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Continuing Medical Education Application for Designation of CME Credit

(Montana)

CME Office Use only # Credits:

Activity Number

CME Executive Director

Approval Jessica Minick, MPA OR Vice Dean/CME Chair

Approval Suzanne M. Allen, MD

Submit application to: University of Washington - CME Office Box 359558 Seattle, WA 98195

*************************************************************************** Activity Title: Activity Date(s): Activity Chair(s): Organization Name:

1. ACTIVITY TYPE What type of educational activity are you planning? (check one)

Live symposium, course, conference Enduring material (print) Regularly scheduled series (Grand Rounds,

Tumor Board, etc.) Enduring material (CD or DVD)

Live Video Conference Enduring material (internet) Live Web-cast Other - explain

2. ACTIVITY DESCRIPTION Please provide a paragraph, not to exceed 150 words, describing the general focus, content, format and educational methodology for this activity (this description will be used in marketing flyers and brochures). LOCATION

Venue Name

City/State

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3. PLANNING

A. PLANNING COMMITTEE: A member of the Montana Medical Association must be the course chair or on your planning committee. Completed Disclosure and Attestation forms must be attached to the application for all committee members

Committee Members: Please note who is the MMA member Activity Chair:

Name (s): Department/Division/Affiliation

Planning Members:

Name (s):

Department/Division/Affiliation

B. NEEDS ASSESSMENT: How was the educational need/practice gap for this activity identified? Place an X by each source utilized to identify the need for this activity. Attach copies of documentation for each source indicated (required)

Method: Example of required documentation: Previous participant evaluation data Copy of tool and summary data Research/literature review Abstract(s) or articles Expert Opinion Summary Target audience survey Copy of tool and summary data Data from public health sources Abstract, articles, references Other (describe)

C. PRACTICE GAP ANALYSIS:

1 - Describe the problems or gaps in practice this activity will address (physician knowledge, competence, or performance) and how you assessed or measured these issues. (The description must answer these questions - What are you trying to change? What is the problem? Whose problem is it? How do you know? )

2 - Describe the needs of learners underlying the gaps in practice. (The description must answer these questions - What are the causes of the gaps in practice? Why does the gap exist? What do learners need to be able to know or do to be able to address the gaps?)

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D. ACTIVITY OBJECTIVES (LEARNER BASED) Based on the results described (F), state at least three or more things that physician participants should be able to do after they participate in this CME activity. (list as many as apply) Upon completion of this activity, attendees should be able to: E. What ACGME or IOM related competency is associated with this activity? (see descriptions of competencies in procedures document) (check all that apply) Patient Care Practice-based learning and

improvement Medical/Clinical

Knowledge Communication Skills Professionalism Systems-based practice Quality Improvement Utilization of Informatics Evidence-based Practice

F. Based on the needs/gaps described above, what is the activity designed to change ? (check which will apply) Competence (knowing how to do something)

Selecting this option requires that the CME activity being planned provide participants with an opportunity to: • hear information related to advances or best practice • hear examples of application in practice of information presented

Performance (actually doing something) Selecting this option requires that the CME activity being planned provide participants with an opportunity to:

• practice what they have learned during the CME activity • receive feedback about doing what they have learned during the CME activity

1. What potential barriers do you anticipate attendees may encounter in incorporating new knowledge, competency, and/or performance objectives into their practice? (select all that apply)

Lack of time to assess or counsel patients

Lack of administrative support/resources

Insurance/reimbursement issues

Cost Patient Compliance Issues Lack of consensus on professional guidelines

No perceived barriers Other - describe 2. Describe how will this educational activity address these potential barriers?

G. RESULTS:

Based on E & F above, please describe the results expected (outcomes) for this activity in terms of specific improvements in patient care or other work related to the practice of medicine.

