For Office Use Only
11/2013
CHRISTIAN MEDICAL & DENTAL ASSOCIATIONS
Planning Document & Application for
CME Category 1 credit™
X
DISCLOSURES OF THE COURSE DIRECTOR, COURSE CONTACT PERSON AND
PLANNING COMMITTEE MUST BE COMPLETED, SIGNED AND E-MAILED TO
Barbara@cmda.org BEFORE BEGINNING THE PLANNING. ANYONE WHO REFUSES
TO COMPLETE A DISCLOSURE FORM CAN NOT PARTICIPATE IN THE PLANNING,
EXECUTION OR PRESENTATION OF A CMDA EDUCATIONAL ACTIVITY.
Christian Medical & Dental Associations (CMDA) retains the right to withhold/adjust
credit at any time, should it determine that the ACCME Criteria, Policies, ACCME
Standards for Commercial Support and/or Christian Medical & Associations policies
and procedures are violated.
Requirements for Certification by Christian Medical & Dental Associations:
Please read and check that you have read them.
___In order to be considered for sponsorship or joint-sponsorship, completion of this
application is required and emailed to Barbara@cmda.org two months prior to your
activity date. REMEMBER: You can NOT promote CME until the application is
approved. Incomplete applications cannot be reviewed or approved by the CMDA
Committee, which has the final decision on all applications for Continuing Medical
Education, dental and other healthcare professional credits.
___The content of your application must meet:
 ACCME Criteria, Policies, and Standards for Commercial Support
 The American Medical Association (AMA) requirements and
 The CMDA policies and procedures (Go to www.cmda.org/CE)
___HIPPA compliance is the responsibility of the course director
___Recommendations involving clinical medicine in a CME activity are based on
scientific evidence that is accepted within the profession of medicine as adequate
justification for their indications and contraindications in the care of patients.
___Recommendations must conform to the generally accepted standards of
experimental design, data collection and analysis
___All scientific research referred to, reported on, or used in this CME activity will
support or justify patient care recommendations that conform to the generally
accepted standards of experimental design, data collection, and analysis.
___Christian Medical & Dental Associations maintains full oversight and responsibility
for the planning, completion of the application and the educational activity
Screening Criteria: In order to be considered for continuing medical education credit,
all of the criteria listed below must be met. Planner confirms that:
___The content of this activity will be based on evidence that constitutes “best
practices”
___Planners have identified a defined professional practice gap(s) that exists between
current and best practices
___This activity will provide educational content aimed at closing the defined
professional practice gap(s) to result in changed patient health by changing
participants’ knowledge, competence, performance and/or practice
List any prerequisite knowledge/skill required for attending this activity:
__________________________________________________________________________
COURSE OVERVIEW
1) School/organization/department making request:
2)
Direct-sponsored (Organization within the CMDA)
Joint-sponsored (Organization outside of CMDA)
3) Title of course:
4) Course date(s):
5) Course location (include street address, city, state):
6) Please provide a one or two paragraph description of your course. This
statement will be used for promotional materials (brochures, web pages, etc.) a
needs assessment, and/or to obtain additional professional credits. The
description should give an overview of the course and let potential attendees
know why this course is an important one for them to attend:
7) Number of CME Credits Requested (hours):
8) Indicate all professional credits being sought for this course. (A Dental
Application is required to receive AGD PACE credit):
___ CME
CDE (additional fee & Dental Application must be completed)
AAFP (additional fee)
Nursing (additional fee) In order for CMDA to apply for nurse practitioner
credit, you must submit speaker Bio sketches, speaker & planner disclosures and
speaker abstracts with this application two months prior to your conference
Nurse Practitioner (additional fee) - In order for CMDA to apply for nurse
practitioner credit, you must submit speaker Bio sketches, speaker & planner
disclosures and speaker abstracts with this application two months prior to your
conference
Physician Assistant (additional fee)
COURSE PLANNERS AND FACULTY
9)
Name of Course Activity Director:
E-mail:
Telephone:
FAX:
10) Name of Course/Activity Coordinator (contact person):
E-mail:
Telephone:
FAX :
11)
Planning Committee Member – Please list individuals who are planning
committee member(s).
