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
Tumor Board is a Multidisciplinary, RSS, CME Activity held weekly on Friday at noon at Ventura County
Medical Center for physician Medical Staff and VCMC support staff.
Tumor Breast is a Multidisciplinary, RSS, CME Activity held twice a month on Monday 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. Additionally, all oncology, surgical or specialty services are encouraged to submit cases for review.
PROTOCOL FOR RSS TUMOR BOARD AND TUMOR BREAST CME PLANNING
In general, the process of planning of the RSS CME activity 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 planning is based on the data submitted annually to VCMC Cancer Committee as the top 5 diagnoses are evaluated for unmet educational need. Unmet Educational Need is referred to CME
Committee for CME planning. 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
VCMC Oncology multidisciplinary workgroup meets to identify current evidence based cancer care guidelines in order to provide optimal care to patients with cancer.
2) Required Disclosure Form
All Tumor Board/Tumor Breast participants, planning members, staff, and moderators must submit a
CME disclosure form which covers each 12-month period and must include their spouse/partner. For regular Ventura County Health Care Agency Medical Staff, 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) and an ongoing census of diagnoses made by physicians on staff.
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 and 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.
TUMOR BOARD/TUMOR BREAST FORMAT AND PROCEDURES
The conference will begin promptly at 1200 hours and is led by CME Medical Directors, Oncology
Medical Services. The goal is to complete all current cancer RSS Tumor Board/Tumor Breast activity 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 weekly/ bimonthly Tumor Board/Tumor Breast 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 (Oncology, Radiation Oncology, Surgery, ENT,
Anesthesia, Orthopedics, Neurosurgery, Neurology, Pathology, Emergency Medicine, Plastic Surgery,
Radiology, Pediatrics, Obstetrics, Urology, Medical Staff Leadership, Family Medicine and others).
Each case presentation will be summarized (synopsis) on the confidential summary document prior to the CME activity, reviewed by the Activity Medical Director(s) or designee and then summarized during
Tumor Board/Tumor Breast CME activity for future follow up. The synopsis includes Clinical Information,
Primary Site, Clinical/Pathological Stage, Radiology Results, Pathology Results and the Presenting
Physician. The synopsis may reference a specific clinical question or challenge to be addressed by the multidisciplinary group. A CME Attestation Monitor 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. The
Summary of Case Discussion and Treatment Recommendations will be maintained for future Evaluation of Outcomes, evaluated for adherence to evidence based practices. Evaluation of 2 cases a month for outcome (after 46 months) consistent with National Comprehensive Cancer Network® NCCN data will
be submitted to CME Committee for CME planning. Once a year all data is reported to VCMC Cancer
Committee and the Top 5 Diagnoses are evaluated for unmet educational need. Unmet Educational
Need is referred to CME Committee for CME Planning.
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.
Patient outcomes, a total of 2 cases for each month for both Tumor Board and Tumor Breast, will be evaluated for outcome from the clinical primary and outcome of treatment plan. Evaluation will be completed at least 4-6 months after case presentation to allow for completion of planned treatment. The outcome data may be submitted for review to CME Committee every 3-6 months and /or yearly to coincide with data presented to VCMC Cancer Committee. Additionally any unmet educational need as determined by the VCMC Cancer Committee will be referred to CME Committee.