CME APPLICATION AND PLANNING GUIDE
FOR A REGULARLY SCHEDULED
CONFERENCE (RSC) SERIES
New Series or Annual Renewal
RSC SERIES INFORMATION
Academic
Year
RSC Series Title
New Series
Renewal
to
Grand Rounds/Lecture Series
Case-base/M&M/Tumor Conference
Other:
Frequency
Weekly
Monthly
Bi-Monthly
Quarterly
Other:
From
AM
PM
Day(s) of the
Mon.
Tue.
Wed.
Time of Day
Week
Thu.
Fri.
Sat.
To
AM
PM
If monthly or bi-monthly, please specify the week of the month the activity is held:
First Week
Second Week
Third Week
Fourth Week
Every Other Week
Duration - months during the year the activity is available (i.e. July-June)
Location (conference room, facility)
RSC Series Type
Estimated
Attendance
MDs/DOs
Non-MDs/DOs
Is this activity appropriate for non-faculty/GBMC physicians?
(physicians from the community)
Yes
No
CONTACT INFORMATION
Identify the faculty member primarily
responsible for planning and conducting this
Identify the person responsible for submitting
activity on an ongoing basis.
activity session reports to the CME Office on an
ongoing basis. (Dept. Activity
Course Director
Coordinator/Associate)
Title
CME Liaison
Dept./Div./Other
Title
Address
Dept./Div./Other
Telephone
Address
Fax
Telephone
Email
Fax
Email
EDUCATIONAL PLANNING AND EVALUATION
Definition: Continuing Medical Education consists of educational activities that
are designed and directed to serve the clinical and professional performance of
practicing physicians. Those educational activities that are specifically directed to
or developed for residents or medical students are not considered for designation
of AMA PRA Category 1 Credit(s) ™.
1.
2.
TARGET AUDIENCE
Who is the primary
target group for whom
this activity is designed?
PLANNING METHOD
GBMC Physicians
Community MDs
Nurse Practitioners
PAs
Other, please specify
Medical Specialty
Estimated PHYSICIAN attendance per session?
Estimated TOTAL attendance per session?
Course Director Only
1
Planning Committee
Formal or Informal
Describe the process
used to plan this series.
Input from Department Chair or other faculty members
describe.
.
Other, please
Provide a list of individuals who participated in planning this series.
Name
Department/Affiliation
3.
NEEDS ASSESSMENT
How were the
educational needs
identified? Mark all that
apply.
*Please note: If this is a
renewal application, the
CME Office requires an
overall annual evaluation
from the previous series to be
used as part of the needs
assessment
4.
NEEDS ASSESSMENT
STATEMENT
Describe how this data
was incorporated into
the planning of this
series. (i.e., how do you
know this series is needed?)
5.
6.
7.
DOCUMENTATION OF
NEEDS ASSESSMENT
What documentation is
included with this
application?
DESIRED RESULTS
What improvements in
healthcare should result
from this series?
OVERALL
GOALS/OBJECTIVES
What are the overall
goals or overall learning
objectives that should
be achieved through this
RSC series? (i.e., changes
in problem solving,
improvements in knowledge,
changes in attitude, etc.)
Continuing review of changes in medical practice (medical literature)
On going census of diagnosis made by the faculty
Periodic surveys of staff interests (by questionnaires or personal
interviews)
Advice from authorities/experts in the field
Formal or informal requests from faculty members
Discussions in department meetings
Data from outside sources? (public health statistics, JCAHO standards)
Judgment of Course Director or Department Chair
M & M statistical data
Literature Reviews
*Evaluation Data
Please note:
 A summary of the overall activity evaluation or the annual conference review
from the previous year MUST be included with this application.
Past or Annual series evaluation attached.
Other survey results attached.
Department faculty meeting minutes attached.
Course Director/Department Chair assessment summary attached.
Other, please describe.
Please note:
 In order to be approved for AMA PRA Category 1 Credit ™,at least one form
of documentation must be included with the application
At the conclusion of this series the participant will…
2
8.
EDUCATIONAL FORMAT
What educational
format(s) will be used to
achieve the overall
goal/objectives for this
RSC series?
9.
FACULTY SELECTION
AND SCHEDULE
On what criteria
was/were the faculty
selected?
10.
11.
12.
EVALUATION
What is the evaluation
plan for this series?
The ACCME requires that
ALL CME activities be
evaluated.
Standardized RSC evaluation
forms are posted on the CME
Website.
DISCLOSURE OF
FINANCIAL INTERESTS
The ACCME requires
that ANYONE who has
the opportunity to
influence the content of
the CME activity must
disclose and that
potential conflicts in
interest be resolved
before the activity
occurs.
Lectures, panel discussions, Q and A
Case presentations and discussions
Demonstration of procedures
Individual assignments/literature reviews
Expertise
Recommended
Other, (specify)
Faculty Request
Full schedule attached
Partial schedule attached
Schedule will be sent later
Individual session evaluation by participants using standard form
Quarterly evaluation by participants using standard form
Annual evaluation by participants using standard form
Annual assessment by selected participants as determined and
summarized by course director
Other, please describe.
The “Resolution of Personal Conflicts of Interest” Form is one
mechanism that GBMC uses to identify potential conflicts of interest.
This form must be completed by the course director, planning
committee members, department chairman, and anyone who is in a
position to control the content of the CME.
