REQUEST FOR APPROVAL FOR CME ACTIVITY



Department of Continuing Medical EducationAPPLICATION FOR AMA PRA CATEGORY 1 CREDITTM RSS (REGULARLY-SCHEDULED SERIES)This CME Planning Process has been designed to comply with MSSNY’s accreditation criteria and policies. For this educational activity to be approved for AMA PRA Category 1 CreditsTM the planning process outlined in this document is required.RSS Activity TitleClick here to enter activity titlePresenting DepartmentClick here to select a departmentInitial/Renewal ? Initial application ?RenewalStart Time/End Time Start Time: End Time: Frequency?Weekly ?Monthly ?Quarterly ?Varies ?Other (please specify) Day of the Week?Monday ?Tuesday ?Wednesday ?Thursday ?FridayActivity Type?Grand Rounds ?Tumor Board ?Journal Club ?Case conference ?M&MActivity Location Activity Director(s) Number of Instructional Hours Per Segment Administrative ContactPlease identify the individual responsible for submitting reports to the CME Office on an ongoing basis and for the operational/administrative support of the activity.Name: Phone: Estimated AttendanceNumber of attending physicians: Number of other learners: Program SchedulePlease attach a completed schedule which includes dates/topics/speakers. If you do not have this information for the entire year, please submit for at least 3 months and the outline for the year. Provide follow-up details when available. ?Will submit additional information at a later datePrimary Target AudienceDescribe the primary target audience for this activity. Collaboration With Other StakeholdersAre you collaborating with any other internal (e.g., patient safety, quality improvement, research, public health, community health) and/or external (e.g., physician practice group, government health department, insurers, specialty societies, patient advocacy group) to help improve the impact of this activity? ?YES – Please specify: ?NONeeds AssessmentConsidering the Professional Practice Gap(s) of your learners, indicate the educational needs that underlie the professional practice gap.Select all that apply:?Knowledge?Competence?PerformanceProfessional Practice Gap: the difference between what the learners do now (current practice) vs. what you want them to do (best practice)Knowledge: awareness and/or understanding (note that while increased knowledge is an acceptable need for an activity, knowledge alone is not considered by the current accreditation system to be a sufficient outcome).Competence: knowing how to do something, the ability to apply knowledge, skills, or judgement in practicePerformance: what is actually done in practiceProfessional Practice Gap(s) of Your LearnersState the overall professional practice gap(s) of your learners that this series will address. (See Examples of Professional Practice Gaps for Regularly-Scheduled Series - Appendix B) Sources Used to Identify Professional Practice Gap(s)What sources did you use to identify the Professional Practice Gap(s) of your physician learners? (How did you know this was a gap for your physician learners?) You are required to provide supporting documentation for all sources selected (copies of articles, CME evaluations, QI data, surveys, etc) Select all that apply, minimum of two:?ACGME/ABMS Competencies?County sources?State sources?Federal sources?Expert faculty opinion?Focus Groups?IOM (Institute of Medicine) Competencies?Practice Guidelines?Literature Review?Medical Chart Review?Morbidity and mortality data?New Medical Knowledge?Patient Outcome?Patient Safety Data?Competence (knowing how to do something)?Performance (what is done in practice)?Prior activity feedback (evaluations)?Quality improvement data?Research Finding?Survey of target audience (such as questionnaire or interview)?Admission/Discharge diagnosis data?Referral patterns?Specialty curriculum requirements for training, certification or maintenance of certification?Licensure requirements?Risk management?Other – please specify: PhysicianCompetenciesCompetencies and Attributes are nationally established goals for physicians associated with targeted specialties that should be addressed whenever possible when planning CME activities. Which competency areas have been addressed during the planning of this CME activity?Institute of Medicine Core CompetenciesABMS Maintenance of CertificationACGME/ABMSCompetencies?Provide patient-centered care?Evidence of professional standing?Patient care?Work in interdisciplinary teams?Evidence of a commitment to lifelong learning?Medical knowledge?Employ evidence-based practice?Evidence of cognitive expertise?Practice-based learning and improvement?Apply quality improvement?Evidence of evaluation of performance in practice?Interpersonal and communication skills?Utilize informatics?Professionalism?Systems- based practiceOverall Series ObjectivesPlease list the overall series objectives.Upon completion of this course, learners should be able to:123 Format/Methodology/Educational DesignConsidering the setting, objectives and desired results, what format(s) will you use to promote the changes identified in your objectives?