CME ACTIVITY PLANNING WORKSHEET - Global TB Center



SECTION #1 - CME ACTIVITY PLANNING WORKSHEET

ACTIVITY INFORMATION

|ACTIVITY TITLE Working Final |

|Title |

|Title |

|Cultural Competency and TB: General Principles and Case Studies with Ecuadorian Migrants |

|Proposed Date and Time |Proposed Location |

|October 2, 2007, 9:00 am – 4:30 pm |New York State Department of Health Field Office |

| |145 Huguenot Street, 6th floor, Conference Room #612 |

| |New Rochelle, NY 10801-5228 |

|SPONSORING UMDNJ SCHOOL/DEPARTMENT |

|Name |

|     NJMS Global Tuberculosis Institute |

|Activity Director |Academic/Clinical Title |

|     Nisha Ahamed, MPH |     Director, Education & Training |

|Address/Mail Code |

|     225 Warren Street, 1st Fl., West Wing, P.O. Box 1709, Newark, NJ 07101-1709 |

|Telephone |Fax |E-mail |

|     973-972-9008 |     973-972-1064 |     ahamedni@umdnj.edu |

|ACTIVITY DIRECTOR’S ADMINISTRATIVE LIAISON |

|Name |

|     Lauren Moschetta-Gilbert, MA |

|Address/Mail Code |

|     225 Warren Street, 1st Fl., West Wing, P.O. Box 1709, Newark, NJ 07101-1709 |

|Telephone |Fax |E-mail |

|     973-972-1261 |     973-972-1064 |     moschelb@umdnj.edu |

|JOINT OR CO-SPONSORING ORGANIZATION |

|Name |

|     Charles P. Felton National TB Center at Harlem Hospital |

|Activity Co-Director (from joint/co-sponsor) |

|     Bill L. Bower, MPH |

|Address/Mail Code |

|     Samuel L. Kountz Pavilion, 15 W 136th Street, 6th Floor, New York, NY 10037 |

|Telephone |Fax |E-mail |

|      212-939-8258 |     212-939-8259 |     blb3@columbia.edu |

|ACTIVITY CO-DIRECTOR’S ADMINISTRATIVE LIAISON |

|Name |

|     Paul W. Colson, PhD |

|Address/Mail Code |

|      Samuel L. Kountz Pavilion, 15 W 136th Street, 6th Floor, New York, NY 10037 |

|Telephone |Fax |E-mail |

|      212-939-8241 |     212-939-8259 |     pwc2@columbia.edu |

|PLANNING COMMITTEE In addition to the activity director and co-director, list names, titles and affiliations, of persons chiefly responsible for the|

|design and implementation of this activity. Use additional sheet if necessary. |

|Name |Title |Affiliation |

|      Nisha Ahamed / Lauren Moschetta |Director, Education and Training / Training and |     NJMS Global Tuberculosis Institute |

| |Consultation Specialist | |

|Name |Title |Affiliation |

|      Martha Alexander / Xiomara Dorrejo |Director, Education and Training / Training and |     New York City Department of Health and Mental|

| |Consultation Specialist |Hygiene, Bureau of TB Control |

|Name |Title |Affiliation |

|      Francesca M. Gany |Director |NYU Center for Immigrant Health |

CME STATEMENT OF ATTESTATION

I attest that this activity is within the guidelines of the ACCME definition for CME and therefore eligible for accreditation.

____________ YES _____________ NO

________________________________

Signature

SECTION #2 -EDUCATIONAL ELEMENTS

NEEDS ASSESSMENT

To establish a reason for the physician and/or other health professional for wanting to attend an educational activity is the first step in providing a successful program. This reason (need) is the identification of problem(s) in clinical practice and/or gap(s) in current knowledge.