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H. What data will you use to measure your success? (describe) Attach a copy of your evaluation tool. (Utilize the template form provided by the CME Office – additions may be made to that form as needed

or attach copies of pre and post test or case scenarios)

I. DESIGN & METHOD Indicate the format(s) to be utilized in order to achieve the objectives (check all that apply) Lecture Audience response system Demonstration Video presentation Audio presentation Teleconference Case presentation Panel discussion Procedure lab Skills workshop Small group workshop/discussion Web-Based/Internet Other (describe)

1. Other Non-Educational Strategies What other non-educational strategies are happening in your department/organization that could be used to enhance change in your learners as an adjunct to this activity. Example include patient surveys, patient information packets, email reminders to the learner (i.e. summary points from the lecture, or new information), posters, department newsletters, etc. Describe below other non-educational strategies occurring in your department/organization that could be used to enhance your learners’ change as an adjunct to this activity J. TARGET AUDIENCE (describe the physician attributes or specialties, other health professions and geographical areas) K. PLANNING PROCESS Describe the planning process utilized by the planning committee linking the identified educational needs/practice gaps described in section “C” to the content, speaker selection, format and expected results for this activity. (1-2 paragraphs if possible or attach other documentation such as meeting minutes or notes)

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4. ACTIVITY AGENDA

(select A, B, or C below as relevant to your activity)

A. CONFERENCES (Make as many copies as needed or attach a copy of your agenda in another format)

Activity Title:

Day/Date:

MORNING Note: Be sure to include any break times and the time

of adjournment each day.

Time

Lecture Title

Speaker Name

LUNCH Adjourn

Evening

B.REGULARLY SCHEDULED CONFERENCES (Series) (RSC’s are approved for no more than 12 months)

Day of the Week (Mon, Tues, etc.) Time of Day (8-9am, etc) # of times per month/year (every week, 3rd week each month, monthly, etc)

Total number of sessions for the year C.ENDURING MATERIALS

Estimated time to complete the material (hours) If module based – indicate number of modules and time for each

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5. Speaker Biographical Data Please complete the form or attach a CV or Biosketch for all presenters Activity Title: Activity

Date:

Speaker/Faculty First Name Middle Initial Last Name Degrees Academic or other Title Department Division School or Institutional Affiliation Email Daytime Phone FAX Other Affiliations for listing in publicity (e.g. Director, Alzheimer’s Disease Research Center) Mailing Address Box Number City State Zip

OBJECTIVES Fill this portion out for each lecture. Title of your lecture: Objectives for presentation At the conclusion of this presentation, attendees should be able to: 1. 2. 3.

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6. DISCLOSURE The University of Washington School of Medicine policy requires that all speakers complete a Speaker Disclosure and Attestation form. Completed forms for each speaker must accompany the application (see attachment sections). Attach all forms and complete the syllabus disclosure summary page. For series applications, you must include space on your evaluation form to provide the disclosure information each session (attach disclosure forms for at the first three sessions in your series)

7. HONORARIA : Please indicate all honoraria that will be provided Speaker/Faculty Amount of Honoraria

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8. COMMERCIAL INVOLVEMENT: A. Do you plan to apply for commercial support (educational grants)? ____ NO ____ YES (provide the information requested below) - List those companies that you plan to make applications to. - Please forward any updates to this list to UW/CME. - A completed letter of agreement must be signed by the UW CME Office, your organization and the commercial supporter for all educational grants before the activity begins. (designate your organization as the joint sponsor or the educational partner)

COMPANY NAME AMT OF GRANT REQUEST B. Do you plan to have exhibitors at this CME activity? ____ NO ____ YES (provide the information requested below) List those companies that you plan to make invite to exhibit. Please forward any updates to this list to UW/CME. UW CME policy requires exhibitors pay the exhibit fees established for the activity. Exhibit fees cannot be waived based on approval of grant funding.

COMPANY NAME AMT OF EXHIBIT FEE ALL commercial involvement (grants and exhibits) must be acknowledged and announced to the participants. Utilize the templated form provided by the CME Office.

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9. FINANCIAL

University of Washington School of Medicine Office of Continuing Medical Education

Summary of CME Finances Activity number __________________ Name of Activity Date of Activity

REVENUE BUDGETED ACTUAL Registration Fees Exhibit Fees Commercial Support (Educational Grants) Other Revenue, Specify: TOTAL REVENUE DIRECT EXPENSES BUDGETED ACTUAL Speaker Expenses Speaker Fees Staff Expenses Recruitment Expenses (brochure, mailing, etc.) Food and Beverage Service Facilities Course Materials Audio-visual Other Expenses, Specify: TOTAL DIRECT EXPENSES INDIRECT EXPENSES BUDGETED ACTUAL CME Application Fee CME processing fees Other Indirect Costs, Specify: Overhead (UW only) TOTAL INDIRECT EXPENSES BUDGETED ACTUAL TOTAL EXPENSES (Direct + Indirect) BUDGETED ACTUAL DIFFERENCE (Total Revenue - Total Expenses)

Please note:

*Financial information for this CME activity in this budget format must accompany this request for credit. *The budget must be approved by the CME Office before this request for credit can be approved. *A financial summary using the same format must be submitted with the final paperwork after the CME activity.