(See Educational Formats - Appendix A)Select all that apply:?Live activity?Internet?Enduring Material (e.g. CD/DVD, print)?Other – please specify: Please indicate the instructional methods you intend to use.Select all that apply.?Didactic lectures?RSS (regularly-scheduled series)?Case-based discussion?Hands-on-lab?Simulated patients?Panel Discussion?Train-the-trainer?Workshop?Other – please specify: Explain why this educational format is appropriate for this activity: BarriersWhat potential patient and/or physician barriers could block the learner fromimplementing the new learned behaviors, strategies or skills taught in this educational activity? The following barriers have been identified and will be addressed in the educational content:?Staffing Issues?Policy Restrictions?Rigid Schedules?Lack of Time Allotted for Implementation of New Skill?Lack of Resources (equipment)?Lack of Administrative Support?Insurance/Reimbursement Issues?Patient Compliance Issues?Cost?Lack of time to assess/counsel patients?Lack of consensus on professional guidelines?This activity addresses no relevant system barriers?Other – please specify: Describe what attempts will be made to address the identified barrier(s) you indicated. Describe some educational strategies to help learners overcome these barriers in order to achieve physician and/or patient change. Ancillary Tools/Resources to Reinforce Desired Educational ResultsAncillary tools/resources support the achievement of your intended results for this activity. Are there additional resources such as the ones listed below that could be provided to participants to enhance the potential for change or reinforce the desired results? Note: Ancillary tools/resources are supplemental materials and are not materials already presented at the event (i.e., presentation slides). ?Yes ?NoIf YES, what ancillary tools/resources will be provided to the learners? Select all that apply: (Copies of all materials selected must be submitted to the CME Department.)?Provider reminders ?Provider feedback ?Patient Surveys?Follow-up postcards/email?Patient educational materials?Algorithms?Standing orders?Pocket card guidelines?Other – please specify: Outcomes for Learners/EvaluationThis activity is designed to: (Select all that apply):?Increase Competence (minimum basic requirement – must check this box)?Improve Performance competence: knowing how to do something, the ability to apply knowledge, skills or judgement in practiceperformance: what is actually done in practice-------------------------------------------------------------------------------------------------------------------------------------------If your activity is designed to increase competence, how will you measure if these changes have occurred??Post-course Evaluation/self-assessment (will automatically be generated by EEDS)?Audience Response System (ARS)?Customized pre/post-test including case examples?Physician and/or patient surveys and evaluations?Other – please specify: If your activity is designed to improve performance, how will you measure if these changes have occurred??Adherence to guidelines (only check this box if you plan to assess that learners have changed their ability to adhere to guidelines)?Case-based studies?Chart audits?Customized follow-up survey (automatically generated by EEDS)?Direct observations?Physician or patient feedback, surveys and evaluations?Reminders and feedback?Other – please specify: Conflict of Interest/DisclosureList the names of everyone with the potential to control the content of this activity (course directors, activity planners, moderators, faculty, authors, etc. Append a completed Disclosure of Relevant Financial Relationships form from each individual. Individuals who refuse to disclose are disqualified from participating in this activity. HonorariaWill the speakers receive an honorarium? ?Yes ?NoPlease note that physicians on the medical staff at SIUH and within the Northwell Health System are not paid for lectures given as part of our accredited Category 1 CME programs. Advertising Indicate the method(s) of publicizing this activity to prospective participants:?Email announcement ?Website (provide link): ?Flyer?Brochure?Monthly Calendar?Other – please specify: The following attachments must be included with the submission of this CME Application:?Disclosure of Relevant Financial Relationships from all activity director(s)?Disclosure of Relevant Financial Relationships from all activity planners/moderators, etc.?Needs assessment supporting documentation (sources you used to identify the professional practice gaps)?Proposed schedule/agenda (dates/topics/faculty)?Copies of ancillary tools/resources, if developedACTIVITY DIRECTOR All educational requirements for this CME Activity are the responsibility of the activity director.?By