CME ACTIVITY REQUEST FORM
To the Applicant:
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All applications must have a physician serving as the activity director.
The activity director is responsible for assuring completion and compliance with the CME application
process.
The activity director and an Ochsner department chairman must sign the application.
To insure adequate time for review and approval, applications must be submitted to the Ochsner CME
department at least 9 months prior to the activity.
The Ochsner CME department will review all applications for compliance with the ACCME criteria.
ACTIVITY INFORMATION
Name of Activity:
Date(s) of Activity:
Proposed Location of Activity: [The CME Department is responsible for selecting the hotel, reserving the
meeting space, and negotiating any contracts and fees]
________________________________________________________________________
Activity Director(s): [must be an Ochsner physician]:
Address [for inter-office mail]:
Phone:
Fax:
E-mail:
_______________________________________________________________________
Non-Physician Contact Name[i.e. assistant, nurse, PA, etc… ]:
Title:
Address [for inter-office mail]:
Phone:
Fax:
E-mail:
________________________________________________________________________
Joint or Co-Sponsor Organization [if applicable]:
Contact Person:
Phone:
Fax:
E-mail:
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Target Audience
Note: The content of your program must be geared toward physicians. Although other healthcare providers
may attend, the majority of participants should be physicians.
Please list all specialties that should be targeted:
Please list any societies or membership lists that should be targeted:
Please check the geographical area for the specified target audience
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Internal to Ochsner
Local: Louisiana only
Regional: LA, MS, AL, GA, FL (panhandle), and TX (eastern region)
National: USA
National: USA Modified
International: please specify: ______________
Needs Assessment (Criteria 2)
Please describe the needs assessment AND professional practice gap (The difference
between actual and ideal performance and/or patient outcomes) of the target audience for
the educational activity:
Using your statement above, please check the items below from which these needs were
derived:
Competence (Knowing HOW to do something):
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New methods of diagnosis or treatment
Availability of new medication(s) or indication(s)
Development of new technology
Input from experts regarding advances in medical knowledge
Acquisition of new facilities or equipment
Legislative, regulatory, or organizational changes affecting patient care
Other, please describe:
Performance (What one actually DOES in practice):
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Requests submitted on participants’ activity evaluation forms
Formal surveys of potential participants (mail and Internet-based)
Previous Program evaluation tabulations
Patient problem inventories compiled by potential participants
Consensus of faculty members within a department or service area
Library requests
Delivery of care
Processes of care
Other, please describe:
Patient Outcome/Statistical Data
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] Epidemiological data
] Performance Improvement data
] Re-credential review
] Morbidity/mortality statistics
] Infection control data
] Surgical procedures statistics
] Other, please describe:
****Evidence of need for each resource noted in Criteria 2 must be attached. Applications submitted
without this required documentation will be returned without review.
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Desired Results (Criteria 3)
Please describe how this activity/educational intervention is designed to change
Competence (Knowing HOW to do something):
Performance (What one actually DOES in practice):
or
Patient outcomes:
Briefly describe the purpose, and content of the educational activity:
Please list the learning objectives of the educational activity:
Scope of Practice (Criteria 4)
Please describe how the content of this activity matches the participants’ current or
potential scope of professional activities:
Educational Format (Criteria 5)
Please choose an educational format for the activity that is appropriate for the setting,
objectives, and desired result of the activity.
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] Lecture
] Interactive Workshop
] Laboratory Session
] Faculty Panel Discussion
] Question & Answer Session
] Case Studies
] Audiovisual aids (check applicable items):
slides
video
audio
] Syllabus/Handout Materials
] Medical images (e.g. X-Rays, CT, MRI, Nuclear Medicine, Ultrasound)
] Live Transmission (video conference, web cast, satellite, etc…)
] Other (briefly describe):
Program Schedule –Please provide a proposed hour-to-hour conference schedule,
including registration times, program activities, breaks, meals, question and answer
sessions, and other items that may apply.
