Continuing Medical Education Office: 315.464.4606
SUNY Upstate Medical University 800.283.4606
766 Irving Avenue WH 2254 Fax: 315.464.4422
Syracuse, New York 13210 www.upstate.edu/cme
2011 -2013
CME PLANNING GUIDE APPLICATION
REGULARLY SCHEDULED SERIES
The Office of Continuing Medical Education at SUNY Upstate Medical University has been
surveyed by the Accreditation Council for Continuing Medical Education (ACCME) and awarded
accreditation as a provider of continuing medical education for physicians through 2013. This
status seeks to assure both physicians and the public that continuing medical education activities
sponsored by SUNY Medical University at Upstate meet the high standards of the ACCME
Essential Areas and Elements (including Standards for Commercial Support) and Accreditation
Policies. For a complete listing of the Essential Areas, Elements and Policies for Accreditation
please visit the ACCME website at www.accme.org.
This application has been designed with the intent of meeting these standards as well as our
CME Mission as summarized below:
To provide information and opportunities to advance knowledge and skills relative to the
latest technological and scientific advancements in medicine
To become firmly established in central and northern New York as the premier provider
of the highest quality professional education programs which focus on identified needs
To support and encourage the development of new continuing professional education
initiatives in a variety of formats among SUNY Upstate Medical University faculty,
departments and areas of special expertise
To ensure balance, independence, objectivity and scientific rigor in sponsored programs
To provide a continuing medical education program which follows the essentials,
guidelines and standards of the Accreditation Council for Continuing Medical Education
Continuing Medical Education www.upstate.edu/cme
SECTION 1: GENERAL INFORMATION
ACTIVITY TITLE / LOCATION / DATES:
Series Name: Series Code:
Location: Time:
Start Date: End Date:
Duration in terms of month of the year when the activity is available (i.e. September to June, January to December)
Estimated Attendance: MDs/Dos Other
Credits desired (one hour = one credit):
SPONSORSHIP:
Direct : Upstate ONLY Departments:
Joint: Non-Upstate Organization: Departments:
TYPE OF ACTIVITY:
Format Day Frequency If Monthly
st
Grand Rounds Monday Weekly 1 Week
nd
M&M Tuesday Monthly 2 Week
rd
Journal Club Wednesday Semi-monthly 3 Week
th
Noon Conference Thursday Quarterly 4 Week
Other: Friday Other Every other
CME ACTIVITY DIRECTOR:
SUNY affiliated physician with overall responsibility for planning, developing, implementing and
evaluating activity.
Name:
Title: Department:
Address:
Phone: Fax: Email:
CONTACT PERSON:
Individual responsible for operational and administrative support.
Name:
Title: Department:
Address:
Phone: Fax: Email:
PLANNING COMMITTEE:
List individuals responsible for design and implementation of this activity. A signed disclosure
form with sufficient lead time for any conflicts to be identified and resolved prior to the activity is
required from all Planners and Speakersill not be certified with out complete documentation.
FACULTY/SPEAKERS: **
Individuals who present/speak/moderate/author the activity are required to submit a signed
disclosure form with sufficient lead time for any conflicts to be identified and resolved prior to the
presentation. Speakers are required to disclose to the audience the content of these forms prior
to presenting. Individuals who have no disclosures are required to inform the participants of this
as well. All non-SUNY speakers must submit CV with disclosure form
Name Affiliation if Non-Upstate Title Planner Speaker
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Continuing Medical Education www.upstate.edu/cme
SPEAKER SELECTION:
Who was involved in speaker/topic selection?
Course Director Planning Committee
Other (please provide names)
What criteria were used to select speakers?
Expert in field Other (please describe)
SECTION 2: PLANNING & DESIGN:
EDUCATIONAL FORMAT: Check all that apply.
Lectures Video/Audio
Hands-on/Skills Session Case Presentations
Internet/Webcast Panel Discussion
Q & A/Discussions Other (please describe)
DESIRABLE PHYSICIAN ATTRIBUTES:
Activity should be planned with IOM, ACGME, ABMS competencies in mind. Check all that this
conference will address.
Provide patient centered care Apply quality improvement
Medical knowledge Professionalism
Work in interdisciplinary teams Utilize informatics
Employ evidence-based practice Systems based practice
Interpersonal and communication skills Professional standing
Practice-based learning and improvement Commitment to lifelong learning
TARGET AUDIENCE: Who is this educational activity intended for?