checking this box, I confirm that I have read and understand my responsibilities. Activity Director: Date: Click here to select a date.Revised2019APPENDIX AEDUCATIONAL FORMATS AND THEIR RATIONALEFORMATRATIONALELecture/presentationProvide a large amount of information (knowledge) in a limited amount of time. Allows faculty to talk about a chosen topic.Panel DiscussionProvide an opportunity for experts or a group of learners to present differing viewpoints on a topic, issue, or problem to other panelists and the audience (learners).Self-Directed Learning/Computer-aided instruction/journalProvides an opportunity for adults to learn the subject at their own pace. An effective method of providing active learning with immediate feedback and re-enforcement.Group discussionProvides an opportunity for learners to think together constructively for purposes of learning, solving problems, making decisions, and/or improving human relationships.Case StudyProvides an account of an actual problem or situation an individual or group has experienced. An effective method of provoking controversy and debate on issues for which definite conclusions do not exist.Problem SolvingProvides the opportunity for learners to solve a problem through the collection, application, and assessment of information. An effective teaching method to encourage learners to inquire into, and think critically about, a topic.Role PlayProvides learners with the opportunity to experience common human relations problems, practice communications skills in a secure environment.BrainstormingSolicits creative ideas or to identify possible solutions to problems. Allows learners to express opinion and ideas without the threat of being judged by other learners.DemonstrationModels the correct step-by-step procedures needed when performing a specified task.Role Modeling/MentoringProvides the learner with one-on-one access to expert. Learning takes place over time with opportunities to reflect, apply, question.Journal ClubProvides a format for discussion of journal articles. Useful for a group with similar interests to share opinions and discuss published literature in an organized, face-to-face fashion.M & MProvides a safe venue for presentation of cases by learners with possible untoward outcomes. Allows peer interaction with current problems in practice.Patient SimulationProvides a standardized method for a group of physicians to compare their individual skills of diagnosis, treatment and management of a patient with their peers.GamesProvides an interactive and competitive process to validate new learning in a positive emotional situation.Chart AuditPeer or selfAPPENDIX B EXAMPLES OF PROFESSIONAL PRACTICE GAPS FOR REGULARLY-SCHEDULED SERIESThe field of surgery is broad, complex, and specialized in the surgical management of a wide variety of medical conditions. Due to the complexity of the field, surgeons cannot maintain competence without ongoing education in the field as a whole. Participation in this series will improve the knowledge and competence of the participants, both in and out of the areas of specialty.Ethical challenges in medicine are not simple and often require a great deal of thought to manage appropriately. A solid knowledge of medical ethics and the practical application of clinical ethical reasoning skills are essential components of a physician’s skills. This series is designed to develop a greater awareness among participants of how to recognize, analyze, and respond to situations with ethical challenges.Pediatric Series will address the core competencies of common pediatric problems and provide an update about standards of care in order to reflect the most current evidence-based knowledge and guidelines to improve pediatrician competence.This tumor board is designed to review existing cases and apply the most current evidence-based knowledge and guidelines to establish treatment plans for improved patient outcomes.The field of psychiatry is rapidly changing with new and innovative diagnosis and treatment protocols. Psychiatric physicians who are using older protocols for management of psychiatric-related diseases and disorders are not able to provide optimal patient care. Through increased knowledge about and competence in the use of newer therapies psychiatric physicians will improve patient outcomes and decrease disease burden in our community.Currently, PCP’s, general pediatricians, and family practice providers do not have the knowledge or tools to confidently assess, diagnose, treat, and manage children with autism spectrum disorders. With a discrepancy between the population of children within the Autism Spectrum and the number of professionals available to help them and their families, primary care providers, nurses, and allied professional are increasingly being charged to provide the basic tasks of early identification, early intervention, and coordination of care for them. To achieve quality of care and confidence