Fillable CME Application Department of Medical Education ACTIVITY INFORMATION (Northside Hospital)

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CME Application Department of Medical Education ACTIVITY INFORMATION (Northside Hospital)

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rev. 10.29.19
Page 1 of 7
Department of Medical Education
CME Application
ACTIVITY INFORMATION Definition of Continuing Medical Education (CME) – Continuing medical
education consists of educational activities, which serve to maintain, develop, or increase the
knowledge, skills, professional performance, and relationships that physician uses to provide services
for patients, the public, or the professions. The content of CME is that body of knowledge and skills
generally recognized and accepted by the profession as within the basic medical sciences, the discipline
of clinical medicine, and the provision of health care to the public.
Title of activity:
Date(s):
Time(s):
Location:
ACTIVITY DIRECTOR
Name:
Professional Title:
Address:
Telephone:
Email:
Administrative Contact:
Administrative Email:
Activity Planning Committee Individuals involved in design, development, and implementation.
(Each member must complete a Disclosure and Attestation form.)
Name and Credentials
Title/Affiliation/Practice
Email
Phone
☐ Additional planning members attached
rev. 10.29.2019
Page 2 of 7
Teaching Faculty Please attach CV.
Name and Credentials Title/Affiliation/Practice Email/Phone Admin. Contact
Name and Email
TYPE OF ACTIVITY (C3)
Course – symposium, workshop, conference (Agenda with speakers, topics, times, must be provided)
Regularly Scheduled Series (Case Conference)
1/month Quarterly
Frequency: 2/week 1/week 2/month
Other Live Video Conference to
Web Conf
erence (GoToMeeting, etc.)
Enduring Material
PROGRAM OVERVIEW (This synopsis will be used in marketing materials to give a brief overview of
what to expect.)
PLANNING PROCESS (C2-6)
Meeting minutes or emails can
be helpful in documenting the activity planning process. (Please attach here or
describe)
Who identified the speakers and topics?
CME Professional
Planning Committee Member
Activity Director
Other (provide
names):
What criteria were used in
the selection of speakers?(select all that apply)
Expert in subject matter Excellent teaching skills/effective communicator Experience in CME
Other:
Were any employees of a pharmaceutical company and/or medical device manufacturer involved with the
identification of speakers and/or topics? NO YES, please explain:
rev. 10.29.2019
Page 3 of 7
Expert Consensus (provide names and description of their input)
Literature review (provide summary)
National or local clinical quality, safety or performance data (describe)
Survey of target audience (provide survey results)
Prior program evaluations (provide or describe)
New medical information (describe)
External requirements such as: (NCQA, JCAHO, CMS, Prof Society, MOC requirements (describe)
PERFORMANCE GAP (C2)
State the healthcare quality improvement needs that are addressed by this activity. The difference between
what is happening (actual) and what should be happening (ideal). What problem are you trying to solve?
(Attach additional pages if necessary.) Practice gaps are based on underlying causes, such as a need for
knowledge about a particular topic, a need to improve competence (know when and how to apply new
strategies in practice) and/or improved performance (such as adoption of new skills or behaviors).
EDUCATIONAL NEEDS ASSESSMENT (C2, C3, C6)
Identify the need that exists for this program. How do you know this course is needed? Provide at least two
data sources used to identify educational need or clinical practice gap described above. For the data sources
chosen, provide a brief description of the source and the data.
Legislative, regulatory, or organizational changes effecting patient care
Other:
EDUCATIONAL FORMAT (C5)
Please identify the instructional formats of this activity:
Didactic Lecture Case Presentation Skills workshop Audience Response (pre/posttest)
Group/Panel Discussion Simulation Other:
TARGET AUDIENCE (C4)
Internal National
Local/Regional
International
Anticipated # of Participants:
rev. 10.29.2019
Page 4 of 7
Please select the audien
ce for whom the activity is being planned.
Allergy
Anesthesiology
Cardiology
Infectious Disease
Internal Medicine
Nephrology
Surgery - General
Surgery - CRS
Surgery - Neuro
Dermatology
Emergency Medicine
Endocrinology
Neurology
OB/GYN
Surgery-Thoracic
Surgery - Vascular
Urology
ENT/Otolaryngology
Family Medicine
Gastroenterology
Oncology
Ophthalmology
Orthopedics
Gynecology
Hematology
Hospitalists
Pathology
Pediatrics
Plastic Surgery
Physical Therapy
All Specialties
Psychiatry
Athletic Training
Other(please specify): Nurses (RN, LPN) Nurse Practitioners
Pulmonology
Radiation Oncology (RDT)
Radiology
Rheumatology
rev. 10.29.2019
Page 5 of 7
EDUCATIONAL LEARNING OBJECTIVES (C4)
Please list 3-5 objectives. Objectives should clearly link to the educational need, and should be attainable and
