VENTURA COUNTY MEDICAL CENTER
SANTA PAULA HOSPITAL
Associated with the UCLA School of Medicine
ADMINISTRATIVE POLICY
1.8
PROCEDURE:
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VCMC CONTINUING MEDICAL EDUCATION
REGULARLY SCHEDULED SERIES MEDICINE
M & M PLANNING, DOCUMENTATION AND SUBMISSION
FOR CME APPROVAL
SUBJECT: PURPOSE OF DEPARTMENT
DEPARTMENT:
AFFECTS:
APPROVED BY:
OFFICE OF MEDICAL EDUCATION
EFFECTIVE DATE:
REVISION DATES:
3/19/2014
ALL DEPARTMENTS
Cheryl Lambing, M.D., FAAFP, CME Director and Chair
Medical Director, Professional Education, Ventura County Health Care Agency
REVIEW DATES:
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.
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 activities to the accredited organization’s (VCMC) professional staff. RSS cannot be a
joint-sponsored activity.
BACKGROUND
Medicine Morbidity and Mortality (M & M) is a Multidisciplinary, RSS, CME Activity held monthly on the
2nd Thursday at noon 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.
PROTOCOL FOR RSS MEDICINE 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 1st and ending December
31st of that year. Should the CME application be presented and approved after January 1st, the RSS
CME program will be approved through 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 issues of
hospitalized medical patients that require either a departmental, or systemic opportunity for quality
improvement and to identify, evaluate and assess treatment options for hospitalized patients and
provide recommendations to reduce complications.
2) Required Disclosure Form
All Medicine M & M Medical Staff 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
Continuing review of changes in quality care as revealed by medical audit or other patient care
reviews (audit reports, chart reviews, Committee reports on ADR’s).
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 must
be on separate lines.
Evaluation
Will be used as per VCMC Administrative Policy 1.2 and will be provided by the CME Department.
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 acting as moderator 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.
MEDICINE M & M FORMAT AND PROCEDURES
The conference will begin promptly at 1200 hours and is led by CME Medical Directors, Medicine
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 reflects the
multidisciplinary nature of this audience for case review, Physician Development and improving patient
outcomes.
Each case presentation will be submitted on the designated case form at the conclusion of 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.
Cases that could 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 complication resulting from a diagnostic, judgement or systems error.

Any case which meets the Medical Staff Review Trigger.
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 Medicine M & M CME Activity Medical
Director and the CME Committee for planning purposes.
A CME Attestation Monitor and timekeeper will be identified. The Activity Medical Director moderator
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 patient care and outcomes in the hospital, reducing
complications with a 2014 focus on ADR’s in Diabetics (Hypoglycemia) and Heparin Drips
(Anticoagulation).