New York Methodist Hospital
CME Program
Self Study Report
for
MSSNY Reaccreditation
I. Introduction
2
INTRODUCTION
A)
Demographic Information
NEW YORK METHODIST HOSPITAL, the applicant, is a large voluntary teaching
hospital situated in Park Slope, a prime area of Brooklyn. The hospital was founded in
1880 and has continued to grow. The hospital hosts 640 beds, 80 bassinettes and a whole
slew of ambulatory services including extensive clinics in general medicine and general
surgery in addition to almost all subspecialties in medicine. The hospital supports 8 fully
accredited residency programs in general medicine, surgery, pediatrics, obstetrics and
gynecology, anesthesia, radiation oncology and emergency medicine besides several
fellowships (e.g. geriatrics, hematology and oncology, pulmonary and critical care and
cardiology). It also supports active programs in neurosciences, cardiology and cardiac
surgery, neurosurgery, vascular surgery, and surgical oncology.
The hospital has an active medical staff (Medical Board) that
representative executive committee with a broad based structure of
committees including a Medical Education Committee, which
subcommittee of CME (the CME committee). Practicing physicians
of the membership of these committees.
is governed by a
supporting steering
has established a
form three quarters
All these committees report regularly to the Executive Committee and the full Medical
board. There are also several interdisciplinary committees such as the Graduate Medical
Education Committee, and Tumor Board. CME is an integral part of almost every
committee in the hospital. For example the Quality Improvement Committee identifies
various educational needs through its regular monitoring activities, Graduate Medical
Education Committee and Medical Education Committee address all CME activities as
an essential component for the residency training programs. For scientific boards and recredentialing CME is part and parcel of their “raison d’etre”
The board of trustees, which governs both hospital management, and the medical board,
is the ultimate hospital authority, and receive regular reports of CME Committee.
3
A) Application for MSSNY Accreditation or Reaccreditation
Demographic Organizational Information
Name of applicant organization as it should appear on accreditation certificate:
1.
New York Methodist Hospital
2.
Chief executive officer of applicant organization:
3.
Name:
Mark Mundy
Title: President
Address:
506 Sixth Street, Brooklyn, NY 11215
Telephone number:
(718)780-3101
e-mail address:
N/A
Fax number: (718)780-5975
Individual responsible for CME unit :
Name:
Stanley Sherbell, MD
Title: Executive VP for Medical Affairs
Signature:
4.
Date: 04/19/10
Address:
506 Sixth Street, Brooklyn, NY 11215
Telephone number:
(718)780-3284
e-mail address:
Sts9006@nyp.org
Fax number: (718)780-3287
Individual responsible for survey application materials:
Check here
if the contact person is the same as individual responsible for CME unit.
Name:
Sameer Rafla, MD, PhD
Title: Chairman Emeritus, Radiation Oncology,
Director CME Program
Address:
506 Sixth Street, Brooklyn, NY 11215
Telephone number:
(718)780-3677
e-mail address:
srafla@verizon.net
Fax number: (718)780-3637
Shipping Method and Account # (for return of materials if necessary)
FEDEX - #1768-5497-9
4
5.
Type of organization (Check the classification which most accurately describes your
organization)
X
6.
Communications Company
School of Medicine
Consortium/ Alliance
Not For Profit Foundation (501c3)
Education Company (Physician
own/operate)
Specialty Physician Member Organization
Insurance Company/Managed Care
Non-Specialty Physician Member Organization
Government or Military
Voluntary Health Association
Health Care Delivery System
State Medical Society
Hospital (not-for-profit)
Other ______________________ (Specify Type)
The CME program of the applicant organization (Check all that apply)
does receive commercial support
does produce Journal-based CME
does participate in Joint Sponsorship
does produce Internet CME
does produce Enduring Material
does produce Point of Care CME
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B) Summary of CME Activities
9/1/2008 – 6/30/2009
Name of Organization
Contact Person
New York Methodist Hospital
Sameer Rafla, MD, PhD
Phone Number
(718) 780-3677
CME Program Summary
Please provide the following information about your CME
activities, indicating N/A if information is not applicable to
your organization
Number of
Type of activity
Directly sponsored
Live
Courses
Regularly scheduled series (count each series) as 1
activity)
Performance Improvement (RSS) Includes all 5 M&M with
full chart review and responsible MDs, QA case review
Internet
Internet Search and Learning
Enduring Materials
Internet
Others
Journal-based CME
Subtotal, Directly sponsored
Jointly- sponsored
Live
Courses
Regularly scheduled series (count each series) as 1
activity)
Internet
Performance Improvement
Internet Search and Learning
Enduring Materials
Internet
Others
Journal-based CME
Subtotal, Jointly sponsored
Total for all activities
Activities
Hours of
Instruction
Physician
Participants
5
17
40
399
139
5319
5
114
1621 mandated
553
7077
Non-Physician
Participants
38
622
19 relevant
mandated ●
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
27
6
679
C)
Attach Hard copy of Activity List 2008-2009 (Excel Document)
(My documents 2008-2009 Reports)
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D)
Self Study Report Prologue
D.1.
Brief History of CME Program:
This application is for a reaccreditation of a preliminary program that has
been active for 2 years located at New York Methodist Hospital. The
hospital is seeking reaccreditation by MSSNY as a CME provider. The
hospital has a long history of continuing medical activities that cover
practically every discipline of medicine. 646 hours of accredited CME
activities were offered during the period of September 06 – June 07. Since
preliminary accreditation in years 2008 – 2009 sponsored over 1000 hours
in 58 programs (enclosure 46). Sponsoring of these CME activities was
through present program. The hospital medical community has continued
to support CME activities and has contributed significantly to the program
($20,000). The success of the program is encouraging and adding to CME
in the institution by increasing the scope of available CME activities and
encouraging its physicians to participate avidly has been recognized by the
medical board, hospital and board of trustees. In addition, the program
created a sense of organization of this important factor and its impact of
physician practice and patient outcome. It is important to point out that the
structure of various programs are strongly held to physicians needs and
possible sources of deficiencies that surface during the various M&M
meeting and QI program. There are more than 1200 physicians accredited
as members of the hospital medical staff. Over 7000 attendees enjoyed
CME sponsored meetings in 2008-2009.
D.2a. Leadership and Structure of CME Program
New York Methodist Mission Statement:
The physician community of NEW YORK METHODIST Hospital
recognizes that maintaining the medical knowledge and skills necessary to
care for patients is a critical ongoing and dynamic process. Educational
needs can be expected to develop and change consistent with current
evidence based practice and in response to emerging technology,
information, and new standards of quality improvement. Our community
believes that identifying and organizing an adequate response to these
educational needs emanate from a self-imposed will to excel and deliver
the best available medical care.
Our purpose is to maintain a program of CME that enables our physicians
to achieve this goal.
The community recognizes that during these efforts, professionalism,
ethics, and confidentiality (of patients data) are paramount.
The community also aims at fusion of its mission with that of the Hospital,
especially as pertains to education, training and creating an environment
8
hospitable to intelligent solutions for better patient care and for the benefit
of all.
We would also consider extending this support to outside educators in
other hospitals or medical societies.
The Mission of New York Methodist Hospital, a member of the New
York-Presbyterian Healthcare System, is to provide excellent health care
services in a compassionate and humane manner to the people who live
and work in Brooklyn and its surrounding areas.
In serving its community, the Hospital works to achieve these primary
objectives:





To provide excellent health care services which are accessible to
patients and physicians without regard to age, sex, race, creed national
origin or disability;
To serve as an educational and research center for the training of
physicians, nurses and health care professionals committed to the
Brooklyn community;
To provide an active ecumenical program of pastoral care and to
conduct a clinical pastoral education program;
To offer an environment which is responsive to new and changing
technologies and management principles which will stimulate creative
solutions for our patients, physicians and employees;
To engage in ongoing assessment of the health care needs of
community and to respond to these needs and to work with members
of the New York- Presbyterian Healthcare System and other health
care institutions, physicians and community grouping in jointly
pursuing the delivery of quality health care services, medical education
and clinical research.
It is clear that items 2,4 and 5 above is enhanced by CME Mission
Statement
The Content of CME programs will be directed at satisfying the needs
already identified through various QI steps of the hospital (Enclosure 21).
The contents will address practice gaps. The contents will update
knowledge and practice of new emerging technologies. Contents will
address patient outcome and satisfaction.
Target Audience are primarily the physicians involved in the activity
discussed, as well as other physicians who may be involved at a secondary
level. Medical students are also accepted as a target audience. Other
health professionals such as nurses, physician assistants, and technologists
are accepted as audience. However, CME credits are awarded only to
physicians. Others will be given letters of attendance. Activities
sponsored are symposia, guest lecture series, practice outcome monitoring
9
(M&M), grand rounds, multidiscipline conferences,(eg, Tumor Board,
NeuroOncology, Radiation Oncology/Rad Path Conference, Pulmonary
Conference) and one time conference events that addresses an important
topic (eg. The Sickle Cell Bi-Annual Program).
Expected Results of the program include improved physician knowledge
and methods of practice, improved physician awareness of new changes in
his/her field and other related fields, as well as improved and measured
outcome. Data regarding these expected changes will be collected and
analyzed on a regular basis using computerization as much as possible to
assure timeliness of results of analysis. Results of analysis will be shared
with all concerned and used to improve subsequent programs or create
new activities.
The CME committee is responsible for approving the mission statement of
CME Program.
Committee is composed of:
Members of CME Committee
Name
1- Baccash,
Emil MD
FACP
2- Bharathan,
Thayyullathil
MD
Buckner,
3- Cary MD
Dept.,
Title
Contact Info.
Pulmonary Medicine
Present President of Medical
Staff and P.P.
