subject_line
MetroHealth Medical Center
CME
Conference Application
Questions or concerns?
Please contact
Steven Ostrolencki
at
216-778-1175
or
Carrie Henceroth
at
216-396-1136.
Please Note:
This form must be completed in one session. You will be asked to upload and attach the following documents:
• Complete Program Schedule (Including: dates, times, topics, and speakers.)
•
Faculty Disclosure Form [PDF]
(This must be completed by all activity planners, faculty/presenters,
and staff participating in this activity.)
• Sources of information used to identify practice gap.
• If the CME activity will receive commercial support,
Written Agreement for Commercial Support [PDF].
CME Activity Director / MetroHealth Faculty Member
First Name
*
Last Name
*
Email Address
*
Department/Program
*
Degree
*
Phone Number
*
Meeting Planner/Staff Coordinator #1
First Name
*
Last Name
*
Email Address
*
Department/Program
*
Phone Number
*
Meeting Planner/Staff Coordinator #2
First Name
*
Last Name
*
Email Address
*
Department/Program
*
Phone Number
*
Activity Information
Activity Title
*
Activity Type
*
Grand Rounds
Tumor Board
M&M Conference
Journal Club
Other
New or Repeat Activity?
*
New
Repeat
If Other Activity Type, please specify:
Activity Dates and Location
Start Date
*
End Date
*
Start Time
*
End Time
*
Day of Week
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Frequency
*
Location City
*
Location State
*
Please list any additional start/end dates or locations, if applicable.
*
Program Schedule
Please insert a completed schedule which includes dates/times/topics/speakers. If you do not have this information for the entire fiscal year, please submit for at least 3 months and the outline for the year and follow up with the details, when available.
I will submit at a later date.
*
Yes
No
How many credits are you requesting?
*
Faculty/Planning Committee
Please provide a complete list of faculty/presenters, course director(s), and planning committee; including title and affiliation. Note: Each committee member
must
sign a
disclosure form
[PDF] .
At least three planners are required. Click the PLUS sign to add rows.
+
-
Additional Members
*
Estimated Attendance # and Target Audience
MDs/DOs
*
Non-MDs
*
Target Audience including specialties (required in all promotional and syllabus materials). Select all that apply:
*
MD/DOs
Psychologists
Social Work
NP/PAs
Nurses
Scientists/Researchers/PhDs
Other (specify and indicate specialty)
Other (specify and indicate specialty)
Practice Gap
The ACCME describes a professional practice gap as the
difference between what the target audience does now vs. ideal or best practices
. Please describe the professional practice gap that this educational activity will address.
*
Please indicate the educational need(s) that this activity addresses. Select all that apply:
*
Increased Knowledge
Increased Competence
Improved Performance
Needs Assessment
What source of information did you use to identify your practice gap? Select all that apply:
*
Expert faculty opinion
Prior activity feedback
Focus groups
Practice guidelines
Literature review or journal article
Medical record review
Morbidity and mortality data
Patient outcome review
Patient safety data
Quality improvement data
Public health statistics
Research finding
Patient survey
Admission/discharge diagnosis data
Referral patterns
Licensure requirements
Risk management/compliance
Specialty curriculum requirements for training, certification or maintenance of certification
Other
Other
If available, attach your practice gap source of information here. (Allowed extensions: *.doc, *.docx, *.jpeg, *.jpg, *.pdf, *.ppt, *.pptx, *.txt, *.xls, *.xlsx)
Core Competencies
CME activities should address core competencies as determined by national or specialty society, specialty credentialing boards, or other sources of national priority. Please indicate the competency and/or other desirable physician attributes that would be used/address in the development of this activity.
Select all that apply:
Accreditation Council for Graduate Medical Education (ACGME) / American Board of Medical Specialties (ABMS)
*
Medical knowledge
Patient care
Practice-based learning
Interpersonal and communication skills
Professionalism
Systems-based practice
Institute of Medicine (IOM)
*
Provide patient-centered care
Work interdisciplinary teams
Utilize informatics
Employ evidence-based practice
Apply quality improvement
Other
Other
Objectives
Based on the need/professional practice gap identified, what are the learning objectives of this activity? These objectives should be measureable and include the increased competence and/or improved performance and/or improved patient outcome that you wish to address in this activity. Please use
How to Prepare Educational Objectives [PDF]
to formulate.
At the end of this CME activity, participants should be able to:
(
3 answers are required
. Click the PLUS sign to add rows)
*
+
-
Please indicate how these objectives will be communicated. Select all that apply:
*
Website
Brochures/Flyer
Email
Other
Other
Format/Methodology/Design
Considering the setting, objectives and desired results, what format(s) will you use to promote the changes identified in your objectives? Select all that apply:
*
Live activity
Internet webinar-live activity
Enduring material (e.g. CD/DVD, monogram, web-based)
Other
Other
Please indicate the instructional methods that you tend to use. Select all that apply:
*
Case presentations
Laboratory activity (e.g. animal lab)
Lectures with questions & answers
Panel discussion
Small group discussion
Standardized or Live Patients
Stimulated patients
Symposium
Workshop
Other
Other
Is the format appropriate for the activities’ setting, objectives and desired outcomes?