|NEEDS ASSESSMENT DATA AND SOURCES |

| |

| |

|Please indicate how the need for this program was brought to your attention. For CME accreditation purposes, please provide examples of the sources |

|that you have indicated. Please designate at least (2) TWO sources. |

|If you cannot provide documentation, do not check that source. |

| | |

| |Continuing review of changes in quality of care as revealed by medical audit or other patient care reviews. |

| |(Sources of documentation: audit reports/chart reviews) |

| | |

| |Ongoing census of diagnoses made by the physicians on staff. |

| |(Sources of documentation: summary of notes or minutes of meetings) |

| |Advice from authorities of the field or relevant medical societies. |

| |(Sources of documentation: list of expert names/medical societies and summary of recommendations) |

| |Formal or informal requests or surveys of the target audience. |

| |(Sources of documentation: description of the audience make-up and summary of informal requests or survey) |

| |Formal or informal requests from members of staff or faculty. |

| |(Sources of documentation: description of staff/faculty make-up and summary of informal requests or survey) |

| |Periodic discussion in departmental meetings. |

| |(Sources of documentation: departmental meeting minutes) |

| |Perception of need from CME activity director and/or Departmental Chair. |

| |(Sources of documentation: summary of notes or meeting meetings or note to file ) |

| |Data from library/government sources |

| |(Sources of documentation: public health statistics, data, publications) |

| |Literature review and/or consensus reports |

| |(Sources of documentation: publication review and/or report) |

| |Formal tests to determine physician competence |

| |(Sources of documentation: test and summary of statistics) |

| |*Evaluations and recommendations from previous CME activities. |

| |(Sources of documentation: evaluation summaries and data )*MUST be included for repeated activities. |

| |Review of board examinations and/or re-certification requirements |

| |(Sources of documentation: review/update requirements) |

| |Planned periodic survey of the field |

| |(Sources of documentation: a description of the audience make-up, survey and summary of statistics) |

| |Review of problem cases managed by staff |

| |(Sources of documentation: summary of patient problem logs) |

| |Need suggested by an industry representative |

| |(Sources of documentation: note to file of recommendations) |

| |New technology |

| |(Sources of documentation: description of new procedure and date of inception) |

| |New legislation/regulations |

| |(Sources of documentation: copy of the measure) |

| |Other; please describe:       |

| |

|List the specific source(s) that you, along with your planning committee, used to assess the educational need(s) for the activity. Attach planning |

|meeting minutes or a summary of any notes, if applicable. |

| |

|1. TB Control programs in the Tri-State Area report increasing numbers of TB patients from Ecuador who speak Quichua (not Spanish). Staff need |

|training in cultural competency and culturally-specific information to serve this group. |

| |

|2. Working Group on TB among Ecuadorian Migrants met in May 2006 and one of their recommendations was to organize training in cultural competency. |

| |

|3. TB surveillance data from the Tri-State Area submitted to the Centers for Disease Control and Prevention reveals that Ecuadorian migrants are now |

|among the top three countries of origin of TB cases in the area. |

| |

|TARGET AUDIENCE |

|Upon the assessment of the identified of needs, the target audience should then be determined. |

|Indicate the population for whom this activity is designed: |

| |

| |

| |Physicians: list specialty(ies): Infectious disease, internal medicine, pulmonary medicine |

| | |

| |      |

| |Other Health Care Providers: list area(s) of interest: Public Health Nurse Supervisors, Public Health Nurses, Physician Assistants, Nurse |

| |Practitioners, Managers of health care settings responsible for TB control, and nurse managers.       |

| |Other: please specify: Disease Control Investigators, Outreach Workers |

| |      |

|Any special background requirements necessary for effective learning? No Yes (please specify) |

|Participants must be responsible for implementing and enforcing TB control activities. |

|GOALS |

|We need to attract the physician’s attention otherwise he/she will never know about nor be interested in the activity. (NOTE: Research has shown that |

|physicians may not be aware of what they do not know.) This is best done by listing the overall goal(s) of the activity. What are you trying to |

|accomplish? What benefits will the physician accrue by attending this activity? Emphasize how goals are derived from the needs and applied to the target|

|audience. |

|Provide a brief synopsis of the activity’s overall goal(s): |

| |

|The goal of this course is to impart general principles of cultural and linguistic competency in TB control and use Ecuadorian examples to explore |

|in-depth how to work effectively with this culture. The information and skills imparted will also be generalizable – applicable to dealing with |

|patients from other countries, as well. |

|LEARNING OBJECTIVES |

|To fulfill the promise that the activity will be beneficial, the next step is the development of specific, individualized objectives. What should the |

