CME Planning/Application Form
Office of Continuing Medical Education
3560 Business Drive, Suite 130, Sacramento, CA 95820
Phone: (916) 734-5390 Fax: (916) 734-0776
This form collects information needed to plan and develop a CME activity that improves patient care and meets
accreditation requirements. Completed forms and attachments are required six months before the proposed activity date.
CME Planning Form Guidelines are provided to answer common questions. CME staff is available to assist you as needed.
SECTION 1 OF 4: ACTIVITY DESCRIPTION
TITLE:
PROPOSED DATE(S):
NOTE: Dates cannot be confirmed until activity is approved by CME Advisory Committee
ACTIVITY TYPE
Select one appropriate format for a live activity, an enduring material, or one of the other activity types listed below.
LIVE ACTIVITY
If live activity will be recorded and released as an enduring
Course with Full Service
material with CME credit, complete the following:
Course with Credit Only
Format:
Internet
CD-ROM
Print
Other:
Live Internet Webinar
Anticipated release date:
Regularly Scheduled Series (RSS addendum required)
Recording to be done by:
Department
Contracted Service:
ENDURING MATERIAL
ADDITIONAL ACTIVITY TYPES
Internet
Journal-based CME
CD-ROM
Test-item Writing
Print
Manuscript Review
Other:
Performance Improvement (PI)
Internet Point-of-Care
Rationale for selecting activity type:
EDUCATIONAL DESIGN/METHODOLOGY
Check all that apply (at least one in each category) and provide rationale for methods and processes
METHODS TO ENGAGE LEARNERS
RATIONALE
Case studies
Audience response system
Panel discussion with Q&A
Debate
Hands-on lab sessions
Simulation
Small work groups
Other:
TAKE-HOME TOOLS TO REINFORCE LEARNING
RATIONALE
Algorithms
Patient educational material
Pocket card guidelines
Other:
SPONSORSHIP
NOTE: Pharmaceutical companies or medical device manufacturers are not sponsors
Direct: OCME and UCD department/division and, if applicable, an outside accredited entity involved in planning
Joint: OCME and UCD department/division and non-UCD, non-accredited provider involved in planning
Identify joint sponsor(s):
COLLABORATION
Collaborators are groups with special expertise in subject matter or influence over target learners. Indicate below if you intend to
collaborate with others to develop the activity; i.e. QI department, medical specialty societies, patient advocacy groups, etc.
Collaborator:
How this collaboration will enhance the activity’s results:
Page | 1
S:\CHT\Cme\FORMS\Forms - ACCRED/CME_Planning_Form_rev_Apr16_2012_FINAL1.doc
COMMERCIAL SUPPORT
Activity directors agree to develop this activity independent of commercial interests and according to accreditation requirements.
All commercial support is managed appropriately by the OCME. Letters of agreement for educational grants must be signed by the
OCME representative. The OCME maintains separation of promotion from education, and exhibit fees are also managed by OCME.
No
Yes Are you partnering with for-profit organizations (commercial interests)?
If yes, identify:
SECTION 2 OF 4: LEADERSHIP AND ADMINISTRATIVE STAFF SUPPORT
ACTIVITY DIRECTOR
Physician or base scientist who has overall responsibility to plan, develop, implement, and evaluate content and logistics.
Name/Degrees:
Title:
Department:
Division:
Address:
Phone:
Fax:
Email:
Administrative Contact:
Phone:
Email:
ACTIVITY CO-DIRECTOR (optional)
Individual who shares responsibility to plan the activity.
