SAINT JOSEPH’S HOSPITAL
DEPARTMENT OF MEDICAL EDUCATION
APPLICATION FOR SPONSORSHIP OF A
CONTINUING MEDICAL EDUCATION ACTIVITY
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Please consider this application the initial planning of the activity for which you are requesting Category 1 CME credit. Before
submitting this application to the Department of Medical Education, please read and review thoroughly the attached guidelines around
which every sound educational CME activity must be designed. The Department of Medical Education will be happy to help you
complete this application. Applications for multi-credit programs must be received a minimum of 4 months prior to program date.
Please allow 60 days for approval of proposed CME activities.
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Office Use Only  FA  MF  EM  RSS
 Renewal
Date Received: _____________ Date Reviewed:______________ Date Approved: _______________
Approved for __________ AMA Category 1 Credit(s)™.
Activity # ____________________
Disapproved (description): __________________________________________________________________________
CME Program Coordinator:_________________________________________________
Submitted by:
E-Mail:
Date:
Tel. #:
SJH- Department
Title of Activity:
Activity Type:
Formal Activity (Conference, Course, Symposium)
Mini fellowship
RSS (grand rounds, teaching conferences, tumor boards, journal clubs)
Enduring Material (live or archived internet, podcast, CD, journal article)
Start Date:
Time of Activity:
Location of Activity:
Activity Director (MD):
Address:
E-mail:
End Date:
Frequency of Activity:
Phone:
*Organization-if Jointly Sponsored: Attach non-SJHA organization’s mission statement/purpose/description
* All decisions must be free of control of commercial interests including: (a) identification of needs; (b) determination of
objectives; (c) selection & presentation of content; (d) selection of educational methods; (e) selection of faculty; (f)
evaluation of activity. (Criterion 7 and the Standards for Commercial Support)
List all SJHA departments, sections, institutes, centers etc., that are co-hosting this CME activity.
A.) Planning Committee Structure: Please list all persons responsible for planning, designing, and implementing
the CME activity. Include names, degrees, titles and affiliations. Note: No employee of a commercial interest may
serve on the planning committee nor be allowed to influence educational content (nuance or direct).
Name/Degree:
Name/Degree:
Name/Degree
Name/Degree:
Name/Degree:
Name/Degree:
Title/Affiliation:
Title/Affiliation:
Title/Affiliation:
Title/Affiliation:
Title/Affiliation:
Title/Affiliation:
(Please complete Disclosure & Attestation Form for each committee member)
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B.) Professional Practice Gaps, Educational Needs, Desired Results & Learner Objectives:
As outlined in its mission statement, by identifying educational gaps, the Department of Medical Education
helps physicians and other healthcare providers recognize the difference between their current practice patterns
and those potentially achievable that would lead to practice improvement and thus better, safer care of
individuals, communities and populations.
1. A professional practice gap is the difference between health care processes and outcomes currently in
practice and those potentially achievable. Put simply, it is actual practice (what learners currently know
and/or do) vs. best practice (what they should know and/or do). These gaps are measure in terms of:
▲ Knowledge - being aware of what to do
▲ Competence - knowing how to do it
▲ Performance - actually doing it
Describe the identified professional practice gap for this CME activity. (Criterion 2)
Is the gap in (check all that apply):
Knowledge
Competence
Performance
2. CME activities incorporate the educational needs (knowledge, competence, or performance) that
underlie the professional practice gaps. Needs assessments look at gaps from various points of view,
showing current practice vs. ideal practice. Possible methods include: review of previous CME evaluations;
identification by medical staff; referral data, expert opinion; regulatory or institutional requirements; survey
results; national guidelines; literature reviews; QI data; patient chart audits; Joint Commission Standards; core
competencies; new medical information, and/or research findings. [Note: For RSS, a need can be addressed in
more than one session, and new needs can be incorporated over time into a series as long as they are appropriate
to the target audience.]
Describe the needs assessment used for this CME activity. How was this brought to the attention
of the planning committee? (Criterion 2)
Based upon the identified professional practice gap and the needs assessment used, state the
educational need.
3.
Based on the identified gap/need the CME activity is intended to address, what are the desired
results? What is the activity designed to change? (Criterion 3)
This CME activity is designed to change (check all that apply):
Competence (give physicians new abilities/strategies/knowledge)
How do you intend to measure these changes? Possibilities include evaluation questions,
audience response, pre-test, post-tests, surveys, etc.
Performance (help physicians modify their practice):
How do you intend to measure these changes? Possibilities include adherence to
guidelines, interviews, focus groups, chart audits, peer review, direct observation, etc.
