CME Activity Application - Version 3: 11/19/10
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Lancaster General CME Activity Application
Instructions: This form must be completed and submitted with the sample program brochure when applying for CME
Category 1 Credit. All responses in the form must be completed. Provide the following or any other relevant
documentation as attachments.
Required Attachments
The following attachments must be included with the submission of this CME Activity Application:
1. Flyer and promotional materials with times, topics, objectives, speakers and CME accreditation information.
2. Problem information supportive documentation (i.e., excerpts from PI minutes, survey results, data collected,
journal articles, etc.)
Completed CME activity applications with supporting documentation are due in the CME Office at a minimum 6 weeks
prior to the activity. No promotion of the activity may occur that mentions CME credits until the activity is approved by
the Lancaster General CME Committee.
1. Name, address, phone number, e-mail and contact name for individual(s) requesting this event. (If this
will be a joint sponsorship, please list the physician office and /or entity sponsoring this event.)
2. CME Activity Details
Title
Time/Date
Location
Agenda
Number of
Desired CME
Credits
3. List any planning committee members (Anyone who is in a position to control the content of the educational activity.
Each activity must have at least one person identified in this section. Add additional lines as needed.)
Name
Role in Planning Process
E-mail and Phone
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4. Identify the problem(s), documentation/evidence for the problem(s) and the nature of the problem(s)
that are to be addressed by the proposed CME activity (see example below).
For CME activities, we are required to identify problems as the rationale for holding the CME activity. A
problem is a difference between desired and actual knowledge/competence/performance/outcomes. Please
state the problems that the CME activity will address in terms of problems – an example is provided below.
EXAMPLE
Problem
New standards have recently been published
relative to management of CHF in the primary
care office. Primary care physicians are not
familiar with the new standards.
Lancaster General has identified CHF readmission
in 30 days as a primary performance
improvement initiative for FY 2011. Data has
identified that the 30-day readmission rate is 20%
and there are gaps in the performance of primary
care providers in providing adequate postdischarge follow-up care – particularly with
medication management.
Primary care physicians in busy practices lack
tools to support their management of post
discharge CHF to ultimately reduce 30-day
readmission and improve patient outcomes.
EXAMPLE
Documentation/Evidence for the Problem
(check all that apply)
Performance improvement/quality data, audits or initiatives
Medical literature, reports, conferences
Professional/specialty societies
Surveys of target audience
Discussion in department, with peers/colleagues
New standards, evidence, technology
Legislative, accreditation or licensure requirements
Other – Please describe:
Performance improvement/quality data, audits or initiatives
Medical literature, reports, conferences
Professional/specialty societies
Surveys of target audience
Discussion in department, with peers/colleagues
New standards, evidence, technology
Legislative, accreditation or licensure requirements
Other – Please describe:
Performance improvement/quality data, audits or initiatives
Medical literature, reports, conferences
Professional/specialty societies
Surveys of target audience
Discussion in department, with peers/colleagues
New standards, evidence, technology
Legislative, accreditation or licensure requirements
Other – Please describe:
EXAMPLE
Nature of the Problem
(check all that apply)
Knowledge or
Competence
Performance or
Behavior Change
Patient Outcomes
Knowledge or
Competence
Performance or
Behavior Change
Patient Outcomes
Knowledge or
Competence
Performance or
Behavior Change
Patient Outcomes
Insert your problem information in this table.
Problem
Documentation/Evidence for the Problem
(check all that apply)
Performance improvement/quality data, audits or initiatives
Medical literature, reports, conferences
Professional/specialty societies
Surveys of target audience
Discussion in department, with peers/colleagues
New standards, evidence, technology
Legislative, accreditation or licensure requirements
Other – Please describe:
Performance improvement/quality data, audits or initiatives
Medical literature, reports, conferences
Professional/specialty societies
Surveys of target audience
Discussion in department, with peers/colleagues
New standards, evidence, technology
Legislative, accreditation or licensure requirements
Other – Please describe:
Nature of the Problem
(check all that apply)
Knowledge or
Competence
Performance or
Behavior Change
Patient Outcomes
Knowledge or
Competence
Performance or
Behavior Change
Patient Outcomes
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Continued: Insert your problem information in this table.
Problem
Documentation/Evidence for the Problem
(check all that apply)
Performance improvement/quality data, audits or initiatives
Medical literature, reports, conferences
Professional/specialty societies
Surveys of target audience
Discussion in department, with peers/colleagues
New standards, evidence, technology
Legislative, accreditation or licensure requirements
Other – Please describe:
Performance improvement/quality data, audits or initiatives
Medical literature, reports, conferences
Professional/specialty societies
Surveys of target audience
Discussion in department, with peers/colleagues
New standards, evidence, technology
Legislative, accreditation or licensure requirements
Other – Please describe:
Performance improvement/quality data, audits or initiatives
Medical literature, reports, conferences
Professional/specialty societies
Surveys of target audience
Discussion in department, with peers/colleagues
New standards, evidence, technology
Legislative, accreditation or licensure requirements
Other – Please describe:
Nature of the Problem
(check all that apply)
Knowledge or
Competence
Performance or
Behavior Change
Patient Outcomes
Knowledge or
Competence
Performance or
Behavior Change
Patient Outcomes
Knowledge or
Competence
Performance or
Behavior Change
Patient Outcomes
Please provide any relevant problem information supportive documentation (i.e., excerpts from PI minutes,
survey results, data collected, journal articles, etc.)
