For Office Use Only11/2013

CHRISTIAN MEDICAL & DENTAL ASSOCIATIONS

Planning Document & Application forCME Category 1 credit™

X DISCLOSURES OF THE COURSE DIRECTOR, COURSE CONTACT PERSON AND PLANNING COMMITTEE MUST BE COMPLETED, SIGNED AND E-MAILED TO

Barbara@cmda.org BEFORE BEGINNING THE PLANNING. ANYONE WHO REFUSES TO COMPLETE A DISCLOSURE FORM CAN NOT PARTICIPATE IN THE PLANNING,

EXECUTION OR PRESENTATION OF A CMDA EDUCATIONAL ACTIVITY.

Christian Medical & Dental Associations (CMDA) retains the right to withhold/adjust credit at any time, should it determine that the ACCME Criteria, Policies, ACCME Standards for Commercial Support and/or Christian Medical & Associations policies and procedures are violated.

Requirements for Certification by Christian Medical & Dental Associations: Please read and check that you have read them.

___In order to be considered for sponsorship or joint-sponsorship, completion of this application is required and emailed to Barbara@cmda.org two months prior to your activity date. REMEMBER: You can NOT promote CME until the application is approved. Incomplete applications cannot be reviewed or approved by the CMDA Committee, which has the final decision on all applications for Continuing Medical Education, dental and other healthcare professional credits.

___The content of your application must meet: ACCME Criteria, Policies, and Standards for Commercial Support The American Medical Association (AMA) requirements and The CMDA policies and procedures (Go to www.cmda.org/CE)

___HIPPA compliance is the responsibility of the course director___Recommendations involving clinical medicine in a CME activity are based on

scientific evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.

___Recommendations must conform to the generally accepted standards of experimental design, data collection and analysis

___All scientific research referred to, reported on, or used in this CME activity will support or justify patient care recommendations that conform to the generally accepted standards of experimental design, data collection, and analysis.

___Christian Medical & Dental Associations maintains full oversight and responsibility for the planning, completion of the application and the educational activity

Screening Criteria: In order to be considered for continuing medical education credit, all of the criteria listed below must be met. Planner confirms that:

___The content of this activity will be based on evidence that constitutes “best practices”

___Planners have identified a defined professional practice gap(s) that exists between current and best practices

___This activity will provide educational content aimed at closing the defined professional practice gap(s) to result in changed patient health by changing participants’ knowledge, competence, performance and/or practice

List any prerequisite knowledge/skill required for attending this activity: __________________________________________________________________________

COURSE OVERVIEW

1) School/organization/department making request:

2) Direct-sponsored (Organization within the CMDA)

Joint-sponsored (Organization outside of CMDA)

3) Title of course:

4) Course date(s): 5) Course location (include street address, city, state):

6) Please provide a one or two paragraph description of your course. This statement will be used for promotional materials (brochures, web pages, etc.) a needs assessment, and/or to obtain additional professional credits. The description should give an overview of the course and let potential attendees know why this course is an important one for them to attend:

7) Number of CME Credits Requested (hours):

8) Indicate all professional credits being sought for this course. (A Dental Application is required to receive AGD PACE credit):___ CME CDE (additional fee & Dental Application must be completed) AAFP (additional fee) Nursing (additional fee) In order for CMDA to apply for nurse practitioner credit, you must submit speaker Bio sketches, speaker & planner disclosures and speaker abstracts with this application two months prior to your conference Nurse Practitioner (additional fee) - In order for CMDA to apply for nurse practitioner credit, you must submit speaker Bio sketches, speaker & planner disclosures and speaker abstracts with this application two months prior to your conference Physician Assistant (additional fee)

COURSE PLANNERS AND FACULTY

9) Name of Course Activity Director:E-mail:Telephone: FAX:

10) Name of Course/Activity Coordinator (contact person): E-mail: Telephone: FAX :

11) Planning Committee Member – Please list individuals who are planning committee member(s).

Planning Committee Member

Telephone Number E-mail Address

Barbara Snapp, CE Director barbara@cmda.orgSharon K. Whitmer, EdD, MFT Accreditation Officer

sharon.whitmer@cmda.org

CE Committee Members On file

12)Who are the proposed faculty for this activity? MANDATORY: List confirmed and

non-confirmed faculty. You must include their name & credentials, business title, E-mail address & whether honorarium and travel expenses will be paid to faculty.

Name and credentials (MD, PHD, etc.)

