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CME ACTIVITY CHECKLIST FOR COURSE DIRECTOR
(To be completed by Course Director AFTER planning application is completed
to ensure that all the components are attached)
I. APPLICATION AND ENCLOSURES (MUST be included for activity to be approved)
A. Agenda or outline of content
B. Data sources to support identified gaps
C. Signed disclosure forms from all planners committee members
D. Signed letters of agreement with commercial supporters (if applicable )
E. Evaluation
F. Activity promotional materials (announcements, flyers, emails)

The Page and William Black
Post-Graduate School
Icahn School of Medicine at Mount Sinai
One Gustave L. Levy Place, Box 1193
New York, NY 10029-6574
T 212-731-7950
F 646-537- 9203 cme@mssm.edu
SECTION 1: GENERAL INFORMATION – January 2015 – December 2015
Name of RSS:
Date of RSS:
Days of the Week (check all that apply):
Time of Day
(from-to):
Monday
__________ to ________ AM/PM
Tuesday
Meeting
Location:
Wednesday Thursday Friday
RSS Frequency: Weekly Monthly Bi-Monthly Quarterly Other:
*Any changes or additions to the schedule will be communicated to the CME as soon as possible.
Type of RSS:
Grand Rounds/Lecture Series Tumor Board
Please indicate the educational format you intend to use. M&M Journal Club
Please select only 1 that best describes your series.
Case Conference Other
Sponsoring Department:
Institution
(check)
Mount Sinai
Elmhurst
Queens Hospital Center
Division: St. Luke’s Cornwall
List Other: ___________________
Are sessions video conferenced in real-time (webcast)?
YES NO Location : Institution:
CONTACT INFORMATION: (Activity Director must be a faculty member at Mount Sinai )
Department:
Activity Director:
Academic Title:
Activity Coordinator:
Phone: Email:
Department Manager:
(if applicable)
Phone:
Phone:
Email:
Email:

ACTIVITY SCHEDULE
Please attach a copy of the proposed RSS schedule. A partial schedule will suffice in cases where a complete schedule is not yet available (3 months minimum).
Your planned activity agenda for the proposed activity include:

Date(s), Time(s) and Location

Topics

Speakers including their clinical title and their academic appointment to a medical school
PLANNING COMMITTEE
LTY DISCLOSURE (“Appendix B”)
Planners: Include names and titles of those individuals directly involved in the planning and who influence the content of this activity. Please attach a completed signed disclosure form for every planner. (Appendix B)
If necessary, attach additional list of planners.
Activity Director
Academic Title
Dept/Institution
E-mail
Name
Academic Title
Dept/Institution
E-mail
Name
Academic Title
Dept/Institution
E-mail
Additional planning committee members attached
Faculty Disclosures: All faculty , even those on staff, who present/moderate/or author at any CME Activity must submit a completed Faculty Disclosure Form to the CME Office prior to their participation.
The process will include:

Completion of a Disclosure of Relevant Financial Relationships and Unapproved Product uses form signed and dated prior to the session with disclosure relevant to the content of the presentation.

Identification and resolution of conflict of interest prior to the session (when the presenter has disclosed relevant financial relationships).

Disclosure of relevant financial relationships or the lack thereof to the learners immediately prior to the presentation on the CME handout.

Any individual who refuses to disclose will be disqualified.
Failure to complete the entire relevant financial disclosure process may result in the appropriate session(s) not being certified for CME and participants not receiving credit.
PRINTED MATERIALS – ANNOUNCEMENT FLYERS/BROCHURE
All promotional materials, including emails, flyers, web-posting, brochures, signs, etc. must comply with the Guidelines for
Promotion of an RSS which is included in the attached template.
Failure to follow the Guidelines for Promotion of an RSS may result in the appropriate session(s) not being certified for CME and participants mot receiving credit.

