The mission of Rady Children's Hospital - San Diego's Continuing Medical Education (CME)
program is to develop and coordinate educational programs effective in improving practice for
Medical Staff in order to restore, sustain and enhance the health and developmental potential
of children through excellence in care, education, research and advocacy.
Meeting Name:
Date(s):
Time(s):
Location:
RCHSD Medical Staff Coordinator:
Contact:
Please indicate if this is a:
Live Activity (not a Regular Series)
Select Type of Live Activity:
Course
Live Internet Webcast
Regularly Scheduled Series
(examples: Grand Rounds/Case Conference/Tumor Board)
Select Frequency:
Weekly
Monthly
Quarterly
Other: Describe:
Enduring Materials (hardcopy, not live CME)
Select all of the type of materials that apply for Enduring Materials CME (not live courses):
CD-ROM/DVD/USB Flash Drive/Other Media or Recording
Internet Website (not live)
RCHSD CHEX
Training
Printed Materials
Other: Describe:
Course Description: (Please be brief-include in brochure/flyer/ad)
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Page 1 of 8
The mission of Rady Children's Hospital - San Diego's Continuing Medical Education (CME)
program is to develop and coordinate educational programs effective in improving practice for
Medical Staff in order to restore, sustain and enhance the health and developmental potential
of children through excellence in care, education, research and advocacy.
Target Audience:
☐ Physicians / DO’s
Non-Physician Clinicians:
☐ Pharmacists
☐ Dentists
☐ Psychologists
☐ Physician Assistants
☐ Nurses / Nurse Practitioners
☐ Mental Health Professionals (LCSW, MFT, etc.)
☐ Therapists (OT, RT, PT, etc.) - Please list:
☐ Other – Please list:
Please list:
☐ Target Specialty:
☐ All Specialties
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Cardiology
Dermatology
Emergency Medicine
Endocrinology / Metabolism
Gastroenterology
General Pediatrics
Genetics
Hematology / Oncology
Hepatology
Hospital Medicine
Infectious Disease
Neonatology
Nephrology
Neurology
Ophthalmology
Orthopedics
Otolaryngology
Pathology
Pharmacology
Psychiatry
Pulmonology
Radiology
Rheumatology / Allergy / Immunology
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Page 2 of 8
The mission of Rady Children's Hospital - San Diego's Continuing Medical Education (CME)
program is to develop and coordinate educational programs effective in improving practice for
Medical Staff in order to restore, sustain and enhance the health and developmental potential
of children through excellence in care, education, research and advocacy.
☐ Surgery
☐ Urology
☐ Other – Please list:
Scope of Practice:
What is the current or potential scope of practice of the target audience?
ACCME Criteria 4. Activity matches the content and the scope of the learners’ current or
potential scope of professional activities.
The range or breadth of a practitioner’s actions, procedures, processes. (Select all that apply)
☐ Office Based (community)
☐ Hospital Staff
☐ Residents / Fellows / Trainees
☐ Administration
☐ Teaching
☐ Research
☐ Other – Please list:
Meeting Attendance Estimate:
☐ 0-5
☐ 6-10
☐ 11-25
☐ 76-100
☐ 101-150
☐ 151-200
☐ 26-50
☐ 51-75
☐ 201-250
☐ 251-300+
Percentage of RCHSD Medical Staff Physicians
☐ 100%
☐ 75% or more
☐ 50% or more
☐ 25% or more
☐ 10% or more
☐ less than 10%
Percentage of Other Physicians
☐ 10% or more
☐ 25% or more
☐ 50% or more
☐ 75% or more
Percentage of Non-Physicians
☐ 10% or more
☐ 25% or more
☐ 50% or more
☐ 75% or more
Needs Gap Assessment:
ACCME Criteria 2. Incorporate the educational needs (knowledge, competence, or
performance) that underlie the professional practice gaps of the learners.
Rady Children's Hospital San Diego has a commitment to provide education that impacts
physician's knowledge and behavior with the ultimate goal of improved patient care. Program
planning begins with the identification of clinical practice gaps for the targeted audience.
