A Guide for and Documentation of the Planning of a CME ...
Rutgers Biomedical and Health Sciences is accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing education for the healthcare team.
This CE Planning Process has been designed based on the Criteria for Joint Accreditation for Interprofessional Continuing Education™ and accepted adult learning principles. For this educational activity to be approved for AMA, ANCC or ACPE credit/contact hours, the planning process outlined in this document is required.
This CE Activity Planning Worksheet with all supporting forms and documents must be completed and submitted at least 90 days in advance of the proposed activity date. Incomplete worksheets will be returned.
Required Attachments:
Preliminary agenda (live event)
Supporting needs assessment sources (see page 4)
Signed Disclosure Forms for all individuals involved in the development and/or implementation of the activity. If not all disclosure forms are available at the time this worksheet is completed, they must be submitted to the CE unit in a timely manner in order to identify and resolve conflicts of interest.
Budget summary indicating anticipated income (including grants) and expenditures
Marketing
PLEASE NOTE: The CE unit is required to review all marketing materials before they are made available to prospective participants. If any of the below methods will be used to generate an audience, please forward the draft versions to the CE unit for review.
• Invitation/brochure/letter (mail, fax, email)
• Web-based announcements
• Advertisements/journal announcements
• Posters
• Save-the-Date card (Note: A Save-the-Date card cannot be used as the only method to generate an audience.)
|General Activity Information |
|Title: |
|Date(s): |
|Location(s): |
|Activity/Delivery Type |
| |Live Event | |Enduring Material | |Journal-based | |Performance/Quality Improvement |
|If live event, anticipated number of minutes of instruction (excludes meals, breaks, introductions): |
|Format |
| |Audioconference | |Case Study | |Conference/Symposium | |DVD |
| |Journal Supplement | |Meeting Series | |Monograph | |Newsletter |
| |Podcast | |Satellite | |Webcast/Webinar | |Other: |
| | | |Symposium | | | | |
|Target Audience |
| |Physicians | |Nurses | |Advanced Practice Nurses | |Pharmacists |
| |Pharmacy Technicians | |Physician Assistants | |Fellows | |Psychologists |
| |Social Workers | |Dentists | |Podiatrists |
| Other Healthcare Professional(s): |
| Other Non-healthcare Stakeholder(s): |
|Content Focus |
| |
|Geographic Area of Target Audience |
| Internal Local/Regional National International |
|Sponsoring School/Unit: NJMS RWJMS SN PHARM UBHC Other: |
|Sponsoring Department: |
|Is the activity being jointly provided (planned and implemented with a non-accredited organization)? |
|Yes No |
|If yes, joint provider(s): |
|Credits Requested |
|Physician (AMA PRA) Nurse (ANCC) Pharmacist (ACPE) Pharmacy Technician (ACPE) |
|Other: |
|Note: Planning committee must include professionals who are reflective of the target audience. |
|Activity Description (one paragraph description of overall purpose and goal of this activity) |
| |
|Pharmacy (ACPE) Activity Type (select one) FOR PHARMACY ONLY |
|Knowledge-based (designed to acquire factual knowledge; minimum 0.25 contact hour) |
|Application-based (designed to apply information learned in time frame allotted; minimum 1 contact hour) |
|Practice-based (designed to acquire specific knowledge, skills, attitudes, and performance behaviors with |
|didactic and practice components; minimum 15 contact hours) |
|Pharmacy (ACPE) Topic Designator FOR PHARMACY ONLY |
|01: Drug Therapy Related (addresses drugs, drug therapy, and/or disease states) |
|02: AIDS Therapy Related (addresses therapeutic, legal, social, ethical, or psychological issues related to |
|understanding and treatment of patients with AIDS) |
|03: Law (addresses federal, state, or local laws and/or regulations affecting the practice of pharmacy) |
|04: General Pharmacy Topics (addresses topics relevant to the practice of pharmacy other than those |
|included in the classifications of drug therapy related, AIDS therapy related and law) |
|05: Patient Safety (addresses prevention of healthcare errors and the elimination or mitigation of patient injury caused by healthcare errors) |
|Verification of Identified Learner Needs |
|INSTRUCTIONS: Learner needs will be identified through an analysis of a variety of sources. There are many sources of information that can be used for |
|conducting a needs assessment and the table below is intended to guide you in the needs assessment process. |
|Select at least two sources by which you identified the need for the activity. You must submit documentation that supports each of the selections. |