Internal Medicine
Geriatric
Chief and director of geriatric
program and fellowship chair
medical education committee
Tel: (718) 780-5110
Fax: (718) 780-3222
Email: eiw9001@nyp.org
Tel:(718) 780-5255/50
Fax:(718) 780-3259
Email: thb9001@nyp.org
Neurology
Practicing Physician
Tel: (718) 246-8614/ Caroline 5490
Fax: (718) 246-8656
Practicing Physician &
Director of GYN., Oncology
Tel: (718) 780-3090
Fax: (718) 780-3271
Email: kae9001@nyp.org
Tel:(718) 780-5040 - Yesmine
Fax: (718) 780-3153
Email: thg9001@nyp.org
Tel:(718) 780-5870
Fax:(718) 780-3494
Email: cll9006@nyp.org
Tel:(718) 833-5273 (outside)
Email: poopamas@hotmail.com
Tel:(718) 780-3634
Fax:(718) 780-3673
Email: rnm9001@nyp.org
Tel:(718) 780-5260
Fax:(718) 780-3266
4- Economos, GYN Oncology
Katherine
MD FACOG
5- Gaeta,
Emergency Medicine
Theodore
MD MPH
6- Lapidus,
Radiology
Claudia MD
7- Mascatello, Medicine
Antonio MD
8- Mir, Rabia
MD
Pathology
9- Narula,
Pediatrics
Pramod MD
Practicing Physician and
Chairman research committee
Radiologist
Practicing Physician
Practicing physician and
Past President of Medical Staff
Pathologist,
Practicing Physician
Chairman and
Practicing Physician
10
10- Rafla,
Radiation Oncology
Sameer MD
Chairman and
Practicing Physician
Rucinski,
James, MD
General Surgery
Email: prn9001@nyp.org
Tel: (718) 780-3677
Fax: (718) 780-3637
Email: srafla@verizon.net
Deputy program director for
Program of Surgery and P.P.
Tel: (718) 780-3288
Fax: (718) 780-3154
Email: jrucinski@pol.net
12- Salama,
Pulmonary Medicine
Practicing Physician
Tel:
SalamaMD
Fax: (718) 621-7103
Email: None (outside)
13- Salgado,
Neurology
Practicing Physician and
Tel: (718) 246-8614
Miran MD
Chair of Neurological Sciences
Fax: (718) 246-8656
Email: miranws@aol.com
14- Sherbell,
Pulmonary Medicine
Executive V.P. for Medical Affairs Tel: (718) 780-3284
Stanley MD
Fax: (718) 780-3287
Email: sts9006@nyp.org
15- Schifter,
Int., Medicine Cardiology Cardiology, Past President,
Tel: (718) 499-5300 (outside)
David MD
Medical Board, Practicing Physician Fax: (718) 499-6161
Email: does not have
16- Simon, Todd Internal Medicine
Vice Chairman Dept., of Medicine Tel: (718) 780-5251
MD
Fax: (718) 780-3259
Email: tos9017@nyp.org
17- Vardi, Joseph OB/GYN
Practicing Physician
Tel: (718) 871-3737
MD
Fax: (718) 871-4595
Email: call Annete
18- Yarmush,
Anesthesiology
Vice Chairman and
Tel: {718) 780-3279
Joel MD
Fax: (718) 780-3281
Practicing Physician
Email: jmy@aol.com
19- Zonenshayn, Neuro-surgery
Practicing Physician
Tel: (718) 246-8610
Martin MD
Fax:(718) 246-8611
Email: maz9001@med.cornell.edu
Committee is Chaired by Sameer Rafla, MD, PhD, CME Program Director.
Committee minutes become part of Medical Education Committee Minutes → Board of
Trustees after Executive Committee reviews
Mission Statement is reviewed regularly. Last review November 2009.
Date: January 2010
D.2.a. Links between CME mission and organization mission:
The CME mission includes the identification, development and
promotion of quality CME (CME) utilized by physicians in their
maintenance of competence as well as incorporation of new
knowledge aimed at improving quality care for patients in the
community. NY Methodist Hospital considers medical education,
both graduate medical education and CME of their physicians (and
11
other health professionals) as an essential component of its
mission. The institution believes that keeping its physicians (and
all its health professionals) abreast of recent medical and scientific
development is an integral component of quality medical care.
We calculated that the hospital sponsors over 26 hours of medical
education everyday, most of that comes under the purvue of CME.
There is a strong link between CME and continuing accreditation.
D.2.b. CME Program strength:
We believe that our proposed program enjoys the following points
of strength and distinction:
i.
Commitment of the hospital medical staff as represented by
the medical board leadership. All physicians at NY
Methodist are members of the medical board. A president is
elected every year as well as an executive committee.
Enclosure 3 is a letter from the president of the medical
staff and expressing strong support of the program and the
financial support for that year. We have in our records over
500 signed copies of letter of support submitted by
physicians from all disciplines. Over 14,000 physician
attendees frequent various CME activities since provisional
approval. There is a widespread of support of the program
among hospital physician community.
Another evidence of support of the medical staff is the
strong financial support extended to the program by a
significant yearly contribution towards the expenses of the
program.
ii.
Commitment of hospital management to the program is
evident and their investment in the program is substantial.
The CME office of NY Methodist is part of the office of
the Senior Vice President of Medical Affairs who has the
overarching management responsibility of the program
(page 25). There are full time staff members who are
managing the program. In addition, the hospital has
supported full computerization of the program allowing
digital scanning of attendees, evaluations and generation of
various reports. Since approval, CME reports become a
required component of these deliberations of GMEC, the
12
medical education committee and the executive committee
of the medical board.
iii.
Commitment of leadership of CME Committee: A review
of the membership of the CME committee with its
complements of academic physicians, practicing physicians
and administrators physicians, (all volunteers) reveals a
commitment of the institution as a whole and each member
individually. Included in Enclosure #3 are letters from
committee members assuring their enthusiastic support for
the CME mission and its objectives. It must be noted that
committee membership have full representation from the
various institutional medical communities, namely the
medical board (all the medical staff), clinical chairmen and
section chiefs, program directors, practicing physicians and
medical administration. Each group has a special interest in
maintaining an active CME program in order to maintain a
cadre of physicians whose knowledge and expertise is
continuously updated to assure best patient care and the
maintenance of quality practices in the face of market place
competition.
iv.
Commitment of graduate program leadership to the
program:
Graduate programs (residencies) leadership are strongly
supportive of CME program as it certainly adds to the
knowledge and skills of their graduates who continue to
practice in the institution.
The requirement of the various medical boards for recertifications has required CME activities to rise to an
organized approach rather than patchy programs.
Graduate program leadership view CME as a necessary
extension of their programs in the “afterlife”.
v.
Availability of funds and continuing support:
As will be seen in part 4 under administration, both
hospital management and medical board are supportive of
the program. The hospital is committed to support the
operational costs (personnel, computerization…. etc.) as
well as the maintenance of the program. Medical staff
organization is committed to a significant annual
contribution towards the program. Enclosure 8 is a copy of
communication from the President of the medical staff to
that effect.
vi.
Availability of space: The hospital has over 15000 square
feet allocated for educational and scholarly activities with
13
an attractive auditorium that seats 120 participants and
equipped with full state of the art electronic audiovisual
tools including an audience response system.
vii.
A New York Methodist Hospital CME authority will
increase the availability of CME programs to other
physician communities in Brooklyn.
viii.
All CME activities are electronically displayed and updated
weekly in the doctors’ lounge.
D.2.c. Areas for Improvement and Plans for Addressing
Through our experience with the program so far we plan to
develop it to achieve the following objectives:
1.
2.
3.
4.
5.
Making CME credits acquisition mandatory for physicians’
reaccreditation.
Purifying the CME by requiring that > 70% of the credits is
obtained either through our program or programs offered
by professional societies or academic centers. That will
limit commercially sponsored CME credits to less than
30% of required credits.
Link CME credits to identifiable points in physician
performance and patient outcome. Several networks may
be utilized; the simplest could be upgrading the credit
points offered by certain programs.
Creating stronger links between CME programs and
community needs identified in public local media and ER,
OP surveys, as well as other venues such as community
board.
CME will conduct an institution wide activity to which all
present or potential program directors are invited to alert
them to updated accreditation requirements especially all
the evaluation activities with attention to measuring
outcome and impact.
14
E.
Monitoring System of RSS for Compliance
New York Methodist CME Program reviews and accredits several RSS.
E.1.
Sampling and Monitoring Methods
CME Program at New York Methodist Hospital
conducts an extensive monitoring system that starts at point of conception,
carried through implementation and participant evaluation, as well as
unannounced site visits by CME representatives and early actions on
monitor reports. Monitor reports, program directors final reports as well as
specifics of application for program renewal are examined carefully for
compliance with the guidelines:
1.
Planning Stage:
a.
A member of the CME Committee must be included in the
planning committee (see Enclosure 10)
b.
Assessment of educational needs and how was this
developed
c.
The objective of the program must be clearly indicated and
linked to needs
d.
The venue chosen by the program is monitored to verify
educational needs are met (eg audiovisual, space, access,
etc.)
2.
Application Form:
Is monitored for compliance, as well as all the attached documents
of activity agreement. Close attention is paid to possible
commercial support (clarity, detailed budget, disclosure forms,
brochures, etc…(See Enclosure 11 for an example).
All the above-steps are reviewed by the Steering Committee if
there is a positive recommendation from staff; Steering Committee
applies its own monitoring steps.
3.
Implementation Phase:
Several monitoring steps are in place:
a.
Attendance is monitored by card swiping in a computerized
terminal. All cards are regularly monitored for accuracy
and relevance. Cards are collected at end of meeting to
prevent tampering.
b.
Data of attendance are monitored and analyzed and
reported at end of program.
c.
Evaluation forms are completed by attendees (Enclosure
12)
d.
Evaluation forms are monitored along with attendance data.
Evaluations are computerized and analyzed (Enclosure13)
by Steering Committee. We also plan to conduct a
15
f.
midterm evaluation analysis, if the need arises e.g.
monitoring step reveals a significant regularity.
e.