*
Yes
No
Barriers
CME activities should give consideration to the system of care in which the learner will incorporate new or validate existing learned behaviors. What potential barriers do you anticipate the learner may encounter when trying to make the changes this activity is designed to promote? Select all that apply:
*
Cost
Lack of time
Lack of administrative support/resources
Insurance/reimbursement issues
Patient compliance issues
Lack of consensus on professional guidelines
Formulary restrictions
No relevant barriers
Other
Other
In this CME activity, how will you incorporate strategies to remove, overcome or address these barriers?
*
Non-Educational Strategies
In the process of planning this activity, what non-educational strategies will you utilize to enhance the changes this activity is promoting? Select all that apply:
*
Provider reminders
Provider feedback
Patient surveys
Standing orders
No non-educational strategies will be used
Others
Others
Evaluation and Outcomes
The MetroHealth CME mission and the Ohio State Medical Association (OSMA) require that every CME activity be designed to change physician competence, and/or performance, and/or patient outcomes.
Which of the following outcomes is the activity designed to facilitate?
Note:
Follow-up reports/data will be required for each item selected below. Select all that apply:
*
Increased competence (learner developed new strategies)
Improved performance (learner implemented new strategies/made an actual change in practice)
Improved patient outcomes
How will you measure if changes in Competence, Performance or Patient Outcomes have occurred? Select all that apply:
*
Competence: Post-activity evaluations - Evaluation questions might include: a) Ways in which the learner will improve care to patients. b) Ideas that will be useful in care of patients. c) Will you make a change in your current practice? If so, what?
Competence: Pre- and post-tests – Identical tests measure self-perception of competence
Competence: Post-tests that cover key ideas, skills, or strategies
Competence: Case studies and audience response system during the activity- ask physicians to make decisions to evaluate competence
Competence: Roll-playing exercises
Performance: 4 or 6 month post-activity survey – survey questions might include: Did you make a change in your practice based on what you learned in the activity? Why or why not?
Performance: Evaluation/testing during the activity – hands-on workshops and stimulations with a trainer
Performance: Evaluation/observation at a later date – Live patient care setting or stimulation exercise
(refresher)
Performance: Review of internal performance data/QI and other data
Performance: Patient surveys (exit surveys)
Patient Outcomes: Measures of quality metrics already being used by MetroHealth
Patient Outcomes: QI data comparisons (over time)
Patient Outcomes: Chart audits that test the new strategy
Patient Outcomes: Patient surveys (e.g. Press Haney, HCAHPS)
Patient Outcomes: Claims data (before/after)
Other
Other
Commercial Support
Will the CME activity receive commercial support from a pharmaceutical, medical device company or other commercial entity? Support includes financial and in-kind grants or donations. Exhibit fees are NOT considered education program commercial support. View our
Commercial Support Policy [PDF].
*
Yes
No
If yes, please review the
ACCME Standards for Commercial Support
. Do you agree to abide by them?
Yes
No
Honoraria
Will speaker(s) receive an honorarium and/or reimbursement?
*
Yes
No
If yes, payments must be made in compliance with the MetroHealth CME office’s written
Policy on Honoraria and
Reimbursement [PDF]
as well as the
ACCME Standards for Commercial Support
.
If yes, what is the source of payment? For Jointly Provided activities, payments must be made in compliance with MetroHealth CME office’s written
Jointly Provided Policy on Honoraria [PDF]
as well as the
ACCME Standards for Commercial Support
.
Commercial Support
Department Funds
Other
Other
Course Director Signature (MetroHealth Faculty Member)
Name
*
Date
*
Note: By submitting this form, you agree your electronic signature is the equivalent of your written signature.
Electronic Signature
*
clear
Conflict of Interest/Disclosure
All activity planners, faculty/presenters and staff participating in this activity must complete a
Faculty Disclosure Form [PDF].
Disclosure forms must be updated every 12 months.
Email
ccrane1@metrohealth.org
if you have any questions.
CME Credit will not be awarded for this activity until all disclosure forms are received and reviewed. All completed forms must be sent to the CME Office at the email address below:
Email:
ccrane1@metrohealth.org
Fax: 216-778-5862
Upload Completed Conflict of Interest/Disclosure
*
Letters of Agreement for Commercial Support
Letters of Agreement are
required
for all commercial support.
All Letters of Agreement (LOAs) for educational grants
must be completed
and signed by a MetroHealth CME Specialist (accredited provider) and the commercial supporter (exhibitors exempt) and then returned to
Steven Ostrolencki
in the CME Department
prior to the start of the activity.
Letters can be scanned to expedite approval and signatures.
Written Agreement for Commercial Support [PDF]
All disclosures must be sent to
sostrolencki@metrohealth.org
prior to application being reviewed for approval.
Upload Completed Letters of Agreement
*