The “Disclosure of Relevant Financial Relationships” Form must be
completed by all speakers, authors, moderators, etc. For case
conferences ALL regular attendees should complete form if they
intend to contribute to the discussions.
Disclosure forms for planners, faculty members, and confirmed speakers
or contributing case conference attendees are attached.
Please note:
 THESE DISCLOSURE FORMS MUST BE INCLUDED WITH THE
APPLICATION.
 Disclosure forms for speakers not yet identified and/or confirmed may be sent
with the appropriate session’s closing report.
Written:
Evaluation
3
Slides
Other, describe.
How will disclosure be
communicated to the
audience?
Attendees at each session
MUST be informed about
disclosure, even if
individuals have indicated
NO FINANCIAL
RELATIONSHIPS EXIST.
The CME Office requires
that this disclosure be made
on the evaluation form but
encourages a verbal
disclosure to be made, as
well.
Verbal:
Speaker
Moderator
Other, describe.
Please note:
 Speaker disclosure is required, even if the conference does not receive
commercial support
 Disclosure is required, even if the speaker indicates that NO financial
relationship(s) exist.
 No matter how disclosure is communicated, a written record of the disclosure
must be kept and submitted with each session report.
13.
COMMERCIAL
SUPPORT
Will commercial support
be received for any
sessions of this series?
Yes
No
Maybe
If so, please read the ACCME’s “Standards for Commercial Support of
Continuing Medical Education” & GBMC Policy #372 Educational
Commercial Support
Support is provided on a session-by-session basis.
Support is provided for or all or part (multiple sessions) of this RSC
series.
14
Commercial Support
Letters of Agreement
All educational grants provided to support CME require a “Letter of
Agreement for Commercial Support”. Agreements must be signed by
the company’s representative, the CME institutional representative, and/or
the joint sponsor/educational partner, if applicable.
15.
Management of
Commercial Support
16
Acknowledgement of
Commercial Support
How will the audience be
informed about the
commercial support?
A complete accounting of the receipt and distribution of educational grants
must be provided to the OCME with the closing activity session report on
the “RSC Commercial Support Budget Report”
In writing
Verbally
Other, explain
Please note:
 The CME Office requires that the acknowledgement be made in writing and
encourages a verbal acknowledgement to be made, as well.
 A written record of the acknowledgement must be kept and submitted with the
appropriate session report.
ADVERTISING AND PROMOTIONAL MATERIALS
Announcement
Email
Monthly calendar
Interdepartmental mail
Website: URL site:
Other, please describe.
Please note:
 The ACCME requires objectives, correct sponsorship, specified accreditation
statements, AMA PRA Category 1 ™ designation statement, faculty disclosure,
and commercial support be included.
 All RSC will be included in the educational calendar published bi-monthly by
the CME Office unless instructed otherwise.
17.
How will notification of
the RSC be distributed
to the participants prior
to the activity session?
18.
Speaker Notification and Honoraria Payment
Will speakers be paid an
Yes
No
Maybe
honoraria for their
4
presentation?
If so, please read the GBMC’s Policy #377 Honoraria and
Reimbursement for CME Activities
Honoraria is paid on occasion throughout the year
Honoraria is paid to all speakers
Honoraria/travel reimbursement will be paid by department and all
details will be submitted to CME Office with session forms
Honoraria/reimbursement will be paid by CME Office and we will provide
CME Office with tax ID # of speaker/mailing address and honoraria amount
All honoraria requests sent to Accounts Payable must be accompanied by a
completed W-9 form. This form is completed by speaker.
19.
Speaker notification
Speaker Letter and Form will be sent by Department directly to speaker and
directions for returning forms including address and fax number of CME
Liaison will be provided.
RSC Content
The ACCME has
developed updated
accreditation criteria for
which we are required to
be in compliance.
20.
To ensure compliance
beginning in September
2008 all RSCs will be
required to have at least
one educational
sessions during the year
focus on “Practice
Improvement”.
Practice Improvement topics are non-clinical in nature and designed to be
of benefit to the physician audience and to help improve their overall
practice of medicine.
Example topics include but are not limited to
o
Coding
o
Staff Retention
o
Dealing with Difficult Patients
o
Delivering Bad News
Has the topic and date for your practice improvement session already been
set?
Yes
No
If so, please list ______________ (date) ______________ (topic)
If no, please let CME Office know when date and topic are chosen.
Approval Signatures:
5
This program was planned in compliance with the Essentials of CME, the ACCME Guidelines of Commercial Support and
the AMA "Ethical Opinion on Gifts to Physicians." The content, objectives and design of the program are solely for
educational purposes and were planned by a committee representing GBMC. All profits from this program will be
reimbursed to the assigned budget and that budget will also reimburse the CME Department for any loss.
_________________________
Program Director
____________________
Date
I agree with the needs assessment, target audience, conference goal, objectives, instructional method, publicity and budget. I
have reviewed the content of this program and assure departmental support of this activity.
_________________________
Chairman's Signature
____________________
Date
This program has been reviewed and meets the Essentials for planning a CME activity. This program is approved for
Category 1 credits.
_________________________
CME Coordinator’s Signature
____________________
Date
_________________________
CME Director’s Signature
____________________
Date
approved
not approved
missing information
For CME Office use:
does not meet Category 1 criteria
If approved,
Paperwork sent to Department
entered into MeetingTrak
6
entered into Excel
other