An unannounced site visitor attends a meeting to monitor it,
complete a special form (Enclosure 14) and submit a report
if a major deviation is noted. Such reports are addressed
immediately and a remedial action is taken. We have had
to withdraw CME credit from a particular meeting that was
found non-compliant (example Enclosure 15). Educators,
hospital-wide, have been warned that a repetition of such
infraction will result in denial of CME accreditation to
whole program.
The final report about the activity is monitored to assure its
compliance with the numbers on the ground (eg. Number of
attendees, degree of program success in achieving its objectives,
impact of program or physician skills and impact of program on
practice modification.)
All the above data are reported directly to the CME Steering Committee
and CME Committee for input. The final reports are submitted to the
Executive Committee of Medical Board via the Medical Education
Committee. All these recommendations are eventually submitted to the
Board of Trustees.
E.2
Accreditation Requirements Monitored
With a focus on RSS, NEW YORK METHODIST CME Program
monitors the following accreditation requirement in programs it approves.
E.2.1
Educational needs are identified by various departments or
multidisciplinary groups (eg, Tumor Board) based on identified gaps in
knowledge of physicians (eg, related to new technology or new important
finding), progress in the particular discipline, which has identified new
standards of practice, changes in the requirements of regulatory agencies
vis-à-vis infection control or child abuse or radiation protection, etc., alerts
from CDC or Department of Health regarding an existing or impending
problem.
E.2.2
Objectives of the program must meet the mission of CME vis-à-vis the
content, target audience, and expected result. The type of program is also
important eg. M&M Program must target or identify gaps of practice and
remedies of these gaps. (See Enclosure 16). Equally important new
technical services, for example, must focus on technologies and not
products (See Enclosure 17)
16
E.2.3
Learner Change Data are collected and analyzed regularly. Feedback is
submitted to program directors for future planning (Enclosure 18). In
some programs, we have succeeded in implementing some written
questions on the topic discussed before and after the meeting to gauge the
scope of change (Enclosure 19).
E.2.4
Patient outcomes and its relations to a particular education program is
difficult to match due to the many confounding factors in patient outcome.
However, we are able to monitor outcome through constant observation of
M&M and adverse events reported in a particular department. Any
repetition of poor patient outcome raises a red flag and creates an
opportunity for an in-training educational activity, some of those go
through the CME program but others may be instituted almost
immediately depending on the urgency of the situation.
E.2.5
Of 2,958 evaluations analyzed, over 87% of physicians indicated they
learned new data and over 71% indicated that this will impact their
practice (Enclosure 20) shows a limited sample of evaluations analysis by
program during the period of January – June 2009. Analysis of different
components of evaluations program namely consisting of objectives with
CME program, content, participation of attendees, changes in competence
and outcome is ongoing. The sample size now allows relevant statistical
analysis.
17
F)
Organization’s Change Process
F.1
We intend to update our application forms to incorporate the new accreditation
data especially those pertinent to monitoring the identification of needs, planning
of the program with objectives that meet the needs, parameters to measure the
effectiveness of the program.
F.2
We will conduct a survey of all attendees of each program at the end of the
program to monitor their possible gain in knowledge and change in practice.
F.3
We will observe the rate of success of various physicians in receiving their board
certification. After all, a large part of new information, which are the subject of
recertification exam come through the CME Program of the hospital. It must be
acknowledged, however, that other CME Programs may have also contributed to
this.
F.4
Approach the Medical Executive Committee, management and Board of Trustees
to take steps that would highlight the relevance of the CME activities. Upgrading
CME to a hospital department may be useful.
18
G.
Annual Report
CME Program
2008 – 2009 ANNUAL REPORT
CME Mission Statement:
The physician community of NEW YORK METHODIST Hospital recognizes that
maintaining the medical knowledge and skills necessary to care for patients is a critical
ongoing and dynamic process. Educational needs can be expected to develop and change
consistent with current evidence based practice and in response to emerging technology,
information, and new standards of quality improvement. Our community believes that
identifying and organizing an adequate response to these educational needs emanate from
a self-imposed will to excel and deliver the best available medical care. Our mission is to
maintain a program of CME that enables our physicians to achieve this goal.
The community recognizes that during these efforts, professionalism, ethics, and
confidentiality (of patients data) are paramount. The community also aims at fusion of its
mission with that of the Hospital, especially as pertains to education, training and
creating an environment hospitable to intelligent solutions for better patient care and for
the benefit of all.
We would also consider extending this support to outside educators in other hospitals or
medical societies.
CME Steering Committee at New York Methodist met at least six times for the 2008 –
2009 academic year. The committee addressed various issues from the implementation
of the CME program to the distribution and cost of certificates to participants.
The card scan-swipe system “eeds” had been used to monitor and document the
attendance for each participant in all programs. An ACCME report is attached, which
reflects the hours of instruction, physician attendance, non-physician attendance and total
for all regularly scheduled series, as well as one-time conference events. (Attached)
For accurate reporting and rating of each program standard electronic evaluations were
developed (January 2009) using a standard format (copy enclosed) and the “Scantron
System”. Cumulative count and percent reports were generated to tabulate responses
from participants. All reports were issued to program directors for assessment and
review of the outcome of their program. Program directors were given the opportunity to
consider the outcome evaluation results in the design of their new programs as necessary.
19
We have, repeatedly, stressed the importance of completing evaluations by all attendees
in order to ensure the accuracy and relevance of the evaluations.
It is estimated that approximately 11% of CME costs had been received from commercial
industry or other “outside” financial sources. Unrestricted commercial grants amounted
to $35,000. The total cost of various programs offered by the hospital exceeds
$300,000/year. The administrative cost amounts to about $35,000/year.
According to results of program evaluations submitted and tabulated, which addressed
the effectiveness of the speaker, topics presented, time allowed, objectives of activity,
opportunity for discussion and venue satisfaction, an estimated 91% of participants
maintain and gained the educational needs, medical knowledge and skills necessary to
care for patients at New York Methodist.
20
Report of
CME Activities for the Year 2009
Submitted by:
Dr. Sameer Rafla, Director CME Program
Our first year as a CME accreditation provider has been very productive. The attached
tables demonstrate a snapshot of the program:
 Total number of programs:
27
 Number of Sponsors (Program Directors)
22
 Total number of physician attendees:
7077
All the programs seemed to have complied with program requirements.
The evaluation program consists of 2 parts:
1.
A summary of the evaluation forms completed by the attendees and analyzed
by an E-Listen for each program. Report is assembled on a monthly basis (an
example is included. A full one-year overview is being generated and will be
submitted in next meeting).
2.
A report from each sponsor about the program they conducted.
The satisfaction with various programs has been on the whole very laudatory. The
reports from various sponsors are yet to be completed. These will be summarized and
submitted to you as soon as possible.
MSSNY, the parent authority for accreditation, has strongly suggested a close monitoring
of the programs we accredit. Towards that end, a proposal of a monitoring system will be
submitted to the next meeting of CME Committees, scheduled February 18, 2010.
We are in continuing communication with MSSNY who hold a monthly telephone
conference for monitoring and update.
We are in the process of completing application for accreditation according to following
timetable.
21
II.
Essential Area 1: Purpose and
Mission (Criterion 1)
22
Essential Area 1: Purpose and Mission
A.
CME Mission Statement:
The physician community of NEW YORK METHODIST Hospital recognizes
that maintaining the medical knowledge and skills necessary to care for patients is
a critical ongoing and dynamic process. Educational needs can be expected to
develop and change consistent with current evidence based practice and in
response to emerging technology, information, and new standards of quality
improvement. Our community believes that identifying and organizing an
adequate response to these educational needs emanate from a self-imposed will to
excel and deliver the best available medical care. Our mission is to maintain a
program of CME that enables our physicians to achieve this goal.
The community recognizes that during these efforts, professionalism, ethics, and
confidentiality (of patients data) are paramount. The community also aims at
fusion of its mission with that of the Hospital, especially as pertains to education,
training and creating an environment hospitable to intelligent solutions for better
patient care and for the benefit of all.
We would also consider extending this support to outside educators in other
hospitals or medical societies.
The Content of CME programs will be directed at satisfying the needs already
identified through various QI steps of the hospital (Enclosure 21). The contents
will address practice gaps. The contents will update knowledge and practice of
new emerging technologies. Contents will address patient outcome and
satisfaction.
Target Audience are primarily the physicians involved in the activity discussed,
as well as other physicians who may be involved at a secondary level. Medical
students are also accepted as a target audience. Other health professionals such as
nurses, physician assistants, and technologists are accepted as audience.
However, CME credits are awarded only to physicians. Others will be given
letters of attendance.
Types of Activities: Activities sponsored are symposia, guest lecture series,
practice outcome monitoring (M&M), grand rounds, multidiscipline
conferences,(eg, Tumor Board, NeuroOncology, Radiation Oncology/Rad Path
Conference, Pulmonary Conference) and one time conference events that
addresses an important topic (eg. The Sickle Cell Annual Program).
Expected Results of the program include improved physician knowledge and
methods of practice, improved physician awareness of new changes in his/her
field and other related fields, as well as improved and measured outcome. Data
regarding these expected changes will be collected and analyzed on a regular
basis using computerization as much as possible to assure timeliness of results of
analysis. Results of analysis will be shared with all concerned and used to
improve subsequent programs or create new activities.
23
The CME Steering Committee is responsible for approving the mission statement
of the program. Reports of Steering Committee are ratified by CME full
committee.
Mission Statement was last reviewed in November 2009. (See Enclosure 45)
24
ORGANIZATIONAL FRAMEWORK AND CHART
ADD
25
Members of CME Committee
Name
Dept.,
Title
Contact Info.
1- Baccash, Emil
MD FACP
Pulmonary Medicine
Present President of Medical
Staff and P.P.
