
Sources, if known
Registration Fees
Physicians
Residents/Fellows
Other Health Professionals
RU Faculty, Residents, Students, Staff
Other
School/Departmental Donation
Commercial Support (Grant)
Estimated
Amount
Name of company, foundation, or organization,
contact and phone number.
List as many as applicable, use additional sheet if
necessary.
Foundation Fund/Grant
Federal/State Agency Award
Exhibit Fees
Other:
SECTION 9: Approvals
Center for Continuing and Outreach Education
Name (Please Print)
Signature
Date
Educational Partner
Name (Please Print)
Signature
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Date
APPENDIX A
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