9-14-2015
Cancer Case Conferences
CME Program Series Application
Quillen College of Medicine, East Tennessee State University, Office of Continuing Medical Education
Thank you for considering us to support you in your continuing medical education
activity plans. Completing this application is one of the earliest steps in working
with us to achieve your education goals. Should you wish, you may call us before
you begin the application so we can have a preliminary discussion on your plans.
That should make the application process easier for you. We can be reached at 423
439 8081.
For information that can provide a resource as you complete the application, hover your mouse
over the footnotes both here and throughout this document:
 Application instructions:i
 Deadlines:ii
o Important information related to the months the Board does not meet iii
o Cancer Case Conferences for which Educational Grants are being soughtiv
 Contact Informationv
Type of Activity
1. What type of activity is this?
Cancer case conference in
which the team examines the
patient findings prior to a plan of
care being determined, and in
which discussion at the
conference results in decisions
on how the patient will be
treated going forward (this type
of case conference is called
“prospective” and typically meets
weekly or biweekly)
Office Use Only
Prospective Cancer
Conference
Retrospective
Cancer Conference
Planner note: For PARA
Data, this activity’s
format is considered
“Case Based Discussion”
Cancer case conference that
looks back at the presentation,
diagnosis, treatment and
outcomes of the patient and
which is primarily used for
physician and team education.
Rarely is the patient’s plan of
care determined during the
conference (This type of case
conference is called
“retrospective” and typically
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010
9-14-2015
meets monthly or less
frequently)
Activity Information
1. Proposed Activity Name:
2. Has this activity been
accredited in the past by the
ETSU Office of CME?
Office Use Only
Additional Planner
Commentsvi
No
Yes. When?
2. Proposed Start and End
Dates:
Additional Planner
Commentsvii
Additional Planner
Comments
(If approved, accreditation of this
series will expire 364 days from when it
was approved)
3. Activity’s proposed
beginning and ending time:
4. Frequency of the program:
Additional Planner
Comments
Frequency
Semi Annually
Quarterly
Bi monthly (6
meetings per year)
Monthly
Bi-weekly (25
meetings per year)
Weekly
Additional Planner
Comments
Day of the Week
Monday
Tuesday
Wednesday
Thursday
Friday
Week of the Month
First Week
Second Week
Third Week
Fourth Week
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010
9-14-2015
Other:
5. Proposed number of contact
hours per scheduled event:
6. Location:
Additional Planner
Comments
Facility:
Additional Planner
Commentsviii
City:
7. What is the name of the
sponsoring organization?
8. Has this activity been
accredited in the past by the
ETSU Office of CME?
No
Yes
When?
Target Audience
9. Who is your target
audience?
10. How many professionals
typically attend on any given
week?
11. Is your cancer conference
restricted, primarily, to
members of your
organization’s medical staff?
Medical Oncologists
Radiation Oncologists
Surgical Oncologists /
Surgeons
Pathologist
Radiologists
Primary Care Physicians
Oncology Nurses
Tumor Registrar
Residents, Fellows
Other: Please List:
Physicians :
(excluding
residents)
NP/PAs:
Other Non-Physicians:
(including residents)
Yes
No. Please explain:
Statement of Need and Learning Gap
12. Please read the following
“Statement of Need/
Educational Gap” for Cancer
Conferences.
“Learning Gap: “Because of
3
Yes, this description
adequately reflects our
Statement of
Need/Educational Gap
No, we would like to
substitute the following:
Additional Planner
Comments
Additional Planner
Comments
Office Use Only
Additional Planner
Comments
Additional Planner
Comments
Additional Planner
Comments
Office Use Only
Additional Planner
Comments
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010
9-14-2015
new and emerging
technology and treatment
protocols, without an
opportunity for regular
multidisciplinary
collaboration, our
physicians would not
provide the most advanced,
focused, integrated, timely
and appropriately
sequenced care “
13. Which ABMS/ACGME
physician attributes will this
activity impact?
Patient careix
Practice-based learning and
improvementx
Interpersonal and
communication skillsxi
Professionalismxii
Medical knowledgexiii
Systems-based practicexiv
Educational Format
14. Educational Format: Which
of the following typically
occurs at your case
conference? (Check all that
apply)
Presentation and review of
How patient first presented
Patient’s pertinent history
Additional Planner
Comments
Office Use Only
Additional Planner
Comments
Presentation. viewing of and
discussion of:
Radiologic and imaging
studies
Pathology studies, including
Margins
Staging, prognostic indicators
Consideration, discussions of and
recommendations for:
Medical options
Radiation options
Surgical options
Clinical Trial Options
Sequencing
Genetic Testing and
Counseling
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010
9-14-2015
Palliative options
Psychosocial Care
Rehabilitation Services
Other. Please describe:
Learning Objectives
Office Use Only
15. Please read the following
Prospective Cancer Conferences: Additional Planner
learning objectives which are  Obtain multidisciplinary input
Comments
into the diagnosis and treatment
typically associated with
options for the presented
cancer case conferences.