Name/Degrees:
Department:
Address:
Phone:
Title:
Division:
Fax:
Email:
ADMINISTRATIVE COORDINATOR/CME ASSOCIATE (required for RSS and credit only activities)
Individual responsible for operational and administrative support of the activity (i.e. staff assistant in director’s department)
Name/Degrees:
Title:
Department:
Division:
Address:
Phone:
Fax:
Email:
SECTION 3 OF 4: PLANNING
PLANNING COMMITTEE (optional) (identification of others responsible for designing and implementing the activity)
Name/Degrees:
Title:
UCD Employee
No
Yes
Institution/Department/Division:
Email:
Name/Degrees:
Title:
UCD Employee
No
Yes
Institution/Department/Division:
Email:
TARGET AUDIENCE: Check all that apply
Geographic Location
Provider Type
Internal only
Primary care physicians
Local/Regional
Specialty physicians
National
Pharmacists
International
Psychologists
Physician assistants
Nurses
Nurse Practitioners
Other (specify):
Page | 2
Specialty
All specialties
Oncology
Anesthesiology
Orthopaedics
Cardiology
Pediatrics
Dermatology
Psychiatry
Emergency Medicine
Radiology
Family Medicine
Radiation Oncology
General Medicine
Surgery
Neurology
Other (specify):
OB/GYN
S:\CHT\Cme\FORMS\Forms - ACCRED/CME_Planning_Form_rev_Apr16_2012_FINAL1.doc
CREDIT DESIGNATIONS
Credit statements are provided as appropriate for the target audience. Note: Only AMA/PRA Category 1 applicable for RSS
American Medical Association AMA/PRA Category 1 CreditsTM
American Academy of Family Physicians (AAFP): AAFP member must be involved with planning activity
Accreditation Council for Pharmacy Education (ACPE): Pharmacist must be involved with planning activity
California Board of Behavioral Science (BBS): LCSW/MFT
Other (specify):
SCOPE OF PRACTICE
Activity is related to what learners actually do in their
professional practices.
If this is an interprofessional audience, what are the
differences in the various groups targeted and how will content
reflect this distinction?
If the activity will relate to various regional audiences with
different demographics, how will you account for this in the
content?
Has the relevant specialty board/society developed a scope
of practice that sets a new standard? If so, will content reflect
the potential scope of practice?
Are there relevant national guidelines that address quality
and patient safety gaps that also re-set the scope of practice for
these learners to a higher level? If so, how will content address
those quality/safety gaps?
Other (specify):
CONTENT THAT MATCHES SCOPE OF PRACTICE
QUALITY IMPROVEMENT
CME providers focus on contributing to healthcare quality improvement. Identify connections you have made and the contribution
this activity will make.
CONTRIBUTIONS ACTIVITY WILL MAKE TO QI/PATIENT SAFETY
QUALITY CONNECTIONS MADE
Hospital QI Department
Risk Management
Sentinel Events/Root
Specialty Society Quality
Causes Analysis
Goals
Managed Care HEDIS Data
Insurance Company
Reports/Analyses
Reports
Other (specify):
Page | 3
S:\CHT\Cme\FORMS\Forms - ACCRED/CME_Planning_Form_rev_Apr16_2012_FINAL1.doc
SECTION 4 of 4: NEEDS ASSESSMENT AND EDUCATIONAL DESIGN
First identify current practices of the target audience, and then state best practices to be achieved through the activity. The
difference (gap) between current and best practices identifies the educational need of the target audience and determines if the
learners lack knowledge (awareness), competence (knowing how to do it), or performance (doing it). Learning objectives use action
verbs specific to knowledge, competence, and/or performance. Learning objectives are needed for each gap, not for each lecture.
Attach needs assessment documentation to support current and best practices (required).
EXAMPLE
EXAMPLE
EXAMPLE
EXAMPLE
EXAMPLE
Educational Need
This Identifies a
Learning Objective
Current Practice
Best Practice
of Target Audience
Gap in
(what learner will do in practice)
HIV providers and patients Healthcare
HIV providers need
Identify current guidelines in order to
Knowledge
are faced with a
professionals are able
educational
Competence provide optimal care to women with HIV.
constantly evolving
to address constantly
initiatives related to
Performance
standard of care. This
poses a challenge for
assuring that HIV
treatment is consistent
with current guidelines.
evolving standards to
ensure consistent
application of current
and new HIV treatment
guidelines in practice.
current HIV
treatment guidelines.