Does curriculum content match the target audience’s current or potential scope of
professional practice? Yes No
PROFESSIONAL PRACTICE GAPS: This educational activity should address a “problem”
physicians face or an area of practice that needs improvement. Please fill in the blanks that
pertain to you activity. The answers to these questions will drive the learning objectives
Describe one or more institutional problems/issues this series will address.
Describe a quality issue, if any, this series will address.
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Describe the areas your participants need more knowledge in.
Describe what skills, if any, the participant will take away.
EDUCATIONAL NEEDS:
What is the educational need that underlies the above mentioned practice gaps?
Knowledge Competence Performance
HOW DID YOU IDENTIFY THE PROFESSIONAL PRACTICE GAPS LISTED ABOVE?
The ACCME requires supporting documentation. Please choose all that apply and submit the
proper documentation with this application.
Departmental Meetings Potential source of documentation: summary of meeting minutes showing information
discussed was related to areas of educational need or topics of interest.
Continuing review of quality of care. Potential source of documentation: audit reports, chart reviews, case
reviews.
Formal or informal requests from target audience Potential source of documentation: summary of
requests or surveys.
QA/QI Data Potential source of documentation: office, hospital, regional, national reports.
Literature review. Potential source of documentation: abstracts, journal articles, gov’t publications, statistical
reports.
Regulatory changes. Potential source of documentation: copy of measure, mandate, law.
New technology/treatments/procedure. Potential source of documentation: description of new procedure,
technology, treatment, etc.
Increased prevalence/epidemic. Potential source of documentation: newspaper articles, gov’t. or other
sources, statistics, etc.
Mortality//Morbidity Statistics
Other: (please describe)
LEARNING OBJECTIVES/EXPECTED RESULTS:
Objectives/expected results are driven by practice gaps. These should directly address the
professional practice gaps listed above. Please list in general terms (each session or series of
sessions will have their own specific objectives) what learners should be able to do after they
participate in this series. Do not use general/vague terms such as learn, understand or know but
rather use specific verbs such as demonstrate, identify, explain, utilize, etc.
At the conclusion of this activity, participants should be able to:
SECTION 3: OUTCOME MEASURES
DOCUMENTING CHANGES IN CME ACTIVITIES:
The ACCME requires that we report on the impact our CME activities have by collecting data
regarding changes in learners’ behavior that can be linked to the educational activity. Choose
one or more areas and briefly describe how you plan to measure and document if changes
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Continuing Medical Education www.upstate.edu/cme
have/have not occurred as a result of your educational activity.
Type of Change EXPLAIN HOW CHANGE WILL BE MEASURED
(EXAMPLES of acceptable documentation)
Participant Example:
intent to change Question about intent to change behavior or practice will be asked on post-
behavior or activity evaluation
practices
Participant Example:
change in a) A post-activity survey will be taken after ___months have elapsed and a
behavior or question regarding actual change in behavior will be asked
practice or
b) Physical observation of behavior will be documented
or
c) Procedural changes implemented
Participant Example:
change in a) QA/PI reports prior to educational intervention will be compared to QA/PI
organizational reports ___ months following educational intervention
practice or
b) Participants will self-report via survey
or
c) Administrative/procedural changes implemented
Patient health Example:
changes after a) Patient survey regarding health status
program) or
b) Chart reviews with pre- and post-activity comparisons/changes
CHOOSE ONE OR MORE AND EXPLAIN HOW YOU WILL DOCUMENT CHANGES:
Type of Change EXPLAIN HOW CHANGE WILL BE MEASURED
(See examples above)
Participant
intent to change
behavior or
practices
Participant
change in
behavior or
practice
Participant
change in
organizational
practice
Patient health
changes after
program)
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Continuing Medical Education www.upstate.edu/cme
SECTION 4: EVALUATION
EVALUATIONS: **
We are required by the ACCME to demonstrate a formal process to evaluate the effectiveness of
all educational activities designated for AMA PRA Category 1 Credits ™ and to collect data and
information regarding changes in physician learners’ behavior.
Frequency of evaluations is dependent on series format and content. A series of related topics
with common objectives over a period of time (monthly, quarterly, semi-annually) need only one
evaluation per topic. In contrast, independent, stand-alone meetings each with its own topic and
objectives should be evaluated each time.