Business title, institutional affiliation & locationexample:Professor of MedicineUniversity of Education Mayberry, FL

E-mail address Will honorarium and/or travel expenses be provided to the faculty member? (CMDA must have documentation of payment)

CONTENT DEVELOPMENT

13) How does this activity support the CMDA CE Mission (see the CMDA Mission in the Course Director Manual)?

14) This CME activity is planned to meet the needs of what groups of practicing healthcare professionals (target audience)? List all groups:

15) How does the content of this activity match the learners’ current or potential

scope of professional activities?

16) What are the educational format(s) for this CME activity? (check all that apply)

___Lecture___Teleconference

___Internet___Roundtable___Q & A session___Self-directed___Case studies___Panel discussion___Skilled demonstration___Stimulations___Lab activity___Audience Response System

17) Please UNDERLINE the activity type for this CME activity?   

Live ActivityEnduring MaterialJournal-based CME activityInternetCD-ROM/DVDPodcastOther (explain)_____________________________________________________________________

18) Briefly explain how your format and type of activity are appropriate for the setting, objectives, and the results of this educational activity.

19) What procedures were used to identify the existing professional practice gap(s) between current and best practices of your target audience? Please check all that apply. If a part of your process has been identification of gaps by experts and your planning committee, faculty or planners’ perception of need, or opinion leader interviews, please attach a one or two paragraph description detailing your discussions and how you intend to address gaps through the educational activity.

Documentation for each procedure indicated must be attached___Survey of targeted learners___Review of peer reviewed literature___Clinical practice data___Professional Practice Gap(s) identified by target audience/expert___National clinical guidelines (NIH, NCI, AHRQ)___Requirements of state licensing board, specialty societies___Required by practice administration___Required by governmental authority/regulation/law___Research findings/translations of research into practice___New information (diagnostic techniques, treatment plans)___Requests from physicians or physicians groups___*Helps to meet CMDA CE Mission___Public health data

___Faculty and/or planners’ perception of need (attach a statement)___Summary of previous outcomes data___Practice or specialty society clinical guidelines___Committee findings/audits___Epidemiological data___Direct to consumer ads___Lay press___Societal trends___Other (please attach description)

*Please review CMDA Mission (see Course Director Manual)

20) Please provide citations of peer-reviewed articles (scientific/medical journals, etc.) that were used as one of the determining factors for identifying each of the professional practice gaps.

21) Identify the professional practice gaps(s), what has caused the gap, the desired results of the educational intervention and classify the need for this educational intervention in terms of knowledge, competence or performance (see chart below).

IDENTIFY THE EDUCATIONAL PRACTICE GAP(S)(Current practice)

What are healthcare professionals not doing?

DESCRIBE WHAT HAS CAUSED THE PROFESSIONAL PRACTICE GAP

Why aren’t they doing it?

Desired results(best-practice)

What will be the results of solving this problem?

Classify the educational needs in terms of knowledge, competence, performance and/or patient outcomesChanges in competence and/or performance are required.

EXAMPLEPhysicians are not using the diagnostic criteria to screen pre-school age children for Autism.

EXAMPLELiterature indicates that at least 25% of physicians have not been educated on the diagnostic criteria for autism screening.

EXAMPLEParticipants will be able to:-Write the diagnostic criteria for screening pre-school age children for Autism,-Create individualized treatment plans to manage pre-school age autistic patients, and-Develop procedures to screen pre-school age children who present with autistic behaviors.Patient outcomes: Using procedures to screen pre-school age children earlier and the individualized treatment plan will change the outcome of the patients.

_X_Knowledge:_X_Competence_X_Performance_X_Patient Outcomes

_ _ Knowledge Competence Performance___Patient Outcomes_ Knowledge Competence Performance___Patient Outcomes Knowledge Competence Performance___Patient Outcomes_ _ Knowledge Competence Performance___Patient Outcomes

(add additional rows to this table as needed)

22) Based on the desired results you described in the gap chart above, list the learning objectives for this activity. Learning objectives help learners understand the specific result they can expect to achieve by participating in this educational activity. LIST AT LEAST ONE OBJECTIVE FOR EACH OUTCOME YOU LISTED ABOVE As a result of participating in this activity, participants will be able to: (example: Explain the diagnostic criteria used to screen autism).1.2.3.(continue numbering if additional objectives are listed)

23) Is this activity designed to change competence, performance and/or patient outcomes?

24) The competencies/physician attributes were founded on the Maintenance of Certification (MOC) competencies designed by the American Board of Medical Specialties (ABMS) the competencies established by the Accreditation Council for Graduate Medical Education (ACGME), and the desirable physician attributes established by the Institutes of Medicine (IOM). Once you have decided on the competencies/physicians attributes to be used to develop this activity, (1) place an “X” in the first box of the table for each competency/physician attribute, (2) write the objective(s) number in the last column of the table that corresponds to the competency/physician attribute you selected. Example: Objectives numbers 1, 3, and 6.