In order to obtain CME approval, you must:
1.
Identify the area(s) that require improvement and provide specific evidence that substantiates the need
(PRACTICE GAPS/DATA SOURCES);
2.
Identify specific learning objectives (LEARNING OBJECTIVES) and describe the program;
3.
Specify how you will evaluate the effectiveness of your program (PREPARATION OF OUTCOMES QUESTIONS).
PRACTICE GAPS/DATA SOURCES
The ACCME requires that all educational activities be based on an identified gap in practice. A gap represents the
difference between a Best Practice and the Current Practice. It is the difference between what actually occurs and what is ideal or what evidence based practice should be. This is the method by which the learning objectives will be defined and measured.
1.
Using the space below describe how you link the planning and development of your RSS to other departmental/institutional performance or quality improvement initiatives.
2.
What has changed in the practice of your specialty over the past year, and would therefore merit educational interventions focused on that issue?
3.
Is there breaking research in your specialty that physicians will find interesting and medically relevant to the quality of care for their patients? What are the educational strategies that will expedite the translation of the research to practice?
4.
Are there traditional core performance areas in your specialty that are worth reinforcing and updating?
5.
What gaps have you identified from your specialty's MOC requirements that would merit a RSS iteration or iterations?
Summarize the educational or professional practice gap(s) that underlies the need(s) that the activity will address.
The professional practice gap represents a deficit in knowledge, competence and/or performance among prospective participants. The gap should be audience specific. Provide evidence (data sources) that you used to identify the professional practice gap of your audience (minimum of two).
Possible sources of evidence include: (Check which sources you are attaching –minimum of two)
Clinical practice guidelines
Health Performance Data
AHRQ/Government/Snapshots
Local Data
Quality Improvement Data
Research/Peer-reviewed literature
Peer-reviewed scientific/clinical publications
Exam performance analysis
Epidemiology data
Government mandates/legislation
Public Health Data
Survey of Targeted Learners
Expert opinion (Planning Committee, Course
Faculty, Consensus of Experts)
Evaluation data/gaps identified by target audience
(previous CME evaluations)
Requirements of State licensing board, Specialty
Societies
New medical development/technology

EXAMPLES OF CLINICAL GAPS
Note: All specific references are professional clinical gaps of learners for illustration purposes
NEED IN GAP:
Knowledge
Competence
Performance
GOOD EXAMPLE
Referral patterns to orthopedists from PCPs greater than 80%,
EVIDENCE OF GAP
Data Source: as cited in JAMA
(Dec 2011, pp. 240-251).
BAD EXAMPLE
PCPs consult orthopedists inappropriately.
No data to support gap.
Knowledge
Competence
Performance
Knowledge
Competence
Performance
Inadequate recognition of and use of diagnostic testing for common musculoskeletal complaints.
Underutilization and misinterpretation of cardiac ultrasound by Emergency
Department physicians identified through 2011 quality improvement review.
Data Source: Mount Sinai utilization data for 2010
<20%.
Data Source: Emergency
Medicine College of Physician
Guidelines.
PCPs lack of training about common musculoskeletal disorders.
No data to support gap.
Importance of cardiac ultrasound as a diagnostic procedure.
No data to support gap.
Please Complete:
NEED IN GAP: SPECIFIC CLINICAL GAP
(Current Practice)
EVIDENCE OF GAP
Indicate Data Source
(copies of sources used must be
attached)
Knowledge
Competence
Performance
GAP 1:
Knowledge
Competence
Performance
GAP 2:
Knowledge
Competence
Performance
GAP 3:
PERFORMANCE/LEARNING OBJECTIVES
Based on the gaps you have identified, what are your learning objectives? They must be measurable and action-based.
For help selecting action based verbs, you can obtain a list of appropriate verbs from the CME office or website. If learning objectives are clearly articulated, they become valid means by which to measure educational outcomes.
Competence = knowing how to do something.
Performance = what a physician does in practice
Patient Outcomes = goal is to improve patient outcomes

EXAMPLES OF LEARNING OBJECTIVES AND OUTCOME MEASURES
FOCUS OF
OBJECTIVE
Competence
Performance
Patient
Outcomes
GOOD EXAMPLE OF OBJECTIVE
Describe recent innovations in XXX and when they should be appropriately utilized.
Identify current barriers and an action
plan to increase screening for and appropriate management of XXX.
Explain to patients and check for understanding about the reasons for
and how to appropriately monitor
HgbA1C levels to improve diabetic blood sugar control
BAD EXAMPLE OF OBJECTIVE
List 2 recent innovations in XXX.
Increase knowledge of XXX
Identify the guidelines for HgbA1C monitoring in patients with diabetes
LINK OBJECTIVES TO STATED CLINICAL GAPS
At the conclusion of this activity, participants will be able to:
Designed to Change:
Clinical Gap 1- Objective: Competence
Performance
Patient Outcomes
Clinical Gap 2- Objective:
Clinical Gap 3- Objective:
Clinical Gap 4- Objective:
Competence
Performance
Patient Outcomes
Competence
Performance
Patient Outcomes
Competence
Performance
Patient Outcomes
Learners for this RSS (select all that apply) :
Hospital-Based Physicians
Medical Students
Nurses
Fellows/ Residents
List Medical Specialties:
Allied Health Professionals
Administrators
Other (Specify):
What learning formats and tools will be used in your activity to ensure that your objectives are achieved and the learner is engaged? We encourage that >25% of your activity will be interactive. Check all that apply).
Lecture
Panel Discussion
Q/A format
Case based/problem solving discussion
Small group discussion
Hand-on practice workshop
Simulation training (including standardized patients)
Audience Response System
Other _______________

