Southern Kentucky AHEC



Activity Proposal

To fulfill the requirements of the Kentucky Medical Association (KMA), the following information is necessary to be eligible for AMA PRA Category 1 credit. The Southern Kentucky Area Health Education (AHEC) will have the final decision regarding activity content, design and faculty selection.

The activity planner(s) have ensured that all decisions in the approval of this activity have been made free of the influence/control of any commercial interest. These decisions include: Identification of needs; determination of educational objectives; content; speakers; and format and evaluation of the activity.

___ YES ___ NO ___ INITIAL _______ DATE

Planning Form Must Be Completed for Approval

***Please fill out all sections highlighted in orange. ***

ORGANIZATION INFORMATION

|Date Submitted: | |

|Organization Name: | |

|Address: | |

|City: | |State: | |Zip: | |

|Phone: | |Fax: | |

Email: ______________________________ Tax ID: _______________________________________

Contact: ____________________________________________________________________________

Mission Statement

Include mission, values, goals and/or other relevant information about the organization.

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ACTIVITY INFORMATION

Has planning for the activity begun? Yes No

If yes, explain the extent of the planning:

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|Proposed Activity Title/Topic: | |

|Activity Director: | |

|Planning Committee: | |

| |(you must provide a signed disclosure for each planning |

| |committee member) |

|Activity Date(s): | | Location(s): | |

|Expected # of Participants: | |Expected # of Faculty: | |

|Number of Category 1 Credits Requested: _____ |

|The Southern AHEC reserves the right to deny credit for any activity that does not comply with KMA/ACCME guidelines. |

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|ACTIVITY FORMATS (Select all that apply) |

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PROFESSIONAL PRACTICE GAP

This educational activity intends to address the professional practice gap by changing the learners’:

(Select all that apply)

|___ Competence – Knowing (knowledge( and having the ability to do it) |

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|State the Competence need(s) (max 50 words): ______________________________________________ |

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|____________________________________________________________________________________ |

|___ Performance – Doing it |

|State the Competence need(s) (max 50 words): ______________________________________________ |

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|____________________________________________________________________________________ |

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|___ Patient Outcomes – The result of competence and performance |

|State the Competence need(s) (max 50 words): ______________________________________________ |

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|____________________________________________________________________________________ |

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|Expert Identified Needs |Participant Needs |

|ABMS MOC criteria |Needs assessment survey |

|XXXXX Clinical expert/Faculty opinion |New medical equipment |

|Committee identified gap |New technology |

|XXXXX Literature review |Patient problem inventories |

|XXXXX Peer-reviewed literature |Peer review/Focus group |

|Research findings |Physician group/Affiliated entity request |

|School of Medicine Department |Previous evaluation summary: |

|State licensure requirement |Other: __________________________ |

|Other: ___________________ | |

| |Environmental |

|Observed Needs/Outcomes |Competitive trend |

|Admission/Discharge diagnosis data |Direct – to – consumer ads |

|Adverse drug effects |Internet search |

|Clinical guidelines (AHRQ, ASCO, FDA, NIH) |Laws/Regulations |

|Epidemiological data |Lay press/News Media |

|Hospital, Practice, or System PI/QI data analyses |Local, Regional or National website |

|Morality/Morbidity data |Public health organizations |

|Patient Satisfaction surveys |Societal trends |

|Pre-test/Post-test data |Other: ___________________________ |

|Referral diagnosis data | |

|Other: _____________________ | |

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Desirable Physician Attributes (Select all that apply)

|ACGME/ABMS Competencies |Institute of Medicine Competencies |Interprofessional Education |

| | |Collaborative Competencies |

|Patient Care and Procedural Skills | Provide Patient-centered Care |Values/Ethics for Interprofessional Practice |

|Medical Knowledge | Work in Interdisciplinary Teams |Roles/Responsibilities |

|Practice-based Learning and Improvement | Employ Evidence-based Practice |Interprofessional Communication |

|Interpersonal and Communication Skills | Apply Quality Improvement |Teams and Teamwork |

|Professionalism | Utilize Informatics | |

|Systems-based Practice | | |

Other Competency(ies) (specify):      

Support your response by including current documentation explaining the need for this continuing education activity from journals, newsletters, NIH, CDC, newspapers, patient data, questionnaires, past activity evaluation summaries, new technology, and/or meeting minutes/notes.

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Include Supporting Data with application. Approval will not be issued without data.

TARGET AUDIENCE

Specifically, which healthcare professionals comprise the target audience affected by this practice gap? Include specialty areas.

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EXPECTED OUTCOMES

What are the expected outcomes (what is currently being achieved and what could be achieved). As a result of this activity, what do you expect participants to do differently (change) to improve their practice?

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LEARNING OBJECTIVES

List the learning objectives for this activity that will enable the audience members to improve their knowledge and/or skills from the current practice gap to the expected outcomes.