Planning Committee Member
Telephone Number
Barbara Snapp, CE Director
Sharon K. Whitmer, EdD, MFT
Accreditation Officer
CE Committee Members
E-mail Address
barbara@cmda.org
sharon.whitmer@cmda.org
On file
12) Who are the proposed faculty for this activity? MANDATORY: List confirmed and nonconfirmed faculty. You must include their name & credentials, business title, E-mail
address & whether honorarium and travel expenses will be paid to faculty.
Name and credentials
(MD, PHD, etc.)
Business title,
institutional affiliation &
E-mail address
Will honorarium
and/or travel
location
example:
Professor of Medicine
University of Education
Mayberry, FL
expenses be
provided to the
faculty member?
(CMDA must have
documentation of
payment)
CONTENT DEVELOPMENT
13) How does this activity support the CMDA CE Mission (see the CMDA Mission in the
Course Director Manual)?
14) This CME activity is planned to meet the needs of what groups of practicing
healthcare professionals (target audience)? List all groups:
15) How does the content of this activity match the learners’ current or potential scope
of professional activities?
16) What are the educational format(s) for this CME activity? (check all that apply)
___Lecture
___Teleconference
___Internet
___Roundtable
___Q & A session
___Self-directed
___Case studies
___Panel discussion
___Skilled demonstration
___Stimulations
___Lab activity
___Audience Response System
17) Please UNDERLINE the activity type for this CME activity?
Live Activity
Enduring Material
Journal-based CME activity
Internet
CD-ROM/DVD
Podcast
Other
(explain)_____________________________________________________________________
18) Briefly explain how your format and type of activity are appropriate for the setting,
objectives, and the results of this educational activity.
19) What procedures were used to identify the existing professional practice gap(s)
between current and best practices of your target audience? Please check all that
apply. If a part of your process has been identification of gaps by experts and your
planning committee, faculty or planners’ perception of need, or opinion leader
interviews, please attach a one or two paragraph description detailing your
discussions and how you intend to address gaps through the educational activity.
Documentation for each procedure indicated must be attached
___Survey of targeted learners
___Review of peer reviewed literature
___Clinical practice data
___Professional Practice Gap(s) identified by target audience/expert
___National clinical guidelines (NIH, NCI, AHRQ)
___Requirements of state licensing board, specialty societies
___Required by practice administration
___Required by governmental authority/regulation/law
___Research findings/translations of research into practice
___New information (diagnostic techniques, treatment plans)
___Requests from physicians or physicians groups
___*Helps to meet CMDA CE Mission
___Public health data
___Faculty and/or planners’ perception of need (attach a statement)
___Summary of previous outcomes data
___Practice or specialty society clinical guidelines
___Committee findings/audits
___Epidemiological data
___Direct to consumer ads
___Lay press
___Societal trends
___Other (please attach description)
*Please review CMDA Mission (see Course Director Manual)
20) Please provide citations of peer-reviewed articles (scientific/medical journals, etc.)
that were used as one of the determining factors for identifying each of the
professional practice gaps.

21) Identify the professional practice gaps(s), what has caused the gap, the desired
results of the educational intervention and classify the need for this educational
intervention in terms of knowledge, competence or performance (see chart below).
IDENTIFY THE
EDUCATIONAL PRACTICE
GAP(S)
(Current practice)
DESCRIBE WHAT HAS
CAUSED THE
PROFESSIONAL
PRACTICE GAP
Desired results
(best-practice)
What are healthcare
professionals not doing?
Why aren’t they doing it?
What will be the results of
solving this problem?
EXAMPLE
Physicians are not using the
diagnostic criteria to screen
pre-school age children for
Autism.
EXAMPLE
Literature indicates that at
least 25% of physicians have
not been educated on the
diagnostic criteria for autism
screening.
EXAMPLE
Participants will be able to:
-Write the diagnostic criteria
for screening pre-school age
children for Autism,
-Create individualized
treatment plans to manage
pre-school age autistic
patients, and
-Develop procedures to
screen pre-school age
children who present with
autistic behaviors.
