Continuing Medical Education Activity Request Form

Activity Information

Thank you for considering a faculty role with East Tennessee Children’s Hospital’s (ETCH) Continuing Medical Education (CME) Program. ETCH CME is accredited by the Accreditation Council for Continuing Medical Education (ACCME). The ACCME employs a rigorous, multilevel process for evaluating institutions' continuing medical education programs. This rigor ensures the community and the public that ETCH develops and implements relevant, effective, practice-based continuing medical education that supports the health of children and adolescents. The Children’s Hospital CME: Content Validation Policy and Program Development Guide provide information/guidelines to ensure your content focuses on improving healthcare and is free of any other influence. Please utilize these as you develop your activity content.

As a beginning step to planning the activity, please address the information/questions below.

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* 1. Requestor Contact Information

Name

Cell number

Best email contact

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* 2. Activity Information

Proposed Faculty

Proposed Topic

Proposed Date(s)

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* 3. In a broad sense, what is the largest problem or "gap" in professional practice associated with the issue? 50 word minimum.

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* 4. Would you consider this a gap in

Knowledge (knows)

Competence (knows how)

Performance (shows, behavior in practice)

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* 5. Who would you consider to be the most appropriate target audience? In other words, describe the groups of healthcare providers that need to learn about what you are going to teach.

Disciplines:

All Providers: Physicians, NPs, PAs

All Other Clinical Staff: Pharmacists, Psychologists, PCAs, RTs, Dieticians, etc.

All Nurses

All Direct Patient Contact Support Staff: Social Work, Interpreters, Pastoral Care, Child Life, etc.

Other (please specify)

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* 6. When considering the content focus, what are the applicable practice settings of the disciplines indicated above?

Practice Setting:

Inpatient

Emergency Department

Primary Care

All Subspecialty Areas: Neonatalogy, Intensive Care, Gastroenterology, Cardiology, Urology, Neurology, etc.

Community Resources: Minute Clinic, School Nurses, Athletic Trainers, etc.

Other (please specify)

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* 7. What are the specific learning needs that cause the professional gap you identified? In other words, what specifically will you be teaching providers about? 50 word minimum

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* 8. Which core competencies will you cover (select all that apply)?
More information about the core competencies is available on the ABP website.

Patient Care

Medical Knowledge

Practice-based Learning and Improvement

Interpersonal and Communication Skills

Professionalism

Systems-based Practice

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* 9. What resources will you use to develop your content?

Clinical guidelines

Professional association recommendations

Evidence based practice models

Recent literature

Other (please specify)

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* 10. What teaching format would you like to use?

Presentation slides

Case studies

Group discussion

Audience Response System

Other (please specify)

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* 11. Are there any barriers that providers may identify as outside of his/her control, but prohibitive of the change CME is trying to influence? If any are identified, please address the perceived barriers directly in your content.

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* 12. A downloadable handout will be created from any presentation slides you provide. This will be made available before and after the activity via https://etch.webex.com/..

Will you have any additional educational materials to provide to participants?

Clinical Guideline

Practice Tool

No Other Materials

Algorithm

Other Handout

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* 13. Working through this information creates opportunity to focus on your content. As a result, you should now be able to identify a title and build objectives for your presentation. Remember, objectives should be learner focused as opposed to faculty focused. What do you want the participant to be able to do when he/she returns to practice? Create 1-3 objectives below. Keep in mind the accreditation team may "tweak" objectives to reflect appropriate educational verbiage. For example, "Understand" is not an action verb.

At the end of this activity, the participant should be able to:

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* 14. What would you like the title of your presentation to be?

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* 15. Every ETCH CME activity is evaluated with a post activity evaluation. Participants will be asked to identify one thing he/she will do differently in practice as a result of attending. Additionally, faculty is asked to create a "strategy statement". This statement reflects one thing a provider should be able to go back and implement immediately. The provider is asked to "Read the following strategy and think about how often you applied it in practice before the program and how often you intend to apply it after the program." The statement is evaluated using a Likert Scale: Never, Rarely, Sometimes, Usually, Always. All strategy statements begin with a verb. For example, a sleep medicine specialist creates a strategy statement that reads "Ask a question about snoring on well visits."

An accreditation staff member will read this information and will be contacting you if there are incomplete sections. Thank you in advance for taking time to thoroughly complete this planning document.

Question Title

* 1. Requestor Contact Information

Question Title

* 2. Activity Information

Question Title

* 3. In a broad sense, what is the largest problem or "gap" in professional practice associated with the issue? 50 word minimum.

Question Title

* 4. Would you consider this a gap in

Question Title

* 5. Who would you consider to be the most appropriate target audience? In other words, describe the groups of healthcare providers that need to learn about what you are going to teach.Disciplines:

Question Title

* 6. When considering the content focus, what are the applicable practice settings of the disciplines indicated above?Practice Setting:

Question Title

* 7. What are the specific learning needs that cause the professional gap you identified? In other words, what specifically will you be teaching providers about? 50 word minimum

Question Title

* 8. Which core competencies will you cover (select all that apply)?More information about the core competencies is available on the ABP website.

Question Title

* 9. What resources will you use to develop your content?

Question Title

* 10. What teaching format would you like to use?

Question Title

* 11. Are there any barriers that providers may identify as outside of his/her control, but prohibitive of the change CME is trying to influence? If any are identified, please address the perceived barriers directly in your content.

Question Title

* 12. A downloadable handout will be created from any presentation slides you provide. This will be made available before and after the activity via https://etch.webex.com/..Will you have any additional educational materials to provide to participants?

Question Title

Question Title

* 14. What would you like the title of your presentation to be?

Question Title

* 5. Who would you consider to be the most appropriate target audience? In other words, describe the groups of healthcare providers that need to learn about what you are going to teach.

Disciplines:

* 6. When considering the content focus, what are the applicable practice settings of the disciplines indicated above?

Practice Setting:

* 8. Which core competencies will you cover (select all that apply)?
More information about the core competencies is available on the ABP website.

* 12. A downloadable handout will be created from any presentation slides you provide. This will be made available before and after the activity via https://etch.webex.com/..

Will you have any additional educational materials to provide to participants?