Application for Grand Rounds

& Enduring Materials Programs

Application Requirements

Grand Rounds Programs will now apply and be

considered for a 3 year approval.

OCCME will meet with the Activity Director and

Administrative Contact prior to completing a CME

Application.

The Office will only review CME Applications

submitted electronically in Microsoft Word format.

To receive full consideration, a completed

application needs to be submitted at least 8 weeks

in advance of the educational activity.

Each CME Application must conform to the

Accreditation Council for Continuing Medical

Education’s (ACCME) definition of CME and to the

School’s CME Policies (see below).

Definition of CME

“Continuing medical education consists of educational

activities which serve to maintain, develop, or increase

the knowledge, skills, and professional performance and

relationships that a physician uses to provide services for

patients, the public, or the profession. The content of

CME is that body of knowledge and skills generally

recognized and accepted by the profession as within the

basic medical sciences, the discipline of clinical medicine,

and the provision of health care to the public” (ACCME).

CME Policies (C22)

The Office follows explicit policies that relate to the

provision of AMA PRA Category 1 CME Credit(s)TM

at

the University of Connecticut School of Medicine. Please

review the School’s CME policies, paying particular

attention to policies 5-10.

2019-2020

Contact Information

Please contact the CME office with any questions regarding this application: 860.679.4590

Additional forms and FAQs are available on the CME website.

Office of Community and Continuing Medical Education

(OCCME)

CME Application

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Section A: General Information

1. Title of Activity or Program:

(Exact title that will appear on promotional materials. Avoid abbreviations and acronyms.)

2. Format of the learning activity:

Additional information on each format can be found on the CME website.

Course, Workshop, or Conference

Regularly Scheduled Series (e.g., grand rounds or journal club)

Internet Activity - Live

Internet Activity - Enduring Material

Enduring Material (i.e., CD ROM, video tapes, etc.)

Journal-Based CME

Performance Improvement

3. Location(s):

For activities held at the UConn Health, indicate “UConn Health.” For other locations, list the facility name,

city, and state. If the activity is web-based, please simply write “Internet” and include the name of organization

hosting the website if not UConn Health.

4. Please list the specific Date(s) and Time(s) for each Session(s):

5. Total number of credit hours requested: ________

The maximum number of hours, rounded to the nearest quarter hour, a participant can earn in one academic

year. Credit hours cannot include activities that are not part of the formal educational program.

6. Describe the target audience for this CME activity (e.g., specialty, level of training, institutional

affiliation, etc.) (ACCME C4)

The target audience is the one group at which the program is directed. While programs may invite or allow

other clinicians to attend their CME activities, planning efforts must center on the needs of the target audience.

7. Estimated number of attendees:

MD/DO/Residents: Other Learners (Clinicians):

8. Providership:

All activities must be sponsored by a department or unit of UConn Health and/or jointly provided by an entity

outside of UConn Health.

Type of Providership: Direct Providership Joint Providership

Name of Joint Provider (Required, if applicable):

For Office Use Only:

Date Application Received: _______________________

Date of Final Approval: _______________________

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9. Activity Director:

The Activity Director is the faculty member of UConn Health or the person affiliated with the joint providership

that is responsible for planning, conducting, and evaluating the CME event.

Name and Title:

Department:

Address:

City, State, Zip:

Phone: Fax:

E-Mail:

10. Co-Director (Optional):

The Co-Director is the faculty member who shares the responsibility for planning, conducting, and evaluating

the CME event.

Name and Title:

Department:

Address:

City, State, Zip:

Phone: Fax:

E-Mail:

11. Administrative Contact:

Complete only if the Activity Director has an administrative support person involved in the application process.

Name and Title:

Department:

Address:

City, State, Zip:

Phone: Fax:

E-Mail:

12. Is the administrative contact involved with selecting speakers, topics and/or influencing the educational

content?

Yes: No:

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Section B: Planning Information

1. List of Planning Committee members and their respective institutional affiliation. (ACCME C7 and C10) The Activity Director and School of Medicine faculty or joint provider faculty must have a major role in, if not

complete control of, the planning, implementation, and evaluation of the CME activity.

Name Institutional Affiliation

a)

b)

c)

d)

e)

f)

Disclosure Declaration Forms: Each member of the Planning Committee, including the Activity Director, Co-

Director (if applicable) and Administrative Contact (if applicable), must complete a Disclosure Declaration

Form as part of the application approval process. Completed disclosure declaration forms should be scanned

and submitted with this application.