Patient Outcomes (help improve patient outcomes):
How do you intend to measure these changes? Possibilities include patient feedback,
chart audits, QI data, etc.
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4.
Learner objectives should connect the identified need with the desired result and are framed in
terms of the expected changes in competence, performance, and/or patient outcomes. Based on
the desired, identified results, list the learner objective(s) for this CME activity. “Upon
completion of this activity, the participant should be able to…”
C.) Target Audience:
The content of a CME activity should be designed to match learner’s current or potential scope of professional
activities. (Criterion 4)
1.
Is this CME activity targeted to an internal, local/regional, and or national audience?
2.
Indicate which specialties of medicine will be targeted (list all that apply):
3.
Indicate the target audience’s level of experience (check all that apply):
Beginner
Intermediate
Advanced
4.
Is the target audience multidisciplinary?
Yes
No
If yes, list other healthcare providers that are part of the target audience.
5.
What is the estimated attendance size for this activity?
6.
If additional types of CME credit are needed, list them.
Expert
D.) Core Competencies:
1.
A CME activity should be developed in the context of desired physician attributes. Indicate which will
be addressed with this activity. (Criterion 6) [Note: Post-activity evaluations will ask learners to identify
which core competencies they felt were addressed.]
Quality Improvement
Evidence/Practice-Based learning
Patient-Centered Care
Systems-Based Practice
Working in Interdisciplinary Teams
Interpersonal Communication
Medical Knowledge
Professionalism
Informatics
E.) Barriers to Change, Collaboration, and Non-Education Strategies:
1.
List any potential or real barriers facing the learner for this need/gap to be addressed. Examples include
lack of time; too few resources; administrative support; reimbursement; healthcare system issues; patient
compliance; costs; etc. (Criterion 18)
2.
Describe the educational strategies that will be included in this CME activity to help remove, overcome,
or address these barriers. (Criterion 19)
3.
List stakeholders with whom collaboration or cooperation in the development or execution of this
activity is possible in order to build bridges to quality. Examples include other departments; QI; risk
management; infection control; library services; medical records; compliance office; billing office; government
agencies; community and patient organizations; etc. (Criterion 20)
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4.
List any non-educational strategies to enhance/reinforce change as an adjunct to the CME activity.
Examples include post-activity reminders to attendees; patient feedback or surveys; patient education materials;
algorithms; flow sheets; outcomes data; poster displays; newsletters; protocols; forms; care maps; electronic
reminders; etc. (Criterion 17)
F.) Adult Learning Principles & Educational Methodology:
Adult learning tends to be problem-centered rather than content-oriented, and experience provides the basis for
learning, which is focused on material that has immediate relevance. Adults learn by solving genuine problems;
practicing and applying new knowledge; and developing a framework for application. There are five stages of
physician learning:
1. Recognize a need for learning
2. Searching for learning resources.
3. Engaging in learning.
4. Trying out what is learned.
5. Incorporating what is learned.
Describe how this CME activity will incorporate adult, more specifically physician, learning principles.
G.) Educational Format and Faculty:
Educational formats should be appropriate for the setting, objectives and the desired results of the CME activity.
(Criterion 5)
1.
Please check the teaching methods you will use:
Webcast
Lecture-Didactic
Lab Exercises
Post Q/A
Simulation
Case Presentations
Teaching rounds
Workshop
Tumor Boards
Group discussion
Panel Discussion
Other:
2.
Attach a schedule/agenda of the activity and the faculty including name, degree, academic/professional
title, and institutional affiliations, as well as, a CV and Disclosure Form for each speaker.
H.) Handout Materials: Which of the following handout materials will be provided?
x
Syllabus
Summary
Mock Exam
Bibliography
Reprint
Other:
Note: A copy of all handouts must be reviewed by the Activity Director and the Department of Medical
Education in advance. Please forward originals via mail (not faxes) to the Department of Medical Education,
5665 Peachtree Dunwoody Rd, NE, Atlanta, GA. 30342 or by e-mail to dgordon@sjha.org.
I.) Evaluation Method:
The Medical Education Department requires use of its standard evaluation form in addition to other evaluation
tools the Activity Director may prefer.
1.
Please check the evaluation method(s) you will use for this activity.
Self-assessment form
Pre-/Post tests*
Standard evaluation
Other:
2.
A Pre/Post test is to be developed by the Activity
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Agreed
Director to be administered to the physician audience
attending a formal activity (conference, symposium) to
determine knowledge, competency or performance
outcomes for the purpose of improving patient care.
3.