This Identifies a
Gap in
Knowledge
Competence
Performance
Source Documentation (i.e. peer review journal article, society guidelines):
Current Practice
Best Practice
Educational Need
of Target Audience
Learning Objective
(what learner will do in practice)
Knowledge
Competence
Performance
Source Documentation (i.e. peer review journal article, society guidelines):
Knowledge
Competence
Performance
Source Documentation (i.e. peer review journal article, society guidelines):
Knowledge
Competence
Performance
Source Documentation (i.e. peer review journal article, society guidelines):
Knowledge
Competence
Performance
Source Documentation (i.e. peer review journal article, society guidelines):
Knowledge
Competence
Performance
Source Documentation (i.e. peer review journal article, society guidelines):
Knowledge
Competence
Performance
Source Documentation (i.e. peer review journal article, society guidelines):
Page | 4
S:\CHT\Cme\FORMS\Forms - ACCRED/CME_Planning_Form_rev_Apr16_2012_FINAL1.doc
Page | 5
S:\CHT\Cme\FORMS\Forms - ACCRED/CME_Planning_Form_rev_Apr16_2012_FINAL1.doc
DESIRABLE PHYSICIAN ATTRIBUTES/CORE COMPETENCIES
CME activities are developed in the context of desirable physician attributes. Check below to identify American Board of Medical
Specialties (ABMS)/Accreditation Council for Graduate Medical Education (ACGME) or Institute of Medicine (IOM) core
competencies to be addressed in this activity. Briefly describe activity content related to competencies identified.
COMPETENCY
CONTENT (e.g. lecture title; new medication, diagnostic tool, or standards)
Provide patient care or patient-centered care
Medical knowledge
Practice-based learning and improvement
Interpersonal and communication skills
Professionalism
System-based practice
Work in interdisciplinary teams
Apply quality improvement
Utilize informatics
Employ evidence-based practice
EVALUATION AND OUTCOMES MEASUREMENT
How will you measure if changes occur in competence, performance, and/or patient outcomes? Check all that apply and indicate
the overall outcome measurement.
COMPETENCE
Evaluation form for participants (required)
Physician and/or patient surveys
Audience response system (ARS)
Evaluation summary of change in practice comments
Customized pre- and post-test
Other (specify):
PERFORMANCE
Adherence to guidelines
Chart audits
Case-based studies
Direct observations
Customized follow-up survey/interview/focus group
Follow-up email with survey respondents planning to make changes
about actual change in practice at specified intervals
in practice
Other (specify):
PATIENT OUTCOMES
Observed changes in health status measures
Obtain patient feedback and surveys
Observe changes in quality/cost of care
Other (specify):
Measure mortality and morbidity rates
OVERALL, THIS ACTIVITY OUTCOME MEASURES:
Competence and/or
Performance and/or
Patient Outcomes
ALIGNMENT WITH UCDHS CME MISSION STATEMENT
CME activities are designed to change competence and/or performance and/or patient outcomes as described in the mission
statement. This activity is designed to: (check all that apply)
Assist physicians and healthcare professionals gain competency and improve performance in order to become better able to
provide quality care to enhance the health status of the population
Address professional practice gaps of identified specialties and/or the interprofessional health care team as appropriate for the
scope of practice
Assist in the dissemination of new medical knowledge
Promote the practice of evidence-based medicine
Collaborate with like-minded organizations in the planning process
Other (specify):
Page | 6
S:\CHT\Cme\FORMS\Forms - ACCRED/CME_Planning_Form_rev_Apr16_2012_FINAL1.doc
CULTURAL AND LINGUISTIC COMPETENCY
Select one or more areas of emphasis you will implement to address this competency as required by California Business and
Professions Code, Section 2190.1.
