CME Certified Activity - Preplanning Worksheet
Please read the following information, in its entirety, prior to completing the attached
worksheet.
Submission Timeline: Preplanning worksheets must be submitted as follows:
Live Activities:
Regularly Scheduled Series: At least 1 month prior to start of series
Courses: At least 2 months prior to course date
Other CME activity types: At least 4 months prior to course date
All activities requesting CME credit must first complete the CME Preplanning worksheet prior to filling out a CME
application. The worksheet was designed to ensure that all Continuing Professional Development (CPD) activities
approved by the INTEGRIS Medical Education Office (the provider) for AMA PRA category 1 creditsTM, meet the
Oklahoma State Medical Association’s adoption of the ACCME’s (Accreditation Council for Continuing Medical
Education) 2006 Criteria.
This worksheet is specifically designed to address Criterion 2 (C2): The provider incorporates into CME the educational
needs (knowledge, competence, or performance) that underlie the professional practice gaps of their own learners.
Definitions for C2
1. Educational Needs – Deficits in knowledge, competence, or performance that contribute to a
professional practice gap.
2. Competence – The participant will have the ability to apply knowledge or a strategy to change
their practice.
3. Knowledge – Familiarity, awareness or understanding gained through experience or study.
4. Patient Outcomes: - i.e. how patients are affected. May include health status, delivery of care, patient
perceptions, and patient experience.
5. Performance – What one actually does in practice; Skills, abilities, and strategies implemented in
practice.
6. Professional Practice Gap – The difference between actual and ideal performance and/or patient
outcomes. Professional practice gaps are the description of a problem in practice or an area that needs
improvement.
Three steps used in the planning process for C2:
1.
Identifies professional practice gaps – The planning committee identifies professional practice gaps from:
national data, peer-reviewed published literature, registries such as www.clinicaltrials.gov, practice guidelines,
national data, professional society/college data, chart audits, standardized assessment exercises, focus groups, or
reflection in/on practice, computerized tools, office visit diary, learning portfolios, improved question-asking
skills.
Answers the question: Why do they need this learning activity on this topic?
2. Identifies underlying needs and link this information to professional practice gaps of their
learners – To identify the underlying needs the provider can:
a. Interview recognized thought leaders in the content area related to a practice gap to review the
data to determine the underlying needs.
b. Participants can complete pre-activity surveys to define their own practice gaps and identify their
underlying needs related to the identified gaps.
c.
Review hospital or clinical data
Answers the question: What is it about the learners knowledge, competence, or performance that
needs to change?
3. The provider then develops CME activities to address these needs.
Instructions For CME Preplanning Worksheet
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Please read this document in its entirety, and then complete. If you have questions, or difficulty in filling out the
form, please contact Marilyn Fick, CME Specialist, 405.949.3284 or email marilyn.fick@integrisok.com
Return the completed form to the INTEGRIS Medical Education Office via email to Marilyn Fick:
marilyn.fick@integrisok.com
Name of person submitting completed form: Start typing here
Contact number of person submitting form: Start typing here
Section 1 – Activity Information
1. Insert Activity Name: Start typing here
2. Insert Activity Date(s): Start typing here
The activity, to be in compliance with Oklahoma State Medical Association criteria it must address one of the following:
Competence – The participant will have the ability to apply knowledge or a strategy to change their practice.
Performance – The participant will actually apply the knowledge in their practice.
Patient outcomes – There will be a measurable change in patient health status.
Section 2 – Program Purpose
In the space below, please describe the desired outcome of this program (what will your learner be able to
do). EXAMPLE of a program purpose statement: To enhance the culture of safety within Aurora obstetrics the
learner will be able to react to patient emergencies within the obstetrical unit. This will be accomplished via the use of
simulation of obstetrical emergencies in a controlled environment.
Your Program Purpose Statement: This activity is intended to…Start typing here
Section 3 – Identify Professional Practice Gaps and Content Focus
A professional practice gap is defined as the difference between what is actually occurring in the practice and what the
ideal performance is. We are asking you to identify the gaps in the clinical or organizational practice that you
want to close. Why do they need this learning session on this topic? In the space provided, state by topic,
the evidence (why this is needed) for each professional practice gap identified through your needs assessment,
and then provide (attach) the supporting documentation.
In the space below, state (and submit the documentation), the professional practice gaps identified through your needs
assessment. The gaps are organized by topic. Please check which attribute the topic will address: Knowledge,
Competence, Performance, and/or Patient Outcomes. If you need more Topic categories, please make a copy of this
sheet.
Overall Activity Topic:
Knowledge
Competence
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Performance
Patient Outcome
Topic #1:
Knowledge
Start typing here
Competence
Performance
Patient Outcome
Topic #2:
Knowledge
Start typing here
Competence
Performance
Patient Outcome
Topic #3:
Knowledge
Start typing here
Competence
Performance
Patient Outcome
Topic #4:
Knowledge
Start typing here
Competence
Performance
Patient Outcome
Competence
Performance
Patient Outcome
Competence
Performance
Patient Outcome
Topic #5:
Knowledge
Start typing here
Topic #6:
Knowledge
Start typing here