Patient outcomes: Using
procedures to screen preschool age children earlier
and the individualized
treatment plan will change
the outcome of the patients.
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Classify the
educational needs in
terms of knowledge,
competence,
performance and/or
patient outcomes
Changes in
competence and/or
performance are
required.
_X_Knowledge:
_X_Competence
_X_Performance
_X_Patient Outcomes
_ _ Knowledge
Competence
Performance
___Patient Outcomes
_ Knowledge
Competence
Performance
___Patient Outcomes
Knowledge
Competence
Performance
___Patient Outcomes
_ _ Knowledge
Competence
Performance
___Patient Outcomes
(add additional rows to this table as needed)
22) Based on the desired results you described in the gap chart above, list the learning
objectives for this activity. Learning objectives help learners understand the
specific result they can expect to achieve by participating in this educational activity.
LIST AT LEAST ONE OBJECTIVE FOR EACH OUTCOME YOU LISTED ABOVE As a
result of participating in this activity, participants will be able to: (example: Explain
the diagnostic criteria used to screen autism).
1.
2.
3.
(continue numbering if additional objectives are listed)
23) Is this activity designed to change competence, performance and/or patient
outcomes?
24) The competencies/physician attributes were founded on the Maintenance of
Certification (MOC) competencies designed by the American Board of Medical
Specialties (ABMS) the competencies established by the Accreditation Council for
Graduate Medical Education (ACGME), and the desirable physician attributes
established by the Institutes of Medicine (IOM). Once you have decided on the
competencies/physicians attributes to be used to develop this activity, (1) place an
“X” in the first box of the table for each competency/physician attribute, (2) write the
objective(s) number in the last column of the table that corresponds to the
competency/physician attribute you selected. Example: Objectives numbers 1, 3,
and 6.
PLACE AN “X”
COMPETENCIES/PHYSICIANS ATTRIBUTES
Patient Care (provide care that is
compassionate, appropriate and effective
treatment for health problems and to promote
health).
Medical Knowledge (demonstrate knowledge
about established and evolving biomedical,
clinical and cognate sciences and their
application in patient care).
Practice-based Learning and Improvement
(investigate and evaluate patient care
practices, appraise and assimilate scientific
evidence and improve practice of medicine).
Systems-based Practice (demonstrate
awareness of and responsibility for larger
Content in this activity
that reflects the
competencies you
selected – Cite the
learning objective
number(s) 1, 3, 6, etc.
context and systems of healthcare; call on
system resources to provide optimal care, e.g.,
coordinating care across sites or serving as the
primary case manager when care involves
multiple specialties, professions, or sites).
Professionalism (demonstrate a commitment to
carrying out professional responsibilities,
adherence to ethical principles and sensitivity
to diverse patient populations).
Interpersonal and Communication Skills
(demonstrate skills that result in effective
communication and teaming with patients, their
families and professional associates, such as
fostering a therapeutic relationship that is
ethically sound; using effective listening skills
with non-verbal and verbal communications;
working as both a team member and at times as
a leader).
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 educate patients; share
decision making and management; and
continuously advocate disease prevention,
wellness, and promotion of healthy lifestyles,
including a focus on population health).
Work in Interdisciplinary Teams (cooperate,
collaborate, communicate, and integrate care in
teams to ensure that care is continuous and
reliable).
Employ Evidence-based Practice (integrate
best research with clinical expertise and patient
values for optimum care; participant in learning
and research activities to the extent feasible).
Apply Quality Improvement (identify errors and
hazards in care; understand and implement
basic safety design principles; continually
understand and measure quality of care in
terms of structure, process and outcomes in
relation to patient and community needs;
design and test interventions to change
processes and systems of care with the
objective of improving quality).
Utilize Informatics (communicate, manage
knowledge, mitigate error, and support decision
making using information technology).