A summary of each activity evaluation is required to be submitted to the CME Office as soon as
possible after the activity.
Note: A measure of the participant’s intention to change practice is routinely included on a
standard evaluation form. Additionally, Program Directors will be asked whether the activities
changed physician performance or patient outcomes.
How often will participants evaluate the activity?
Each session
Group of sessions If group of sessions, specify how often:
Combination of both Please explain:
**The CME Office is now making use of Zoomerang for Evaluations. Please contact us if you are
interest in taking advantage of this tool.
SECTION 5: FINANCES & PROMOTION
BUDGET: Check all funds that will support this activity (year-end expense report required)?
Internal department funds
Commercial support
State or Federal Grant
Other support (please identify):
COMMERCIAL SUPPORT:
Will this activity receive financial or in-kind support from any commercial entity such as a
pharmaceutical or medical device manufacturer?
No
Yes. I have read and agree to abide by the ACCME’s Standard for Commercial Support.
If yes, please list all commercial supporters and provide a Letter of Agreement for each. Each
must be signed by a company representative and a representative of the CME Office prior to the
date of the event.
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Continuing Medical Education www.upstate.edu/cme
COMMERCIAL EXHIBITS:
Will vendor exhibits be present? Vendor exhibits are not considered commercial support but must
be reported on final revenue/expense report.
No
Yes. I have attached list of anticipated vendors and will provide a Vendor Registration Form.
METHOD OF PROMOTION:
All materials distributed announcing the activity must be approved by the CME Office prior to
distribution. All material must contain the following activity information:
Title , Date, Location Acknowledgment of Commercial
Learning objectives Support, if any
Target audience Accreditation/Designation Statement
Faculty listing and disclosures (see section 6)
Check all promotional materials that apply and submit sample to the CME office:
Flyer/Brochure Email
Website Interdepartmental Mail
Conference Calendar Other:
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Continuing Medical Education www.upstate.edu/cme
ACCREDITATION/DESIGNATION STATEMENT
The American Medical Association (AMA) requires that all accredited continuing medical
education (CME) providers use the current AMA credit designation statement in promotional
material, announcements and activity materials for all educational events that are designated for
AMA PRA Category 1 Credit(s) ™.
This identifies the accredited organization responsible for ensuring compliance with ACCME
Essential Areas and Elements (including Standards for Commercial Support) and Accreditation
Policies.
*Please note the italics **No deviation from the wording is permitted
If directly sponsored:
SUNY Upstate Medical University is accredited by the ACCME to provide continuing
medical education for physicians.
The SUNY Upstate Medical University designates this (insert type of activity) for a
maximum of (insert # of credits offered) AMA PRA Category 1 Credit(s) ™.
Physicians should claim only the credit commensurate with the extent of their
participation in the activity.
If jointly sponsored:
This activity has been planned and implemented in accordance with the Essential
Areas and policies of the Accreditation Council for Continuing Medical Education through
the joint sponsorship of SUNY Upstate Medical University and (insert name of joint
sponsor). SUNY Upstate Medical University is accredited by the ACCME to provide
continuing medical education for physicians.
The SUNY Upstate Medical University designates this (insert type of activity) for a
maximum of (insert # of credits offered) AMA PRA Category 1 Credit(s) ™.
Physicians should claim only the credit commensurate with the extent of their
participation in the activity.
Types of Activities
Live Activity
Enduring Material
SECTION 7: DOCUMENTATION CHECKLIST
At time of planning:
Completed Planning Guide
Disclosure Forms (planners and presenters for the year) (section 1)
Supporting Documentation for Practice Gaps/Needs (section 2)
Evaluation Form (copy of the form you intend to use) (section 4)
Letter of Agreement (If applicable) (section 4)
Prior to each meeting:
Proof copy of flyer (must include learning objectives, target audience, disclosures and the
Accreditation/Designation statement)
Non-SUNY Faculty CV’s and disclosures if applicable (section 1)
Letter of Agreement for commercial support (If applicable) (section 5)
After each activity:
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Continuing Medical Education www.upstate.edu/cme
Summary of Evaluations after each session or group of related sessions (section 4)
Attendance spreadsheet (attachment)
Year-end reporting:
Summary & Analysis Questionnaire (section 3)
Expense Report (section 5)
Any questions regarding this Planning Guide Application, required material
or additional documents, please contact the CME office at 315.464.4606.
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