Desirable Physician Attributes (Criteria 6)
Select all desirable physician attributes this course will address
IOM Competencies
ACGME Competencies
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] Provide Patient-Centered Care
] Work in interdisciplinary teams
] Employ evidence-based practice
] Apply Quality Improvement
] Utilize informatics
] Patient Care
] Medical Knowledge and Skills
] Interpersonal and Communication Skills
] Professionalism
] System-Based Practice
] Practice-Based Learning and Improvement
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Engagement with the Environment (Criteria 16-22)
Can you incorporate opportunities for performance improvements into the curriculum?
I.e. addressing patient safety and quality, a decrease in unnecessary expenses, more
appropriate prescribing, implementation of best practices or a reduction in medical errors
(C16 &C21):
What are the potential or real barriers that may impede our ability to implement these
improvements (i.e. patient compliance, insufficient quality measures, system-based
management issues, etc)? Are any of these barriers beyond your control? Are there any
tools that address how to overcome these barriers (C18 &C19):
Are there any non-educational strategies that can help narrow the professional practice
gap(s)? Are there any strategies that can reinforce the points of this educational activity
such as e-mail reminders, model order sheets, patient education materials, etc. Examples of
a "non-educational strategy to enhance or facilitate change as an adjunct to activities or educational
interventions" would be, 1) implementing a mechanism to send reminders to participants following CME
activities (e.g., "Don't forget to..." or "Have you incorporated...?"), or 2) working with others to facilitate a
peer to peer feedback system to reinforce new practices, or 3) incorporating new questions about the new
practices into patient satisfaction questionnaires. These types of strategies assist in reinforcing the message
of the educational event as well as facilitating changes in behavior (C17):
Are there other initiatives within OCF or elsewhere in the medical community directed at
these issues? Does this activity contribute toward building bridges with other
stakeholders and how? Can any of these groups remove these barriers (C18 &C20):
Disclosure
Disclosure: Anyone that is on the planning committee or has control of the content or is
engaged in the decision making of this activity is required to complete a disclosure form.
Please list all speakers and planning committee members below:
Cost Center
Please list the cost center name and number for this conference budget. Any revenues at
the conclusion of this course will be deposited to this cost center and any deficit will be
taken from this cost center (for Ochsner funded courses only):
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Signature
Please sign below as Activity Director, then forward to your Department Chairman/Section Head for review
and signature. If the Activity Director is the Department Chairman/Section Head, please have your AMD
review the application and also sign below. Applications are reviewed by an assigned CME Meeting Planner;
and a physician liaison of the CME Executive Committee.
By signing below, I approve and recommend the implementation of this proposed CME activity and attest that
the activity will comply with the Criteria for compliance with ACCME’s Accreditation Elements, including
such requirements concerning content validity and scientific integrity.
Submitted by:
__________________________________________________________
Activity Director
Date
Reviewed by:
__________________________________________________________
Department Chairman/Section Head
Date
or AMD, if Department Chairman/Section Head is Activity Director
Please forward completed application and to:
For Interoffice Mail: EMC/ 4 /CME
(located at1201 S Clearview Blvd
on the fourth floor of the Elmwood Medical Center, Suite 402)
Ochsner Clinic Foundation
Continuing Medical Education Department
1514 Jefferson Highway
New Orleans, Louisiana 70121
Telephone (504) 842-3702 Fax (504) 842-4805
FOR CME
Identification Number ______________
DEPARTMENT USE ONLY
Date Received: _________________________
Sponsorship: [ ] Directly Sponsored [ ] Jointly Sponsored
Classification: [ ] New [ ] Annual [ ] Other: (describe) ___________________
Assigned to:
_________________________________________
Sr. Meeting Planner, CME
After reviewing the application and disclosures:
[ ] Mission Statement (Criteria 1) This activity is congruent with the CME Department’s Mission
I [ ] recommend/ [ ] do not recommend planning as a CME activity. Comment Attached
Reviewed by: _________________________________________
CME Executive Committee Member
_____________
Date
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