|Only select those sources for which you can provide documentation. You will be asked to interpret the information gleaned from the sources on the |
|following page. |
|NOTE: Documentation is required for each selection made. For larger documents, please highlight the section(s) that specifically identifies the need. |
|Learner Identified Needs |Expert Identified Needs |Data-based Observations |
| | |( A summary description of the data should be|
| | |submitted in lieu of the actual data.) |
| Evaluation results from previous | National guidelines (NIH, CDC,| Planning/Advisory Committee members | QA/QI data or dashboards |
|activities |AHRQ, etc.) | | |
| Needs assessment survey | Specialty society guidelines | Department Chair/ leadership | Departmental quality metrics |
| Focus group/ discussion | Peer-reviewed literature | Requested by institution(s) or health | Publicly reported performance data |
| | |care professional group(s) | |
| Request from relevant healthcare | Regulatory requirements (Joint| Current research | Database analyses (utilization, practice |
|professionals |Commission, MOC, etc.) | |management, medication Rx, etc.) |
| Other, please specify: | Other, please specify: | Department/specialty case reviews that |
| | |highlight potential problems |
| | | Other, please specify: |
| | | |
|Needs Assessment and Intended Outcomes |
|INSTRUCTIONS: Please complete the table below in order to identify the specific educational needs of learners that this activity will address related to|
|the specific practice gaps in learner knowledge and/or competence and/or performance. |
|Current Practice |Indicate the issues, problems, and/or practice gaps you want to address |
| |(Check all that apply) |
| |Learners are not aware of new methods for diagnosis and treatment |
| |Learners do not know how to apply the new information into practice |
| |Learners are not applying evidence-based guidelines into practice |
| |Learners are having difficulty managing patient care scenarios |
| |Patient problems or challenges that have not been adequately addressed |
| |Areas of patient care within the department or institution in need of improvement |
| |Gap identified by PI/QI process |
| |Broad variations of patient care among colleagues |
| |Issues reported by patients that need more attention |
| |Other (specify): |
| |Describe the specific issues, problems, and /or practice gaps indicated above |
| | |
| |List the specific sources you used to identify the practice gaps and provide documentation to support the existence of the gaps |
| |(list the specific sources selected on page 4) |
| | |
|Best Practice |Describe the quality, performance, and/or standards of care measures that highlight optimal expectations related to the practice |
| |gaps |
| | |
| |List the specific sources that support these standards of care and provide documentation to support it (list the specific sources |
| |selected on page 4) |
| | |
|Educational Need(s)|Indicate the reason(s) the practice gaps exists related to the gap analysis above |
| |Knowledge (learners’ lack of understanding) |
| |Skills/Strategy (learners’ difficulty or inability to apply strategy) |
| |Performance (practice not meeting standard of care) |
|Desired Result(s) &|What will the learners be expected to do differently as a result of their participation in this activity that addresses the practice|
|Intended Outcome(s)|gaps above? |
| | |
| |Classify the expected change(s) of the learners’ behavior as a result of their participation in this activity |
| |Skills/Strategy (gain new abilities/strategies to apply to practice) |
| |Performance (practice modification as a result of application learned) |
| |Patient Outcomes (change in health status of patients due to change in practice behavior) |
|Learning Objectives |
|INSTRUCTIONS: Please check off the area(s) of improvement that this activity will address and provide a minimum of two (2) overall learning objectives. If you would like to use measureable action verbs not listed |
|below, please write it in the text box. |
|Area(s) of Improvement |
| Knowledge (what learners need to know) | Skills/Strategy (what learners need to know how to do) | Performance (what learners need to do) |
|Learning Objectives |
|As a result of this educational activity, learners should be |As a result of this educational activity, learners should be better able |As a result of this educational activity, learners should be better able |
|better able to: |to: |to: |
|Choose one measurable verb below: |Choose one measurable verb below: |Choose one measurable verb below: |
| |Define | |
|Choose one measurable verb below: |Choose one measurable verb below: |Choose one measurable verb below: |
| |Define | |
