Vassar Brothers CME Joint Providership Application

***NOTE: This application form CANNOT be filled partially and saved. Please make sure you have ALL the necessary information before beginning this online application. Remember to print a copy of this application for your records before submitting.***

This form attempts to collect all information necessary to plan and develop the proposed CME/CE activity. Completion of all sections of this form is necessary to meet accreditation. CME staff are available to help you navigate this process.

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* JOINT PROVIDER INFORMATION:

Institution:

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* Please select department:


Department	Department menu

If Other (please specify)

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* ACTIVITY INFORMATION

Title of Activity

Location of Activity

City of Activity

Total Number of Credits Requested

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* Date and Time of Activity

Start Time:

Date

Time

AM/PM

End Time:

Date

Time

AM/PM

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* TYPE OF ACTIVITY (select all that apply)

Course (symposium, workshop, conference, etc) - Note, Agenda with faculty, topics, times must be provided

Internet, Live

Home (self) Study/Enduring Material

Regularly Scheduled Series (tumor boards, etc)

Performance Improvement

Other type of activity

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* If Home (self) Study/Enduring Material, select what type:

N/A

CD-ROM

Internet

Monograph

Other

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* If Regularly Scheduled Series (tumor boards, etc.), please select frequency

N/A

1/week

2/month

1/month

Quarterly

Other (please specify)

Regularly Scheduled Series are daily, weekly, monthly or quarterly CME activities that are primarily planned by and presented to the organization's professional staff.

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* ACTIVITY MEDICAL EDUCATION DIRECTOR: The medical staff member who has overall responsibility for planning, developing, implementing, and evaluating the content and logistics of a certified activity.

Name:

Degree(s):

Title:

Department:

Email Address:

Phone Number:

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* ADMINISTRATIVE CONTACT: Please supply the contact information for the individual submitting this application.

Name: *

Degree(s):

Title:

Affiliation: *

Email Address: *

Phone Number: *

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* PLANNING COMMITTEE: In addition to the education director, list the names, degrees, titles, affiliations and emails of persons chiefly responsible for the design and implementation of this activity. NOTE: All individuals listed will be required to complete a CME disclosure before the application will be reviewed and approved.

Name:

Degree(s)

Title:

Affiliation:

Email Address:

Phone Number:

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* PLANNING COMMITTEE:

Name:

Degree(s):

Title:

Affiliation:

Email Address:

Phone Number:

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* PLANNING COMMITTEE:

Name:

Degree(s):

Title:

Affiliation:

Email Address:

Phone Number:

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* PLANNING PROCESS {criteria 7}

Who identified the speakers and topics?

Education Director

CME Associate

Other (provide sources)

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* What criteria were used in the selection of faculty (select all the apply)?

Subject matter expert

Excellent teaching skills/effective communicator

Experienced in CME

Other (please specify)

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* Were any employees of a pharmaceutical company and/or medical device manufacturer involved with the identification of faculty and/or topics?

Yes (please explain)

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* Faculty Name(s)/Affiliation (A CV or bio must be submitted for each faculty)

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* TARGET AUDIENCE (select all that apply-at least 1 box from geographic location, provider type, and specialty must be selected)

Geographic Location:

Internal Only

Local/regional

National

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* Provider Type:

Primary care physicians

Specialty physicians

Pharmacists

Physician Assistants

Nurses

Nurse Practitioners

Other (please specify)

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* Specialty:

All specialties

Anesthesiology

Cardiology

Dermatology

Emergency Med

Family Medicine

General Medicine

Neurology

OB/GYN

Oncology

Orthopedics

Pediatrics

Internal Medicine

Radiology

Radiation Oncology

Surgery

Other (please specify)

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* NEEDS ASSESSMENT AND EDUCATIONAL DESIGN

ALIGNMENT WITH CME MISSION STATEMENT {criteria 3}: CME activities should be designed to change competence, performance, or patient outcomes as described in the CME mission statement. The mission of Vassar Brothers CME is to provide educational activities, which will assist practitioners in providing the highest standards of care and service and will enhance outcomes for both patients and the community.

