This application should be completed with the assistance of the physician faculty member familiar with the activity.

Please feel free to ask for help from the CME staff as you complete your application. We can be reached at (330) 543-8407 (x38407).

Will you be videotaping? Yes No (required)
Will this be a joint sponsorship program? Yes No (required)
Will this be viewed live over the internet? Yes No (required)
From Department of: (required)
Date of Activity: (required)
Number of Hours Requested:
Time of Activity:
Activity Title: (required)
Presenter: (required)
Course Director/Planning Committee: (required)
Contact Email: (required)
Contact Phone: (required)


Important Note!! We should remember to integrate the ACCME Standards for Commercial Support into our planning processes at every step. For every activity/education intervention, have you ensured that:

  • Everyone who is in a position to control content DISCLOSES ALL RELEVANT FINANCIAL RELATIONSHIPS with a commercial interest.
  • We implement a mechanism(s) to IDENTIFY AND RESOLVE ALL CONFLICTS OF INTEREST before the education activity is delivered to learners.
Yes No (required)

Definitions to be utilized in planning

Competence (Strategy) - "knowing how to do something" ". . .a combination of knowledge, skills and performance . . the ability to apply knowledge, skills and judgement in practice." "The simultaneous integration of knowledge, skills, and attitudes required for performance in a designed role and setting."

Performance - "What one actually does, in practice."

Knowledge - awareness or familiarity gained by experience of a fact or situation

Gap - The difference between health care processes or outcomes observed in practice, and those potentially achievable on the basis of
current professional knowledge.

A. Professional Practice/Quality Gap (C2)

Please describe what prompted you to develop this course for physicians? What is the quality gap or professional gap to be addressed? Briefly describe the reasoning for the selection of your speaker(s).

B. List the methods used to identify the need for this educational activity (C2)

If you are having difficulty identifying a gap here are some ideas. (Please provide an explanation of specific resources utilized)

Expert Sources (required): (example sources include:,,,, NACHRI,,)

Peer-reviewed Literature (please provide summary)
Research Findings
Required by institution/Governmental Authority Regulations Law:

Participant Sources (required)

Needs Assessment Survey of Target Audience (please provide summary)
Focus Panel Discussions/Interview (please provide summary)
Previous Related Evaluation Summary (please provide summary)

Observed Sources (required): (example sources include: http://groups/ce/Safety/idex.htm,,

Adverse drug event(s):
Database analyses (e.g., RX changes, diagnosis trends, etc.)
Epidemiological data
Hospital/clinical QA analyses
QI data/guidelines
Mortality/morbidity data:
National clinical guidelines (NIH, NCI, AHRQ, etc)
Other clinical observances (specify):
Referral diagnosis data:
Specialty society guidelines (specify)

Other (required): (example sources include:,,

Healthy People 2010 Objectives
JCAHO Standards/Core Measures
Lay Press:
Public health Organizations (specify)
Other societal trends
CHMCA Strategic Plan
Additional Planning Resources


C. Please describe the target audience below (check or write)? (C4)

General pediatricians
Pediatric sub-specialists (specify):
Family physicians
Surgical Specialties (specify):

How will this activity be applicable to their type of practice? (required)

Anticipated number of participants:

Anticipated number of physician participants:


D. What category of educational needs or type of professional practice gaps have you identified and will be addressing?



Patient Outcomes




E. What is the activity designed to change? (C3)


Based on the need/gap the activity is addressing, please describe the desired results of the activity. Please be specific:

F. EDUCATIONAL DESIGN/METHODOLOGY: How do you plan to deliver this content? (C3, 5)

Lecture (oral didactic followed by Q&A)

Forum (open dialogue among participants)

Case Presentation (followed by Q&A and recommendations for revision of treatment plan)

Live patients

Symposium (2-5 lectures on various components of a topic)

Simulation/Procedure Lab/Workshop

Panel Discussion and Q&A

Seminar (Interactive learning activity lad by an expert




Planners are required to address nationally-established goals for physician core competencies as developed by the Institute of Medicine, Accreditation Council on Graduate Medical Education (ACGME), Association of American Medical Colleges (AAMC), and the American Board of Medical Specialties (ABMS) related to specialty maintenance of certification.

Please check all competencies that your activity will address: (required) (C6)

Institute of Medicine Core Competencies ABMS (MOC)/ACGME
AAMC Competencies
Provide patient-centered care - identify, respect, and care about patients' differences, values, preferences, and expressed needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educated patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of health lifestyles, including a focus on population health.