|physician be able to accomplish after successfully completing the activity? Think of it as “What are the take-home messages the physician will leave |

|with?” With the new directive in continuing medical education on educational outcomes, what impact will this activity have on the physician’s |

|performance and patient care? |

|Complete the chart below indicating linkages between identified needs, learning objectives and anticipated outcome. |

|Identified Needs: Analyzing the data obtained and summarize the needs to be addressed. Why is there an interest in this subject? |

| |

|In many cities, counties, and states of the Northeast the majority of TB cases are occurring among foreign-born persons. In some program areas, Ecuador|

|is now among the top three countries of origin. Immigrants from rural areas of Ecuador present special difficulties because of the high incidence of TB|

|among this population and its historical alienation from the modern health care system. |

|Objectives: List 3-5 objectives the target audience should be able to achieve at the conclusion of the activity. |

| |

|Explain why cultural and linguistic competency are important for healthcare/TB control |

|Describe the differences between race, culture, and ethnicity |

|Describe the impact of one’s own health beliefs and experiences on health care service delivery |

|Name at least one area of knowledge, one skill, and one attitude necessary for developing cultural and linguistic competency |

|Describe at least three possible characteristics of Ecuadorian migrants and their experience with migration, health care systems, and tuberculosis |

|Demonstrate techniques for effective cross-cultural communication |

|Describe how to enhance organizational cultural competency |

|Anticipated Result: How will the information presented in this activity impact the clinical practice and/or behavior of the participants? Indicate how |

|this change could be reasonably measured. |

| |

|The knowledge, skills, and attitudes imparted in this course will equip participants with the tools to enhance both the individuals’ and their TB |

|control programs’ s competence to achieve successful outcomes of TB treatment and contact investigations, in order to continue progress toward the |

|elimination of tuberculosis. |

|At the conclusion of the course, participants will complete a brief survey regarding the value of the training and what changes they plan to implement |

|as a result of the learning activity. Follow-up surveys will also be sent to the participants 3 months after the course to determine changes in current |

|practices. |

|EDUCATIONAL DESIGN AND METHODS |

| |

|Please indicate the educational methods you plan to use in order to achieve the stated objectives and check the appropriate box of the teaching tools |

|being used. The activity should be structured to achieve the stated learning objectives. |

| | | |

| |LIVE COURSE |Traditional Teleconference (audio) Videoconference Internet |

| | |Mini-Residencies/Fellowships Other:       |

|Teaching Tools Used |

| Didactic Lectures | Audio/Video Presentations | Formal Discussion Group |

|Case Presentations |Hands-On Lab |Computer Program |

|Panel Discussions |Procedures Demonstration |Audience Response System |

|Q&A Sessions |Self-Graded Assessment |Other       |

|Workshops |Skills Session | |

|Indicate the method(s) of opportunities that will be incorporated into this activity that will allow the exchange of ideas between participants and |

|faculty. |

| Questions from the audience following each presentation |

|Formal question and answer segment(s) |

|Formal panel discussion session(s) with presentation of questions and cases from the audience |

|Interactive audience response system |

|Scheduled workshops and breakouts/tracks for discussion of a specific topic in-depth |

|Other: Demonstration of fit testing       |

| | | Newsletter/Monograph Audiotapes Videotape CD-ROM Internet |

| |ENDURING MATERIAL |Journal Article/Supplement Other:       |

|The learner must read/view listen/comprehend the entire educational piece and answer a series of multiple choice questions in order to fully participate|

|in the activity. |

|Teaching Tools Used |

| Case Studies/Presentations | Self-Graded Assessment |

|Didactic Material |Computer Interactive System |

|Panel Discussions |Chat Rooms |

|Q&A Sessions |E-Mail |

|Procedures Demonstration |Other:       |

|EVALUATION TOOL |

| |

|All educational activities should have a process to evaluate the educational effectiveness of the activity. The evaluation should address and measure |

|the following items: |

|( extent to which each of the educational |( adequacy of learning aids (audiovisual, syllabi, |( actual or perceived impact on the physicians |

|objectives were met |etc.) and facilities |professional practice/effectiveness |

|( effectiveness of each of the |( assessment of content as it relates to objectivity, |( identification of future educational needs |