2- Bharathan,
Thayyullathil
MD
Internal Medicine
Geriatric
Chief and director of geriatric
program and fellowship chair
medical education committee
Tel: (718) 780-5110
Fax: (718) 780-3222
Email: eiw9001@nyp.org
Tel:(718) 780-5255/50
Fax:(718) 780-3259
Email: thb9001@nyp.org
Neurology
Practicing Physician
Tel: (718) 246-8614/ Caroline 5490
Fax: (718) 246-8656
GYN Oncology
Practicing Physician &
Director of GYN., Oncology
Tel: (718) 780-3090
Fax: (718) 780-3271
Email: kae9001@nyp.org
Tel:(718) 780-5040 - Yesmine
Fax: (718) 780-3153
Email: thg9001@nyp.org
Tel:(718) 780-5870
Fax:(718) 780-3494
Email: cll9006@nyp.org
Tel:(718) 833-5273 (outside)
Buckner, Cary
3- MD
4- Economos,
Katherine MD
FACOG
5- Gaeta, Theodore Emergency Medicine
MD MPH
Practicing Physician and
Chairman research committee
6- Lapidus, Claudia Radiology
MD
Radiologist
7- Mascatello,
Antonio MD
Medicine
8- Mir, Rabia MD Pathology
9- Narula, Pramod Pediatrics
MD
10- Rafla, Sameer
MD
Radiation Oncology
11- Rucinski,
JamesMD
General Surgery
12- Salama,
SalamaMD
Pulmonary Medicine
13- Salgado, Miran Neurology
MD
14- Sherbell, Stanley Pulmonary Medicine
MD
Practicing Physician
Practicing physician and
Past President of Medical Staff
Pathologist,
Email: poopamas@hotmail.com
Tel:(718) 780-3634
Fax:(718) 780-3673
Practicing Physician
Email: rnm9001@nyp.org
Chairman and
Tel:(718) 780-5260
Fax:(718) 780-3266
Practicing Physician
Email: prn9001@nyp.org
Chairman and
Tel: (718) 780-3677
Fax: (718) 780-3637
Practicing Physician
Email: srafla@verizon.net
Deputy program director for
Tel: (718) 780-3288
Program of Surgery and P.P.
Fax: (718) 780-3154
Email: jrucinski@pol.net
Practicing Physician
Tel:
Fax: (718) 621-7103
Email: None (outside)
Practicing Physician and
Tel: (718) 246-8614
Chair of Neurological Sciences
Fax: (718) 246-8656
Email: miranws@aol.com
Executive V.P. for Medical Affairs Tel: (718) 780-3284
Fax: (718) 780-3287
26
Email: sts9006@nyp.org
15- Schifter, David Int., Medicine Cardiology Cardiology, Past President,
Tel: (718) 499-5300 (outside)
MD
Medical Board, Practicing Physician Fax: (718) 499-6161
Email: does not have
16- Simon, Todd
Internal Medicine
Vice Chairman Dept., of Medicine Tel: (718) 780-5251
MD
Fax: (718) 780-3259
Email: tos9017@nyp.org
17- Vardi, Joseph
OB/GYN
Practicing Physician
Tel: (718) 871-3737
MD
Fax: (718) 871-4595
Email: call Annete
18- Yarmush, Joel Anesthesiology
Vice Chairman and
Tel: {718) 780-3279
MD
Fax: (718) 780-3281
Practicing Physician
Email: jmy@aol.com
19- Zonenshayn,
Neuro-surgery
Practicing Physician
Tel: (718) 246-8610
Martin MD
Fax:(718) 246-8611
Email: maz9001@med.cornell.edu
Committee is chaired by S. Rafla, CME Program Director. Committee minutes become
part of Medical Education Committee minutes → Board of Trustees after Executive
Committee reviews
CME Steering Committee Members:
Sameer Rafla, MD. PhD
Chairman Emeritus, Radiation Oncology
Director, CME Program
Stanley Sherbell, MD
Executive Vice President for Medical Affairs
Thayyullathil Bharathan, MD
Vice Chairman Department of Medicine
Associate Program Director
Todd Simon, MD
Vice Chairman Department of Medicine
Associate Program Director
Antonio Mascatello, MD
Internist, Department of Medicine
27
III. Essential Area 2: Educational
Planning (Criteria 2-3)
28
2.A.
Element 2.1:
Planning Process:
1. Needs evaluation and assessment: gap definition
Each department and section in the hospital has a mandated quality review and
improvement committee in addition to an institution wide quality improvement
committee (enclosure 1) as well as various AD HOC quality improvement
committees that are continuously created as pertinent issues of health care arise.
Examples of standing committees in internal medicine are: general medicine,
pulmonary critical care medicine, cardiology, oncology-hematology,
gastroenterology, infectious disease, geriatric medicine, AD HOC committees in
that department during the year of 2006, amounted to 3. Enclosure 1 represents
samples of such meetings.
It is estimated that there are about 50 different quality program committees and
subcommittees that were active at NEW YORK METHODISTH during the last
12 months.
The corrective action steps for issues that arise out of these extensive activities
start with an educational effort. Various clinical leaders in the hospital regularly
mount educational programs (e.g. a symposia, a lecture or a workshops) that are
organized as part of an institution wide effort to respond to these needs. Most of
these efforts constitute CME.
The academic programs, by their nature, are continuously mounting educational
programs directed at their faculty, practicing physicians and physicians in
training. Among the main features of many of these programs is the CME credit
attached to worthy programs. That need drives several CME activities. In
addition, the continuing process of credentialing and re-credentialing for all
hospital physicians requires the acquisition of a minimum of 50 hours of CME
credits every 2 years. The need associated with this requirement is self-evident.
The evolution of many new procedures in various disciplines and the need to
make these procedures available to hospital patients creates a recurring
requirement for CME programs. An example of a recent such effort was
introduction of partial breast irradiation as part of organ sparing technology for
treating breast cancer. An interdisciplinary (surgery, radiation oncology,
radiology, pathology, physics) symposium was mounted which constituted the
basis for credentialing physicians who perform the procedures as well as the
larger group of physicians who recommend it for their patients. (Enclosure 3)
2. Planning Process:
29
As a need arises that requires a CME intervention in any of its various forms (a
lecture, a visiting professor activity, or symposium), the following planning steps
occur:
1. Interested parties are required to form a program committee with definable
leadership (enclosure 22 shows minutes of such committee along with a
member of CME and identifiable chair.
2. Program committee approaches CME office for possible award of CME
credit, a preliminary application submitted (enclosure 11) and a planning
meeting is held where CME office is represented. Four elements must be
discussed during that meeting and data completed on a computerized form
that addresses, objectives, audience targeted, program outline and evaluation
methods. As this step is satisfied program is considered Preliminary.
3. “Preliminary” program is reviewed by the CME Steering Committee (which
meet every month) for advice and consent.
P.S. In special circumstances, (e.g. an urgent event that requires rapid
approval) a preliminary review is conducted by the CME program coordinator
who advises the steering committee as soon as possible.
Preliminary program is reviewed for:
a. Feasibility (timing, planned space, planned budget, required resources)
b. Appropriateness (objectives and evidence).
c. Budget review (grants, commercial support, etc…) and financial
disclosures.
d. Evaluation method
4. Advice is conveyed to program committee which schedules a final working
meeting with participation of CME where:
 Objectives, target audience, program outline are finalized.
 Speakers are identified.
 Meeting details discussed and finalized.
 Budget finalized
 Request for CME accredited hours is submitted according to computerized
format along with financial disclosures.
5. CME steering committee examines the submission and evaluates program
plan vis-à-vis the same 4 items listed under item 3. In the addition the draft of
the brochure is submitted and examined.
Decision regarding tentative approval and number of credit hours awarded is
made pending the final copy of brochure. Letter of agreement signed
(enclosure 36)
6.
As soon as brochure is finalized the CME approval is formalized pending
evaluation of audience and program evaluation.
30
2.B.
Enclosure 3 shows activities, which were generated based on specific identified
needs.
2.C.
The example we chose to demonstrate CME activity designed to change
competence and performance is the symposium program of radiation oncology
(Enclosure 27). All update items are designed to add competence and improve
performance. As an example the update given by Dr. Ashamalla about
Stereotactic body Radiosurgery was planned and implement to achieve that. The
Department of Radiation Oncology moved to add this method of cancer treatment
following this activity.
The objectives of each CME activity are built in the program announcement.
Enclosure 39 is an example of method of conveying objectives of CME. This
component is mandatory in each program. It is also included in a special
electronic announcement board located in the doctor’s lounge, which announces
all the CME activities of the day classified according to sponsoring discipline.
31
IV. Essential Area 2: Education and
Planning (Criteria 4-6)
32
Essential Area 2
A.
See attached examples (Enclosures 23 & 39), one for Radiation Oncology
(RSS) and the other for Medicine (Single event program). All topics chosen
are pertinent to the learner’s current or potential scope of practice whether it is
Radiation Oncology, which concerns itself with all aspects of cancer,
epidemiology and management including quality of life issues. Aspects of of
practice in sickle cell disease are addressed in example 2 in great detail.
Programs are monitored at its inception, during its implementation
(Enclosures 25 & 26). Learners evaluations are also obtained when
appropriate learner’s were subjected to questions, before and after the activity
to gauge the scope of benefit (Enclosure 19).
B.
Educational formats used in our programs are:
a. Symposia
b. Guest lecture series
c. Grand Rounds
d. One issue events
e. Courses
f. Multidisciplinary
C. The two examples used are:
1. One issue event: The Sickle Cell Program
 The program is designed to meet the demonstrated needs surrounding
this important disease.
 The Program contents upgrade the learner’s information about aspects
of this disease.
 The format had been used successfully before for this disease.
 The hospital serves a large population at risk for this disease making
the program relevant.
 The program director is a recognized leader in her field.
2. An example of RSS is the Radiation Oncology Resident Symposium
(Enclosure 27)
 We have demonstrated the appropriateness of objectives of this
program.