Thoughtful tools that assist physician-learners in attaining intended results for this activity should be developed and encouraged. These tools/strategies might include treatment algorithms, patient compliance handouts, reference guides, flow charts and examples of procedures.
This Activity will include these tools: Yes* No
*If you indicated yes, check the tools/strategies that will be distributed to your learners
Patient Care Algorithms
Patient compliance handouts
Reference guides
Flow charts
Patient feedback tools
Learner reminders (emails, newsletters)
Interactive web tools
Chart audit process
Other:
Please check:
Tool may be found or downloaded: ________________________________
Tool to be provided to the CME Office.
Core Competencies and Physician Attributes are national goals for physicians associated with the targeted specialty
(ies) that should be addressed when planning a CME Activity.
What physician competencies/attributes will this educational activity address?
IOM, ABMS(MOC)/ACGME, AAMC Competencies:
Patient-centered care
Work in interdisciplinary teams
Employ evidence-based medicine
Apply quality improvement
Utilize informatics
Medical knowledge
Practice-based learning and improvement
Interdisciplinary & communication skills
Professionalism
Systems-based practice
Evidence of Professional Standing
Lifelong learning
Cognitive expertise (examination)
Performance in practice
PATIENT SAFETY CONSIDERATIONS
Planners should examine planned activities for patient safety concerns in accordance with the national public interest.
Please list issues of patient safety associated with these educational interventions that need to be addressed in this activity:
There are no patient safety issues applicable to this activity.
The following patient safety issues have been identified and will be addressed in this activity:
I DENTIFIED
P ATIENT S AFETY I SSUES
P LANNED D ISCUSSION IN
A CTIVITY C ONTENT

EVALUATION METHODS
Evaluations are tools that are used to determine if the result you intended for the learners has actually been achieved.
What evaluation tools will you be using to measure activity outcomes?
METHOD SELECTED
Audience Response System (measures immediate learning and provides learning reinforcement.)
Pre-Test (measures current learning)
Post-Test (measures transfer of knowledge or new skills attained)
CME Immediate Activity Evaluation Form (measures impact of learner’s perceived change of practice
for better patient care)
Case discussion or vignettes (measures application of knowledge to practice or competence)
Barriers or potential barriers are factors affecting the learners that could impact the desired objectives of incorporating improvements in competence and/or performance and/or patient outcome into practice.
What factors outside your control or barriers can you identify that learners may encounter that will prevent them from applying the strategies and/or best practices taught in this activity?
Example: Patient education requires time and giving patient education tools helps solve the problem.
This activity has no relevant system barriers.
The following barriers have been identified and will be addressed in this activity (check all that apply)
Lack of time for implementation
of new skills or behaviors
Technical Skills
Formulary restrictions
Resistance to Change
Lack of Staff Support
Lack of Health System
Lack of time to assess/counsel
patients
Lack of Equipment
Lack of consensus or professional
Insurance does not reimburse
Support
Policy issues within institution
guidelines
Other, Please Specify: _____________ for treatments
If barriers have been identified, will they be addressed in your activity? Yes No
If yes, how will they be addressed: _________________________________________________________
If no, please indicate why they will not be address: ________________________________________

STANDARDS FOR COMMERCIAL SUPPORT AND EDUCATIONAL GRANTS
The Icahn School of Medicine at Mount Sinai’s Office of Continuing Medical Education fully supports and adopts the
ACCME Standards for Commercial Support of Continuing Medical Education as its basis for relating to organizations that provide commercial support for CME activities or the overall CME Program.
Industry (pharmaceutical and device companies):
1.
May NOT pay speakers directly.
2.
May NOT pay for catering or any other expenses directly.
3.
Must give all funds in the form of an educational grant to the department sponsoring the activity and the department may use the funds for paying speakers and catering .
COMMERCIAL SUPPORT
 ISMMS must be listed as the Accredited Provider on EVERY Letter of Agreement.
 ALL commercial support for an activity must be documented by a fully executed and signed letter of agreement and the grant received by Icahn School of Medicine at Mount Sinai BEFORE the start of the activity or it will not be recognized as support for that activity. No retroactive acknowledgments will be made for any funds not provided before an activity.
 The Director of CME as the designated institutional signatory must sign ALL LOAs.
 Any company providing an educational grant for the activity must be acknowledged.
 Attach documentation that acknowledgment and faculty disclosure was made to the audience prior to each activity. (Submit to CME after the activity.)
Failure to obtain an ACCME compliant letter of agreement signed by a representative of the commercial support and a representative of the OCME when commercial support is sought or to disclose commercial support on the CME Handout may result in the appropriate session(s) not being certified for CME and participants not receiving credit.
 What is the expected financial source for the activity? Check all that apply.
ANYAPPLICATION
Educational Grant(s) Department Other (specify)