|speakers/moderators/discussants |fair-balance and clinical relevance | |

|Please check the evaluation method(s) you plan to use: | |

| | |

|Formal questionnaire |Focus group at the completion of the activity |

|Follow-up questionnaire in the near future |CME Observer |

|Pre- and/or post-test |Interviews |

|Skills /performance assessment |Other:       |

|Informal discussion during the activity | |

|FACULTY SELECTION |

| |Attach a list of the proposed participating faculty including complete name, degree(s), academic rank, clinical title(s), department, and |

| |affiliation(s). |

| |Please see attached faculty list. |

| |

|Describe the process for identification and selection of the faculty, moderators and discussants: |

|     Faculty members were identified based on clinical expertise, knowledge and experience in TB infection control practices. |

|PROPOSED AGENDA |

| |Attach a proposed agenda based on the planning process including topics, inclusive times and participating faculty. |

| |See attached agenda. |

SECTION #3 - IMPLEMENTATION, MARKETING & BUDGET

|IMPLEMENTATION, MARKETING AND BUDGET |

|Will other parties (non-UMDNJ affiliated) be involved in the planning and implementation of this activity (communication companies, meeting planners, |

|convention bureaus, joint/co-sponsors)? Yes No |

| |

|If yes, please list companies, the individuals chiefly responsible, their credentials, and description of their anticipated roles. |

| |

|Bureau of Tuberculosis Control, New York City Department of Health & Mental Hygiene; Shama Ahuja, MPH, Martha Alexander, MHS and Xiomara Dorrejo, BS; |

|involved in planning agenda and presenting selected sessions. |

|Charles P. Felton National TB Center at Harlem Hospital; Bill L. Bower, MPH, Director of Education and Training; convenor of Working Group on TB among |

|Ecuadorian Migrants; overall course facilitator involved in planning agenda, coordinating logistics, moderating sessions, designing and conducting |

|evaluation. |

|Center for Immigrant Health, New York University School of Medicine; Francesca M. Gany, MD, MS, Director, Javier González, Sapna Pandya, MPH; involved |

|in planning agenda and presenting selected sessions. |

|Central Massachusetts Area Health Education Center; Germán Chiriboga; leading session about experience and world view of Educadorian migrants. |

|Rockland County (NY) Department of Health; Germaine Jacquette, MD (retired); involved in planning agenda and presenting selected sessions. |

|New York State Department of Health, Bureau of Tuberculosis Control; Margaret J. Oxtoby, MD, Director; planning and presenting selected sessions. |

|Will this activity compete with any other meeting(s) that could affect attendance? Yes No |

| |

|If yes, how will the competition not negatively affect this activity? |

|      |

|Estimated number of registrants 25 |

| |

|How were you able to come to this conclusion? |

|Based on the number of individuals who have expressed interest in the course content. |

|Has this activity been previously conducted? Yes No |

|If yes, but not as a UMDNJ activity, please attach copies of previous brochures/announcements/evaluation summaries |

|Has another sponsoring or certifying organization reviewed this activity? Yes No |

| |

|If yes, please explain. |

|      |

|SPONSORSHIP TYPE |

| | |

|UMDNJ sole sponsored activity |Co-Sponsorship with another accredited entity |

|Joint Sponsored with a non-accredited entity |UMDNJ as primary sponsor |

|Name of Organization       |Other accredited entity as primary sponsor |

|Other:       |Name of Organization       |

|CREDITS |

|Certification of AMA PRA Credit Hours Category 1 |

|Do you wish CCE to apply for other certification? Yes, Indicate the type below No |

| AOA (American Osteopathic Association) | Pharmacy |

|AAFP (American Academy of Family Physicians) |Social Worker |

|ACOG (American College of Obstetricians & Gynecology) |General CEU’s |

|Nursing |Other:       |

| MARKETING |

|How will the activity be publicized to prospective participants? |

|Geographic Area of the target audience: Northeast region of U.S. (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New Jersey, |

|New York City, New York, Philadelphia, Pennsylvania, Detroit, Michigan, Indiana, Ohio, West Virginia, Delaware, Baltimore, Maryland, and Washington DC.)|

| |

|Direct mail. List the mailing list source(s) (AMA, medical assoc./societies, etc)       |

