CME Activity Proposal for Consideration
Program Title: Program Date(s):
I have attached a list of those responsible for the planning of this activity to this proposal
(Activity Course Director(s) and Planning Committee members).
In order for an activity to be considered for CME certification, the sponsor of the activity must
identify a professional practice gap the activity will address. To assist in the identification of
possible practice gaps, please answer the following questions. If you require additional space
for your answers, please add attachments to this form.
1.) Who is the target audience for this CME activity?
2.) When considering your target audience,
a.) What are some questions they have and where is their deficit of knowledge evident?
b.) What patient problems or professional challenges are they unable to address?
c.) Why are they unable to address the patient problems/challenges articulated above?
3.) Using the answers to the questions above (2a-c), please identify the professional practice
gap(s) that will be addressed in this CME activity? (C2)
4.) What evidence/data/sources were consulted in your planning of this educational activity
and identification of professional practice gap(s)? Sources must prove that the need for this
activity goes beyond the sponsor’s own perception/observation of need.
a.) Check all that apply:
Journal articles or other peer reviewed sources
Attach bibliography citing journals or other sources, include journal abstracts or
relevant paragraphs that support your educational needs assessment.
Attach abstract of evidence.
Discussion w/ faculty (clinical/research)
Attach minutes or notes of discussions and include any references to data,
journals, and other sources. Audio recordings of minutes should be digital and
readily convertible to MP3.
Needs assessment of audience
Attach summary of needs assessment and include description of representative
Cite all studies, references, or data used to support educational needs.
b.) Please provide a description of your planning process and how you used the sources listed
above to identify professional practices gaps and the educational format of this activity.
5.) Identify other competencies or sources that were considered when identifying the
professional practice gap(s) and planning your educational activity? Refer to the List of
Desirable Physician Attributes (Example: IOM competencies, ACGME Competencies, etc.) found
on the last page of this Proposal. (C6)
6.) The professional practice gap(s) identified for this activity must be classified as a gap in
physician knowledge, competence or performance. Please classify each professional practice
gap identified for this activity as a gap in knowledge, competence or performance. (C2, C3)
Gaps in Knowledge = target audience does not have the answers or knowledge.
Gaps in Competence = target audience has the knowledge but does not know how to act on it.
Gaps in Performance = target audience has a strategy but is unable to implement the strategy
or implement the strategy properly in practice.
7.) Based on the need/gap the activity is addressing, what are the desired results of the
activity? Said differently, “What is the activity designed to change?” You must be able to detail
how you plan to measure these changes in question 8. (C3)
8.) What type(s) of evaluation method(s) will you use to know if the activity was effective at
meeting the need and creating change in competence, performance, or patient outcomes? (C11)
To measure a change in COMPETENCE, you must measure if the learner has developed new
strategies based on the information provided in the activity.
To measure a change in PERFORMANCE, you must measure if the learner made a change in
their practice or implemented new strategies as a result of the activity. (As a result of this
activity, how do you intent to change your practice? Evaluate learners intent to change, 6
month follow up)
To measure a change in PATIENT OUTCOMES, you must measure if the changes implemented
by the learner in practice have affected patient outcomes. (chart reviews, changes in quality
improvement numbers, etc.)
9.) Are there other initiatives within your institution working on this issue? Are there other
organizations we could partner with that are working on this issue? Yes No
If yes, what are those initiatives/ organizations and do you have any plans to partner with
10.) Given the information provided above, identify the topics that will be covered in your
activity and how will they relate to the professional practice gap(s).
11.) What is the right format to use for the activity? What type of activity will it be (Live,
Enduring Material, Internet, Other?)? What will be the educational design of the activity (e.g.
presentation, case studies, round table, and simulation)? What is the benefit of this
educational format? Please remember to consider adult learning principles and the physician
learning and change process. (C3, C5)
Desirable Physician Attributes
Please “X” all competencies that apply to your conference/meeting.
Institute of Medicine Core ABMS(MOC)/ACGME AAMC
1. Provide patient-centered care 6. Patient care that is 12. Evidence of professional
identify, respect, and care about patients' compassionate, appropriate, and standing such as an
differences, values, preferences, and effective for the treatment of health unrestricted license, a license
expressed needs; relieve pain and problems and the promotion of that has no limitations on the
suffering; coordinate continuous care; health. practice of medicine and
listen to, clearly inform, communicate surgery in that jurisdiction.
with, and educate patients; share decision 7. Medical knowledge about
making and management; and established and evolving 13. Evidence of a
continuously advocate disease prevention, biomedical, clinical, and commitment to lifelong
wellness, and promotion of healthy cognate(e.g., epidemiological and learning and involvement in a
lifestyles, including a focus on population social behavioral) sciences and the periodic self-assessment
health application of this knowledge to process to guide continuing
patient care learning
2. Work in interdisciplinary teams
cooperate, collaborate, communicate, and 8. Practice-based learning and 14. Evidence of cognitive
integrate care in teams to ensure that care improvement that involves expertise based on
is continuous and reliable investigation and evaluation of their performance on an
own patient care, appraisal and examination. That exam
3. Employ evidence-based practice assimilation of scientific evidence, should be secure, reliable and
integrate best research with clinical and improvements inpatient care. valid. It must contain questions
expertise and patient values for optimum on fundamental knowledge,
care, and participate in learning and 9. Interpersonal and up-to date practice-related
research activities to the extent feasible Communication skills that result in knowledge, and other issues
effective information exchange and such as ethics and
4. Apply quality improvement identify teaming with patients, their families, professionalism
errors and hazards in care; understand and and other health professionals
implement basic safety design principles, 15. Evidence of evaluation of
such as standardization and simplification; 10. Professionalism as manifested performance in practice
continually understand and measure through a commitment to carrying including the medical care
quality of care in terms of structure, out professional responsibilities, provided for common/major
process, and outcomes in relation to adherence to ethical principles, and health problems (e.g., asthma,
patient and community needs; and design sensitivity to a diverse patient diabetes, heart disease, hernia,
and test interventions to change processes population hip surgery) and physicians
and systems of care, with the objective of behaviors, such as
11. Systems-based practice as
improving quality communication and
manifested by actions that
professionalism, as they relate
5. Utilize informatics demonstrate an awareness of and
to patient care
responsiveness to the larger context
communicate, manage, knowledge, and system for healthcare and the
mitigate error, and support decision ability to effectively call on system
making using information technology resources to provide care that is of