 We have demonstrated that the program meets the requirements of the
scope of practice of patients.
 We have demonstrated that the continuing evaluation of the program
format assures the participation of the learners (presenters and
discussants), participation of educators (various contents for
completion and appropriateness), as well as a detailed evaluation of
outcome.
The program is planned during a whole day retreat meeting (Enclosure 28)
33
D.
In the examples we used, the attributes examined were the successful completion
of the Certification for the American Board of Radiation Oncology for new
physicians and Continuing Certification for practicing physicians.
All our physicians, new or practicing, have acquired the desired attributes.
Similar attributes for the surgical or medical programs were also examined.
Success among their new physicians is high, e.g. 100/in medicine. All surgeons
who sought recertification were successful. In addition, the content of both these
programs were examined vis-à-vis the requirements for the attributes and all were
found applicable.
In the examples used, we have demonstrated the participation of all physicians
involved either by presenting, discussing, generating written questions, correcting
and discussing answers.
34
V. Essential Area 2:
Educational Planning (Criterion 7:
Standards for Commercial Support –
Independence)
35
Essential Area 2 – Commercial Support
A.
See Enclosure 29 for standing guidelines when a commercial support exists.
Commercial support for our program is sparse and only few programs receive any
commercial support.
All decisions related to identification of needs, educational objectives, content and
personnel who control it, as well as the program design and evaluation of activity
are under the exclusive control of the program director. The CME director, staff,
steering committee and CME committee keep a sharp eye for any infraction.
B.
We have had no joint sponsorship relationship. The only arrangement we accept
is an educational grant without strings attached.
C.
Enclosure 30 is a disclosure statement. Refusals are disqualified.
D.
Our standing guidelines address conflict of interest issues (Enclosure 31)
E.
Our standing guidelines mandate that participants demonstrate this
F.
All those who are accepted to lead a program and control its contents, are required
to disclose relevant financial relationships according to our guidelines.
(Enclosure 31 & 32)
G.
New York Methodist has a policy of assuring non-conflict of interests (Enclosure
31) of the institution and its staff. This is a pre-requisite.
H.
Monitoring System of RSS for Compliance
New York Methodist CME Program reviews and accredits several RSS.
H.1.
Sampling and Monitoring Methods
CME Program at New York Methodist Hospital
conducts an extensive monitoring system that starts at point of conception,
carried through implementation and participant evaluation, as well as
unannounced site visits by CME representatives and early actions on
monitor reports. Monitor reports, program directors final reports as well as
specifics of application for program renewal are examined carefully for
compliance with the guidelines:
1.
Planning Stage:
e.
A member of the CME Committee must be included in the
planning committee (see Enclosure 10)
f.
Assessment of educational needs and how was this
developed
g.
The objective of the program must be clearly indicated and
linked to needs
h.
The venue chosen by the program is monitored to verify
educational needs are met (eg audiovisual, space, access,
etc.)
2.
Application Form:
Is monitored for compliance, as well as all the attached documents
of activity agreement. Close attention is paid to possible
36
commercial support (clarity, detailed budget, disclosure forms,
brochures, etc…(See Enclosure 11 for an example).
All the above-steps are reviewed by the Steering Committee if
there is a positive recommendation from staff; Steering Committee
applies its own monitoring steps.
3.
Implementation Phase:
Several monitoring steps are in place:
a.
Attendance by card swiping in a computerized terminal.
All cards are regularly monitored for accessory and
relevance. Cards are collected at end of meeting to prevent
tampering.
b.
Data of attendance are monitored and analyzed and
reported at end of program.
c.
Evaluation forms are completed by attendees (Enclosure
12)
d.
Evaluation forms are monitored along with attendance data.
Evaluations are computerized and analyzed (Enclosure13)
by Steering Committee. We also plan to conduct a
midterm evaluation analysis.
e.
An unannounced site visitor attends a meeting to monitor it,
complete a special form (Enclosure 14) and submit a report
if a major deviation is noted. Such reports are addressed
immediately and a remedial action is taken. We have had
to withdraw CME credit from a particular meeting that was
found non-compliant (example Enclosure 15). Educators,
hospital-wide, have been warned that a repetition of such
infraction will result in denial of CME accreditation to
whole program.
f.
The final report about the activity is monitored to assure its
compliance with the numbers on the ground (eg. Number
of attendees, degree of program success in achieving its
objectives, impact of program or physician skills and
impact of program on practice modification.)
All the above data are reported directly to the CME Steering Committee
and CME Committee for input. The final reports are submitted to the
Executive Committee of Medical Board via the Medical Education
Committee. All these recommendations are eventually submitted to the
Board of Trustees.
H.2
Accreditation Requirements Monitored
With a focus on RSS, NEW YORK METHODIST CME Program
monitors the following accreditation requirement in programs it approves.
37
H.2.1
Educational needs are identified by various departments or
multidisciplinary groups (eg, Tumor Board) based on identified gaps in
knowledge of physicians (eg, related to new technology or new important
finding), progress in the particular discipline, which has identified new
standards of practice, changes in the requirements of regulatory agencies
vis-à-vis infection control or child abuse or radiation protection, etc., alerts
from CDC or Department of Health regarding an existing or impending
problem.
H.2.2
Objectives of the program must meet the mission of CME vis-à-vis the
content, target audience, and expected result. The type of program is also
important eg. M&M Program must target or identify gaps of practice and
remedies of these gaps. (See Enclosure 16). Equally important new
technical services, for example, must focus on technologies and not
products (See Enclosure 17)
H.2.3
Learner Change Data are collected and analyzed regularly. Feedback is
submitted to program directors for future planning (Enclosure 18). In
some programs, we have succeeded in implementing some written
questions on the topic discussed before and after the meeting to gauge the
scope of change (Enclosure 19).
H.2.4
Patient outcomes and its relations to a particular education program is
difficult to match due to the many confounding factors in patient outcome.
However, we are able to monitor outcome through constant observation of
M&M and adverse events reported in a particular department. Any
repetition of poor patient outcome raises a red flag and creates an
opportunity for an in-training educational activity, some of those go
through the CME program but others may be instituted almost
immediately depending on the urgency of the situation.
H.2.5
Enclosure 20 shows a sample of early and limited evaluation analysis of
2958 evaluations 87 % of physicians indicated they learned new data and
71% indicated that this will impact their practice. Complete and detailed
analysis of different components of the program (content, attendees
participation, competence and outcome is ongoing. Enclosure 20B shows
an example of one program detailed analysis.
38
VI. Essential Area 2: Education and
Planning (Criterion 8: Standard for
Commercial Support – Management
of Funds
39
Our policy and procedures addresses the issue of sources of funds. They also address the
issues of honoraria, planers, disclosures, etc. Follows are pertinent data requested.
Speakers are paid an honorarium consistent with prevailing academic standards and their
standing in the discipline and written agreements with them reached before conference
planning is completed.
In-house speakers honoraria are subject to same rules. Planners, whether in-house or
outside consultants are paid a fee dependent on the extent of services they provide,
expected number of attendees, complexity of arrangements (eg, overseas speakers) and
length of the conference. The market reputation of the planner is also an important
factor. A written agreement signed by a legal representative of the outside planner and a
hospital senior manager (VP for Medical Affairs) and program director is completed
before the planners can start their activities. To summarize:
A.
B.
C.
D.
E.
F.
Hospital planners are allowed a fee consistent with the time they spend on this
task, prorated to their hourly income.
Teachers, speakers, authors are paid an honoraria compatible with their rules
and contribution to the activity they participate in.
Any durable material, which may be supplied, is reviewed by the program
director to assure compliance with SCS 2.7, 3.10. This material will be
forwarded to CME program before the activity, if available, or with the final
report of the activity. CME will review material for compliance. Infraction of
guidelines may result in denial of CME credits even if the conference receives
prior approval. However, this remedy is only applied in extreme cases of
intentional and callous disregard of guidelines, since it may also penalize
attendees who may not have played a role in the infraction.
All funds are received as unrestricted grants and they are deposited in hospital
specific accounts. No restricted or conditioned grant is accepted for a CME
program. All expenses are disbursed by hospital finance directly to the
recipients based on a special check request, approved by program director and
the chairman of the department sponsoring the activity. These check requests
are usually reviewed by the higher echelon of hospital management (Vice
President) before approval. The grantor of any commercial support does not
play a role in planning the activity, its conduct or contents.
A review of point D shows that:
a. Commercial support is given with full knowledge of the hospital
(Enclosure 33)
b. Funds disbursed to honoraria, planners or other items are disbursed from
hospital finance after full review and approval of management.
(Enclosures 33 demonstrate the system implementation).
All programs are required to submit a final report of the activity including
disbursement of funds. Enclosure 34 shows final disbursement of funds in 2
programs to very adherence to guidelines.
40
G.
H.
I.
A review of the program brochure (2 examples attached – Enclosure 35)
shows that only minimal social events are planned, essentially coffee and
lunch breaks.
Enclosure 36 shows 2 examples of a written agreement documenting terms,
conditions and purposes of commercial support used to fulfill relevant
elements of SCS 3.4-36
Our program does not produce hard copies as a routine. For post script hard
copies of materials see Enclosure 37.
41
VII. Essential Area 2: Educational
Planning (Criteria 9-10) Standards for
Commercial Support-Separation of
Education from Promotion, Promotion of
Improvements in Healthcare
42
Essential Area 2 – Separation of Education from Presentation
A.
B.
C.
D.
E.
New York Methodist CME does not organize commercial exhibits. Only
scientific papers can be posted during appropriate conferences.
No advertisements are accepted during CME conferences. We only have a poster
that discloses the name of supporters.
All hard copy materials (slides, handouts, abstracts) are received before hand, if
available; to ensure that there is no adversity or trade names. Material submitted
postscript is subject to same scrutiny. Violators, if any, are sternly dealt with.
Enclosure37 represents an example of handouts.