25) Based on the Gap (educational needs) of your target audience, provide a timed
agenda along with the topics and the faculty names for each topic. Application
cannot be reviewed if this information is missing. (CMDA approves to the quarter
hour and only the time actually spent in the educational session)
EXAMPLE:
TIME
8 - 9 am (1 HR Requested)
9:00 am
9:15 – 10 am (.75 HR
Requested)
10:00 AM
TOPIC TITLE
Overview of Autism
Break
Topic
FACULTY NAME
John Doe, MD, PhD
N/A
Jane Doe, MD
Adjourn
26) Please provide an abstract for each topic. Include the topic title and faculty name
with each abstract. Application cannot be reviewed if this information is missing.
EDUCATIONAL EVALUATION, BARRIERS, NON-EDUCATIONAL STRATEGIES
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27) CMDA will develop an online evaluation to evaluate and analyze changes in your
learners’ professional practice gaps (i.e., changes in knowledge, competence,
performance and practice changes). Three to four months after the completion of
the activity, CMDA will send a follow-up outcomes survey to measure changes to
professional practice as well as competence, performance and/or patient outcomes
from this activity. The outcomes survey is sent to all participants who submitted the
initial evaluation.
28) Please identify factors outside your control that have an impact on patient outcomes
(examples: insurance, patient not following recommended dosage, patient’s
support system, etc.).
29) Identify anticipated barriers that the participant’s may have in trying to implement
changes in their practice (examples: formulary restrictions, insufficient time for
implementation of new skills or behaviors, lack of insurance reimbursement, lack
of organizational support, lack of resources, policy issues within the organization,
unwillingness to make changes). Recommend educational strategies that you will
discuss during this activity to remove, overcome, or address these barriers.
ANTICIPATED BARRIER(S) TO PARTICIPANT
CHANGES IN PRACTICE
PLANS TO ADDRESS OR OVERCOME THE
BARRIER(S)
30) Planners of this activity are encouraged to employ non-educational strategies for
participants (examples: handouts, CD’s, videos, websites, etc.) to reinforce the
intended results of this activity. Please list any non-educational strategies that you
will use and the purpose of the strategy.
Non-educational Strategy
CMDA will E-mail a follow-up outcomes survey
to participants of this activity.
Purpose of the Strategy
The outcomes survey will remind participants
of the changes they will implement as well as
focus on changes in professional practice.
COURSE LOGISTICS
CMDA neither sponsors nor joint-sponsors activities that are supported by a
commercial interest, however CMDA does accept commercial exhibitors.
The ACCME definition for a commercial interest: “A commercial interest is any entity
producing, marketing, re-selling, or distributing health care goods or services
consumed by, or used on, patients.”
31) Will this activity have Commercial exhibits?
Yes
No
See definition of commercial interest above. Review the ACCME Standards for
Commercial SupportSM) in the Course Director’s Manual. If Yes, please provide list
of participating commercial exhibitors and COMPLETE THE EXHIBIT FORM.
The ACCME requires that a list of all exhibitors be distributed to your participants
before the educational activity is presented. For that reason, CMDA will provide a
Welcome Letter, which will include this information for your participants.
NAME OF EXPECTED/INVITED COMMERCIAL EXHIBIT ORGANIZATION(S)
and contact e-mail address:
NAME OF ORGANIZATION
E-MAIL ADDRESS
Add additional rows to this table as needed
The ACCME definition of non-commercial exhibitor: Providers of clinical services
directly to patients, such as hospitals, health systems, medical group practices, blood
banks, and diagnostic laboratories, are an integral component of accredited CME and
CDE because they represent the provision of CME by the profession for the profession.
Therefore, these entities have been deemed NOT to be commercial interests.
32) Will this activity have non-commercial exhibits?
Yes
No
See definition of non-commercial interest above. Review the ACCME Standards for
Commercial SupportSM) in the Course Director’s Manual. If Yes, please provide list
of participating non-commercial exhibitors. NON-COMMERCIAL EXHIBITORS DO
NOT NEED TO COMPLETE THE EXHIBIT FORM.
