GRAND ROUNDS/SERIES

							                             2012 GRAND ROUNDS/OUTREACH SERIES
                             AMA CATEGORY 1 CREDIT APPLICATION
                        UNIVERSITY OF NEW MEXICO SCHOOL OF MEDICINE
                          OFFICE OF CONTINUING MEDICAL EDUCATION

            Only applications with complete information will be approved. Please type.

1. DEPARTMENT:

    ADDRESS:

    PHONE:                  FAX:                     EMAIL:


2. NAME OF PERSON COMPLETING THE APPLICATION:

    FACULTY RESPONSIBLE FOR EDUCATIONAL PLANNING:


3. SERIES TITLE:


4. DATES OF SERIES:


5. LOCATION:


6. CREDIT HOURS:

        Indicate the starting time and ending time for each activity, and the number of activities
        for the accreditation period (up to one year). Series will be accredited for the total number
        of hours for the period.

7. WHAT WILL BE THE EDUCATIONAL DESIGN OF THE ACTIVITY?

            Lecture and Questions                      Panel Discussion
            Seminar/Small Group Discussion             Case Presentation & Discussion (M & M)
            Interactive lecture with audience response
            Other - Please describe:

8. FACULTY DISCLOSURE & CONFLICT OF INTEREST:

        Each presenter and program planner MUST complete a Faculty Disclosure form PRIOR to
        the activity. If presenters or planners DO NOT complete a disclosure statement prior to the
        activity they will be disqualified from presenting or the activity will not be certified for CME
        credit.

        You must give the disclosure information to the audience in WRITING, whether the faculty
        has a financial relationship or not. This can be done in your program announcement,
        evaluation form, or in a written disclosure statement given to the participants at the activity.



        If there is a conflict of interest, the following steps will be taken to resolve the conflict:

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        1. The Grand Rounds Coordinator will notify the Faculty responsible for the grand rounds
           of faculty disclosing a conflict of interest.

        2. The Faculty Chair will discuss the conflict with faculty prior to their presentation(s); i.e., if
           the speaker is including a name brand in his/her presentation, they must include two
           additional brands in their presentation.

        3. The Faculty Chair will review the faculty presentation(s) prior to their presentation(s).

        4. The Faculty Chair will complete an evaluation form on each presentation for those
           speakers that disclosed a conflict of interest.


9. COMMERCIAL SUPPORT:

        Will the activities be supported by funds from the manufacturer of drugs, devices or
        services?         Yes          No

        If you answered yes, please contact the CME office as soon as you know that there will be
        commercial support for a presentation.

        Any commercial support for this event must be acknowledged to the audience. You will
        need to provide a copy of the acknowledgment to the Office of CME, and a signed Letter of
        Agreement from the Commercial Supporter.

        Commercial Support should be in the form of a Grant to the organizer. The commercial
        supporter may never pay honorarium directly to a speaker.

         Commercial support for refreshments should be made in the form of a grant, and the
          refreshments purchased by the department.
         Social events provided by a commercial supporter must be totally separate from the
          educational activity.

10. HONORARIUM:

        The UNM School of Medicine has approved honorarium guidelines.

11. EVALUATION:

        It is NO longer necessary for each grand round series to be evaluated. If the department
        wishes to continue this process, they may do so. You will need to evaluate your series on
        a SEMI-ANNUAL basis and then submit the evaluation summary to the CME Office.

        The evaluation form must assess:
              a. The extent to which educational objectives are met
              b. If the presentation is balanced, objective, and evidence-based
              c. Was the source of evidence presented
              d. The quality of the instructional process
              e. Will the information be incorporated in the participant’s medical
                  practice
              f. Any commercial bias conveyed by the presentation(s).

12. ATTENDANCE:

        The department is responsible for recording attendance. A typewritten list of

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        attendees must be submitted to the Office of CME NO later than 30 days
        after each event.

        Attendees can request a transcript of their CME credits from the Office of
        CME by calling 272-3942. Please allow 1 week for processing the request.


13. ACCREDITATION STATEMENT:

        The announcement(s) must include the following statement ( ___ fill in the number of hours
        approved for the session).

        The University of New Mexico School of Medicine, Office of Continuing Medical Education
        is accredited by the Accreditation Council for Continuing Medical Education to provide
        continuing medical education for physicians.
        The Office of Continuing Medical Education designates this live activity for a maximum of
        (number of credits) AMA PRA Category 1 Credit(s)™. Physicians should only claim credit
        commensurate with the extent of their participation in the activity.

14. EDUCATION PLANNING:

        The faculty course director must complete and sign the Education Planning Form which is
        on the last page of this application.