PLACE AN COMPETENCIES/PHYSICIANS ATTRIBUTES

Content in this activity that reflects the competencies you selected – Cite the learning objective number(s) 1, 3, 6, etc.

“X”Patient Care (provide care that is compassionate, appropriate and effective treatment for health problems and to promote health).Medical Knowledge (demonstrate knowledge about established and evolving biomedical, clinical and cognate sciences and their application in patient care).Practice-based Learning and Improvement (investigate and evaluate patient care practices, appraise and assimilate scientific evidence and improve practice of medicine).Systems-based Practice (demonstrate awareness of and responsibility for larger context and systems of healthcare; call on system resources to provide optimal care, e.g., coordinating care across sites or serving as the primary case manager when care involves multiple specialties, professions, or sites).Professionalism (demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations).Interpersonal and Communication Skills (demonstrate skills that result in effective communication and teaming with patients, their families and professional associates, such as fostering a therapeutic relationship that is ethically sound; using effective listening skills with non-verbal and verbal communications; working as both a team member and at times as a leader).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 educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy 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; participant 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; continually understand and measure quality of care in terms of structure, process and outcomes in relation to patient and community needs; 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).

25) Based on the Gap (educational needs) of your target audience, provide a timed agenda along with the topics and the faculty names for each topic. Application cannot be reviewed if this information is missing. (CMDA approves to the quarter hour and only the time actually spent in the educational session)EXAMPLE:TIME TOPIC TITLE FACULTY NAME8 - 9 am (1 HR Requested) Overview of Autism John Doe, MD, PhD9:00 am Break N/A9:15 – 10 am (.75 HR Requested)

Topic Jane Doe, MD

10:00 AM Adjourn

26) Please provide an abstract for each topic. Include the topic title and faculty name with each abstract. Application cannot be reviewed if this information is missing.

EDUCATIONAL EVALUATION, BARRIERS, NON-EDUCATIONAL STRATEGIES 27) CMDA will develop an online evaluation to evaluate and analyze changes in

your learners’ professional practice gaps (i.e., changes in knowledge, competence, performance and practice changes). Three to four months after the completion of the activity, CMDA will send a follow-up outcomes survey to measure changes to professional practice as well as competence, performance

and/or patient outcomes from this activity. The outcomes survey is sent to all participants who submitted the initial evaluation.

28) Please identify factors outside your control that have an impact on patient outcomes (examples: insurance, patient not following recommended dosage, patient’s support system, etc.).

29) Identify anticipated barriers that the participant’s may have in trying to implement changes in their practice (examples: formulary restrictions, insufficient time for implementation of new skills or behaviors, lack of insurance reimbursement, lack of organizational support, lack of resources, policy issues within the organization, unwillingness to make changes). R ecommend educational strategies that you will discuss during this activity to remove, overcome, or address these barriers.

ANTICIPATED BARRIER(S) TO PARTICIPANT CHANGES IN PRACTICE

PLANS TO ADDRESS OR OVERCOME THE BARRIER(S)

30) Planners of this activity are encouraged to employ non-educational strategies for participants (examples: handouts, CD’s, videos, websites, etc.) to reinforce the intended results of this activity. Please list any non-educational strategies that you will use and the purpose of the strategy.

Non-educational Strategy Purpose of the StrategyCMDA will E-mail a follow-up outcomes survey to participants of this activity.

The outcomes survey will remind participants of the changes they will implement as well as focus on changes in professional practice.

COURSE LOGISTICS CMDA neither sponsors nor joint-sponsors activities that are supported by a commercial interest, however CMDA does accept commercial exhibitors. The ACCME definition for a commercial interest: “A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.”

31) Will this activity have Commercial exhibits? Yes No

See definition of commercial interest above. Review the ACCME Standards for Commercial SupportSM) in the Course Director’s Manual. If Yes, please provide list of participating commercial exhibitors and COMPLETE THE EXHIBIT FORM.The ACCME requires that a list of all exhibitors be distributed to your participants before the educational activity is presented. For that reason, CMDA will provide a Welcome Letter, which will include this information for your participants.

NAME OF EXPECTED/INVITED COMMERCIAL EXHIBIT ORGANIZATION(S) and contact e-mail address:NAME OF ORGANIZATION E-MAIL ADDRESS

Add additional rows to this table as needed

The ACCME definition of non-commercial exhibitor: Providers of clinical services directly to patients, such as hospitals, health systems, medical group practices, blood banks, and diagnostic laboratories, are an integral component of accredited CME and CDE because they represent the provision of CME by the profession for the profession. Therefore, these entities have been deemed NOT to be commercial interests.