| |

|Journal advertising. List the publication(s). |

|      |

| |

|Other marketing methods; please specify (ex.: distribution of brochures by the grantor’s sales force). |

|   Northeastern Regional Training and Medical Consultation Consortium Website, posting on the TB Education and Training Network listserv, email |

|announcement to TB programs within the Northeast region noted above.    |

|PRINTED MATERIALS |

|What forms of printed materials will be developed to promote this activity? |

| Announcement card (“Save the date”) | Materials posted at specific locations (e.g. hospitals) |

|Brochure |Other:       |

|Invitation-type letter with program materials | |

|FUNCTIONS, FACILITY AND MATERIALS |

|Indicate the needs that are required for this activity. |

|Meal Functions |

| Not applicable (e.g. enduring material) | Luncheon | Coffee break(s) |

| |Boxed Buffet Plated |Mid-morning Mid-afternoon |

|Breakfast | |Reception |

|Continental Buffet Plated |Dinner |Other:       |

| |Buffet Plated | |

|Facility Needs |

| | |

|Large conference room |Workshop breakout rooms (Number of rooms       ) |

|Small board-type room |Exhibition area |

|Reception area (food functions, registration, etc.) |Laboratory |

|Educational Materials |

| | |

|None |Posters, Educational |

|Syllabus, Handouts |Other       |

|SOURCES OF EXPECTED FINANCIAL SUPPORT |

|Check all that apply and complete that specific section. |

| | | | |

| |Sources, if known |Estimated Amount |Name of company, foundation, or organization, contact and phone|

| | | |number. |

| |Registration Fees |$375 | |

| | | |      |

| | Physicians |      | |

| | Residents/Fellows |      | |

| | Other Health Professionals |      | |

| | UMDNJ Faculty, Residents, Students, Staff |      | |

| | Other |      | |

| | School/Departmental Donation |      | |

| |Commercial Support (Grant) | | |

| | | |List as many as applicable, use additional sheet if necessary. |

| | |      |      |

| | | | |

| |Foundation Fund/Grant |$3167.50 |     NJDHSS TB Program (RTMCC Funds) |

| | | |Thomas Privett, (609) 588-7522 |

| | | | |

| |Federal/State Agency Award |      |      |

| | | | |

| |Exhibit Fees |      |      |

| | | | |

| |Other:       |      |      |

|BUDGET |

| | |

| |Attach a budget summary indicating your anticipated income and expenditures. |

| |See attached budget. |

ACADEMIC ENDORSEMENTS

The Activity Director and/or Co-Director must have a UMDNJ appointment and is responsible for the content, quality and scientific integrity of this activity. The Activity Director and/or Co-Director will develop this activity to conform with UMDNJ policies and guidelines, the ACCME Essential Areas and the AMA Ethical Opinion on Gifts to Physicians.

( Requirements for Obtaining Sponsorship & Credit Designation for Jointly Sponsored Activities # 50-20.req

Or

( Requirements for Obtaining Sponsorship & Credit Designation for Solely Sponsored Activities # 50.35.req

Or

( Requirements for Obtaining Sponsorship & Credit Designation for Solely or Jointly Sponsored Series # 50.25.req

( Guidelines for Needs Assessment # 40-20.gdl

( Disclosure Requirements # 50-05.req + # 50-10.req

( Requirements and Standards for Commercial Support of CE Programming # 50-60.req

( Guidelines for Promotional Brochure Development # 40-40.gdl

( Activity Faculty Letter Template # 40-10.gdl

|UMDNJ Activity Director (Medical Liaison or Advisor) and Joint Sponsor, if applicable |

|The Activity Director and Joint Sponsor, if applicable, signatures imply that the above stated polices and guidelines have been read, are understood, |

|and will be adhered to. |

| | |

| | |

|Activity Director Nisha Ahamed, MPH Signature |Date |

| | |

| | |

|Joint Sponsor Signature |Date |

|Department Chair – Academic Approval |

| |

|      |

|Name (Please Print) Jerrold J. Ellner, MD |

| | |

| | |

|Signature |Date |

|Center for Continuing and Outreach Education |

| |

| |

|Name (Please Print) |

| | |

| | |

|Signature | |

| |Date |

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