CME Activity Application CME Activity Application Activity Title * Organization * Activity Director * Activity Director Email * Administrative Contact * Administrative Contact Email * Proposed Activity Date * MOC Part II requested? * Yes No Please select one of the following: * Live Activity Enduring Activity Live Regularly Scheduled Series (RSS) Enduring Regularly Schedule Series (RSS) Journal Based CME Test Item Writing Manuscript Review If you choose Live Activity, please select one of the following Course Internet Live Course Regularly Scheduled Series (RSS) Learning from Teaching Proposed Activity Location * How many credits will this activity contain? * Please list the names of all individuals that have control over the content of the activity, and indicate their role next to their name. * Please have all individuals listed in the box complete a Disclosure Form at the following link: https://www.surveymonkey.com/r/OhioAAPCOI Professional Practice Gap (PPG) Criteria 2: The provider incorporates into CME activities the educational needs that underlie the professional practice gaps of their own learners. Knowledge - A gap in learner knowledge. Competence - A gap in the ability to apply knowledge. Performance - A gap in the actual application of knowledge to practice. Select the underlying professional practice gap (PPG) Knowledge Competence Performance Why does your target audience need to learn about this topic? Include evidence for the PPG. What sources were used to identify the current state of knowledge, competence, or performance? Each source checked must be cited or summarized below. Expert Faculty Physician Requests Peer-Reviewed Literature National Clinical guidelines Hospital/Clinic QA Analyses Other Please cite & summarize the sources checked above. The full text of your citations need to be sent to edawson@ohioaap.org Design to Change Criteria 3: The provider generates activities/educational interventions that are designed to change competence, performance, or patient outcomes as described in its mission statement. Your series will be designed to change Competence Performance Patient Outcomes Describe the ideal/desired state of knowledge, competence or performance: What sources were used to identify the ideal/desired state of knowledge, competence, or performance? Each source checked MUST be cited or summarized below. Expert Faculty Physician Requests Peer-Reviewed Literature National Clinical Guidelines Hospital/Clinic QA Analyses Other Please cite the sources checked above. The full text of these citations need to be sent to edawson@ohioaap.org What are the learning objectives for this activity? The ultimate goal of your activity must directly relate to the PPG previously selected. In addition, all learning objectives listed must be evaluated. Therefore, plan on incorporating your learning objectives into your method of evaluation of the activity. Examples: Knowledge/competence - "To increase knowledge regarding current diagnostics and treatment methods". Performance - "To increase the utilization of current evidence-based diagnostics and treatment methods". Patient Outcomes - "To decrease infection rates and improve patient satisfaction". Please describe your target audience. Explain how the content pertains to this target audience? Please be specific. Educational Format Criteria 5: The provider chooses educational formats for activities/interventions that are appropriate for the setting, objectives, and desired results of the activity. What is the educational format of the activity? Please all that apply. Symposium Didactic Lecture Case Presentations Panel Discussion Live Webinar Enduring-Internet Other What is the rationale for using the format selected above? Please be specific. Evaluation Criteria 11: The provider analyzes changes in learners (competence, performance, or patient outcomes) achieved as a result of the overall program's activities/educational interventions. Criteria 12: The provider gathers data or information and conducts a program-based analysis on the degree to which the CME mission of the provider has been met through the conduct of CME activities/educational interventions. All CME activities must be evaluated to assess the extent to which the program has achieved the change in competence, performance, or patient outcomes. Your method of evaluation will depend upon the PPG you selected. Examples: Competence - Physician self-report of intended application of new knowledge to their practice. Performance - Physician self-report on the application of the new knowledge to their practice. Patient Outcomes - Data, such as re-admittance rates, compared prior to the activity and 6 months later. How will you be evaluating this course? Please refer to the description in order to answer this question correctly, to avoid revision. Please be specific to your course & evaluation. I will send a 6 month post evaluation to attendees to assess change in practice based on the learning objectives of the course. I will send a 6 month post evaluation to attendees to assess change in practice based on the learning objectives of the course. Physician Competencies & Attributes Criteria 6: The provider develops activities/educational interventions in the context of desirable physician attributes [eg, Institute of Medicine (IOM) competencies, Accreditation Council for Graduate Medical Education (ACGME) Competencies]. What ACGME, ABMS or IOM competencies are associated with this series? Competencies and Attributes are national goals for physicians associated with targeted specialties that should be addressed in CME. Apply Quality Improvement (IOM) Utilize Informatics (IOM) Work in Interdisciplinary Teams (IOM) Patient - Centered Care (ACGME/ABMS) Practice - Based Learning (ACGME/ABMS) Systems - Based Practice (ACGME/ABMS) Interpersonal Communication Skills (ACGME/ABMS) Professionalism (ACGME/ABMS) Medical Knowledge (ACGME/ABMS What specific content in this activity address the selected competencies? MOC Part II Only Click here to view Evaluation/Assessment Examples. Learner Assessment Tool: Please select one of the following: Learner Assessment Tool: Please select one of the following: ----- Case Discussion Written responses Audience response system Quiz Table-top exercise Simulation Review of manuscript Writing test items Learning from teaching 1.Learner assessment description, please include what the passing standard is for the learner assessment mechanism. Examples are multiple choice question test, passing score, small group discussion, observation, and feedback during simulation: 2. UPLOAD - Learner assessment tool, the specific multiple choice questions used in the activity, the criteria use by a small group leader, skill demonstration in simulated setting or prompts for reflective statements Uploading Files. Please Wait. Drop a file here or click to upload Choose File Maximum upload size: 134.22MB 3. A description of the process by which feedback will be provided to learners; and if credit has been awarded, verification that the learner(s) successfully met the passing standard for the activity. Feedback to the participant must include learner results with rationale for correct answers or attainment of applicable skill(s) and include relevant citations where appropriate. 4. Speciality(ies) activity addresses: 5. (For enduring materials, journal-based CME and live activities.) Upload peer review documentation during the planning process from 2 non-author physicians. Drop a file here or click to upload Choose File Maximum upload size: 134.22MB Download from Survey Monkey form 6. Explain how the activity is relevant to physicians certified by the ABP, as demonstrated by the professional practice gap(s) and content of the activity. Funding Criteria 7: The provider develops activities/educational interventions independent of commercial interests. (SCS 1, 2, and 6). It is the policy of the Rochester Academy of Medicine (RAM) to ensure balance, independence, objectivity, and scientific rigor in all educational activities. Will you be seeking commercial support for this series? Yes No Unsure From which companies are you seeking commercial support? Only if you selected yes to the above question. Will you have exhibits/vendors during this series? Yes No Unsure If you selected "No" to the above 2 questions: How will your series be funded? Include all sources of funding. Barriers to Change Criteria 18: The provider identifies factors outside the provider's control that impact on patient outcomes. Criteria 19: The provider implements educational strategies to remove, overcome or address barriers to physician change. What could block the learner from implementing the new learned behaviors, strategies, or skills taught? Patient Noncompliance Lack of time with patients Health insurance coverage Poor disciplinary communication Lack of Administrative Support Other Are there any ways to remove, overcome, or address these barriers? Building Bridges with Stakeholders Criteria 20: The provider builds bridges with other stakeholders through collaboration and cooperation. Are there other initiatives within your organization working on this issue? Yes No Unsure Attachment Checklist Needs Assessment Documentation Planning Meeting Notes and Emails (email to edawson@ohioaap.org) Speaker Bios and CVs Signed Commercial Support LOAs (if applicable) Signed Exhibit Agreement (if applicable) Preliminary Budget Draft Agenda Draft Promotional Materials