on taking on these tasks, our PCP’s need to be equipped with the ability to appropriately identify children with Autism Spectrum Disorder, the initial step to diagnosis and co-morbidities with the help of other experts in the field, to understand their multiple medical and mental health needs, and finally to coordinate the necessary services to succeed in school, at home, and in their community.Effective management of subarachnoid hemorrhage (SAH) is critical in pre-hospital, hospital, and post-hospital care. TTUHSC El Paso physicians in critical care, ED, neurology, psychiatry, anesthesiology, surgery, and neurosurgery need an update on current guidelines in the identification, treatment, and management of SAH. Interdisciplinary teams are responsible for treating patients with SAH in hospitals. According to observations from hospital leaders, physicians and residents need to improve their skills in patient transport, diagnosis, ED care, monitoring, and management. Improved management skills will result in mortality rate reductions.Because rib fractures are rarely life-threatening, severe visceral injury inside the abdomen or chest can be missed. Physicians are not knowledgeable about critical signs and symptoms or fully trained on assessment, treatment, and management of patients with thoracic trauma. Following this educational intervention, the practice gap will be closed as physicians make accurate diagnoses, order appropriate tests/radiographs, and initiate effective treatment strategies for improved patient outcomes.Hyperthermia in patients is often related to toxic ingestions. Physicians do not currently have all of the pertinent information required to properly identify specific antidotes that may be used to treat toxin-induced hyperthermia. This course is designed to close the gap in clinical practice by improving knowledge and competence to diagnose these conditions correctly, institute appropriate therapy, and improve patient outcomes.Over the last decade, technological advances have made huge strides in diagnosing common GI disease. In addition, several new and innovative treatment protocols have emerged for managing GI diseases. Primary care physicians who are using older guidelines for identifying GI-related diseases and disorders are not providing optimal care to their patients. Primary care physicians must be equipped with the ability to appropriately identify GI diseases and disorders, as well as be knowledgeable about treatment options for their patients.The field of pain management is complex and challenging for the physician. In addition to numerous treatment methodologies to choose from, multiple causative factors, co-morbid conditions, psychological disorders, high risk behaviors, opioid abuse, controlled substance laws, and ethical dilemmas add to the complexity of diagnosis and management of pain. Through increased knowledge about and competence in managing complex cases, physicians will choose effective treatment plans to improve patient outcomes.PROMOTIONAL MATERIALThe CME Department must review and approve all promotional materials prior to distribution.The following statements must be present on all brochures/flyers/ printed announcements for all CME accredited programs. No deviation from the wording is permitted.The statement, AMA PRA Category 1 Credit(s)TM, is a trademarked statement of the American Medical Association and must be used verbatim every time that it appears in a publication.The AMA (American Medical Association) requires that the phrase be printed in italics with the trademark symbol (TM) in superscript. The entire accreditation statement should be regular font with “only” AMA PRA Category 1 credit TM in italics.Please note the italics and trademark symbol.AccreditationStaten Island University Hospital is accredited by The Medical Society of the State of New York (MSSNY) to provide continuing medical education for physicians.Staten Island University Hospital designates this live activity for a maximum of insert the number of credits AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.Disclosure PolicyPolicies 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 relationships they may have with commercial interests whose products, devices or services may be discussed in the content of a CME Activity.Disclosure of Relevant Financial RelationshipsIt is the policy of Staten Island University Hospital’s Department of Continuing Medical Education to ensure balance, independence, objectivity, and scientific rigor in all CME activities. Anyone engaged in content development, planning or presentation must complete this form. Persons who fail to complete this form may not participate in the CME activity. CME Activity Title: ________________________ Title of Presentation: __________________________________________ Live Presentation Date: ____________________ -or- ?Home Study/Enduring Materials/CD/OnlinePlease indicate your role in this CME activity: check all that apply ?Presenter ?Author?Course Director ?Moderator ?Planning Committee Member Name: __________________________________________ Title: ____________________________________________Phone: __________________________________________ E-mail: ___________________________________________DISCLOSURE? ? Have you (or your spouse/partner) had a personal financial relationship in the last 12 months with YES NOthe manufacturer of the products or services that will be presented in this CME activity (planner) or in your presentation (speaker/author)? If NO, skip to DECLARATION section below. If YES, please list your disclosures and resolutions below. Commercial InterestNature of Relevant Financial RelationshipNameofCompanyEmployee, Grants/Research Support recipient, Board Member, Advisor or Review Panel member, Consultant, Independent Contractor, Stock Shareholder (excluding mutual funds), Speakers’ Bureau, Honorarium recipient, Royalty recipient, Holder of Intellectual Property Rights, or Other (specify)1.2.3.4.RESOLUTION OF CONFLICT OF INTEREST Presenter/Authors – Please check one or more of the following boxes?I will support my presentation and clinical recommendations with the “best available evidence” from the medical literature.?I will refrain from making recommendations, regarding products or services, e.g., limit presentation to pathophysiology, diagnosis, and/or research findings.?I will recommend an alternative presenter for this topic for the planning committee’s consideration.?I will submit my talk in advance to allow for adequate peer review.?I will or have divested myself of this financial relationship.Planners - Must check both boxes ?To the best of my ability, I will ensure that any speakers or content I suggest is independent of commercial bias. ? I will recuse myself from planning activity content in which I have a conflict of interest.DECLARATIONI will uphold academic standards to ensure balance, independence, objectivity, and scientific rigor in my role in the planning, development or presentation of this CME activity. In addition, I agree to comply with the requirements to protect health information under the Health Insurance Portability & Accountability Act of 1996. (HIPAA) Signature _______________________________________ Date __________________________________________ Additional information may be requested to resolve any conflict of interest. All identified conflicts of interest will be resolved, and disclosure will be made to activity participants.FACULTY DISCLOSURE POLICYAs a provider accredited by the Medical Society of the State of New York (MSSNY) to provide continuing medical education for physicians, Staten Island University Hospital must ensure balance, independence, objectivity and scientific rigor in all its directly provided or jointly provided educational activities. We are required to identify all relevant financial relationships with any commercial interest; determine whether these relationships create a conflict of interest with the individual's control of content and resolve all conflicts before the educational activity occurs.Staten Island University Hospital relies upon course directors, planners, moderators and invited faculty participants in its CME programs to provide educational information that is objective and free from bias. In this spirit, and in accordance with the ACCME Standards for Commercial SupportSM, anyone with the potential to control the content of a CME activity is expected to disclose the existence of any relevant financial interest or other relationship the faculty member (spouse or partner) or provider has with the manufacturer of any commercial product discussed in an educational presentation.All are expected to disclose:Any relevant financial relationship with the provider of commercial products or services discussed in their educational presentation or that have directly supported the CME activity through an educational grant to the sponsoring organization(s).All commercial relationships that create a conflict with the faculty’s control of content must be resolved before the educational activity occurs.Glossary of TermsCommercial InterestThe ACCME defines a “commercial interest” as any entity producing, marketing, re-selling, or distributing health care goods or services, consumed by, or used on, patients. The ACCME does not consider providers of clinical service directly to patients to be commercial interests. For more information, visit .Financial relationshipsFinancial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.Relevant financial relationships ACCME focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. ACCME has not set a minimal dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME defines “’relevant’ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.Conflict of InterestCircumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship.2017 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download