Sources may include information from the prospective audience, public health data/statistics,
literature reviews, expert opinions, patient review committees, evaluations/surveys, or new
Return CME APPLICATION to cme@rchsd.org
Page 3 of 8
The mission of Rady Children's Hospital - San Diego's Continuing Medical Education (CME)
program is to develop and coordinate educational programs effective in improving practice for
Medical Staff in order to restore, sustain and enhance the health and developmental potential
of children through excellence in care, education, research and advocacy.
knowledge and skills. The practice gaps determine the educational needs and direct the
development of measurable learning and behavioral objectives.
What Professional Practice Gap has prompted your request for this CME activity?
Please choose the items which apply from the following list.
(Cite references or provide documentation for the items checked below.)
☐ 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 effecting patient care
☐ Epidemiological data
☐ Quality assurance/audit data
☐ Re-credential review
☐ Morbidity/Mortality
☐ Statistics Infection control data
☐ Surgical procedures statistics
☐ Professional society requirements
☐ Journal articles/literature citations
☐ News media
Needs Assessment Description:
Provide a summary of the practice gaps and how this data was used to design this CME activity.
Desired Educational Goals/Outcomes this CME activity is designed to facilitate:
ACCME Criteria 3. This educational activity is designed to change competence, performance, or
patient outcomes as described in the CME mission statement.
Outcomes Measurement (evaluation, follow up reports, data) will be required for items
selected.
☐ Increased Competence
Return CME APPLICATION to cme@rchsd.org
Page 4 of 8
The mission of Rady Children's Hospital - San Diego's Continuing Medical Education (CME)
program is to develop and coordinate educational programs effective in improving practice for
Medical Staff in order to restore, sustain and enhance the health and developmental potential
of children through excellence in care, education, research and advocacy.
☐ Improved Performance
☐ Change Patient Outcomes
Objectives:
Based on the professional practice gaps identified, what are the learning objectives you wish to
address? Objectives should be measurable and describe the Educational Goal marked above.
At the conclusion of this course, participants should be able to:
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Focus:
ACCME Criteria 6. The provider develops activities/educational interventions in the context of
desirable physician attributes (e.g., IOM competencies, ACGME Competencies).
ACGME core competencies this activity will focus on:
☐ Patient Care that is compassionate, appropriate, and effective for the treatment of health
problems and the promotion of health.
☐ Medical Knowledge about established and evolving biomedical, clinical, and cognate
(e.g., epidemiological and social-behavioral) sciences and the application of this knowledge
to patient care.
☐ Practice-Based Learning and Improvement that involves investigation and evaluation of
their own patient care, appraisal and assimilation of scientific evidence, and improvements in
patient care.
☐ Interpersonal and Communication Skills that result in effective information exchange and
teaming with patients, their families, and other health professionals.
☐ Professionalism, as manifested through a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to a diverse patient
population.
☐ Systems-Based Practice, as manifested by actions that demonstrate an awareness of and
responsiveness to the larger context and system of health care and the ability to effectively
call on system resources to provide care that is of optimal value.
☐ Other (Non-ACGME, i.e., ABMS, IOM, etc.) – Please list:
Educational Design:
ACCME Criteria 5. Educational format(s) are appropriate for the setting, objectives, and
desired results of the activity.
☐ Didactic
%:
☐ Case Presentation
%:
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Page 5 of 8
The mission of Rady Children's Hospital - San Diego's Continuing Medical Education (CME)
program is to develop and coordinate educational programs effective in improving practice for
Medical Staff in order to restore, sustain and enhance the health and developmental potential
of children through excellence in care, education, research and advocacy.
☐
☐
☐
☐
Workshop
%:
Panel Discussion
%
Review/Q & A
%:
Other
%, Describe:
Handout material utilized:
☐ Reference lists
☐ Outline materials
☐ Other, Describe:
CME Credits requested:
(Submit a complete schedule of presentations with start/end times to calculate CME credits.)
Do you wish to have this conference identified in the CME calendar? ☐ Yes or ☐ No
Collaboration:
ACCME Criteria 20. The provider builds bridges with other stakeholders through collaboration
and cooperation.
Are you collaborating with any entities, institutions or organizations for this activity? (e.g.
community groups, government agencies, foundations or societies.)
☐ Yes, please list:
or ☐ No
Expenses:
(Honoraria, printing, food, equipment, room rental, etc.)
