Stanford Center for Continuing Medical Education (SCCME)
Internal Commercial Support Request for a Stanford Certified CME Activity
According to the Stanford University School of Medicine Industry Interactions Policy (SIIP), directors of CME activities may seek support from industry for specific CME activities under the following conditions: 1) industry support is sought in collaboration with and under the auspices of the SCCME; and 2) this support is intended only for activities in areas that previously have been designated by Stanford for curricular development. This Internal
Commercial Support Request will be reviewed by the Strategic Advisory Committee, which will determine if the proposed activity will be designated by Stanford for curricular development.
Please submit this document, completed, along with either a live activity agenda or enduring material content outline (Section 9) at least 9-12 months in advance of the date you propose for this CME activity. Submit an electronic version to CMECommSupport@stanford.edu
with the subject line “Commercial Support Request”.
To check boxes throughout the Request, click on the checkbox and a checkmark will be inserted.
Explanations
Modes of Educational Activities
Live symposium/conference: Didactic setting: Presentation of information often followed with Q&A. Simulation, breakout sessions, panel discussions, case studies, etc.
Live internet activity (Webex, etc.): Didactic setting: Presentation of information often followed with Q&A, may use polling or other internet technologies to engage the learners.
Live performance improvement activity: An analysis of the learner’s current practice combined with an educational intervention and a re-assessment of performance after the implementation of the intervention.
Enduring material (Internet, iPad, Podcast, etc.): Self-directed learning at a time convenient for learners.
Methods to Engage Learners
Case studies: Provides an actual problem or situation an individual or group has experienced. An effective method of provoking controversy and debate on issues for which definite conclusions do not exist.
Audience response/interaction: Provides a simultaneous large audience response to faculty questions, allowing the faculty to interact with their audience.
Debate and panel discussion: Provides an opportunity for experts or a group of learners to present differing viewpoints on a topic, issue, or problem to other panelists and the audience.
Question/answer: Provides an opportunity for faculty to answer specific participant questions.
Small group work/discussion: Provides a less formal setting for peer interaction, discussion, and problem-solving.
Patient simulation: Provides a standardized method for physicians to assess their individual skills of diagnosis, treatment, and management of a patient.
Online case studies and Online games: Provides an actual problem or situation an individual or group has experienced. An effective method of adding interaction and applying educational concepts in an online environment.
Internal Commercial Support Request
Sept 2014
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Stanford Center for Continuing Medical Education (SCCME)
Internal Commercial Support Request for a Stanford Certified CME Activity
In accordance with Stanford’s CME Mission, this educational activity must be designed to improve
(1) physician competence, and/or (2) physician performance-in-practice, and/or 3) patient outcomes.
ACCME Definitions:
 Competence: ability to apply knowledge plus a strategy in practice when the opportunity presents
 Performance in Practice: the application of new strategies or skills in the practice setting

Gap: the difference between what physicians are currently doing in practice and what is considered best or ideal practice