Describe how the results of the evaluation will be used for this CME activity, including determining the
effectiveness in meeting the educational need and creating changes in competence, performance and/or
patient outcomes. (Criterion 11)
.
J.) Publicity:
What method(s) will be used to publicize the activity?
Monthly conference calendar
Departmental schedule
Hospital signage
Newspaper
Individual mailings
Internal Memos
Email
Website posting
Other:
All promotional materials must include the Accreditation Statement (as noted in the attached Criteria for
Awarding CME Credit) and must be approved by the Department of Medical Education before final draft.
Agreed
Promotional materials will not be mailed outside the contiguous states of Georgia.  Agreed
Agreed
K.) Audiovisuals:
Which types of audio-visual equipment will be needed?
Laptop Computer
Overhead projector
VCR
CD/DVD Player
White board/Markers
X-Ray View Box
LCD Projector
Other:
Note: Expectation is to use A/V from Holy Cross, No SJH hardware, no anticipated rental
L.) Catering:
Include caterer and/or vendor providing service, if applicable.
M.) Funding Sources & Budget:
1.
This activity will be funded by (check all that apply):
Registration $
/ Person (Please attach scale if more than one category)
Vendor Grants
Foundation Grants
Exhibit Fees (Criterion 9 & Standards for Commercial Support)
Pharmaceutical Education Grants (Criterion 8 & Standards for Commercial Support)
Departments/Institutional Funds
Other, please specify:
2.
Will speakers be paid an honorarium?
Yes* Amount-$
No
*SJHA policy states that honorarium higher than $2,500 for local speakers and $3,000 for out-of-town
speakers must be approved by the Medical Education Advisory Committee.
3.
In addition to honoraria, planners and speakers can be reimbursed for out-of-pocket expenses consistent
with SJHA policies. No other payment, apart from those paid by SJHA, shall be given to the Activity
Director, planning committee members, speakers, or others involved with the CME activity. (Criterion 8
and Standards for Commercial Support)
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4.
A final budget is required and should be provided to the Department of Medical Education within two
weeks post-conference.
Agreed
Note: A projected budget should be prepared in the early planning stages and should include the party
responsible for catering, brochure printing and mailing, and other expenses.
5.
Requesting entity assumes financial responsibility for this activity. Expenses in excess of actual cost are
assumed by the requesting entity. Residual funds may be returned to the requesting entity at the discretion
of the Department of Medical Education
Agreed
6.
Please see attached Criteria for Awarding CME Credit for overview of Standards for Commercial
Support. The Department of Medical Education will be happy to assist you with documentation and
compliance. Full disclosure is required of all vendor grants collected for this educational activity.
Name of person soliciting funds:
Tel. #
Department of Medical Education will deposit all vendor grants into the Hospital Foundation/Medical
Education Fund.
Agreed
If there is an exception, please specify who will coordinate payment of conference expenses.
In all activities with vendor support, there will be an accreditation fee charged to vendors. This fee will be
determined during the planning stages of the activity.
Agreed
Company 1 name:
Representative name:
Company 2 name:
Representative name:
Company 3 name:
Representative name:
Company 4 name:
Representative name:
Tel. #
Tel. #
Tel. #
Tel. #
Additional Information/Comments:
(Please attach additional information on separate sheet of paper.)
N.) Required Attachments:
* Disclosure & Attestation Forms for Activity Director, Planning Committee Members, and Faculty
* Schedule of events -Agenda/Topics/Faculty information (name, degree, title, affiliation) and timeframe
* CV for all faculty members
* Signed Financial Agreement
* Evaluation Pre/Post-Test to supplement the CME standard evaluation form for formal activities
* Non-SJHA Joint Sponsoring Organization’s mission statement, purpose, description (if applicable)
By submitting this Certification Request, the Activity Director and his/her staff understand that the
proposed CME activity must be consistent with the overall CME mission and policies of SJH and follow
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all ACCME Essential Areas, Policies and Updates Accreditation Criteria, including the 2007 ACCME
Standards for Commercial Support.
Submitted by: (Print Full Name)
Signature:
Date:
- - -- - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - CME Office Use Only- - - - - - - - - - - - - - - - - - - -- - - - - - - - Category 1 Credit:
 A. Approved as initial planning tool subject to modifications worked out in planning sessions
 B. Proposed CME activity does not meet the accreditation criteria of the ACCME for the following
reasons… (please see attached)
 C. Proposed CME activity should be modified and resubmitted per attached
 D. Proposed CME approval delayed pending receipt of additional information
 E. Unapproved
Howard J. Cohen, M.D.
Chairman, Saint Joseph’s Hospital CME Committee
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Date