Texas Children's Hospital



Each speaker must complete one form for each presentation within the activity. Failure to submit this form prior to the start of the activity will prohibit the ability to award credit for the presentation.

Speaker Instructions:

1. Complete pages 1 and 2.

2. The following items must be submitted with this form if a relevant financial relationship is noted on your Addendum A: Conflict of Interest Disclosure:

a. Your preliminary presentation (slides, abstract, outline, summary, or other) and applicable handouts

b. A current copy of your CV/bio

3. You may refer to Addendum D: Guidance for Preparing CME Content for assistance with presentation material. (If you are not able to access the CME Connect page, contact the CME office for assistance at cme@)

4. Submit completed form to the Activity Coordinator or Director (with applicable attachments) for review.

|Title of Activity: |Texas Children's Hospital Advanced Practice Provider Conference |

|Title of Session: |      |

|Speaker Name: |      |

|Organization: |      |

|Title or Position: |      |

|Phone: |      |Fax: |      |

|Email: |      |

What educational methods (other than lecture) will be incorporated into your presentation to enhance this educational offering?

| |None |

| |Audience Response (interactive surveying of the audience for immediate results) |

| |Brainstorming session(s) |

| |Games |

| |Group discussion |

| |Panel discussion |

| |Patient Simulation |

| |Problem solving |

| |Role modeling/mentoring |

| |Role play |

| |Other (describe below): |

| |      |

What do you intend to change as a result of this presentation (check all that apply)?

| |Knowledge – lack of understanding |

| |Competence – inability to apply strategy |

| |Performance – sub-optimal behavior |

Will you measure outcomes in clinical practice as a result of this specific presentation? (Please note that you are NOT required to perform additional outcomes measurement unless required by the Activity Director.) Check all that apply.

| |No, I do NOT intend to further evaluate outcomes as a result of this presentation. |

| |Yes - I will administer an evaluation form to the participants that is specific to my presentation.* |

| |Yes - I will administer a Pre and Post-test to measure changes in knowledge, skills and/or |

| |attitudes.* |

| |Yes - I will conduct a 3-6 month follow-up survey of participants to measure application of |

| |knowledge/skills.* |

| |Yes - I will conduct an assessment of health status data of patients in practice of participants.* |

| |Yes - Other (specify below)*: |

| |      |

*You will be asked to provide documentation supporting this option.

PRESENTATION OBJECTIVES

All speakers are required to create objectives that are measurable and describe a potential impact on physician competence, performance and/or patient outcomes. List goals that you would like for the participants to be able to do as a result of participating in your presentation. Next, tie each goal to a competency number on page 3 of this document. Indicate the corresponding competency number next to each objective.

A list of behavioral verbs appropriate for writing learning objectives can be found on page 5 of this packet.

AVOID using the following words when creating cognitive objectives:

|Know |Really know |Understand |Appreciate |Become |

|Learn |Thinks critically |Approach |Improve |Grow |

|Increase |Expand horizons |Grasp the significance of | | |

YOUR OBJECTIVES SHOULD BE WRITTEN TO COMPLETE THIS SENTENCE: Following the conclusion of this activity, participants will be better able to…

| |Objectives (create a minimum of 2) | |Competency Numbers |

| | | |(refer to page 4) |

|1 |      | |     |

|2 |      | |      |

|3 |      | |      |

|4 |      | |      |

|5 |      | |      |

Submit your completed document to the Activity Coordinator or Director for review.

Institute of Medicine Core Competencies

|1 |Provide patient-centered care – identify, respect, and care about patients’ differences, values, preferences, and expressed needs; |

| |relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educated patients; share |

| |decision making and management; and continuously advocate disease prevention, wellness, and promotion of health lifestyles, |

| |including a focus on population health |

|2 |Work in interdisciplinary teams – cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous|

| |and reliable |

|3 |Employ evidence-based practice – integrate best research with clinical expertise and patient values for optimum care, and |

| |participate in learning and research activities to the extent feasible |

|4 |Apply quality improvement – identify errors and hazards in care; understand and implement basic safety design principles, such as |

| |standardization and simplification; continually understand and measure quality of care in terms of structure, process, and outcomes |

| |in relation to patient and community needs; and design and test interventions to change processes and systems of care, with the |

| |objective of improving quality |

|5 |Utilize informatics – communicate, manage, knowledge, mitigate error, and support decision making using information technology |

ABMS/ACGME Competencies

|6 |Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health |

|7 |Medical knowledge about established and evolving biomedical, clinical, and cognate (e.g., epidemiological and social-behavioral) |

| |sciences and the application of this knowledge to patient care |

|8 |Practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and |

| |assimilation of scientific evidence, and improvements in patient care |

|9 |Interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and |

| |other health professional |

|10 |Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, |

| |and sensitivity to a diverse patient population |

|11 |Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and |

| |system for health care and the ability to effectively call on system resources to provide care that is of optimal value. |

AAMC Competencies

|12 |Evidence of professional standing, such as an unrestricted license, a license that has no limitations on the practice of medicine |

| |and surgery in that jurisdiction. |

|13 |Evidence of a commitment to lifelong learning and involvement in a periodic self-assessment process to guide continuing learning. |

|14 |Evidence of cognitive expertise based on performance on an examination. That exam should be secure, reliable and valid. It must |

| |contain questions on fundamental knowledge, up-to-date practice- related knowledge, and other issues such as ethics and |

| |professionalism. |

|15 |Evidence of evaluation of performance in practice, including the medical care provided for common/major health problems (e.g., |

| |asthma, diabetes, heart disease, hernia, hip surgery) and physicians behaviors, such as communication and professionalism, as they |

| |relate to patient care. |

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