|Choose one measurable verb below: |Choose one measurable verb below: |Choose one measurable verb below: |
| |Define | |
|Choose one measurable verb below: |Choose one measurable verb below: |Choose one measurable verb below: |
| |Define | |
|Choose one measurable verb below: |Choose one measurable verb below: |Choose one measurable verb below: |
| |Define | |
|Outcomes Assessment |
|INSTRUCTIONS: Please identify how you plan to assess the relevance and impact of the activity on practice application, clinician performance, and/or health |
|outcomes. Check all that apply. |
|Skills/Strategy | Post-activity evaluation (required) |
| |Pre/post-assessments |
| |Report of skills/strategy changes |
| |Other (specify): |
|Performance | Report of performance or practice changes |
| |Track and identify new practices or policies as a result of activity |
| |Chart audits with analysis of results |
| |Participant focus group about actual change in practice |
| |Other (specify): |
|Patient Outcomes | Report of patient outcome changes |
| |Patient satisfaction survey |
| |Quality assessment data/review (departmental, institutional, external) |
| |Claims data/review with analysis of results |
| |Morbidity/Mortality data with analysis of results |
| |Other (specify): |
|Scope of Professional Activities |
|INSTRUCTIONS: Activity content must match the healthcare team or individual members of the healthcare team’s current or potential scope of professional |
|activities. Please briefly describe below how the activity content will be relevant to each profession selected in the Target Audience section on page 2. In|
|relation to the content focus, consider the daily practice of the profession, relevant practice parameters and practice guidelines, and how the profession |
|participates as a member of the healthcare team. |
|Physicians | |
| | Not applicable |
|Nurses | |
| | Not applicable |
|Advanced Practice Nurses | |
| | Not applicable |
|Pharmacists | |
| | Not applicable |
|Pharmacy Technicians | |
| | Not applicable |
|Physician Assistants | |
| | Not applicable |
|Fellows | |
| | Not applicable |
|Psychologists | |
| | Not applicable |
|Social Workers | |
| | Not applicable |
|Dentists | |
| | Not applicable |
|Podiatrists | |
| | Not applicable |
|Other (specify): | |
| | |
| | Not applicable |
|Format and Design Related to Sustaining Results |
|INSTRUCTIONS: The purpose of continuing education is change in behavior or validation that changes already made are consistent with best practices. In the |
|table below, indicate your choices for each element and the rationale for that choice: |
|VENUE AND/OR MODE OF EDUCATIONAL INTERVENTION APPROPRIATE TO THE TARGET AUDIENCE TO ACHIEVE DESIRED |RATIONALE APPROPRIATE TO OBJECTIVES/RESULTS: |
|RESULTS | |
| |Live symposium | |Internet-based activity | |
| |Print enduring material | |Electronic enduring material | |
| |Journal supplement | |Other: | |
|METHODS TO ENGAGE LEARNERS (Click all that apply, but at least one): |RATIONALE APPROPRIATE TO OBJECTIVES/RESULTS: |
| | |
| |Case studies | |Audience response system | |
| |Reflection worksheet | |Small group work | |
| |Panel Discussion | |Role play | |
| |Question/Answer | |Return demonstration | |
| |Other: | |
|ANCILLARY TOOLS TO REINFORCE AND SUSTAIN LEARNING GOALS: |RATIONALE APPROPRIATE TO OBJECTIVES/RESULTS: |
| | |
| |Email reminder | |Pocket guide | |
| |Patient reminder | |Algorithm worksheet | |
| |Other: | |None | |
|Competencies |
|INSTRUCTIONS: Identify the competencies that this activity is designed to address. |
| |Patient Care |
| |Including: compassionate, appropriate and effective treatment of health problems and/or health promotion |
| |Medical/Clinical Knowledge |
| |Including: established and/or evolving biomedical, epidemiological, social-behavioral knowledge as it applies |
| |to clinical medicine |
| |Practice-Based Learning and Improvement |
| |Including: appraisal of one’s own care patterns, knowledge, expertise and gaps; setting goals and addressing |
| |gaps in one’s own practice and implementing changes with the goal of practice improvement; locating appraising,|
| |and assimilating evidence from scientific studies to apply in own practice |
| |Interpersonal and Communication Skills |
| |Including: effective communication with patients, families, other health professionals; effective collaboration|
| |leadership in a healthcare team |
| |Professionalism |
| |Including: adherence to ethical principles; integrity; respect for others; responsiveness to patient needs; |
| |sensitivity and responsiveness to diverse populations |
| |Systems-Based Practice |
| |Including: coordination of patient care within a healthcare system with appropriate and effective use of system|
| |resources; system-based quality assessment and improvement |