2. Needs Assessment (Select 2 at Minimum):

Please indicate which data sources were used to determine the need for this activity. (ACCME C2)

For each box checked, please provide the supporting data in electronic format; DO NOT check boxes for

which you have no data.

Data Source Potential Source of Documentation

Expert faculty (e.g., planning committee, etc.)

Meeting minutes, informal notes, emails, etc.

showing information discussed was related to the

educational needs/topics of interest of the target

audience

Data from educational activity evaluations Summary of: surveys, evaluations, or questionnaires

Data from the peer-reviewed literature Abstracts, full articles, etc. describing educational

need / physician practice gaps

Hospital Compare data Data for the topic area(s) to be addressed

Healthy People 2020 Objectives Copy of topic area(s), objectives to be addressed

The Joint Commission Standards/Core Measures Copy of competency to be addressed

Public Health Organizations (e.g., NIH, AHRQ) Copy of guidelines, recommendations for topic

area(s) to be addressed

Review of Board exams and or re-certification Board review / updated requirements

National clinical guidelines Guideline summary specific to the topic areas to be

addressed

Medical record audit or patient care review Admitting or discharge diagnoses, chart reviews

Other (specify and describe below) Attach complete documentation

Please use the space below to summarize the data from all checked boxes above and provide all sources

of documentation/relevant citations.

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3. Based on review of the Needs Assessment checked above, please complete the following boxes for each

content area you’ve decided to cover. (ACCME C2)

EXAMPLE

Professional Practice Gap1

WHAT is the problem you want to address?

EXAMPLE

Educational Need2

WHY does the problem exist?

EXAMPLE

This is a gap in: 3

(Check one)

Rheumatologists need to be better able to

assess the role of erosive bone damage in

the morbidity of RA and improve

treatment.

The problem exists because:

Rheumatologists lack information as

to whether RA potentiates

osteoporosis.

X Knowledge

Competence

Performance

Professional Practice Gap1

WHAT is the problem you want to address?

Educational Need2

WHY does the problem exist? This is a gap/need of:

3

(Check one)

The problem exists because:

Knowledge

Competence

Performance

The problem exists because:

Knowledge

Competence

Performance

The problem exists because:

Knowledge

Competence

Performance

The problem exists because:

Knowledge

Competence

Performance

The problem exists because:

Knowledge

Competence

Performance

(Copy and paste additional sections as needed)

Definition of Terms:

1 Professional Practice Gap – The different between actual and ideal performance; the issue that needs to be addressed 2 Educational Need – The necessity for education on a specific topic; i.e., why the issue exists 3 Gap in:

Knowledge – Facts and information acquired by a person through experience or education

Competence – Having the ability to apply knowledge, skills, or judgment in practice if called upon to do so

Performance – What a physician actually does in practice

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4. Further defining the information supplied above, please tell us the topic(s) you’ve decided to cover and

describe the desired result(s) for each one. (ACCME C3)

EXAMPLE

Topic

EXAMPLE

Desired results4

What is your educational activity

designed to change?

EXAMPLE

This is an expected change in: Competence, Performance, or

Patient Outcomes5

(Check one)

Rheumatoid Arthritis This activity is designed to:

Increase Rheumatologists’ ability to

better diagnose and treat RA.

X Competence

Performance

Patient Outcomes

Topic Desired results4

(i.e., What is your educational activity

designed to change?)

Expected change in: Competence, Performance, or

Patient Outcomes5

(Check one)

This activity is designed to:

Competence

Performance

Patient Outcomes

This activity is designed to:

Competence

Performance

Patient Outcomes

This activity is designed to:

Competence

Performance

Patient Outcomes

This activity is designed to:

Competence

Performance

Patient Outcomes

This activity is designed to:

Competence

Performance

Patient Outcomes

(Copy and paste additional sections as needed)

Definition of Terms:

4 Desired Result – What you expect the learner to be able to do in her/his professional setting; after attending your program. 5 Expected Change in:

Competence – Having the ability to apply knowledge, skills, or judgment in practice if called upon to do so Performance – What a physician actually does in practice Patient Outcomes – Measured in terms of the impact (of the educational intervention) on the patient and /or healthcare system

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5. What are the clinical guidelines, evidence-based or otherwise, related to the patient outcome or provider

behavior in your response to question 6 above (check all that apply and indicate source).

Evidence-Based guidelines (e.g., NIH, AHRQ, Up-to-Date, etc.)