5. What are the potential barriers facing these physicians relative to the problem and how can they be
addressed? (check all that apply)
Physicians lack data, information or feedback on their performance relative to the problem
The environmental support, resources (time, money, etc.) and tools to help fix the problem are not available
There is a lack of consequences, incentives or rewards to help improve performance relative to the problem
There is a lack of motivation and low expectations of physicians relative to addressing the problem
Physicians lack skills and knowledge to address the problem
Physicians involved in the problem lack individual capacity to address all of the issues (i.e. there are factors outside
their specialty, etc.)
There are environmental variables that are difficult to cannot be controlled (patients, legislative,
costs/reimbursements, other providers, etc.)
Other – Please describe:
6. What strategies are being employed to address barriers identified in the previous question?
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7. Please identify the target audience for this CME activity. Designation of the target audience confirms
that the content in this CME activity is within their scope of practice.
Target Audience
Select all that apply (at least 1 box from LG affiliation, provider type, and specialty must be selected). Place an “X” in the
appropriate box next to each item.
LG Affiliation
Lancaster General employed
physicians/staff only
All Lancaster General
Medical Staff
All Lancaster and regional
community
Specific
departments/specialties only
Specific practice/group only
Provider Type
Specialty
Physician
All specialties
Oncology
Nursing
Anesthesiology
Orthopaedics
Pharmacists
Cardiology
Pediatrics
Physician Assistants
Dermatology
Psychiatry
Nurse Practitioners
Social Work
Psychologists
Other (specify):
Emergency Med
Family Medicine
Internal Medicine
Neurology
OB/GYN
Radiology
Radiation Oncology
Surgery
Other (specify):
8. What is the anticipated attendance?
Less than 10
Approximately 10 to 20
Approximately 20 to 30
Approximately 30 to 50
More than 50
9. What are the objectives for the conference? (Behavioral objectives should describe the outcomes in terms
of physician’s performance or patient health/outcomes – add additional lines as needed) Following the
completion of this program, the participant should be able to:
Objective 1:
Objective 2:
Objective 3:
Objective 4:
10. Are there IOM, ACGME, ABMS, specialty or other competencies related to this topic or problem
associated with the CME activity?
ABMS MOC Competencies (check all that apply):
Medical Knowledge
Patient Care
Interpersonal and Communication Skills
Professionalism
Practice-Based Learning and Improvement
Systems-Based Practice
Other: Please list
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11. Are there any other entities working on this issue?
No
Yes
If Yes, is this CME activity in conjunction with them?
No
Yes
12. Are you aware of any non-educational strategies that are currently being used to address the problem?
No
Yes
13. What type of evaluation method will be used to know if the CME activity was effective at meeting the
need and creating change in competence, performance or patient outcomes? (Check all that apply.)
Evaluation and Outcomes
Place an “X” next to all that apply; note, you may be asked to provide summary data for the evaluation methods selected.
Evaluation form for participants (required)
Audience response system (ARS)
Pre and post-test
Knowledge/Competence
Physician and/or patient surveys after the activity
Other, specify:
Performance
Measure change in performance through chart review or data
query
Measurement of physician performance change is part of an
existing performance improvement initiative at Lancaster
General
Patient Outcomes
Measure changes in patient outcomes through chart review or
data query
Measurement of patient outcomes is part of an existing
performance improvement initiative at Lancaster General
Customized follow-up survey/interview/focus group
about actual change in practice at specified intervals
Other, specify:
Other, specify:
14. Who is/are the faculty and how were they selected? (add additional rows if necessary)
Faculty Name
Affiliation and Contact (e-mail,
Rationale for Selection (check all
phone, address)
that apply)
Recognized expert
Presentation/education skills
Desires/request of intended audience
Recommendation
Referral relationship
Other
Recognized expert
Presentation/education skills
Desires/request of intended audience
Recommendation
Referral relationship
Other
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15. What is the educational design/type of the activity (check all that apply)?
Presentation/live lecture
Case studies and discussion
Journal club and discussion
Panel discussion
Demonstration
Enduring material (print materials, video/audio archives)
Web based
Other: Please list
16. Budget (basic breakdown of expenses)
Expenses
Faculty Stipend(s)
Faculty Travel
Supplies
Printing
Food
Other: Specify
Income
Registration Fees
Other LG Budget
Grants
Amount
Amount
Is any of the income from commercial entities such as pharmaceutical or device manufacturers?
No
Yes
If Yes, then complete the following table. There are additional requirements for this CME activity – the CME
Office will contact you to insure that these requirements are met.
Grant Amount
Supporting Commercial Entity
Contact Information for Commercial
Support
17. Describe your CME activity and provide any additional information which would be helpful during the
CME Committee review of this application.
Please return or fax this completed from to:
Lancaster General Hospital CME Office
555 N. Duke St.
Lancaster, PA 17604
(717) 544-4500 Fax: (717) 544-5107