FINANCIAL STATEMENT – RSS Budget Estimate
Category
1. STATEMENT OF ANTICIPATED REVENUE
Departmental Contribution
Commercial Support (Educational Grants)*
Other Supporters and grants (i.e. memorial lectureships) – Specify:
* A Signed Commercial Support Letter of Agreement is necessary for each Grant
TOTAL INCOME
2. STATEMENT OF ANTICIPATED EXPENSES
MARKETING EXPENSES
- RSS Flyer Design and Printing Expense
- Printed Handouts/Syllabus
- Posters and Signs
TOTAL MARKETING EXPENSES
SPEAKER EXPENSES
# of Speakers ___________ x Honoraria Amount $_____________ =
Estimated Travel Expenses (includes airfare/train/auto, hotel and meals)
TOTAL SPEAKER EXPENSES
MEETING COSTS (includes room rentals, food and beverage)
TOTAL EXPENSES
PROFIT
Amount

GENERAL GUIDELINES (Initial each section
FACULTY CONFLICT OF INTEREST:
If the speaker has nothing to disclose, this information must also be communicated to the audience.
The Course Director is responsible for identifying, managing and resolving any Conflicts of Interests and
reporting the disclosure information to the audience prior to the activity. Resolution of COI must be performed by a non-conflicted individual, if the course director has conflicts, an independent reviewer must review speaker presentations and validate the content to ensure fair balance and objectivity exists within the presentations.
ISMMS must ensure that Content Validation is performed by a review whose responsibility is to review course materials for scientific objectivity, fair balance and of appropriateness of patient care recommendations when there is a potential for a Conflict of Interest. Please read the ISMMS Policy on Identifying and Resolving Conflict of Interest before your start this process. Once you have reviewed the disclosure forms and materials, please complete the
Conflict of Interest Resolution Form. These forms may be found on our website: www.mssm.edu/cme/forms
Please attest that this activity will adhere to the following ACCME Policy on Validating the
Clinical Content of CME activities:
All the recommendations involving clinical medicine in a CME activity must be based on evidence
that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.
All scientific research referred to, reported or used in CME in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection and analysis.
FINAL CONFERENCE DOCUMENTATION
All materials need to be submitted by the 10 th of each month to:
Nicole A. Henry
RSS Coordinator, CME Office
One Gustave L. Levy Place, Box 1193
New York, NY 10029
212 731-7943
Nicole.a.henry@mssm.edu
(The following are due by the 10 th of the following month of activity completion)
It is the responsibility of the Course Director to assure that this CME activity meets the criteria set forth by the
Accreditation Council for Continuing Medical Education (ACCME). The following documentation must be forwarded to the Office of Continuing Medical Education thirty days after activity completion:
1) Sign-in sheets.
2) Excel Upload Spreadsheet
3) Faculty disclosures
4) A summary of evaluations.
5) Documentation that Objectives, Target Audience, Faculty Disclosure and Acknowledgement of Commercial
Support was made to the audience PRIOR to the educational activity (Activity Flyer)

SIGNATURES
Please provide signatures below indicating acceptance of the following terms and conditions for sponsorship by the
Icahn School of Medicine at Mount Sinai of this RSS.
 To ensure final designation of credit, each Activity Director agrees to collaborate with the Office of CME to ensure that the planning and implementation of the proposed CME activity are consistent with the policies and procedures of the ACCME. Please note that the OCME will be conducting ongoing monitoring of sessions as well as session documentation and that non-compliance with any of these requirements may result in the
OCME withholding credit for individual sessions, your series being placed on probation, and/or denial of eligibility to have your series certified in the next year.
 I have read and agree to abide by the ISMMS Policy for Identifying and Resolving Conflicts of Interest in CME and the ACCME Standards for Commercial Support.
Application reviewed and approved by:
Department Chairperson:
Signature Date
Course Director:
I hereby certify that this application was completed accurately and attest to the validity of the information contained within:
Date Signature
Date Received _______________________ CME Office Reviewer ______________
# Category I Credit Hours Approved____________________
Approval Date___________________ Course Director Notified__________