Registration Fees: $
Income from Other Sources:
(e.g. Cost center, non-profit or Government grant, etc.)
Industry Funding / Commercial Support
All revenue for CME certified meetings with Industry Grants and/or Exhibitor fees will be
processed through the CME cost center and the following will apply:
 All expenses (including faculty honorariums) will be paid through the CME cost center.
 Any proceeds/losses will be transferred to a pre-determined Education fund.
Commercial Support:
ACCME Criteria 7: Disclosure of source of commercial support will be made to learners prior
to activity. (SCS 6.3-6.5)
Return CME APPLICATION to cme@rchsd.org
Page 6 of 8
The mission of Rady Children's Hospital - San Diego's Continuing Medical Education (CME)
program is to develop and coordinate educational programs effective in improving practice for
Medical Staff in order to restore, sustain and enhance the health and developmental potential
of children through excellence in care, education, research and advocacy.
ACCME Criteria 8: Income and expense statement for the activity, including the receipt and
expenditure of commercial support will be required. (SCS3.13) All signed written agreements
(LOA’s) must be processed through the CME Department (SCS 3.4-3.6)
(Support includes financial and in-kind grants and donations – exhibit fees are NOT considered
commercial support.)
Activities providing Category I credit that receive commercial support must comply with
Accreditation Council for Continuing Medical Education (ACCME) standards for "Standards
for Industry Support for CME activities" including submission of the signed Letter(s) of
Agreement (LOA). Please review and provide documentation of compliance to the CME
Department for approval (and forwarding the LOA for the Corporate Administrative
Officer’s signature.) CME Department staff can aid with any questions.
Names of Pharmaceutical/For-Profit Company
Amount(s): $
Commercial Exhibitors:
ACCME Criteria 9. …maintains a separation of promotion from education (SCS 4).
Activities providing Category I credit that receive commercial EXHIBIT support must comply
with Accreditation Council for Continuing Medical Education (ACCME) standards for Industry
Support for CME activities: “Product-promotion material or product-specific advertisement of
any type is prohibited in or during the CME activity. The juxtaposition of editorial and
advertising material on the same products or subjects is not allowed. Live or enduring
promotional activities must be kept separate from the CME activity. Promotional materials
cannot be displayed or distributed in the education space immediately before, during or after a
CME activity. Commercial Interests may not engage in sales or promotional activities while in
the space or place of the CME activity.”
Names of all Exhibitors:
Amount(s): $
Commercial Support of Food Service
Activities providing Category I credit that receive industry support must comply with
Accreditation Council for Continuing Medical Education (ACCME) standards for "Industry
Support for CME activities" (enclosed), including submission of a signed RCHSD CME Food
Service Policy document.
Food Service: ☐ No or ☐ Yes, please describe:
Identify financial source:
Cost Center #:
Estimated cost for food service (per event or annually):
Return CME APPLICATION to cme@rchsd.org
Page 7 of 8
The mission of Rady Children's Hospital - San Diego's Continuing Medical Education (CME)
program is to develop and coordinate educational programs effective in improving practice for
Medical Staff in order to restore, sustain and enhance the health and developmental potential
of children through excellence in care, education, research and advocacy.
NOTE: CME may charge a usual and customary fee based upon the amount of financial support
received for each course. Contact the CME Department for details.
Physician Coordinator:
Phone:
Mail Code:
Email:
Conf. Coordinator / Registration:
Phone:
Mail Code:
Email:
Conference Monitor:
Phone:
Mail Code:
Email:
Course Disclosure:
ACCME Criteria 7: List all individuals in control of content of CME activity with their specified
role (e.g., planner, faculty, reviewer). (SCS 2.1)
The Course staff may alternate responsibility for providing the review at this activity. Disclosure
provided by this Document is included for review at the activity registration area by attendees.
Course Planners & Speakers Industry/Relationship (See notes for code #’s.) Off-label
(Alpha order by last name)
Notes:
1. I will discuss off-label uses and agree to provide disclosure.
2. I will discuss medical devices for indications not FDA approved.
3. I will not be discussing off- label issues or unapproved devices.
4. No relevant financial relation exists.
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Page 8 of 8