15. ANNOUNCEMENT REVIEW:

        The Office of CME must approve a sample announcement before it is distributed. The
        following items must be included in your brochure:
                1. Activity Objective(s)
                2. Accreditation Statement
                3. Detailed program agenda
                4. Disclosure information for all faculty (presenters and planners)
                5. Commercial support acknowledgement, if applicable



___________________________________________________                     _________________________
Signature of Program Chair                                              Date


                   Please submit the Application for annual accreditation prior to July 1.

                                           UNM Office of CME
                                           MSC09 5370 1 UNM
                                         Albuquerque, NM 87131
                                 Phone: 505-272-3942   Fax 505-272-8604




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EDUCATION PLANNING FORM – To be completed and signed by the faculty activity director

ACTIVITY:


1. What is the planning process for your CME activity?

       Yearly or periodic planning meetings
       Who attended?
       Please attach minutes/notes from the meeting(s) or summarize the meeting here
       If your department does not have an annual planning meeting, what is your process for
        identifying needs and choosing speakers and topics?


2. What sources did you use to identify educational needs?

       Evaluations from previous year
       Request from learner(s)
       Self-assessment tests
       Patient care audit/QA reports
       Mortality/morbidity statistics
       Faculty perception
       Survey of target audience


Please attach a summary of the survey results

        Other (Please List)




3. What are the desired results of the activity?
     _____ Increased MD learning?
     _____ Change in physician practice?
     _____ Change in patient outcome?



4. Based on the desired results of the activity, what are the objectives of the activity?




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Please check all that apply:

Patient care
Medical knowledge                          X


Practice-based Learning & Improvement

Interpersonal & Communication Skills

Professionalism

Systems based practice

Provide patient-centered care

Work in Interdisciplinary Teams

Employ evidence-based practice

Apply Quality Improvement

Utilize Informatics




5. What are the quality gaps to be addressed? (For example, for patient care the quality
   gap is “the difference between present treatment success rates and those thought to be
   achievable using best practice guidelines. The quality gap may include but also can go
   beyond patient care to include systems’ base practice, informatics, leadership and
   administration.)




6. What is the professional practice gap? (The difference between actual and ideal
   performance and/or patient outcomes.)




7. The identified gap is in physician:
      _____ knowledge
      _____ skills
      _____ attitude
      _____ performance




8. What are the potential or real barriers facing these physicians if this need (Gap)is to

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    be addressed?

        Examples:
        Patient-related
            * Patient adherence (medications, life style changes)
            * Cognition and memory
            * Side effects of medication
        Environment-related
            * Short time encounter with patients
            * Lack of tracking system to follow up with patients
            * Cost of care or lack of health insurance
            * Lack of multidisciplinary cooperation
        Provider-related
            * Adequate identification of patients w. _________________
            * Variation in physician decision (when to schedule tests, lab work)


9. Are there other initiatives within UNMH or its clinics working on this issue? Are there
   other organizations working on this issue? (Ex. DOH, NMMRA)




10. In what ways could we include these internal or external groups in our CME activity to
    help us address or remove the barriers identified?




11. What is the department link to Q.I. or P.I.? How will this be incorporated in the
    series?




12. Are there non-education strategies that are currently being used that address this
    issue? If no, what kinds of non-educational strategies could be used to address this
    issue? (Examples: sending reminders about techniques or information discussed at a
    CME activity; patient surverys, a physician “report card” or peer feedback.)

        ___ Patient education cards
        ___ Reminders
        ___ Other ____________




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13. How will we formally measure outcomes from this activity?
      _____Audience Response
      _____Surveys
      _____Post Test
      _____UNMH QI Data
      _____NMMRA Quality Data




______________________________________                      _______________
Course Director   (please print)                            Date




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                                   GRAND ROUNDS/SERIES
                               CME ACCREDITATION CHECK LIST

             Applications for CME credit are due July 1 and will cover the period of
                                       July 1 – June 30

1. Fully completed typed application form and education planning form.

2. Evaluation form or description of evaluation method you will use.

3. Sample Program Announcement or annual Course Announcement for Case Conferences,
   Journal Clubs

4. If you do not evaluate each session, you must submit an evaluation of the series for 2011/12
   before your 2012 application can be approved

The Office of CME will review the application and send notification when it is approved for CME
credit.

TO BE SUBMITTED MONTHLY:

1. Program Announcements.

2. Typed list of the program attendees.

3. Documentation that disclosure information was given to the audience in writing.

4. Acknowledgment of Commercial Support and Letter(s) of Agreement, if applicable.

5. Summary of the activity evaluation (if each activity is evaluated). Please do not submit the
   individual evaluation forms – our file space is limited.

    Course evaluation can be done by department faculty twice a year. You must submit written
    summary of the evaluations in order to have your CME application approved for the next year.


Please call the Office of CME at 272-3942 if you have any questions or need assistance completing
the application form.




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