patient
Determine an overall plan of
care for the patient
Yes, we accept these learning
objectives.
No, we would like to propose
the following alternative
objectives:
Retrospective Cancer
Conferences:



In a multidisciplinary format,
retrospectively examine
diagnosis, treatment and
rationale of recently identified
cancer cases
Interpret radiology and
pathology findings, and how
they lead to optimal treatment
plans
Describe how multidisciplinary
collaboration enhances patient
outcomes
Yes, we accept these learning
objectives.
No, we would like to propose
the following alternative
objectives:
16. Does you cancer program
have, or are you currently
preparing for accreditation?
5
No
I don’t know
Yes. With which
Additional Planner
Commentsxv
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010
9-14-2015
17. Has your Cancer Conference
been commissioned by your
organization’s Cancer
Committee?
18. Answer this question ONLY if
you are accredited or
seeking accreditation of your
Oncology Program from COC
or NCI
accrediting body?
Commission on
Cancer (COC)
NCI
Other/ Please
Describe:
No
Additional Planner
I don’t know
Comments
Yes. Is your cancer
conference’s compliance with
cancer conference
accreditation criteria
reported back to cancer
committee at least yearly?
No
I don’t know
Yes. Please
describe the
frequency,
and typically
which months
of the year.
Part A: Which of your
Additional Planner
multidisciplinary team of Comments
physicians are required to
attend the case
conference? (Your Tumor
Registrar Knows)
Medical Oncologist
Surgeon/Surgical
Oncologist
Radiation Oncologist
Pathologist
Radiologist
Tumor Registrar
Other. Please list:
Part B: What is the percent of
multidisciplinary
attendance required by
your Cancer Committee?
% (Your Tumor
Registrar Knows)
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010
9-14-2015
Outcomes
Please Note: Based on your
answers to the questions in this
application, your CME Planner
will describe for you how your
activity’s outcomes will be
measured.
Office Use Only
COC Compliant: Educational need is Performance
Performance outcomes will be measured as follows:
 Annual Compliance with National Standards of the ACOS
Commission on Cancer’s “Cancer Case Conference
Criteria”
 Quarterly Evaluation to measure the extent to which the
activity has met its educational objectives and to
determine how, as a result of this activity, the
participants have changed their practice.
Not COC Compliant: Educational need is Competency
Competency outcomes will be measured as follows:
 Quarterly Evaluation to measure the extent to which the
activity has met its educational objectives and to
determine how, as a result of this activity, the
participants have changed their practice.
Other Planner Comments
Planner Note: For PARS DATA, this activity is considered
A Competency Activity
A Performance Activity
A Patient Outcome Activity
Planner Note: For PARS DATA, this conference is
categorized as
Case-based presentations
Lecture
Panel discussion
Simulation
Skills-based training
Small group discussion
Other. Please describe:
Financial Support
19. Do you intend to seek commercial
support for this activity?
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Office Use Only
No
Yes. Please
explain:
Additional Planner
Comments
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010
9-14-2015
Additional Planner
Comment for PARS Data
Anticipating:
Grants
Activity Director Information
20. Activity
Directorxvi
21. Title
22. Specialty
23. Organization Name / College /
Department
24. Address
25. E-mail Address
26. Phone
27. Fax
Planning Committeexvii
Name and Title
Specialty
Phone Number
E-mail Address
Contact Information
Contact Person Name
Title
Organization
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010
9-14-2015
Address
Phone Number
Fax Number
E-Mail
Is this person the
individual who is
responsible for the day
to day support of this
activity?
Yes
No. If no, who is that person and what is their contact
information?
Next Steps
You may call the Office of Continuing Medical Education during business hours to receive assistance with
completing this application, or to discuss anything related to your potential activity. Our number is 423-4398081.
Save this as a Word document, and email it to dougherty@etsu.edu. Within a few days one of our
educational planners will give you a call. BECAUSE WE WILL BE ADDING ADDITIONAL COMMENTS TO THE
DOCUMENT, WE MUST RECEIVE IT IN ITS ELECTRONIC FORMAT.
Submit Required Attachments
1) Below is the list of additional required attachments. Your application cannot be processed without the
following. All required attachments can be sent electronically or faxed. Our fax number is 423 439 8040.
Our application e-mail address is dougherty@etsu.edu.
Action
Activity
Director
Provide CV
or Resume
Required
Complete
Conflict of
Interest
Disclosure
Required,
and is
embedded
in the
Required
Signatures
Form. No
need for
Activity
9
Contact
Person
Required
only if
he/she
participates
on Planning
Committee
Required
only if
he/she
participates
on Planning
Committee.
All Planning
Committee
Members
Academic
Department
Chair or
Healthcare
Executive
Instructions
Required
Not required
We will accept either electronic or faxed
copies
Required
Not required
Go to this link to complete. Please copy
and send this link to all that need to
complete a conflict of interest, with the
exception of the Activity Director, who
will complete his/her conflict of interest
on Required Signatures Form.
East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010
9-14-2015
Sign
Required
Signatures
Form
Director to
go to web
link to
complete.
Signature
Required
Not
Required
Not Required
Sign Required
Signatures
Form
Required Signature Form can be obtained
at this link: It can be copied and given to
the Activity Director and the
Chair/Healthcare Executive for
signatures. They do not both need to
sign the SAME form. We will accept
either electronic or faxed copies.
- End of Document -
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010
9-14-2015
-
Footnotes
i
Instructions:

This application is in MS Word, and is a form. To complete, put your cursor in a grey shadowed area and start typing. It is
difficult to spell check in a Word Form, so be aware that this is not a problem to us if your spelling is not perfect. If you are the
person completing this application, it is important that you have significant information on the need, focus and expected
outcomes of the proposed activity.

If this is the first time you have completed one of our applications, we do not expect you to complete this application flawlessly.
Once we have received it, our planners will assist you in further refining your application until it is ready for the Advisory Board’s
review. This consultation process is what makes it necessary for the application to be submitted according to the deadlines.

You may contact us at any time if you need clarification on the application or the process.

Once the application is complete, you may either e-mail it to cmeadean@etsu.edu or call the Office of Continuing Medical
Education at (423)439-8081. The contact information is listed at the end of the application.
ii
Deadlines:
All applications and their supporting documentation receive a thorough internal review before they are submitted to the
Advisory Board. Deadlines are set to accommodate that internal review, and to provide the best opportunity for the activity to
be approved.

Advisory Board meetings are the first week of the month. Applications for live conferences must be received by the 10th day of
the month preceding the next Advisory Board meeting. For example, an application that is going to be reviewed by the board
the first week of May must be submitted to the Office of Continuing Medical Education by April 10.

iii
The Advisory Board does not meet in December or July. Applications which would ordinarily be submitted for December or July
review, will need to be reviewed at the November or June meetings respectively.
iv
Commercial support is rarely sought for Cancer Case Conferences. Please discuss this with your CME Planner, and be
aware that NO commercial support can be requested or received by any party to the series except by the Office of
Continuing Medical Education.
v
Office of Continuing Medical Education
James H. Quillen College of Medicine
East Tennessee State University
Box 70572
Johnson City, TN 37614-1708
Phone: 423-439-8081
Fax: 423-439-8040
Email: dougherty@etsu.edu
Website: www.etsu.edu/cme
vi
Planner Notes: If this is a Joint Providership, please add the entity name to the front of the program name.
vii
Planner Notes: Please notate the program number from when it was previously held
Planner Notes: If this cancer case conference is going to be broadcast and networked between sites, please list
all sites and comment if the participants at remote sites will have opportunity for real time exchange.
viii
ix
Patient care that is compassionate, appropriate, and effective for the treatment of health.
x
Practice-based learning and improvement involves investigation and evaluation of their own patient care, appraisal
and assimilation of scientific evidence, and improvement in patient care.
xi
Interpersonal and communication skill results in effective information exchange and teaming with patients, their
families, and other health professionals.
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010
9-14-2015
xii
Professionalism is manifest by commitment to carryout professional responsibilities, adherence to ethical principles,
and sensitivity to a diverse patient population.
xiii
Medical knowledge demonstrates established and evolving biomedical, clinical and cognate (e.g., epidemiological and
social-behavioral) sciences and the application of this knowledge to patient care.
xiv
System-based practice is manifest by actions that demonstrate an awareness of and responsiveness to the larger
context and system for health care and the ability to effectively call on system resources to provide care that is of
optimal value.
Planner Note: If the person completing the application does not know, they may not be the appropriate person
to submit the final application. The planner should ask the individual to introduce them to the clinical coordinator
of the activity, and confirm the information related to this question. This also is the time to verify with the clinical
coordinator the prospective vs retrospective nature of the cancer case conference. While on the phone with this
individual, ask for verification of the information in the following two questions as well, and note the source of the
information if you are adding to or changing the application.
xv
xvi
The Activity Director must be a physician or nurse practitioner. The Activity Director must have direct involvement in
the planning of the activity, and will need to be in a position to collaborate with the Office of Continuing Medical
Education as the planning unfolds.
xvii
EXAMPLE: Medical Staff Grand Rounds e.g.:
 Activity Director (former Chief of Staff or Director of Med Ed)
 Members of the Medical Executive Committee
 VP Medical Affairs or Chief Operating Office
 QI Representative
EXAMPLE: Cancer Case Conference, e.g.:
 Activity Director (Physician)
 Physicians representing other specialties involved (Radiology, Pathology etc.)
 Other representatives, if on staff:
o Tumor Registrar
o Nurse Coordinator
o Educational Coordinator
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East Tennessee State University, James H Quillen College of Medicine, Office of Continuing Medical Education, 2010