Indicate

Source:

Consensus guidelines (e.g., specialty society guidelines)

Indicate

Source:

No guidelines available

Please

Explain:

6. Please list the overall learning objectives for this activity:

A learning objective is an outcome statement that captures specifically what skills and attitudes the target

audience should be able to exhibit after attending your educational activity. They should be specific, actionable,

and measurable. For example: Participants will be able to better assess the role of erosive bone damage in the

morbidity of RA and improve treatment.

Session-specific learning objectives are provided as each session unfolds using the Pre-Session Needs

Assessment form and are included on the session flyer. For your reference, guidelines for writing learning

objectives are available Learning Objectives Guidelines.

Participants will (be able to)…

a)

b)

c)

7. Alignment with the Office of Community and Continuing Medical Education Mission Statement (ACCME C12) The primary mission of the Office of Community and Continuing Medical Education is to be an important

resource in the state of Connecticut to improve the performance and competency of and promote the continued

development of healthcare professionals. To provide educational opportunities for practitioners, teachers, and

researchers conducted in an environment of exemplary patient care, research, and public service.

How does this activity align with the office of CCME? (Check all that apply)

Provides educational opportunities for individuals working in health care pursuing careers in the

patient care professions, education, public health, biomedical and/or behavioral sciences

Advances knowledge through basic, biomedical, clinical, behavioral, and social research

Develops, demonstrates, and delivers health care services based on effectiveness, efficiency, and the

application of the latest advances in clinical and health care research

Helps health care professionals maintain their competence through continuing education programs

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8. What potential barriers do you anticipate your learners having when attempting to apply the new

knowledge, competence, or performance learned from this educational activity/program into their

professional practices (Select 1 at minimum)? (ACCME C18)

Cost Lack of time to assess/counsel patients

Lack of experience Reimbursement/insurance issues

Lack of opportunity (patients) Lack of consensus or professional guidelines

Lack of administrative support/resources Other, please explain below:

9. Please describe how you will address these barriers in your educational activity (ACCME C19)

Example: If the identified barrier is cost, you would attempt to address the barrier by stating, “The agenda will

allow for the discussion of cost issues associated with a new treatment, etc.”

10. Please check the educational method or combination of methods for this CME activity that will be used

during your presentation to promote a change in the learners ‘competence’, ‘performance’, or ‘patient

outcomes’. (ACCME C3 and C5)

Interactive workshop/conference

Case discussion

Panel discussion

Simulations

Other (please specify):

Explain how this method(s) is appropriate for the learning objectives and the target audience:

Example: “This method(s) is designed to change competence through the use of case-based scenarios and an

Audience Response System that poses questions about what the learners would do when presented with …”

11. Please tell us, by checking one of the methods below, after the conclusion of your educational activity,

how will you implement non-educational strategies to reinforce the educational goals of this program?

(check all that apply). (ACCME C17)

Example: Two months ago a grand rounds on new treatments in depression was presented. Specific

recommendations were made by the presenter. To reinforce the recommendations and goals of that

presentation, an email was sent out to the attendees referencing an article that pertained to that new treatment

for depression.

Reminders sent to the learners (e.g., email, etc.)

Program summary points from the lecture, new information

Peer review literature/follow-up articles

Newsletter

Other (please specify):

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12. How will the Activity Director communicate the learning objectives (and other relevant planning

information) to any speakers or faculty responsible for conducting or facilitating the educational activity

(check all that apply)?

Written communication

In-person discussion

Other (please specify):

13. How will the Activity Director communicate the learning objectives and other important CME

information to the target audience (check all that apply)?

Written materials in advance of the activity (e.g., brochure or Flyer)

Other (please specify):

14. Speaker or Author Selection (ACCME C7 and C10).

Please list all speakers or authors, their organizational affiliations, and the reason for their selection in light of

the learning objectives and the educational methods chosen. The term “speaker” applies to a presenter,

facilitator, panelist, academic detailer, or any other person developing content for the educational activity.

Each speaker must complete a Disclosure Declaration Form regarding potential conflicts of interest and

discussion of off-label use of products.

Speaker Name Affiliation Reason for Selection

a)

b)

c)

d)

e)

15. Building Bridges with Other Stakeholders (ACCME C16, C20, and C21)

a) CME activities that complement other related educational or quality improvement initiatives have a

greater impact in terms of improving clinical practice. Please identify other educational programs or

quality improvement initiatives related to your CME activity. These can be internal (UConn Health -

sponsored) or external (e.g., specialty society, Jackson Lab, etc.) quality improvement or patient safety

programs.