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10. Publicity and Accreditation - Please note that all publicity, (i.e., advertisements, brochures ,websites, flyers) must be approved by the CME office prior to their release. - No publicity will be approved by the UW/CME office prior to approval of this application with the exception of “save the date” notices. - All “Save the Date” flyers must be approved by the CME Office prior to distribution. Please see instructions in application packet. A. Please briefly describe your marketing plan (advertising, brochures, email, etc.) B. Are you planning to advertise this activity on a website?

yes no

If yes, please provide the website url (address):

Website listings must contain all of the same information contained in the approved hard copy marketing material. Website postings must be approved by the CME Office prior to activation. C. Please indicate the geographical areas planned for marketing this activity: Regional National International OTHER (describe)

11. ACCREDITATION: UW Continuing Medical Education only designates activities for AMA PRA Category 1 credit™. Please indicate the other types of accreditation you may be applying for: Nursing Contact Credits AAFP ACOG Other (describe)

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CME FEES Application fee: Regularly Scheduled Series, Course or Conference $ 650 8 hours or less $ 950 16.25-64.0 hours $ 800 8.25-16.0 hours $ 1200 64.24 hours or more Processing fee: (per person/pp)

$25 pp 8.0 hours or less $35 pp 8.26-16.0 hours $45 pp 16.25- 64.0 hours

$55 pp 64.25- 99.75 $65 pp 100 hours or more

Application Fee: payment must accompany application Processing Fee: To record and issue certificate per participant requesting credits

Please select one of the options for the processing fee: Participants will pay the fee directly to UW/CME We will collect the Attendance Verification Form and forward them along with fee per participant to UW/CME. APPROVAL This CME activity, the content and presenting speaker, must be approved and signed by the activity chair, the MMA member and the activity administrator. Signatures indicate that this proposed activity has been developed in accordance with the ACCME Essential Areas and adheres to the Standards of Commercial Support and will provide valid clinical content. Specifically,

1. All the recommendations included in this CME activity involving clinical medicine are based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.

2. All scientific research referred to, reported or used in this CME activity in support or justification of a patient care recommendation will conform to the generally accepted standards of experimental design, data collection and analysis.

Name:

MMA Member (if not activity chair) (Type or Print) Signature of MMA Member I approve the sponsorship of this CME activity by my organization and accept responsibility on behalf of my organization for the financial outcome as outlined in the attached budget. Name:

Activity Chair (Type or Print) Signature of Activity Chair Name:

Activity Administrator (Type or Print) Signature of Activity Administrator CONTACT INFORMATION Indicate the contact person responsible for ensuring that the CME Essential Areas and Policies of Accreditation are upheld for this activity and providing UW/CME with the required documentation. Contact Name

Organization

Email address

Mailing address

City, State Zip

Phone Number

Fax Number

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APPLICATION

ATTACHMENTS

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PLANNING COMMITTEE

DISCLOSURE FORMS

Insert all completed disclosure and attestation forms for the activity chair and planning committee members behind this section

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NEEDS ASSESSMENT DOCUMENTATION

Insert all copies of needs assessment documentation indicated

in the application behind this section

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EVALUATION FORM TEMPLATE

Insert a copy of the completed evaluation tool to be utilized

in this activity behind this section

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PLANNING PROCESS

DOCUMENTATION (if applicable)

Insert planning notes behind this section

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ACTIVITY AGENDA

OR SCHEDULE

Insert the entire activity agenda or schedule behind this section

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SPEAKER

BIO FORMS

OR CV’S

Insert all completed bio forms or CV’s behind this section

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SPEAKER

DISCLOSURE AND ATTESTATION

FORMS

Insert all completed disclosure and attestation forms for speakers behind this section

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DISCLOSURE SUMMARY FORM

SYLLABUS FORM OR

EVALUATION TEMPLATE (Series only)

Insert all the completed disclosure summary form behind this section

(for series insert a copy of the evaluation form with the completed disclosure section)

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MARKETING

DRAFT

(if ready)

Insert a copy of the marketing piece behind this section