REQUEST FOR APPROVAL FOR CME ACTIVITY



Department of Continuing Medical EducationAPPLICATION FOR AMA PRA CATEGORY 1 CREDITTMThe 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.Activity Title Presenting DepartmentClick here to select a departmentActivity Start Date Click here to enter a date. Activity End Date Click here to enter a date. Start Time End Time Activity Director(s) Location of Activity Number of Instructional Hours (exclude lunch, breaks, etc) Administrative ContactPlease identify the individual responsible for the operational/administrative support of this activity.Name: Phone: Estimated AttendanceEstimated number of attending physicians: Estimated number of other learners: Primary Target Audience 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: ?NOProfessional Practice Gap(s) of Your LearnersThe ACCME requires that every educational activity be based on an identified gap in practice. The “Professional Practice Gap” is based on the difference between what your learners do now (current practice) vs. what you want them to do (best practice).Complete the chart below by carefully stating…….(1)What is the current learner practice?(What your physicianlearners currently do inpractice)(2)What is the best practice?(What you want yourphysician learners to do inpractice)(3) What is the practice-based issue that you want to address in this activity? (the resulting practice gap)Example: Not screening for colorectal cancer for patients over 50 years of age.Example: American Cancer Society Guidelines recommend annual screening for patients over 50 years of age.Example: In patients over50 years of age, we arenot screening a highenough proportion for colorectalcancer. Needs 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 practice 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: Statement of Need for this ActivityEvery CME activity must be planned and designed to a meet a need for continuing medical education that is identified as a result of a needs assessment process. A statement of need must be developed for the activity based on the results of that processSummarize the need for this activity into a statement or paragraph based on all sources of need. What conditions, issues or problems exist that make it necessary or advantageous for physicians to participate in this activity? Physician CompetenciesCompetencies 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? (check all that apply)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 practiceObjectivesList the educational objectives for this activity.Upon completion of this course, learners should be able to:1 2 3 Format/Methodology/DesignSelect 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? ?This activity addresses no relevant system barriers. ?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/Evaluation This 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. FacultyThe faculty should have a demonstrated expertise on the topic, strong presentation and communication skills, and be able to address the needs and objectives of the activity withoutconflict of interest.PLEASE LIST THE INSTRUCTORS THAT YOU ANTICIPATE USING FOR THIS ACTIVITY HonorariaWill the speaker(s) receive an honorarium? ?Yes ?NoIf YES, please indicate the name of each speaker and amount PLEASE 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 mercial Support/ExhibitsIs commercial support anticipated for this activity? ?YES ? NO(Note: exhibit fees are NOT considered commercial support, however, they must be reported on your course budget)If NO, how will this activity be funded? ?Department Funds ?Other – please specify:Will there be vendor/exhibit tables at this activity? ?YES ? NOIf applicable, list the anticipated commercial interests: If applicable, list the anticipated exhibitors: Registration FeesINDICATE REGISTRATION FEES (IF APPLICABLE):MD’s: $ Other healthcare professionals: $ ?N/A (no registration fees) 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 activity director(s) & all activity planners/moderators?Disclosure of Relevant Financial Relationships from all speakers?Marketing materials (draft flyer/brochure) – must be approved by the CME Department prior to final printing?Agenda (faculty/topics/schedule)?Proposed budget (estimated income/expenses)?Needs assessment supporting documentation (sources you used to identify the professional practice gaps)?CV or bio (required from every non-SIUH presenter)?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.FOR CME OFFICE USE ONLY?Approved for _____AMA PRA Category 1 Credit(s) TM ?Not approved, Reason:_______________________________________________________Date of Committee Action: ______________________________________________________Initialed by CME Staff:2019APPENDIX 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 selfPROMOTIONAL 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.2019Disclosure 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 ................
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