Example: The Department of Medicine sponsors two CME activities: Medical Grand Round and Current

Clinical Medicine: Update and Review. These two CME activities provide overlap on many of the Joint

Commission core measure sets for the Healthy People 2020 Learning Objectives.

b) Could they be included in the development and/or execution of this activity? If yes, in what ways:

Example: The Department of Medicine and Jackson Lab coming together to sponsor a single program on

clinical genomics, etc.

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16. Please indicate which of the following sources of “desirable physician attributes” are related to your

CME activity (check all that apply). (ACCME C6)

ACGME/ABMS Competencies1

Patient care

Medical knowledge

Practice-based learning and improvement

Interpersonal and communication skills

Professionalism

Systems-based practice

National Academy of Medicine Core Competencies2

Provide patient-centered care

Work in interdisciplinary teams

Employ evidence-based practice

Apply quality improvement

Utilize informatics

Interprofessional Education Collaborative Core Competencies3

Values/Ethics for Interprofessional Practice

Roles/Responsibilities

Interprofessional communication

Teams and Teamwork

ABMS Maintenance of Certification4

Evidence of professional standing

Evidence of a commitment to lifelong learning

Evidence of cognitive expertise based on performance on an examination.

Evidence of evaluation of performance in practice

For more information: 1

www.acgme.org; 2https://nam.edu/;

3https://ipecollaborative.org/;

4www.abms.org

17. Please attach a sample of the sign-in sheet you will use for your CME activity. Your sign-in sheet must

capture the following data:

Note: As a friendly reminder, please maintain and save for your records a sign-in sheet for each of your

sessions that capture the below information. Sign-in sheets are needed for verification purposes as well as

tracking any new attendees to your program. Sign-in sheets are maintained by the department hosting the CME

activity for a minimum of 6 years.

Last

Name

First

Name Degree(s)

Number

of CME

credits

E-mail

Address Address City State Zip

Initials to

Verify

Attendance

A “sign-in sheet” template is available on the CME website.

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Section C: Evaluation

Each CME activity must include a formal evaluation mechanism in which participants complete a set of standard

questions. In order to receive CME credit, participants are required to submit an evaluation for each CME activity

attended. A standard program evaluation and a multiple speaker/session evaluation are available at CME

Evaluation Templates. (ACCME C11).

1. Check the box next to the evaluation system you will use for this CME Activity below and submit an

electronic copy of your evaluation form with this application.

MyEvaluations.com*

*MyEvaluations.com evaluations are available for certain regularly scheduled conferences (e.g., grand

rounds, journal clubs) of the University of Connecticut School of Medicine.

Hybrid Evaluations (for grand rounds programs with a large mix of UConn and Non-UConn faculty only)

Custom Electronic Evaluation System (for Internet/Enduring Material programs only)

2. Please indicate how you will use the evaluation data (check all that apply).

Provide summary of feedback to speaker(s)

Provide summary of feedback to participants

Plan future CME activities

Other (please specify):

Section D: Commercial Support

Commercial support is any financial or in-kind contribution given by a commercial interest to support the cost – in

whole or in part – of a CME activity. A “commercial interest” is any entity (e.g., pharmaceutical company, medical

device manufacturer) producing, marketing, re-selling, or distributing health care goods or services consumed by,

or used on, patients.

1. Does this CME activity involve commercial support from any commercial interest?

Yes (If “yes,” please continue completing this section.)

No (If “no,” please skip to the next section.)

2. Please review the ACCME’s Standards for Commercial Support.

3. List any and all sources of commercial support and the exact nature of that support:

Source of Support Nature of Support

Amount of Support (maybe provided on Letter

of Agreement for

Commercial Support)

a)

b)

c)

4. For each company providing commercial support please complete and attach either a (ACCME C8)

Letter of Agreement for Commercial Support for Direct Providership or a

Letter of Agreement for Commercial Support for Joint Providership

NOTE: The Letter of Agreement for Commercial Support is required for all sources of commercial support,

the agreement may not be edited or revised, and only this agreement, as written, will be accepted by the CME

office.

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Section E: Disclosures

As required by the ACCME, commercial support, the presence or absence of conflicts of interest, and the

discussion of off-label use of products must be disclosed to participants in writing prior to the CME activity. (ACCME C7).

1. Describe the mechanism of making any disclosures and/or explanations (check all that apply).

Promotional flyer or brochure (most common and recommended mechanism)

Program handouts

Sign-in sheet

Other written mechanism (please describe):

NOTE: The CME Office must approve disclosure statements/explanations for each mechanism selected.

