Single Activity
Regional CME Pre-Application
Submit ASAP for Review
Kaiser Permanente Northern California
1. Activity Overview
Activity Title:
Estimated Date(s):
Briefly describe this proposed educational activity
2. Planners & Planning Committee
A. Planner Contact(s)
Name
Title
Dept/Facility
Email
Phone
B. Administrative Contact(s)
Name
Title
Dept/Facility
Email
Phone
C. Planning Committee Members
Name
Title
Dept/Facility
Email
3. Target Audience
Describe the intended target audience attendance.
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5. Needs Assessment
A. Gaps in Practice
Describe the problems or gaps in practice (physician knowledge, competence, or performance)
and how you assessed or measured these issues.
What are you trying to change? What is the problem? Whose problem is it? How do you know?
B. Learner Needs
Describe the needs of learners underlying the gaps in practice.
What are the causes of the gaps in practice? Why does the gap exist? What do learners need to
be able to know or do to be able to address the gaps?
C. Health Disparities Linked to Practice Gaps
Describe the health disparities that are linked to cultural or linguistically related practice gaps
(physician knowledge, competence, or performance) relevant to your target audience. Describe
the evidence (or lack of evidence) of health disparities and how you identified it.
D. Barriers to Change
Describe the barriers to change that this activity will address.
What has prevented learners from implementing change or adopting recommendations?
7. Objectives
Describe the key educational objectives.
What do you want clinicians and teams to be able to do as a result of this activity?
As a result of this program, participants will be able to:
1
2
3
4
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8. Outcomes
A. Overall Outcomes
This activity is designed to improve: (check all that apply)

Physician Competence
Physician Performance
Patient Outcomes
B. Outcome Levels
Describe how you plan to evaluate this activity. Describe which outcome levels you will measure,
how you will measure them, and when.
Level 2 outcomes or above are required. Level 3 outcomes and above are highly recommended.
Level 1 – Target audience attendance, participation, feedback
Level 2 – Intent to change practice; change in competence or skills (Competence)
What will be measured?
How will it be measured?
When will it be measured?
Level 3 – Self-reported change in practice (Performance)
What will be measured?
How will it be measured?
When will it be measured?
Level 4 – Objectively measured change in practice (Performance)
What will be measured?
How will it be measured?
When will it be measured?
Level 5 – Change in patient health status (Patient Outcomes))
What will be measured?
How will it be measured?
When will it be measured?
C. Outcomes Analysis
Describe how and when you intend to analyze the evaluation results and educational outcomes.
Submit your CME Pre-Application as early as possible for review.
Submit your completed CME Application not less than 45 days prior to your program.
Send to: marie.c.johnson@kp.org.
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