|INSTRUCTIONS: Check below if this activity will focus on any of the following Core Competencies for Interprofessional Collaborative Practice: |
| |Values/Ethics for Interprofessional Practice |
| |Work with individuals of other professions to maintain a climate of mutual respect and shared values |
| |Roles/ Responsibilities |
| |Use the knowledge of one’s own role and those of other professions to appropriately assess and address the |
| |healthcare needs of the patients and to promote and advance the health of populations |
| |Interprofessional Communication |
| |Communicate with patients, families, communities, and professionals in health and other fields in a responsive |
| |and responsible manner that supports a team approach to the promotion and maintenance of health and the |
| |prevention and treatment of disease |
| |Teams and Teamwork |
| |Apply relationship-building values and the principles of team dynamics to perform effectively in different team|
| |roles to plan, deliver, and evaluate patient-/population-centered care and population health programs and |
| |policies that are safe, timely, efficient, effective and equitable |
|INSTRUCTIONS: Check below if this activity will focus on any of the following National Academy of Medicine competencies: |
| Provide patient-centered care | Apply quality improvement |
|Work in interdisciplinary teams |Utilize informatics |
|Employ evidence-based practice | |
|Identified Barriers and Strategies to Address Them |
|INSTRUCTIONS: Planners are encouraged to give consideration to the system of care in which the learner will incorporate new or validate existing learned |
|behaviors. Planners must be sure to (a) identify barriers that could block implementation and (b) attempt to apply strategies to address, discuss strategies|
|to overcome or remove those barriers (if possible) in the content of the activity. Please indicate below the barrier(s) you have identified: |
|Clinician Barriers | Lack of time to assess or counsel patients |
| |Lack of consensus on professional guidelines |
| |Other (specify): |
|Patient-Based Barriers | Insufficient adherence to treatment plan |
| |Communication/language barriers |
| |Other (specify): |
|Institutional Barriers | Institutional policies |
| |Insufficient administrative support/resources |
| |Insufficient clinical staff |
| |Insufficient technical resources |
| |Organizational culture |
| |Other (specify): |
|System Barriers | Insurance/reimbursement issues |
| |Cost of treatment |
| |Insufficient accessibility/availability of treatment |
| |Other (specify): |
|Not applicable | No perceived barriers |
|If applicable, describe the strategies that will be employed in this activity to address or remove the identified barriers: |
| |
|Planning Committee |
|INSTRUCTIONS: Please complete the table below for each planning committee member. When developing an interprofessional continuing education activity, the |
|planning process must include health care professionals from two or more professions and include professionals who are reflective of the target audience |
|members. |
|COMMITTEE MEMBER NAME |DEGREES/ CREDENTIALS |TITLE AND AFFILIATION |ROLE ON COMMITTEE |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
| | | | |
Add additional rows if necessary
|Faculty/Presenters/Authors |
|INSTRUCTIONS: Please complete the table below for each faculty/presenter/author. |
|FACULTY/AUTHOR/PRESENTER NAME |DEGREES/ CREDENTIALS |TITLE AND AFFILIATION |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
Add additional rows if necessary
|Successful Completion of the Activity |
|INSTRUCTIONS: Indicate the criteria for verifying participation in and successful completion of the activity |
|Criteria for successful completion of the activity include: (Check all that apply) |
|Attendance at entire event or session Attendance for at least % of event |
|Attendance at 1 of more sessions Completion/submission of evaluation form |
|Achieving a passing score of % on post-test |
|Other: |
|How will attendance be verified? |
|Sign-in sheets/registration form |
|Signed attestation by participant verifying completion of entire or part of activity |
|Collection of participation verification via computer log |
|Other: |
|Attestation |
|I hereby certify that this worksheet was completed accurately and attest to the validity of the information contained within. |
|I agree to collaborate with RBHS to ensure that the planning and implementation of the series are consistent with the continuing education policies of RBHS |
|other agencies that regulate continuing education. |
|Name (Please Print ) |
|Signature |Date |
|ADMINISTRATIVE REVIEWER, IF APPLICABLE |
|Name (Please Print ) |
|Signature |Date |
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