Associated with the UCLA School of Medicine ADMINISTRATIVE POLICY
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SUBJECT: PURPOSE OF DEPARTMENT
DEPARTMENT:
OFFICE OF MEDICAL EDUCATION EFFECTIVE DATE:
10/25/2013
AFFECTS:
ALL DEPARTMENTS
APPROVED BY: Cheryl Lambing, M.D., FAAFP, CME Director
Medical Director, Professional Education, Ventura County Health Care Agency
Renee Higgins, M.D.
Chief Operations Officer, Ventura County Health Care Agency
Continuing Medical Education Committee Medical Staff, Staff and Members
REVISION DATES:
12/5/2013
REVIEW DATES:
12/5/2013
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.
REGULARLY SCHEDULED SERIES DEFINITION
A Regularly Scheduled Series (RSS) is defined as an activity that is planned to have 1) a series with multiple sessions that 2) occur on an ongoing basis (offered weekly, monthly, or quarterly) and 3) are planned by and presented to the accredited organization’s professional staff. RSSs are only offered as directly-sponsored activitie s to the accredited organization’s (VCMC) professional staff. RSS cannot be a joint-sponsored activity.
BACKGROUND
Trauma/Surgical Morbidity and Mortality (M & M) is a Multidisciplinary, RSS, CME Activity held monthly on the 3 rd Thursday at 7am at Ventura County Medical Center for physician Medical Staff and VCMC support staff.
Cases to be presented are/can be referred by any physician, professional staff or committee from the
VCMC Medical Staff. Additionally, all surgical services are encouraged to submit complications for review.
PROTOCOL FOR RSS TRAUMA/SURGICAL M & M CME PLANNING
In general, the process of planning of a RSS CME program should begin in advance, with the application submitted for review to the CME Department 2-6 weeks prior to the start of the activity date, January 1,
20__. The CME application will be in effect for one year, beginning January 1 st and ending December
31 st of that year. The worksheet should fit the unique aspect of the RSS CME activity. Attach extra sheets to document the planning stages as needed.

Components required for Accredited CME:
1) Documentation of Needs Assessment
Cases are referred by Medical Staff Committee, Adverse Events from Committees, Department
Meetings, Performance Improvement Committee, Chart Review, Committee Reports, Joint
Commission Patient Safety Goal/Competency in order to detect and identify care of trauma patients that require either a departmental, or systemic opportunity for quality improvement, to discuss multidisciplinary, evidence-based treatment approaches for the treatment of trauma patients and to close the loop on cases identified and provide recommendations to formulate a validated loop closure.
2) Required Disclosure Form
All Trauma M & M participants, planning members, staff, and moderators must submit a CME disclosure form which covers each 12-month period and must include their spouses/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 will be reviewed by CME Director or designee for potential conflict of interest.
3) Needs Assessment Documentation
Standards of care identified by The American College of Surgeons, continuing review of changes in quality of care as revealed by medical audit or other patient care reviews and discussion in departmental meetings or committee.
4) Publicity and Learner Activity Materials
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.
Evaluation
Will be used as per VCMC Administrative Policy 1.2.
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 for this case discussion
RSS format as any materials used during the RSS are collected for confidentiality.

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 moderator (cannot monitor self). This individual will provide a report of compliance for the CME activity to Medical Education for the Activity file.
TRAUMA/SURGICAL M & M FORMAT AND PROCEDURES
The conference will begin promptly at 0700 hours and is led by CME Medical Directors, Trauma
Department. The goal is to complete all referred cases. If the session runs out before all cases on the agenda have been presented, those cases are tabled until the next session. The moderator will endeavor to keep a time limit, such that all presenters have the opportunity to discuss their cases, with ample input from a multitude of specialties.
A sign in sheet for each monthly M & M is on-site and kept on file. This sign in sheet reflect the multidisciplinary nature of this audience for case review, Physician Development and improving patient outcomes (General Surgery, Anesthesia, Orthopedics, Neurosurgery, Emergency Medicine, Plastic
Surgery, Radiology, Pediatrics, Obstetrics, Urology, Vascular, Medical Staff Leadership, Trauma Staff,
Family Medicine and others).
Each case presentation will be submitted on the designated case form prior to the CME activity, reviewed by the Activity Medical Director(s) or designee and then classified during M & M according to the format listed (including recommendations and follow up).
Cases to be presented are/can be referred by any physician, professional staff or committee from the
VCMC Medical Staff. Additionally, all surgical services are encouraged to submit complications for review.
Cases that will be presented independent of referred cases above include the following:

Deaths (unless the patient had a documented DNR/DNI and the sequence of events followed an expected course and there was no opportunity for improvement as determined by the established
VCMC Medical Staff policy).

Any unexpected return to the Operating Room
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Any unexpected complication resulting from a diagnostic, judgement or systems error

Any case which meets the Trauma M & M Trigger or the Medical Staff Review Trigger
Superficial wound infections treated by opening a skin incision do not need to be presented. In addition, deep wound infections resulting from an operation whit a wound classification of III (contaminated) or IV
(dirty-infected) do not need to be presented – unless there was an unexpected sequence of events or another department has requested a formal presentation and review. If any department or Medical Staff member refers a case for potential unmet educational need this should be reflected in the M & M notes and provided to the Surgical Grand Rounds CME Activity Medical Director and the CME Committee for planning purposes. Note for the wounds listed above, the incidence of wound infection is 15-30% and
> 30%. As a reminder if a significant trend is noted by the department, cases may be referred as a group.
A CME Attestation Monitor and timekeeper will be identified. The Activity Medical Directors cannot serve as the CME Monitor but the monitor can be staff or planning committee members. The Attestation Form must be completed and returned to Medical Education along with all evaluations. Note the Monitor will need to document that Cultural and/or Linguistic Disparities were addressed.

All publicity and learner materials must use the appropriate accreditation statement(s):
Ventura County Medical Center is accredited by the Institute for Medical Quality/California Medical
Association (IMQ/CMA) to provide continuing medical education for physicians.
Ventura County Medical Center designates this live activity for a maximum of 1 AMA PRA Category 1
Credit(s)

.
Physicians should claim only the credit commensurate with the extent of their participation in the activity.
To receive CME credit for their participation in the RSS session, learner must complete an evaluation form and return it to the Medical Education Office.
For Evaluation and Outcomes Measurement, the activity will measure Competence, Performance and
Patient Outcome with the goals of improving quality outcomes in the Trauma Department, protocolizing treatment processes of common areas identified as repeated morbidity occurrences and ensuring that appropriate corrective action is taken when an area of improvement is identified.