Commercial interest does not play a recognizable role in access to CME
activities for learners. Brochures and information about meetings are supplied
and distributed free to all potential learners.
Several monitoring steps are used to ensure that CME activities are not utilized to
promote commercial interest. Those include review and approval of the content,
speakers, venues, and deliverables – if any – brochures, budget and final report.
Program participants sign a CME agreement denoting their abiding by the rules
(Enclosure 38)
In addition, the presence of 2 representatives of CME on program committee will
ensure compliance with the standard of balanced approach (Enclosure 10 and
39). Also, there are enough members on the planning committee to assure a
balanced approach (Enclosure 39). Besides the balanced value of the content, its
validity is judged by the reviewing committees. We expect the program director
to watch and report on the content validity such as studies quoted, graphs
displayed and statistics used. In addition, all attendees are asked to report on
content in questions 3 and 4 of Enclosure 41.
43
VIII. Essential Area 3: Evaluation
and Improvement (Criteria 11-15)
44
VIII
Evaluation and Improvement
A.
Enclosure 40 is a general report of evaluation of activities attendees. Of
about 3000 evaluations completed, a significant number said that the
activity has added new information to their knowledge, reported new
clinical skills and went as far as making changes in their practiced based
on the information they had. Reporting and counting in our system is all
electronic.
Enclosure 41 is the evaluation format.
B&C. Enclosures 40, 41 & 42 show the forms used in daily monitoring of all
programs.
Attendance is electronically recorded.
Evaluation is
electronically recorded by program and date of activity (to allow
determination of service of problems if any occurs). Analysis is a
computer generated report – Enclosure 40 and 20B.
D.
Conclusions based on analytical data, site visits, program reports to
CGME meetings follows:
1.
The program reaches its target audience in all occasions,
100% as reported by site visitors, see Enclosure 25 & 26.
2.
Over 80% of respondents to questionnaire believe that the
content was highly appropriate.
3.
Over 90% of attendees reported that enough time was
allowed for a give and take.
4.
About 72% reported learning new skills and a similar
proportion reported intent to make changes in clinical
practice
These figures represent an average across various programs. An analysis
of 62 evaluations of Surgery M&M in 03/10, shows better results. There
is certainly an improving trend but we are analyzing a larger sample to
confirm the results.
E.1.
E.2.
The manner and degree to which New York Methodist Hospital integrated
CME into the process of improving professional practice helped to
enhance the hospital’s success in meeting its CME mission is
demonstrated through the reach of the program (to the bulk of attending
physicians), the relevance of the programs contents to the objectives of the
CME, the stress of the importance of CME that evaluations (which are
generally distributed at meeting end) are completed by a significant
number of attendees, the inclusion of the standard format of evaluation
reduced possibilities of misunderstanding and allowed relevant evaluation
of CME activity.
Non-educational strategies used by NEW YORK METHODIST to
enhance change (e.g. wide introduction of computerizing facilities and
PACK systems) helped NEW YORK METHODIST to meet a substantial
component of CME activities missions such as relevant presentations,
abilities to conduct and analyze evaluations and improvement in patient
care outcome.
45
E.3.
E.4.
E.5.
E.6.
E.7.
F.
F.1
A review of the subsequent section shows examples of factors outside our
control that impact patient outcomes. Identification of deficiencies such
as limited institutional funds dedicated to CME activity helped us to plan
CME activities that require less expenses eg. depending on in-house
available audio-visual means. However, using a deficiency outside one’s
content to create an opportunity for improvement is very challenging.
Barriers to physician change are many. New York Methodist employed
and implemented several educational and training strategies to overcome
that e.g. Errors in medication prescription, dosage and timing were
overcame by the introduction of computerized pharmacy orders where
physicians were trained using hands-on tutorials. Another example is the
use of PACK system to allow physicians accurate and early access to
imaging of their patients allowing faster and more accurate changes in
patient outcome. Training physicians on computer skills utilized hand-on
workshops and several on-site trainers. None of these activities were
CME accredited although they are educational in objectives and
implementation with a recognized outcome.
New York Methodist organization is an avid bridge builder. Notable
among these bridges are 1) An extensive substantial bridge to Weill
Cornell Medical School and Cornell Medical Center 2) Bridges to several
other medical schools such as Downstate Medical Center, St. George
Medical School and Ross Medical School.
The presence of all these bridges allowed New York Methodist Hospital,
CME Program to have 1) access to a wider pool of educators, 2) a longer
cohort of doctors-in-training who get oriented doing their formative years
to the significance of CME Programs 3) a better handle at evaluating its
CME programs since it enlarges the statistical sample 4) Younger
audience are generally more willing to articulated needs and discuss
deficiencies, which allows CME another window at identifying needs.
New York Methodist is part of the Cornell Health Network system. That
status has demonstrated certain qualities, skills and facilities as to upgrade
the whole institution evaluation of the importance of CME and its role in
improving outcome.
The participation and bridges that New York Methodist have adopted
consistently has helped to shape policies in the network it belongs to in
such a way as to enhance New York Methodist abilities to satisfy its own
mission. The close links between New York Methodist mission and that
present CME demonstrates clearly the positive impact of these links of the
CME Program.
The implementation of changes would impact CME as follows:
Update application form:
Benefit to CME:
i.
incorporate new accreditation standards
ii.
stress methods of identification of need
iii.
monitor planning program and its relevance to
identified needs
46
F.2.
F.3.
F.4.
G.
H.
iv.
identify various measures of program effectiveness
An end of program survey of attendees using a special survey tool benefit
to CME: Compare and contrast results of this monitoring tool with
cumulative results of analysis of evaluation form items.
Observing and documenting in real time, the rate of success of various
physicians in being recertified by their boards.
Benefit to CME: highlight the importance of linking programs to
performance results. Enhance the importance of
CME to physicians continued accreditation.
Strengthen the position of CME in hospital and medical staff organization
hierarchy.
Benefit to CME: Enhance the importance of CME mission and its
activities in the hospital. The increased visibility of CME will allow it to
be a first-hand member of the QI committee of the hospital. Presently, Dr.
Rafla is a member of the hospital QI committee by virtue of representation
of radiation oncology. We aim at making the director of CME an ex
officio member of this committee.
Present program was approved on a provisional basis about 2 years.
During this period, the following changes were made:
i.
Complete computerization of the program
developing a verified tool for evaluation, a program
to analyze the various components of evaluations, a
program to create an institution-wide analysis of
CME and its impact on physician improvements.
ii.
Changed the application from repeatedly as to
underline and highlight important items that must
be addressed.
iii.
For RSS, we were able to influence program design
as to address more clearly needs identified. That
step of change was achieved during the process of
program fleshing and finalization after the
preliminary site application. Many confidential
meets were held to verbalize this input.
iv.
We focused on monitoring the programs by
instituting the program of unannounced site visits,
site visit reports and early action on identified
deficiencies.
v.
We approached hospital administration and medical
staff organization to work towards change 4. As a
result of that, the electronic information board was
instituted in the doctors’ lounge.
New York Methodist Hospital organization is result oriented. The impact
of improvements described in G is to strengthen the CME program. A full
accreditation of the program with commendation is the most solid proof of
the worthiness of these changes.
47
Cost-benefit of the program is another measure used by hospital
management for evaluation of worthiness of the program.
Increased number of physicians who are recertified by their boards is a
credible measure of the success of the program.
Increased viability and virtuosity of the medical staff in improving patient
outcome, expending scopes of patient, adoption of new knowledge and
technology and growth of important patient care programs, are all
measures of worthiness of CME.
I.
During the last very few years and consistent with CME
accreditation, success of the following achieves were claimed by New
York Methodist organization:
i.
expansion of their cardiology program to include
cardiac physiology and all aspects of cardiac care
(linked to cardiology CME)
ii.
Expansion of neurology, neuro-oncology and neuroimaging (linked to neruo-oncology CME) The
stroke program was also a beneficiary of that.
iii.
Expansion of pain management (linked to Pain
Management CME program
Many other achievements in nursing, emergency medicine, pediatrics,
pulmonary medicine, onco-surgery are linked into the CME program and
the continuous vibrant development of its activities.
48
IX. Essential Area 3: Engagement with
the Environment (Criteria 16 – 22)
49
IX. Engagement with the Environment
A.
NEW YORK METHODIST HOSPITAL integrates CME into the process of
improving professional practice as follows:
2. Incorporating CME credits as an important component of the
reaccreditation of physician to practice in the hospital (Enclosure 4)
3. Each department has a standard of physicians attendance to
educational activities as part of the continuing system to upgrade and
improve medical practice (Enclosure 5)
4. As the hospital is moving towards comprehensive digital conversion of
record, activities are planned to enhance these skills, thus improving
indicated practice.
B.
The most important strategy pursued by NEW YORK METHODIST
recently to enhance change is the digitization of information that is now
implemented in radiation oncology, pharmacy, nursing and some aspects
of OR practice.
Hands on training is the method of choice. Enclosure 6 represents a
schedule of such training (Cerner schedule Enclosure 6). These skills are
now essential for practice improvement and it affords the physician access
to important up-to-date information. Hands on training is also the
preferred method for ACLS and BCLS. Enclosure 7 represent that
ongoing non-CME activity.
C.
D.
E.
NEW YORK METHODIST has also monitored non-CME activity skills,
targeting at improving documentation and enhancing quality of practice Enclosure 7 – Dr. Silver or Sherbell’s office
Along with other health providers, NEW YORK METHODIST has
identified several blocks to good patient care that is outside the power of
their content such as fragmentation of investigations and resultant waste in
necessary testing, problems of access related to present day third party
influence, indemnified cost of new and useful technologies. These and
other factors that surface through day-to-day practice are used to plan and
mount activities, some CME credentialed, such as courses, others became
the subject of talks during medical board and social meetings of the
medical staff.
Educational strategies are utilized by New York Methodist to address
barriers to physician changes even at its most basic level e.g legible
handwriting for which an activity was planned and carried out by office of
medical affairs.