The ACCME requires that a list of all exhibitors be distributed to your participants
before the educational activity is presented. For that reason, CMDA will provide a
Welcome Letter, which will include this information for your participants.
NAME OF EXPECTED/INVITED NON-COMMERCIAL EXHIBIT
ORGANIZATION(S) and contact e-mail address:
NAME OF ORGANIZATION
E-MAIL ADDRESS
Add additional rows to this table as needed
*NOTE: A final list of confirmed exhibitors MUST be submitted 30 days prior to the conference so that
required follow-up can be done by the CE Department.
33) If this activity will have commercial and/or non-commercial exhibitors, where will
they be located with respect to the CE educational activity?
_________________________________________________________________________________
34) Is there a registration fee for participants?
If yes, how much?
Physicians $
Physicians Assistant
Residents, $
Nurses $
Students, $
Others (please specify): $
Yes
No
X Signature Activity Director (electronic signature or typed name is acceptable if
sending electronically)
Signature
Date:
IF THIS ACTIVITY IS CANCELED WITHIN 30 DAYS OF THE START DATE, THERE WILL BE
A $500 ADDITIONAL CANCELLATION FEE PLUS COLLECTION OF ANY EXPENSES
INCURRED BY CMDA.
Christian Medical & Dental Associations does not share in profit or loss for this
symposium.
Christian Medical & Dental Associations educational activities are reviewed by the
CMDA committee for scientific content, relevance to healthcare professionals,
congruence with the CMDA mission, and credentials of speakers. All symposiums must
be approved by the CMDA committee. By serving in this role, the Committee is serving
as part of the planning process for all activities sponsored by the CMDA.
CMDA FEE FOR SPONSOR/JOINT-SPONSORSHIP
ACTIVITY FEE(s)
*CME Application Fee for direct sponsored activity - $500.00
*CME Application Fee for jointly sponsored activity - $850.00
Total Activity Fee due UPON SUBMISSION OF APPLICATION
$
$
$
*IF during the review process the application is denied by the review committee
OR if the activity is cancelled at any time after submission, there will be a $200
non-refundable application review fee.
DUE AFTER COMPLETION OF THE ACTIVITY
Transcript Fee - $10 per credit hour approved/Per person
(Example: 4 hours approved for the activity = $40 post activity fee x 22
participants
claiming CE = $880.00 Post Activity Fee Due)
A Financial wrap-up report along with Transcript Fee for this course is required within
30 days following activity completion.
__________________________
NOTE: The CMDA CE Department desires to keep its fees reasonable in comparison to the
national average. For large organizations or large events, the CMDA CE Department is willing to
base its fees on the number in attendance and/or whether it is a sponsored or joint-sponsored CE
activity. Please contact Barbara Snapp (1-888-230-2637 or barbara@cmda.org) to discuss
additional options if needed before submitting this application.
FEE FOR ADDITIONAL SERVICES (non-negotiable)
$300 AAFP Credits
$300 Dental (Academy of General Dentistry - IF submitted separately from the medical
application)
$300 Nursing (in order for CMDA to apply for nursing credit, you must submit speaker
Bio sketches, speaker & planner disclosures and overview of each speaker
presentation with this application)
$300 Nurse Practitioner (in order for CMDA to apply for nurse practitioner credit, you
must submit speaker Bio sketches, speaker & planner disclosures and overview of
each speaker presentation with this application)
$300 Physician Assistant
Course/Activity logistics that must be provided to the CMDA/CE office:
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Application for Credits (must be approved by the CMDA Committee).
Draft brochure for review and approval.
5 original brochures.
Sign-in sheets/attendance verification document (typed and electronic).
Copies of faculty/course director reimbursement checks for travel and
lodging etc.
Copies of faculty/course director honoraria checks
List of exhibitors (If applicable)
Budget reconciliation - accounting of income and expenses.
BEFORE YOU SUBMIT THIS APPLICATION MAKE SURE:
APPLICATION IS SIBMITTED ELECTRONICALLY IN A WORD DOCUMENT
ALL QUESTIONS ON THE APPLICATION ARE ANSWERED
PROPOSED BUDGET