32) Will this activity have non-commercial exhibits? Yes No See definition of non-commercial interest above. Review the ACCME Standards for Commercial SupportSM) in the Course Director’s Manual. If Yes, please provide list of participating non-commercial exhibitors. NON-COMMERCIAL EXHIBITORS DO NOT NEED TO COMPLETE THE EXHIBIT FORM.The ACCME requires that a list of all exhibitors be distributed to your participants before the educational activity is presented. For that reason, CMDA will provide a Welcome Letter, which will include this information for your participants.

NAME OF EXPECTED/INVITED NON-COMMERCIAL EXHIBIT ORGANIZATION(S) and contact e-mail address:NAME OF ORGANIZATION E-MAIL ADDRESS

Add additional rows to this table as needed

*NOTE: A final list of confirmed exhibitors MUST be submitted 30 days prior to the conference so that required follow-up can be done by the CE Department.

33) If this activity will have commercial and/or non-commercial exhibitors, where will they be located with respect to the CE educational activity?_________________________________________________________________________________

34) Is there a registration fee for participants? Yes No If yes, how much?

Physicians $ Physicians Assistant Residents, $ Nurses $ Students, $ Others (please specify): $

X Signature Activity Director (electronic signature or typed name is acceptable if sending electronically)

Signature

Date:

IF THIS ACTIVITY IS CANCELED WITHIN 30 DAYS OF THE START DATE, THERE WILL BE A $500 ADDITIONAL CANCELLATION FEE PLUS COLLECTION OF ANY EXPENSES INCURRED BY CMDA.

Christian Medical & Dental Associations does not share in profit or loss for this symposium.Christian Medical & Dental Associations educational activities are reviewed by the CMDA committee for scientific content, relevance to healthcare professionals, congruence with the CMDA mission, and credentials of speakers. All symposiums must be approved by the CMDA committee. By serving in this role, the Committee is serving as part of the planning process for all activities sponsored by the CMDA.

CMDA FEE FOR SPONSOR/JOINT-SPONSORSHIP

ACTIVITY FEE(s)*CME Application Fee for direct sponsored activity - $500.00 $ *CME Application Fee for jointly sponsored activity - $850.00 $

Total Activity Fee due UPON SUBMISSION OF APPLICATION $

*IF during the review process the application is denied by the review committee

OR if the activity is cancelled at any time after submission, there will be a $200

non-refundable application review fee.

DUE AFTER COMPLETION OF THE ACTIVITYTranscript Fee - $10 per credit hour approved/Per person

(Example: 4 hours approved for the activity = $40 post activity fee x 22 participants

claiming CE = $880.00 Post Activity Fee Due)

A Financial wrap-up report along with Transcript Fee for this course is required within 30 days following activity completion.

__________________________

NOTE: The CMDA CE Department desires to keep its fees reasonable in comparison to the national average. For large organizations or large events, the CMDA CE Department is willing to

base its fees on the number in attendance and/or whether it is a sponsored or joint-sponsored CE activity. Please contact Barbara Snapp (1-888-230-2637 or barbara@cmda.org) to discuss

additional options if needed before submitting this application.

FEE FOR ADDITIONAL SERVICES (non-negotiable)$300 AAFP Credits

$300 Dental (Academy of General Dentistry - IF submitted separately from the medical application)

$300 Nursing (in order for CMDA to apply for nursing credit, you must submit speaker Bio sketches, speaker & planner disclosures and overview of each speaker presentation with this application)

$300 Nurse Practitioner (in order for CMDA to apply for nurse practitioner credit, you must submit speaker Bio sketches, speaker & planner disclosures and overview of each speaker presentation with this application)

$300 Physician Assistant

Course/Activity logistics that must be provided to the CMDA/CE office:

Application for Credits (must be approved by the CMDA Committee). Draft brochure for review and approval. 5 original brochures. Sign-in sheets/attendance verification document (typed and electronic). Copies of faculty/course director reimbursement checks for travel and

lodging etc. Copies of faculty/course director honoraria checks List of exhibitors (If applicable) Budget reconciliation - accounting of income and expenses.

BEFORE YOU SUBMIT THIS APPLICATION MAKE SURE:

APPLICATION IS SIBMITTED ELECTRONICALLY IN A WORD DOCUMENT ALL QUESTIONS ON THE APPLICATION ARE ANSWERED PROPOSED BUDGET