Work in interdisciplinary teams- cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable.

Employ evidence-based practice - integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible.

Apply quality improvement - identify errors and hazards in care; understand and implement basic safety design principles, such as standardization and simplification; continually understand and measure quality of care in terms of structure, process, and outcomes in relation to patient and community needs; and design and test interventions to change processes and systems of care, with the objective of improving quality.

Utilize informatics - communicate, manage, knowledge, mitigate error, and support decision making using information technology.

Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health

Medical knowledge about established and evolving biomedical, clinical, and cognate (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care

Practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care

Interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and other health professionals

Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system for health care and the ability to effectively call on system resources to provide care that is of optimal value.

Evidence of professional standing, such as an unrestricted license, a license that has no limitations on the practice of medicine and surgery in that jurisdiction.

Evidence of a commitment to lifelong learning and involvement in a periodic self-assessment process to guide continuing learning.

Evidence of cognitive expertise based on performance on an examination. That exam should be secure, reliable and valid. It must contain questions on fundamental knowledge, up-to-date practice- related knowledge, and other issues such as ethics and professionalism.

Evidence of evaluation of performance in practice, including the medical care provided for common/major health problems (e.g., asthma, diabetes, heart disease, hernia, hip surgery) and physicians behaviors, such as communication and professionalism, as they relate to patient care.

H. Learning Objectives: (C3)

Linking the needs, desired outcomes, and objectives: The learning objectives are the link between the needs and desired outcomes. The learning objectives for your activity should reflect this. See the example below:

Identified Educational Need --> Learning Objectives --> Desired Outcome


Make correct Therapeutic choices in the treatment of allergic rhinitis in patients with asthma. Assess the clinical efficacy of medications and therapeutic Options used to treat allergic Rhinitis as recommended by ACAAI. Improved patient compliance and outcomes due to a physician's appropriate choice of therapy.

Are your objectives S.MA.R.T?
S     Specific - What exactly are we going to do, with or for whom?
M   Measurable - Is it measurable and can we measure it?
A     Attainable - Can we get it done in the proposed time frame?
R     Relevant - Will this objective have an effect on the desired goal or strategy
T      Timely - When will we accomplish this objective?

Learning objectives should utilize action statements and be written from the perspective of what you expect the learner to do in the practice setting with the information you are teaching. They should describe the expected results of the activity.

What are the learning objectives for this activity? (required)




I. Are there non-educational strategies that are currently being used that address this issue?

(Example: Policies and procedures, clinical practice guidelines, just in case reminders, safety alerts, newsletters, patient feedback) (C17)

Yes No

If yes, please explain

If no, what kind of non-educational strategies could be used to address this issue?


J. Evaluation/Outcomes: (C11)

List the evaluation method(s) planned for this activity. (Check all that apply)

Level 1 - Reactions (mandatory) - Measuring if the learners like the activity and were they satisfied with the course
Example measurement tool: CHMCA evaluation form

Level 2 - Learning (mandatory) - Have they learned what they were supposed to learn based upon the identified knowledge gap/course objectives?
Example measurement tool: Pre and Post tests
CHMCA evaluation form

Level 3 - Behavior/Transfer of Learning - Has the transfer of knowledge/skills impacted patient care and/or clinical practice?
Example measurement tools: Post-activity survey (3 months follow-up), observation, review of individual provider patient care data

Level 4 - Results/Impact - Has the transfer of knowledge/skills impacted patient care and/or clinical practice?
Example measurement tools: Organizational/population data review.

Other Specify:


K. Commercial Support

CHMCA does not accept commercial support for CME activities in the form of educational grants, marketing or other involvement, except for exhibitors (C7-10)

Will there be exhibitors at this activity? (required) Yes No

Source: Single Company Multiple Companies

Please provide a list of possible supporters:

Anticipated amount of commercial support?


L. Are there other initiatives within my institution working on this issue?

Are there other organizations we could partner with that are working on this issue? (C18, 20)
Yes No

If yes, explain:

In what ways could we include these internal or external groups identified in question L., in our CME activity to help us address or remove barriers toward achieving improvement the identified gap? (C19)

M. Other strategies used to reach educational objective:

Follow-up mailings/email to participants
Supplemental parent education
Other strategies:

Preliminary Budget
Will there be a fee? Yes No

Purpose of fee:

Do you have budget data? (required) Yes* No Not Applicable

* If yes, please email budget to Katrina Wolford at right after this application is submitted.

Have other information supporting this application? Please submit materials to the Medical Education office at least eight weeks prior to activity.

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