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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.)
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.
☐ 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)
☐ Legislative, regulatory, or organizational changes effecting patient care
☐ Other:
TARGET AUDIENCE (C4)
☐ Internal ☐ National ☐ Local/Regional ☐ International
Anticipated # of Participants:
Please select the audience for whom the activity is being planned.
☐Allergy ☐Hyperbaric Medicine ☐Physiatry
☐Anesthesiology ☐Infectious Disease ☐Plastic Surgery
☐Cardiology ☐Internal Medicine ☐Psychiatry
☐Dermatology ☐Nephrology ☐Pulmonology
☐Emergency Medicine ☐Neurology ☐Radiation Therapy
☐Endocrinology ☐Neuro Surgery ☐Radiology
☐ENT/Otolaryngology ☐OB/GYN ☐Rheumatology
☐Family Medicine ☐Oncology ☐Surgery CRS
☐Gastroenterology ☐Ophthalmology ☐Surgery General
☐Gynecology ☐Orthopedics ☐Thoracic
☐Hematology ☐Pathology ☐Urology
☐Hospitalists ☐Pediatrics ☐Vascular Surgery
☐All Specialties