NEW YORK METHODIST has positioned itself as a major campus for
several medical schools including
a. Cornell Medical School
b. St. George Medical School
c. Ross Medical School
50
d.
e.
f.
g.
h.
Memorial Sloan Kettering
Tulane and Temple Schools
New York College of Podiatric Medicine
Barry University
New York Institute of Technology
Through that influence, which starts in the formative years of these
physicians, NEW YORK METHODIST influences the scope and content
of educational intervention.
These teaching efforts are engaged and supported by the Office of Medical
Affairs, which is also responsible for the CME unit. (Enclosure 9)
F.
We have also demonstrated through the several organizational tables
submitted that these activities occupy a prominent role in hospital mission
and administrative structure. The latter is fully supported financially by
NEW YORK METHODIST funds.
CME unit is part of several multidisciplinary activities that enhance
physicians, knowledge and performance increasing the potential for
improving patient outcome.
The 2 most important multidisciplinary activities are:
1) Tumor Board (Physicians in following disciplines,
Oncosurgery, Oncology, Radiation Oncology, Radiology,
Social Services) attend. Board activities are CME
credentialed.
2) NeuroOncology (Physicians in neurology, neurosurgery,
radiation oncology pathology and rehab attend. Program
is CME credentialed.
3) Radiation Oncology/Rad/Path (Physicians in radiology,
pathology, radiation oncology) weekly meeting. It is
CME credentialed.
G.
All these conferences are also attended by audience approved by CME eg,
medical students, nurses, physician assistants and technologists.
New York Methodist organization has positioned itself strongly to
influence scope of content of educational intervention through the
following procedures and practices:
G.1
Board of Trustees Committee of Professional relations that
receives, reviews and approves minutes of all educational activities and
report to Board of Trustees.
G.2. Office Medical Education: Office is headed by Senior Vice
President to whom all departments report on medical education. CME is
part of this office.
51
G.3. Graduate Medical Education Committee: Chaired by the Senior
Vice President of Medical Affairs and attended by leads of all educator
leaders of the institute. CME director is a member of this committee.
G.4. Medical Education Committee of the Medical Boards, which
monitors all the physician medical education activities in the institute.
CME committee reports to this committee. Reports of this committee go
to Medical Board executive Committee and professional Relations
Committee of the Board of Trustees and Board of Trustees.
Through that comprehensive structure, the institute exercises significant
leadership in influencing content and conduct of all educational activities.
52
X. Administration
53
X.A.Organizational Structure:
 CME unit is part of Medical Affairs Office of NY Methodist Hospital. Office is
headed by Senior Vice Present, Stanley Sherbell, MD. The CME unit is headed
by Sameer Rafla, MD, PhD. The coordinator of CME unit is a full-tme staff
member chosen by the CME Director.
Office is responsible for all medical
education.
 The CME unit (Director) is chosen by Senior Vice President for Medical Affairs
in concurrence with the CME committee and the Medical Education Committee.
 CME Director and CME committee choose members of steering committee.
 CME Director runs CME office and its staff. Chairs and coordinates steering
committee activities. Conducts CME business. Coordinates application for
renewals and site visits. Responsible for all administrative steps of program.
Reports to Senior Vice President for Medical Affairs and interact with Medical
Education Committee.
 CME Committee meets every 3 months and receives reports from the director and
the steering committee. Upgrades all activities. Reviews budget and need.
Evaluates program progress.
 Director chairs CME committee. Committee reports to Senior Vice President for
Medical Affairs and Medical Education Committee of medical board which in
turns reports to the Executive Committee of the Medical Board and Medical Staff.
These reports are then submitted to hospital president and board of trustees.
54
X.B. Resources available to CME Unit:
CME Office:
Office is located in conjunction of the CME Director S. Rafla, MD, PhD
CME Computerization:
Day-to-day computer with adequate terminals and communication links
Eeds data system
Special computer for scanning and analyzing data
Financial Support:
All staff, computerization and coordinators are supported by New York Methodist
The program also receives support from the organization of the Hospital Medical
Staff (Medical Board)
X.C. Business and Management Component
All CME activities are managed by CME Director and coordinator and
responsible for all aspects of management of the unit including
securing accreditation and reaccreditation
reviewing programs and advising on preliminary applications
reviewing all proposed commercial support and advise on
appropriateness and data completion
receiving final applications, budgets, brochures
receiving all attendance computer records
receiving all evaluation forms and their computerization
generating necessary analysis and reports to various committees
and authorities
running all the business and meetings of the CME committee and
steering committee
obtaining physicians computer generated certificates of credits.
Answering the various queries and questions related to CME
activities
CME employees submit to NEW YORK METHODIST Human
Resources rules and regulations
55
Business and Management Practices
1.
2.
Employee issues: CME employees submit to all rules and regulations of Human
Resource of NY Methodist. Enclosure 48 is the Human Resource employee
manual of NY Methodist Hospital.
Copy of budget and final income and expenses summary for example CME
activity
Enclosure 34 is a copy of budget and final expenses of (Pediatric department).
i. Table of contents of Human Resources Employee Manual:
History of New York Methodist Hospital
Getting Started at New York Methodist Hospital
Pre-Employment Process, Monday Morning Welcome,
Identification Badge, New Employee Orientation,
Recording of Time Worked, Pay Day, Employment at
Will, Drug-Free Workplace, Physical Examination,
Evaluation Period
Employee Guidelines and Procedures
Personal Appearance, Confidentiality, Computer
Use, Gratuities, Soliciting, Telephones, Cell Phones,
Work Schedule, Overtime, Change in Status,
Employment of relatives, Reporting Absences From
Work, Performance Evaluation, Determination of
Salary, Transfers and Promotions, Equal Employment
Opportunity, Sexual Harassment, Accommodations
For Religious Practices, Accommodation for Disabled
Employees, Complaints of Discrimination or
Harassment, No Relation for Complaints of
Discrimination or Harassment, Staff Rights,
Employee Grievance Procedure, Resignations and
Terminations, Exit Interviews, Meal time, Breaks
Employee Benefits
Insurance Benefits, Other Benefits, Leave of Absence,
Paid Leave, Sick Leave, Workers’ Compensation,
Disability, Employee Assistance Program
Safety/Health/Conduct
Fire and Safety, Noise Level, Hazardous Materials,
Hospital Disaster and Incident Preparedness, Code
Pink, Infection Control, MRI safety, Smoking Policy,
Security, JCAHO National Patient Safety Goals,
Corporate Compliance, Prevention and Reporting
56
of Fraud and Abuse
Customer Service Standards
Six Customer Service Standards
Miscellaneous Information
Education and Training, NEW YORK METHODIST Federal Credit
Union, Gift Shop, Cafeteria, Pastoral Care,
Publications, Department of Education and
Volunteer Resources, Employment of relatives,
Theater Development Fund, Employee Discounts,
Service Awards, Blood Donation, Inspection of
Packages, Personal Mal, Employees on Hospital
Premises, Visiting Patients, Witnessing
Documents, Visitors
Our Credentials and Institutional Affiliations
Important Phone Numbers
Map
57
Business Practices
CME Budget:
Staff:
CME Director
S. Rafla, M. D., Ph.D., FACR, FRSM.
CME Coordinator
Ms. Jeanine Castellano
Voluntary Unpaid
$ 30,000.00 *
Computerization:
Hardware
Software
Supplies
$ 15,000.00
$ 7,000.00 *
As needed
Funds Supplied NY Methodist office of Medical Affairs
Other Income/Yearly: ♦
Contribution of Medical Board of NY Methodist
Departmental Contributions
* Hospital Budget supports these expenses
♦ All income is deposited in special fund at New York Methodist
58
$ 10,000.00
$ 4,000.00
MSSNY Policies
Accreditation Statement
The purpose of CME is to enhance the physician’s ability to care for patients. NY
Methodist Hospital is applying to be an accredited provider of CME
Standards
1. As an accredited provider NEW YORK METHODIST CME will be responsible
for assuring that the content and scientific integrity of all certified CME activities
are consistent with the mission of the program.
NEW YORK METHODIST CME program shall specifically be responsible for
assuring that:
1.1. Activities are scientifically vetted and valid, free of commercial bias and deal
with objective data and information.
1.2. Any commercial support shall not control the planning, content or execution of
the activity
1.3. The faculty shall control all contents of slides and reference material, which shall
not advance any specific proprietary interest.
1.4. No commercial support shall be allowed to dictate, directly or indirectly the
choice of the speakers, invitees, audience or content.
1.5. All information about the content of CME activity are the responsibility and
under the control of program committee. Dissemination of these brochures,
however, maybe assisted by outside sources (e.g. the Internet).
1.6. If an activity supported by commercial entity is scheduled as a repeated event,
each event will be considered individually and must meet the entire “essential”
requirement.
An example of accreditation statement follows:
The Medical Society of the State of New York (MSSNY) is accredited by the
Accreditation Council for CME to provide CME for physicians.
New York Methodist Hospital CME Program is accredited by the MSSNY to provide
CME for physicians.
New York Methodist Hospital CME Program designates this education activity titled
--------------------- for a maximum of ------------ category 1 credits towards the
American Medical Association Physician’s Recognition Award. Each physician
should claim only these credits that he/she spent in activity.
Disclaimer:
New York Methodist Hospital CME is committed to providing educational activities
that are objective, balanced and as free of bias as possible. All participating faculty
are expected to disclose to the audience, verbally or in writing, any commercial
relationships that might be perceived as a real or apparent conflict of interest related
to the content of their presentation, i.e. with companies whose product may be
referred to during the presentation.
59
Special Needs: In accordance with the American with Disabilities Act, NEW YORK
METHODIST-CME seeks to make this conference accessible to all. If you have a
disability which might requires special accommodations, please contact ……… or email your needs to:
Record Keeping











Application form for a program CME credits activities (enclosure 6).
