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 |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- budget planning worksheet printable pdf
- free financial planning worksheet excel
- global research center for globalization
- financial planning worksheet template
- financial planning worksheet excel
- navy financial planning worksheet excel
- financial planning worksheet printable
- basic financial planning worksheet pdf
- financial planning worksheet navy
- financial goal planning worksheet pdf
- goal planning worksheet pdf
- estate planning worksheet printable