How does this activity align with the mission of CME? (select all that apply)

Designed to assist physicians and healthcare professionals gain competency and improve performance in order to become better able to provide higher quality care thus enhancing the health status of the community

Designed to assist in the dissemination of new medical knowledge

Collaborates on the design of multidisciplinary education strategies to improve patient safety and to facilitate patient-centered care

Designed to optimize appropriate prescribing behaviors

Promotes the practice of evidence-based medicine

Other (please explain)

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* DESIRABLE PHYSICIAN ATTRIBUTES {criteria 6} (select all that apply): CME activities should be developed in the context of desirable physician attributes. Select all American Board of Medical Specialties (ABMS)/Accreditatioin Council for Graduate Medical Education (ACGME) or Institute of Medicine (IOM) core competencies that will be addressed in this activity.

Provide patient-centered care

Medical knowledge

Practice-based learning and improvement

Interpersonal and communication skills

Commitment to lifelong learning

Professionalism

System-based practice

Multidisciplinary teams

Apply quality improvement

Utilize informatics

Cognitive expertise

Employ evidence-based practice

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* NEEDS ASSESSMENT DATA AND SOURCES {criteria 2} (select all that apply): Please indicate how the need for this activity was brought to your attention.

Continuing review of changes in quality of care as revealed by medical audit or other patient care reviews

Ongoing census of diagnoses made by physicians on staff

Advice from authorities of the field or relevant medical societies

Formal or informal requests or surveys of the target audience, faculty or staff

Discussion in departmental meetings

Data from peer-reviewed journals, government sources, consensus reports

Review of board examinations and/or re-certification requirements

New technology, methods of diagnosis/treatment

Legislative, regulatory or organizational changes affecting patient care

Joint Commission patient safety goal/competency

Other (please specify)

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* IDENTIFICATION OF PROFESSIONAL PRACTICE GAPS, EDUCATIONAL NEEDS, LEARNING OBJECTIVES, AND DESIRED RESULTS {criteria 2, criteria 3} (minimum of 3 total must be identified for the overall activity)

Professional Practice Gap

A professional practice gap is defined as the difference between ACTUAL (what is) and IDEAL (what should be) in regards to performance and/or patient outcomes.

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* Educational Need - State the educational need(s) that you determined to be the cause of the professional gap(s).

An educational need is defined as "the need for education on a specific topic identified by a gap in professional practice."

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* This is a gap/need of (select all that apply)

Knowledge

Competence

Performance

Competence is defined as the ability to apply knowledge, skills, and judgment in practice (knowing how to do something).
Performance is defined as what one actual does, in practice.

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* Learning Objective (Minimum of Three Must be Identified)

Learning objectives are the take-home messages; what should the learner be able to accomplish after the activity? What is this CME activity designed to change in terms of learners' competence or performance or patient outcomes?

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* Desired Result

Desired results are what you expect the learner to do in his/her practice setting. How will the information presented impact the clinical practice and or behavior of the learner? Indicate how this change could be reasonably measured.

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* EDUCATIONAL DESIGN/METHODOLOGY {criteria 5} (select all that apply): Please indicate the educational format(s) that will be used to achieve the stated goals and objectives.

Didactic lecture

Panel discussions

Roundtable discussions

Q&A sessions

Case presentations

Simulation/skills labs

Other (please specify)

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* Explain why this educational format is appropriate for this activity

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* *EVALUATION AND OUTCOMES {criteria 3, criteria 11}: How will you measure if changes in competence, performance or patient outcomes have occurred? You will be asked to provide summary data for the evaluation methods selected.

Knowledge/Competence

Evaluation form for participants

Audience response system (ARS)

Customized pre and post-test

Physician and/or patient surveys

Other (please specify)

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* Performance

Adherence to guidelines

Case-based studies

Customized follow-up survey/interview/focus group about actual change in practice at specified intervals

Chart audits

Direct observations

Other (please specify)

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* Outcomes

Observe changes in health status measures

Observe changes in quality/cost of care

Measure mortality and morbidity rates

Obtain patient feedback and surveys

Other (please specify)

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* IDENTIFIED BARRIERS {criteria 18, criteria 19} (select all that apply): What potential barriers do you anticipate attendees may have in incorporating new knowledge, competency, and/or performance objectives into practice?

Lack of time to assess or counsel patients

Lack of administrative support/resources

Insurance/reimbursement issues

Patient compliance issues

Lack of consensus on professional guidelines

Cost

No perceived barriers

Other (please specify)

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* Please describe how you will attempt to address these identified barriers in the educational activity.
Example: If the identified barrier is cost, you would attempt to address the barrier by stating "the agenda will allow for the discussion of cost effectiveness and new billing practices".