Apply linguistic skills to communicate effectively with
Incorporate translation resources and/or integrate relevant
target population
strategies into course materials
Use cultural information to establish therapeutic
Incorporate review and explanation of relevant regulations
relationships
regarding linguistic access
Elicit and incorporate pertinent cultural data in diagnosis
Other (specify):
and treatment
Understand and apply cultural and ethnic data to the
Not applicable to activity content (if checked, please explain):
process of clinical care
PAIN MANAGEMENT
Select one or more areas of emphasis you will implement to address this competency as required by California Business and
Professions Code, Section 2190.5.
N/A to activity content
Pain management
Care of terminally ill and dying patients
GERIATRIC CARE
Select one or more areas of emphasis you will implement to address this competency as required by California Business and
Professions Code, Section 2190.3.
Geriatric medicine
Care of elderly patients
N/A to activity content
IDENTIFIED BARRIERS AND STRATEGIES TO BE ADDRESSED
What potential barriers do you anticipate attendees may have in incorporating new knowledge, competency, and/or performance
objectives into practice? Select all that apply by checking below.
Lack of time to assess or counsel patients
Lack of consensus on professional guidelines
Lack of administrative support/resources
Cost
Insurance/reimbursement issues
No perceived barriers
Patient compliance issues
Other (specify):
Describe how you will attempt to address these identified barriers in the activity:
COURSE DESCRIPTION
Provide a 4-5 sentence paragraph that describes why the learner should attend this activity.
If available at this time, attach the activity outline developed as a result of this planning.
This completes the CME planning process. Thank you!
The CME Advisory Committee approves all requests,
and course chairs are notified after the committee review.
Page | 7
S:\CHT\Cme\FORMS\Forms - ACCRED/CME_Planning_Form_rev_Apr16_2012_FINAL1.doc
REGULARLY SCHEDULED SERIES (RSS) ADDENDUM
RSS are defined by the ACCME as live activities that are:
 Planned by and presented to the accredited organization’s intradisciplinary professional staff
 Offered with multiple sessions that are scheduled on a regular basis (e.g. weekly, monthly, quarterly)
 Scheduled for a minimum of 1 hour and maximum of 4 hours per session
 Offered no less than quarterly or no more than weekly
RSS accredited by UCDHS must be:
 Directed by a UC Davis faculty course chair
 Held on the UC Davis Health System campus
 Supported by a trained RSS coordinator for the department
FORMAT
Grand Rounds/Lecture Series
Journal Club
Case Conference
Mortality/Morbidity Conference
Tumor Board
SCHEDULE
One per week on
Mon Tue
Wed
Thu
Fri
Two per month (e.g. 2nd and 4th Wed) on
One per month (e.g. 4th Thu) on
One per quarter on
Other:
RSS activity location:
RSS previously approved?
No
Yes
If yes, previous course code:
Start time:
End time:
TELECONFERENCE SITES
Will sessions be teleconferenced to other sites?
No
Yes If yes, provide information below for each telesite. A trained site coordinator is required for each telesite.
Telesite Location:
Telesite Location:
Address:
Address:
Site Coordinator:
Site Coordinator:
Phone:
Fax:
Phone:
Fax:
Email:
Email:
Telesite Location:
Telesite Location:
Address:
Address:
Site Coordinator:
Site Coordinator:
Phone:
Fax:
Phone:
Fax:
Email:
Email:
Telesite Location:
Telesite Location:
Address:
Address:
Site Coordinator:
Site Coordinator:
Phone:
Fax:
Phone:
Fax:
Email:
Email:
Telesite Location:
Telesite Location:
Address:
Address:
Site Coordinator:
Site Coordinator:
Phone:
Fax:
Phone:
Fax:
Email:
Email:
Page | 8
S:\CHT\Cme\FORMS\Forms - ACCRED/CME_Planning_Form_rev_Apr16_2012_FINAL1.doc