Attendance record – electronically submitted.
Participant evaluation – paper and electronic participation evaluation (enclosure
10)
Letter of agreement – sample submitted (enclosure 17).
Program evaluation and score form (enclosure 11& 12).
Speaker disclosure form (enclosure 6)
Activity planner disclosure form (enclosure 7& 8).
Budget plan form for the activity (enclosure 7 & 8).
Commercial support disclosure form (signed by the company and program
director)(enclosure 18).
CME steering committee meeting minutes (enclosure 19).
CME committee meeting minutes (enclosure 20).
Educational Enduring Materials
All CME enduring materials including printed, recorded or computer assisted
instructional material shall constitute a planned activity of CME. The development and
utilization of these materials shall follow these guidelines:
1.
2.
3.
4.
All design and use of enduring materials shall comply with CME mission
statement.
Enduring materials shall be relevant to the needs of the target group and assuring
the satisfaction of activity objectives.
Each enduring material used shall have:
1. Stated Objective communicated to participants
2. Its detailed usage including, study time allocated, overall length of recorded
material and scientifically verified content.
3. Enduring material shall be evaluated at least once yearly to assure compliance
with developments in relevant science.
4. Findings from audience evaluations shall be used to upgrade the material
5. All enduring materials shall have the date of its origination as well as reviews
and updates.
All the caveats of development and usage of enduring materials applies to jointly
sponsored programs, with the CME program assuming responsibility for all steps
of planning (identification of needs, target audience, educational objectives),
content, selection of faculty and media as well as quality of production.
60
In addition marketing, dissemination and audience participation shall be part of
CME brief.
In Summary, Enduring materials shall communicate the following information to
participants:
1. Needs addressed.
2. Specific learning objectives.
3. Target audience.
4. Educational content.
5. Faculty and their credentials.
6. Media planned for use.
7. Audience participation methods.
8. Planned time of the program (equal to designated CME hours).
9. Dates of original release, review, and updates.
10. Evaluation methods.
61
X.G. Mechanism to Retain Activity Records
-
All activities records are held in the CME office controlled by
CME coordinator
CME activities attendance computerized records are held by Eeds
(Electronic Education Documentation System)
CME Evaluations forms are held in the CME Office controlled by
CME Coordinator
CME Evaluation computer scanner is kept in CME Office
Computerized CME evaluations and analysis are held by Scantron
62
Members of CME Committee
Name
1- Baccash,
Emil MD
FACP
2- Bharathan,
Thayyullathil
MD
Buckner,
3- Cary MD
Dept.,
Title
Contact Info.
Pulmonary Medicine
Present President of Medical
Staff and P.P.
Internal Medicine
Geriatric
Chief and director of geriatric
program and fellowship chair
medical education committee
Tel: (718) 780-5110
Fax: (718) 780-3222
Email: eiw9001@nyp.org
Tel:(718) 780-5255/50
Fax:(718) 780-3259
Email: thb9001@nyp.org
Neurology
Practicing Physician
Tel: (718) 246-8614/ Caroline 5490
Fax: (718) 246-8656
Practicing Physician &
Director of GYN., Oncology
Tel: (718) 780-3090
Fax: (718) 780-3271
Email: kae9001@nyp.org
Tel:(718) 780-5040 - Yesmine
Fax: (718) 780-3153
Email: thg9001@nyp.org
Tel:(718) 780-5870
Fax:(718) 780-3494
Email: cll9006@nyp.org
Tel:(718) 833-5273 (outside)
Email: poopamas@hotmail.com
Tel:(718) 780-3634
Fax:(718) 780-3673
Email: rnm9001@nyp.org
Tel:(718) 780-5260
Fax:(718) 780-3266
Email: prn9001@nyp.org
Tel: (718) 780-3677
Fax: (718) 780-3637
Email: srafla@verizon.net
4- Economos, GYN Oncology
Katherine
MD FACOG
5- Gaeta,
Emergency Medicine
Theodore
MD MPH
6- Lapidus,
Radiology
Claudia MD
7- Mascatello, Medicine
Antonio MD
8- Mir, Rabia
MD
Pathology
9- Narula,
Pediatrics
Pramod MD
10- Rafla,
Radiation Oncology
Sameer MD
Practicing Physician and
Chairman research committee
Radiologist
Practicing Physician
Practicing physician and
Past President of Medical Staff
Pathologist,
Practicing Physician
Chairman and
Practicing Physician
Chairman and
Practicing Physician
Rucinski,
James, MD
General Surgery
Deputy program director for
Program of Surgery and P.P.
Tel: (718) 780-3288
Fax: (718) 780-3154
Email: jrucinski@pol.net
12- Salama,
Pulmonary Medicine
Practicing Physician
Tel:
SalamaMD
Fax: (718) 621-7103
Email: None (outside)
13- Salgado,
Neurology
Practicing Physician and
Tel: (718) 246-8614
Miran MD
Chair of Neurological Sciences
Fax: (718) 246-8656
Email: miranws@aol.com
14- Sherbell,
Pulmonary Medicine
Executive V.P. for Medical Affairs Tel: (718) 780-3284
Stanley MD
Fax: (718) 780-3287
Email: sts9006@nyp.org
15- Schifter,
Int., Medicine Cardiology Cardiology, Past President,
Tel: (718) 499-5300 (outside)
David MD
Medical Board, Practicing Physician Fax: (718) 499-6161
Email: does not have
63
16- Simon, Todd Internal Medicine
MD
Vice Chairman Dept., of Medicine
17- Vardi, Joseph OB/GYN
MD
Practicing Physician
18- Yarmush,
Joel MD
Vice Chairman and
Anesthesiology
19- Zonenshayn, Neuro-surgery
Martin MD
Practicing Physician
Practicing Physician
Tel: (718) 780-5251
Fax: (718) 780-3259
Email: tos9017@nyp.org
Tel: (718) 871-3737
Fax: (718) 871-4595
Email: call Annete
Tel: {718) 780-3279
Fax: (718) 780-3281
Email: jmy@aol.com
Tel: (718) 246-8610
Fax:(718) 246-8611
Email: maz9001@med.cornell.edu
Committee is Chaired by Sameer Rafla, MD, PhD, CME Program Director.
Committee minutes become part of Medical Education Committee Minutes → Board of
Trustees after Executive Committee reviews
CME Steering Committee Members:
Sameer Rafla, MD. PhD
Chairman Emeritus, Radiation Oncology
Director, CME Program
Stanley Sherbell, MD
Executive Vice President for Medical Affairs
Thayyullathil Bharathan, MD
Vice Chairman Department of Medicine
Associate Program Director
Todd Simon, MD
Vice Chairman Department of Medicine
Associate Program Director
Antonio Mascatello, MD
Internist, Department of Medicine
64
ENCLOSURES
1. Samples of QI meetings, incident meetings and hospital QI meetings
2. Awaiting response from Dr. Silber – organized educational effort
3. Mammosite meeting minutes
4. Guidelines for credentialing and recredentialing (Dr. Sherbell’s Office) Pending
5. Guidelines from department of surgery about attendance of surgeons of department
educational meetings (Tortalani’s Office) Pending
6. List of CERNER training session Pending
7. Handwriting skills course
8. ACLS & BCLS Pending
9. List of medical schools whose students are accepted at New York Methodist
10. A sample of minutes of planning committee with highlighted name of CME
Committee Member
11. Sample of an application form, activity agreement, disclosure forms, financial
agreement forms, budget, etc.
12. Evaluation Form and items of CME it addresses
13. Analysis of Evaluation
14. Site visitor Monitor Form
15. Letter to Anesthesiology
16. M&M of Surgery
17. RT Guest Speaker Program
18. Learner Change Data
19. Pre/Post Test reflecting learner change data
20. An analysis of evaluations/20B. detailed analysis of programs
21. QI Committee report as example
22. Minutes of planning committee – Radiation Oncology
23. Radiation Therapy Resident Symposium
24. Surgery Resident Symposium (Grand Rounds)
25. Monitoring of Radiation Therapy
26. Monitoring of Surgery
27. Resident Symposium Radiation Oncology
28. Retreat of Radiation Oncology Minutes
29. Standing guidelines for commercial support
30. Disclosure Form
31. Guidelines for refusal and conflict of interest
32. Disclosure statements to audience
33. Evidence of hospital knowledge and control of financial support
34. Final budget of two examples
35. Brochures of two programs to show minimal planned social events
36. Examples of written agreement
37. Handouts of two resident symposium from Radiotherapy
38. Letter of agreement with program directors to show that there is no Conflict of
Interest
39. Sickle cell brochure with CME members clearly displayed
40. The final statistical report of evaluation
41. Evaluation form
65
42. Picture of the eeds system
43. Report of site visitors to Radiation Oncology and Surgery
44. Balance sheet (Final activity budget – RSS and single event conferences)
45. Steering Committee Minutes including CME Mission Statement review
46. Activity List
47. Policy and Procedures of CME
Hum
Name of Activity
Date and Time
Location of Activity
Speaker/Program Director Name and Title
Objectives:



Accreditation Statement
New York Methodist Hospital is accredited by the Medical Society of the State of New York to provide
continuing medical education for physicians
New York Methodist Hospital designates this educational activity for a maximum of XX AMA PRA
Category 1 Credit (s) ™. Physician should claim credit commensurate with the extent of their
participation in the activity.
Disclosure Statement
Policies and standards of the Medical Society of the State of New York and the
Accreditation Council for Continuing Medical Education require that speakers and
planners for continuing medical education activities disclose any relevant financial
66
relationships they may have with commercial interests whose products, devices or
services may be discussed in the content of a CME activity.
Please choose one
 The following speakers and planners have no relevant financial relationships to disclose:
(insert names of speakers and planners)
 The following speakers and planners asked us to disclose information about their financial
relationships:
(insert names of speakers and planners along with the name of the commercial interest(s) and the
nature of the relationship(s)
67