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* OTHER STRATEGIES {criteria 17}: Other strategies could be used to enhance change in your learners as an adjunct to this activity. Examples include patient surveys, patient information packets, email reminders to the learners (i.e., summary points from the lecture, new information), posters throughout the hospital, department newsletters, etc.

What other strategies will you include in order to enhance your learners' change as an adjunct to this activity?

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* BUILDING BRIDGES WITH OTHER STAKEHOLDERS {criteria 20}: Occassionally there are other internal and/or external stakeholders working on similar issues that a CME provider can partner with.

Are there other intiatives within your organization working on this issue?

Yes (identify who:)

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* If yes could they be included in the development and/or execution of this activity?

Yes (in what ways?)

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* Are there external stakeholders working on this issue?

Yes (identify who:)

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* If yes, could they be included in the development and/or execution of this activity?

Yes (in what ways?)

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* COMMERCIAL SUPPORT {criteria 8, criteria 9, criteria 10}: Will this activity receive commercial support (financial or in-kind grants or donations) from a company such as a pharmaceutical or medical device manufacturer? Note, exhibit fees are not considered commercial support.

Yes, and I have read and agree to abide by the ACCME Standards for Commerical Support

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* If you are receiving commerical support, please specify below the source, amount, and how it is being used.

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* EXHIBITS: Will vendor/exhibit tables be allowed at this activity?

Yes

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* REVENUE: Are you receiving revenue from this CME activity (i.e. exhibitors, registration fees)?

Yes (please specify source of revenue and estimated amount)

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* EXPENSES: Do you have any expenses for this event (i.e. faculty honorarium, faculty travel reimbursement, food)?

Yes (please specify type of expense and amount)

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* If you do have expenses, please specify source of payment:

N/A

Organization budget

Commercial support

Other (please specify source)

If your CME activity is a Teaching Day, e-mail the budget to the Vassar Brothers CME Office - mpalumblo@health-quest.org. (You will find the template on the joint providers CME live activity webpage.)

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* Agreement to report any changes to budget

I will contact the CME office if there are any significant changes to the financial information provided above.

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* APPLICATION COMMENTS OR ADDITIONAL INFORMATION:

**PLEASE CLICK PRINT A COPY OF THIS APPLICATION FOR YOUR RECORDS BEFORE SUBMITTING**

REMINDER:
In addition to this application you need to submit the following documentation via e-mail to mpalumbo@health-quest.org unless otherwise noted:

1. Signed Joint Providership Agreement (online submission)
2. CVs for all Presenters/Faculty
3. Disclosures for Education Director, Planners, and Speakers
4. Agenda
5. Commercial Support Agreement(s) (if applicable)

*Invoice for the application fee must be paid within 30 days of the invoice date*

Submitted Post Activity:

1. Copy of flyer/brochure with appropriate accreditation statements
2. Attendance Record
3. Participants Evaluations
4. Faculty Evaluation
5. Educational Director Evaluation
6. Handout Material/Syllabus (if applicable)
7. Articles: Copyright obtained (if applicable)
8. Other Documentation for Outcomes Data (if applicable)

PLEASE NOTE CERTIFICATE TEMPLATES FOR PARTICIPANTS AND FACULTY WILL BE SENT TO YOU ONCE YOU HAVE RECEIVED APPROVAL.

Question Title

* JOINT PROVIDER INFORMATION:Institution:

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* Please select department:

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* ACTIVITY INFORMATION

Question Title

* Date and Time of Activity

Question Title

* TYPE OF ACTIVITY (select all that apply)

Question Title

* If Home (self) Study/Enduring Material, select what type:

Question Title

* If Regularly Scheduled Series (tumor boards, etc.), please select frequency

Question Title

* ACTIVITY MEDICAL EDUCATION DIRECTOR: The medical staff member who has overall responsibility for planning, developing, implementing, and evaluating the content and logistics of a certified activity.

Question Title

* ADMINISTRATIVE CONTACT: Please supply the contact information for the individual submitting this application.

Question Title

Question Title

* PLANNING COMMITTEE:

Question Title

* PLANNING COMMITTEE:

Question Title

* PLANNING PROCESS {criteria 7}Who identified the speakers and topics?