Patient Outcomes: self-reported or data supported improvements in patient outcomes as a result of physician performance improvement
Note: Gaps may be based upon problems faced in practice, expert opinion, quality issues, hospital mandates, regulatory requirements, published literature, MOC, previous evaluation data from learners, department surveys, or other identified sources.
The key to planning this CME activity is that you have clearly identified the ‘gap’. The gap is based on the difference between what the learners do now in practice versus what you want them to do based on best
evidence (also known as ‘Best Practice’).
Practice gaps are based on underlying causes, such as a need for knowledge about a particular topic, a need to improve competence (know when and how to apply new strategies in practice) and/or improved performance
(such as adoption of new skills or behaviors).
Internal Commercial Support Request
Sept 2014
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Stanford Center for Continuing Medical Education (SCCME)
Internal Commercial Support Request for a Stanford Certified CME Activity
Activity Title:
Activity Dates:
Planned Location and Venue of Activity:
Anticipated Number of Physician Learners:
Stanford Department/Division/Center:
Who will be responsible for backstopping the course? ☐ Hospital ☐ Department ☐ Center
Department Chair/Center Director
Course Director:
Co-Course Director (if applicable):
Name:
Title:
Phone:
Fax:
E-mail:
Name:
Title:
Phone:
Fax:
E-mail:
Name:
Title:
Phone:
Fax:
E-mail:
I attest that the following decisions related to this request were made free of the control of a commercial interest: (a) Identification of CME needs; (b) Determination of educational objectives; (c) Selection and presentation of content; (d) Selection of all persons and organizations that will be in a position to control the content of the CME; (e) Selection of educational methods.
Print Name of Course Director
Signature of Course Director Date
Will this activity receive in-kind commercial support (loan or donation of equipment, supplies, technology, etc.) from a company such as a pharmaceutical or medical device manufacturer?
☐ No ☐ Yes If yes, list commercial supporters and the nature of the in-kind support:
Provider Type:
Geographic Region:
Specialty:
Surgery
☐ Physician (MD/DO) ☐ Other (Specify):
☐
☐
☐
☐
Stanford Only
All Specialties
Intern. Medicine
Radiology
☐
☐
☐
☐
Local/Regional
Cardiology
Neurology
Urology
☐ National ☐ International
☐ Family Practice ☐ Primary Care ☐ Gen.
☐ Oncology ☐ Pediatrics ☐ Psychiatry
☐ Other (specify):
Internal Commercial Support Request
Sept 2014
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Stanford Center for Continuing Medical Education (SCCME)
Internal Commercial Support Request for a Stanford Certified CME Activity
Provide a brief description of your planned activity and its objectives as well as any partnering organizations which may participate in the activity’s development or implementation. To permit assessment of potential commercial bias, please list the following and note which will be discussed: treatments (e.g. medications, medical devices, medical nutrition therapy, exercise, etc.) and the companies selling those treatments.
Provide Information Below:
Format and design of each educational activity should be based on the designation for the activity (designed to change competence, performance-in-practice or patient outcomes). Educational design should include the appropriate method to engage the learners in the educational process. See an explanation of terms on page
one.
Mode of Educational Activity: Check all that apply:
☐ Live symposium/conference ☐ Live internet activity (Webex, etc.) ☐ Live performance improvement activity
☐
Enduring material (Internet, iPad, Podcast, etc.) Please describe the specific enduring mode you are planning:
Methods to Engage Learners: Check all that apply for your activity:
LIVE: ☐
Case studies
☐
Audience response/interaction
☐
Debate
☐
Panel discussion
☐
Question/answer
☐
Small group work/discussion
☐
Patient simulation
☐
Other (please describe):
ONLINE: ☐
Online case studies
☐
Online game
☐
Online other (please describe):
In the table below, answer the following questions to help identify the purpose of this CME activity.
1.
What are the clinical problems or issues you want to address in this activity?
2.
Why do these issues exist? Is there a lack of knowledge, or competence, or an issue with performance? It can be more than one or a combination of all.
3.
What do you want to change?
Please check off and describe the sources you used to identify the gap and educational need stated in Section 7:
☐ Evaluation data from previous activities ☐ Survey data from learners ☐ Peer Reviewed Literature
☐ Quality and Patient Safety Indicators (e.g. Hospital, National, Department) ☐ Other: Please describe
Internal Commercial Support Request
Sept 2014
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Stanford Center for Continuing Medical Education (SCCME)
Internal Commercial Support Request for a Stanford Certified CME Activity
Please describe the sources you used:
Estimated
Time (in minutes)
Please provide your proposed agenda topics and list with each topic:

Estimated time

Proposed Speaker with Affiliation

Format of the Session (e.g. presentation with Q&A, case study, panel, small group discussion, etc.
Topic Description & Proposed Speaker with Affiliation Format (e.g. presentation with Q&A, case study, small discussion group,
EXAMPLE:
60 min
EXAMPLE: Common Pediatric Epilepsy Syndromes, Dr. Jane Doe, Professor,
Neurology and Neurological Sciences, Stanford etc.)
EXAMPLE: Case studies
Provide Information Below:
Estimated Time (in minutes)
Proposed Authors with
Affiliations
Provide Outline Below:
Internal Commercial Support Request
Sept 2014
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