CME Activity Application – Planning Process "*" indicates required fields Activity Planning ProcessCurrent Concepts Institute collects this information to evaluate an activity. Completion of all sections of this form and supporting documents are necessary to meet our accreditation requirements. For information about ACCME accreditation please review accreditation rules at www.ACCME.org.Activity Title* Who identified the speakers and topics?*Check all that apply. Activity Director Activity Co-Director Administrative Coordinator Planning Committee Include the Planning Committee meeting minutes or other documentation of the planning process.*Max. file size: 1 GB.What criteria were used in the selection of presenters?*Check all that apply. Excellent teaching skills/effective communicator Subject matter expert Experienced in accredited continuing education Other If Other please describe hereWere any employees of an ineligible company involved with the identification of presenters and/or topics?* Yes No If Yes, please explain.Upload a presenter list including an email address. Each will be contacted for financial disclosure information.*Max. file size: 1 GB.Clinical ContentAre recommendations for patient care based on current science, evidence, and clinical reasoning, while giving a fair and balanced view of diagnostic and therapeutic options?* Yes No Does all scientific research referred to, reported, or used in this educational activity in support or justification of a patient care recommendation conform to the generally accepted standards of experimental design, data collection, analysis, and interpretation?* Yes No Are new and evolving topics for which there is a lower (or absent) evidence base, clearly identified as such within the education and individual presentations?* Yes No Does the educational activity avoid advocating for, or promoting, practices that are not, or not yet, adequately based on current science, evidence, and clinical reasoning?* Yes No Does the activity exclude any advocacy for, or promotion of, unscientific approaches to diagnosis or therapy, or recommendations, treatment, or manners of practicing healthcare that are determined to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients?* Yes No How will the stated learning objectives be communicated to the learner?*Check all that apply. Website Brochures/Flyer Email Other If Other please describe herePlease indicate the instructional methods that will be in use for this activity.*Check all that apply. Lectures with questions and answers Roundtable discussion Panel discussion Case presentation Small group discussion Pre and/or post test Symposium Other If Other please describe hereExplain why the above educational format is appropriate for this accredited continuing education activity. (250 character maximum)*Needs Assessment Sources: Select all that were used to identify the practice gaps.* Expert faculty opinion Expert panels Prior activity feedback (course evaluation) Focus groups, discussions/interviews Physician groups Practice guidelines Literature review or journal articles Medical record review Morbidity and mortality data Patient outcome review Specialty curriculum requirements for training, certification or maintenance of certification Quality improvement data Public health statistics Research finding and new technology Patient survey Patient safety data Admission/discharge diagnosis data Referral patterns Licensure requirements Risk management/compliance Patient survey Other If Other please describe hereIdentify any ACGME/ABMS competencies that were considered when identifying the professional practice gap(s) and planning your educational activity?*Check all that apply. Patient Care and Procedural Skills Medical Knowledge Practice-based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-based Practice Identify any Institute of Medicine competencies that were considered when identifying the professional practice gap(s) and planning your educational activity?*Check all that apply. Provide Patient-centered Care Work in Interdisciplinary Teams Employ Evidence-based Practice Apply Quality Improvement Utilize Informatics Identify any Interprofessional Education Collaborative competencies that were considered when identifying the professional practice gap(s) and planning your educational activity?*Check all that apply. Values/Ethics for Interprofessional Practice Roles/Responsibilities Interprofessional Communication Teams and Teamwork Evaluation and OutcomesHow will knowledge/competence be measured?*Check all that apply. Evaluation form for participants (required) Audience response system (ARS) Pre- and post-tests that cover key ideas, skills or strategies. Physician and/or patient surveys Role-playing exercises Other If Other, please describe hereHow will the changes in performance outcomes be measured?*Check all that apply. Adherence to guidelines Case-based studies Customized follow-up survey/interview/focus group about actual change in practice at specified intervals Evaluation/testing during the activity Direct observations Other If Other, please describe hereHow will changes in patient outcomes be measured?*Check all that apply. Chart audits Observe changes in quality/cost of care Observe changes in health status measures Measure mortality and morbidity rates Obtain patient feedback and surveys Other If Other, please describe hereCommercial Support & ExhibitsWill this accredited continuing education activity request commercial support from ineligible companies? Support includes financial and in-kind grants or donations. An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. NOTE: Exhibit fees are NOT considered commercial support.* Yes No Attach a list of all prospective commercial support known at this time and the amount being requested from each.Max. file size: 1 GB.What percentage of your expenses do you anticipate will be covered by commercial support?*Exhibits: Will eligible and/or ineligible companies be encouraged to exhibit or offered other promotion opportunities in conjunction with the activity?* No Yes If Yes, please explain Attach a list of all prospective exhibitors known at this time.Max. file size: 1 GB.What are the other sources for funding this CME activity?*Check all that apply. Funds from non-accredited organization Support from a not-for-profit philanthropic entity Government Tuition fees from registrants Support from a commercial entity NOT producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. AgreementAgreement:*I attest that this activity has been planned and is in compliance with the ACCME standards. I will ensure the timely submission of all materials required and listed within this agreement in the requested format(s). I have the authority to approve payment of all fees as indicated in this agreement. Acknowledged Full Name* Email* Enter Email Confirm Email Signature*