measureable. What will learners be able to do after the activity that they were not able to do before the
activity? Return the completed form by (due date).
At the conclusion of this activity, participants should be better able to:
1.
2.
3.
4.
5.
DESIRABLE PHYSICIAN ATTRIBUTES (C6)
CME activities should be developed to address physician core competencies as described by the ABMS and
ACGME. Please indicate which core competencies will be addressed in this activity.
☐ Patient Care or Patient Centered Care
☐ Medical Knowledge
☐ Practice-Based Learning and Improvement
☐ Interpersonal and Communication skills
☐ Professionalism
System-Based Practice
Interdisciplinary Teams Quality
Improvement
Utilize Informatics
Employ Evidence-Based Practice
FINANCIAL INFORMATION (C7, C8, C9, C10) (Complete Budget form is necessary)
This information is impor
tant for program evaluation and budgeting purposes and to allow the Department of
Medical Education to maintain necessary accreditation records. ACCME requires that commercial support for
CME activities be managed by the CME office, with all honoraria and other expenses paid through the DME.
Direct payment of expenses or participation in planning of program content by a commercial supporter is not
permitted.
Funding – This activity will be fund
ed by:
Registration fees E
Other: (please specify)
Are there any vendors th
at you regularly work with that could be contacted? Please list potential commercial
supporters:
If another organization is jointly organizing or developing this activity with you, please identify them here:
EVALUATION AND OUTCOMES MEASUREMENT (C11)
What change do you plan to meas
ure as a result of this activity:
Competence (i.e. Evaluation form for participants, Audience Response Systems, Case-based test,
Customized pre/posttest)
Performance (i.e. Demonstration of adherence to guidelines, direct observations, chart audits)
Patient Outcomes (i.e. Patient feedback/surveys, measure mortality and morbidity rates, observed changes
ducational Grants
Exhibit Fees
Originating Department Cost Center
rev. 10.29.2019
Page 6 of 7
in quality of care)
IDENTIFIED BARRIERS (C11)
Please identify factors outside of your control that may be a barrier to change:
Lack of time to assess or counsel patients Lack of consensus on professional guidelines
Lack of administrative support/resources
Cost
Insurance/reimbursement issues
No perceived barriers
Patient compliance issues
Other (specify):
BUILDING BRIDGES WITH OTHER STAKEHOLDERS
Occasionally, there are other internal and/or external stakeholders working on similar issues with whom
Northside may partner. Is this educational activity planned in collaboration and/or cooperation with other
stakeholders?
NO Yes, Please indicate other stakeholders
DISCLOSURE STATEMENT & ATTESTATION (C7)
Disclosure forms must be completed by the activity director and each member of the planning committee
Completed forms should be submitted with this application
MARKETING MATERIALS - The Department of Medical Education must develop or review and
approve all flyers, announcements, or brochures. Marketing materials may not be distributed
until the activity is approved for CME (including advertisements, web postings, etc).
ATTACHMENTS – Please attach the following to the application:
Tentative Activity Agenda (including session times)
List of confirmed/proposed faculty (including name, title, affiliation,
contact information, amount of honorarium, if applicable)
Curriculum Vitae for Activity Director and each faculty member
Supporting documentation for identified professional gap
Activity Director’s Agreement – signed
Preliminary Budget (if applicable)
rev. 08.27.20
Page 7 of 7
RETURN COMPLETED AND SIGNED APPLICATION
TO:
Should you have any questions or need assistance,
please call.
CME Contact 404-236-8419, medical.education@northside.com
Edye Mahaffey - 404-236-8418, edye.mahaffey@northside.com
Debbie Berman 404-236-8421, debbie.berman@northside.com
Submitted by: Date:
(Contact Person)
Electronic Signature: Date:
(Activity Director)
Northside Hospital Department Medical Education
975 Johnson Ferry Road, Suite 550
Atlanta, GA 30342
404-236-8419
medical.education@northside.com
CME Office Use Only
ACTIVITY TITLE:
ACTIVITY DATE:
# OF AMA PRA CATEGORY 1 CREDITS™
Approved as an initial planning tool, subject to modifications worked out in planning sessions
Proposed CME activity does not meet the accreditation criteria of the ACCME (see attached)
Proposed CME activity should be modified and resubmitted (see attached)
Proposed CME approval delayed pending receipt of additional information
Not approved
David Rodriguez, M.D. Date
Chairman, Northside Hospital CME Committee
SIGNATURES
SUBMIT APPLICATION
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CME Application Department of Medical Education ACTIVITY INFORMATION (Northside Hospital)

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Completed 6 June 2021

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