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Explain how and why speakers are selected and by whom:

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AGENDA & Speakers

Based on the proposed learning objectives, develop an agenda that will enable participants to progress from the current practice gap to the expected outcomes that will enable them to improve their practice.

|Time |Topic |Faculty |

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Speaker and plannerinformation

Fill out the form below for each speaker and planning committee member.

|Name of individual |Individual’s role in activity |Name of commercial interest |Nature of relationship |

|Example: Jane Smythe, MD |Planner |None |--- |

|Example: Thomas Jones |Speaker |Pharma Co. US |Salary |

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|CREDIT(S) REQUESTED (Select all that apply) |Requested Hours: |

|AMA PRA Category 1 (CME) | |

|Pharmacy (Kentucky) | |

|Nursing | |

|Dentistry | |

|Respiratory (KBRC) ( AARC) | |

|Radiology | |

|Dietary | |

|OT/PT | |

|Other: (please specify)_______________________________ | |

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FINANCIAL ANALYSIS

____ I understand that I must provide the Southern KY AHEC with a detailed list of income and

expenses of the activity.

| |Support Expected |

|Grants non-pharmaceutical |$ |

|Registration Fees |$ |

|Exhibit/Vendor Fees |$ |

|Sponsorship |$ |

|Organization Support/Funds (In-Kind Contributions) |$ |

|Commercial Interest/Pharmaceutical (see below) | |

|List Company(s) | |

| |$ |

Commercial Support/Pharmaceutical

Commercial support is financial, or in-kind, contributions given by a commercial interest, which is used to pay all or part of the costs of a CME activity. A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

Please list proposed commercial supporters and estimated grant amounts:

Do you have any financial relationships with the proposed commercial supporters other than unrestricted educational grants for continuing education activities? Yes No

If yes, please explain:

list proposed commercial supporters and estimated grant amounts:

List some barriers outside your control that might impact patient outcomes.

|Barrier(s) to Physician Implementation of Best or Evidence-based Practice |

|What potential barriers do you anticipate participants may encounter in incorporating the new knowledge, competency, performance and/or |

|skill(s) into practice. |

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|Select all that apply: |

|___ Disparity issues ___ Expense/Costs ___ Lack of proper resources |

|___ Lack of time to assess or counsel patients ___ No perceived barriers ___ No professional consensus |

|___ Reimbursement ___ Other: ________________________________ |

|How will this education program address the identified barrier(s)? |

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|Non-Educational Strategies to Enhance Change |

|What “non-educational” strategies will you use to enhance change as an adjunct to this activity? [ACCME Criterion 17] |

|Physician-related Strategies to Enhance Change: | Patient-related Strategies to Enhance Change: |

|Algorithms/Care maps/Order sets with specific care parameters developed |Community education/Community screening/informational |

|Chart stickers related to content |brochures |

|Committee task force efforts/SWOT analysis |Newsletter/Diagrams/Feedback data |

|Computer pop-ups/Decision support reminders |Patient education materials/patient information packets |

|E-mail reminders after the event |Patient reminders/Call-back systems |

|Follow-up survey to assess change |Patient satisfaction surveys |

|Hospital and/or System policy/Process changes made |Staff meeting reminders |

|Peer Review/Peer-to-peer feedback |Other: _____________________ |

|Screening and/or Assessment tools developed | |

|Other: ____________________________________ |No non-educational strategies will be used |

|Methods of disclosure and identification /resolution |All faculty and planners will complete disclosures prior to activity. |

|of potential or actual conflicts will be completed. |Disclosure results will be included in marketing brochure |

| |Disclosure results will be displayed prior to the activity |

| |Moderator will make reference to the written disclosures |

CHECKLIST (All items needed before approval will be considered)

Provide a copy of your brochure/advertisement. Brochure/Agenda/Advertisement MUST include the following (check when completed):

( Disclosure of relevant financial relationships of speakers

( Target Audience

(List of all speakers

( Activity objectives

( Accreditation Statements for all applied credits

( Acknowledgement of Commercial Support (if applicable) NO LOGOS

Attach the following information for each speaker:

( Signed Disclosures for ALL SPEAKERS

( Biography or CV for ALL SPEAKERS

Attach the following information:

( Activity Director’s credentials and signed Disclosure of Financial Interest form

( Planning Committee members’ credentials and signed Disclosure of Financial Interest forms

( Pre-activity evaluation. With method to measure change.

After the activity please send:

( Completed evaluation summary

( Signed rosters

( Final budget

The Southern Kentucky AHEC CME Coordinator will review this activity proposal and supporting documentation.

Anna Jones, BS, RCP, CCMEC

E-mail to: ajones@

TO BE COMPLETED BY AHEC

|Received: | | | |

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|Reviewed by: | |Date: | |

|Approved for: | |credits/hours of | |

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|Declined: | |

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