Question Title

* What criteria were used in the selection of faculty (select all the apply)?

Question Title

* Were any employees of a pharmaceutical company and/or medical device manufacturer involved with the identification of faculty and/or topics?

Question Title

* Faculty Name(s)/Affiliation (A CV or bio must be submitted for each faculty)

Question Title

* TARGET AUDIENCE (select all that apply-at least 1 box from geographic location, provider type, and specialty must be selected)Geographic Location:

Question Title

* Provider Type:

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* Specialty:

Question Title

Question Title

Question Title

* NEEDS ASSESSMENT DATA AND SOURCES {criteria 2} (select all that apply): Please indicate how the need for this activity was brought to your attention.

Question Title

* IDENTIFICATION OF PROFESSIONAL PRACTICE GAPS, EDUCATIONAL NEEDS, LEARNING OBJECTIVES, AND DESIRED RESULTS {criteria 2, criteria 3} (minimum of 3 total must be identified for the overall activity)Professional Practice Gap

Question Title

* Educational Need - State the educational need(s) that you determined to be the cause of the professional gap(s).

Question Title

* This is a gap/need of (select all that apply)

Question Title

* Learning Objective (Minimum of Three Must be Identified)

Question Title

* Desired Result

Question Title

* EDUCATIONAL DESIGN/METHODOLOGY {criteria 5} (select all that apply): Please indicate the educational format(s) that will be used to achieve the stated goals and objectives.

Question Title

* Explain why this educational format is appropriate for this activity

Question Title

* *EVALUATION AND OUTCOMES {criteria 3, criteria 11}: How will you measure if changes in competence, performance or patient outcomes have occurred? You will be asked to provide summary data for the evaluation methods selected.Knowledge/Competence

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* Performance

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* Outcomes

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* IDENTIFIED BARRIERS {criteria 18, criteria 19} (select all that apply): What potential barriers do you anticipate attendees may have in incorporating new knowledge, competency, and/or performance objectives into practice?

Question Title

* Please describe how you will attempt to address these identified barriers in the educational activity.Example: If the identified barrier is cost, you would attempt to address the barrier by stating "the agenda will allow for the discussion of cost effectiveness and new billing practices".

Question Title

Question Title

* BUILDING BRIDGES WITH OTHER STAKEHOLDERS {criteria 20}: Occassionally there are other internal and/or external stakeholders working on similar issues that a CME provider can partner with.Are there other intiatives within your organization working on this issue?

Question Title

* If yes could they be included in the development and/or execution of this activity?

Question Title

* Are there external stakeholders working on this issue?

Question Title

* If yes, could they be included in the development and/or execution of this activity?

Question Title

* COMMERCIAL SUPPORT {criteria 8, criteria 9, criteria 10}: Will this activity receive commercial support (financial or in-kind grants or donations) from a company such as a pharmaceutical or medical device manufacturer? Note, exhibit fees are not considered commercial support.

Question Title

* If you are receiving commerical support, please specify below the source, amount, and how it is being used.

Question Title

* EXHIBITS: Will vendor/exhibit tables be allowed at this activity?

* JOINT PROVIDER INFORMATION:

Institution:

* PLANNING PROCESS {criteria 7}

Who identified the speakers and topics?

* TARGET AUDIENCE (select all that apply-at least 1 box from geographic location, provider type, and specialty must be selected)

Geographic Location:

* IDENTIFICATION OF PROFESSIONAL PRACTICE GAPS, EDUCATIONAL NEEDS, LEARNING OBJECTIVES, AND DESIRED RESULTS {criteria 2, criteria 3} (minimum of 3 total must be identified for the overall activity)

Professional Practice Gap

* *EVALUATION AND OUTCOMES {criteria 3, criteria 11}: How will you measure if changes in competence, performance or patient outcomes have occurred? You will be asked to provide summary data for the evaluation methods selected.

Knowledge/Competence

* Please describe how you will attempt to address these identified barriers in the educational activity.
Example: If the identified barrier is cost, you would attempt to address the barrier by stating "the agenda will allow for the discussion of cost effectiveness and new billing practices".

* BUILDING BRIDGES WITH OTHER STAKEHOLDERS {criteria 20}: Occassionally there are other internal and/or external stakeholders working on similar issues that a CME provider can partner with.

Are there other intiatives within your organization working on this issue?