Section F: Marketing to the Target Audience and Content of Promotional Materials

The Office of Community and Continuing Medical Education requires promotion of activities be reviewed and

approved prior to distribution to ensure proper disclosure. Please forward all promotional materials (e.g., save-the-

date card, brochure, flyer, etc.) to the CME office at least two-weeks prior to the scheduled session (ACCME C7, C8 and C10).

Sample Flyer for Direct Providership

Sample Flyer for Joint Providership

Section G: Commercial Promotion: Exhibits and Advertisement

Commercial exhibits and advertisements are not continuing medical education. Therefore, fees paid by commercial

interests to providers for exhibits and advertisements are not considered to be “commercial support.” However,

providers must meet certain requirements if commercial exhibits or advertisements accompany CME activities (ACCME C9).

1. Will any commercial exhibits or advertisements be associated with this CME activity?

Yes (If “yes,” please continue completing this section.)

No (If “no,” please skip to the next section.)

2. Review the following information concerning appropriate management of associated commercial

promotion before proceeding to the next question in this section: a) Arrangements for commercial exhibits or advertisements can neither influence planning nor interfere with

the presentation. Exhibit or advertising space may not be a condition for the provision of commercial

support for CME activities.

b) Product-promotion material or product-specific advertisement of any type is prohibited in or during CME

activities. Live (e.g., staffed exhibits) or enduring promotional materials (e.g., printed or electronic

advertisements) must be kept physically separate from CME activities. Additional information regarding

print, computer based, audio and video recording, and live, face-to-face activities available by clicking on

this ACCME link for appropriate management of associated commercial promotion.

c) Educational materials that are part of a CME activity, such as slides, abstracts and handouts, cannot contain

any advertising, trade name or a product-group message.

3. List the names of all exhibitors and attach a diagram (a scanned, hand-written diagram is fine)

indicating the location of each exhibit with respect to the location of the formal educational activities. (ACCME C9)

1 4

2 5

3 6

Section H: Income (i.e., ALL funds) and Expenses

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Please indicate the estimated income and expenses in the tables below. The actual income and expenses will be

reflected in the final report. (ACCME requirement)

1. List anticipated source and amount of income/funding (or other funds) on each line:

Indicate “$0.00” for expenses that are not applicable

a) Departmental funds: $0.00

b) Commercial support: $0.00

c) Exhibit Income (from fees, etc.): $0.00

d) Advertising Income: $0.00

e) Other Income, by category below:

i. Registration fees (registration, subscription, or publication fees received from

activity participants) Please provide total fees received here and attach

spreadsheet with detailed breakdown):

$0.00

ii. Government Grants: $0.00

iii. Private Donations: (including grants from foundations) $0.00

f) Total income/funding: $0.00

2. List estimated expenses:

The CME Office will provide the figures for items a-e.

Indicate “$0.00” for expenses that are not applicable

a) CME application fee* (amount supplied by CME Office): $0.00

b) CME commercial support surcharge (amount supplied by CME Office): $0.00

c) Enduring materials fee (amount supplied by CME Office): $0.00

d) Joint providership fee (amount supplied by CME Office): $0.00

e) CME certificate fee: $15.00 X ______ Participants

(Certificate Fees are $15 per certificate for the first 100 and $5 for each certificate thereafter, for all attendees except for UConn faculty CME Certificate fees are waived for UConn faculty.)

$0.00

f) Honoraria: $ per person X: People $0.00

g) Travel expenses: $0.00

h) Printing: $0.00

i) Mailing/postage: $0.00

j) Room rental for event: $0.00

k) Food: $0.00

l) Hotel accommodations: $0.00

m) Other expenses (please specify): $0.00

n) Total expenses: $0.00 1CME Application fee still applies in the event of a cancellation.

NOTE: For Grand Rounds programs, CME Application and Joint Providership Fees will be invoiced

upon program approval. All other fees (i.e., commercial support surcharge, yearly application continuance

fee, certificate fees, etc.) will be billed at the end of each academic year with the approval of the

interim/final report. For Enduring Materials programs, all fees are invoiced upon program approval with

the exception of CME Certificate fees, if applicable, which will be invoiced upon issuance at the close of

each academic year.

Rev. 9/2016

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3. What entity will absorb financial expenses for this program?

4. What will happen with any profits from this event?

5. Please complete for each account that will receive any funds or make any payments:

Account Information Account 1 Account 2 Account 3

Name of account

Account number

(only for UConn Health)

Person responsible

Section I: Application Signatures:

As the Activity Director, I attest to the accuracy and completeness of this application, and I accept

responsibility for the planning, implementation, and evaluation of this CME. I agree to submit complete and

accurate Interim and Final Reports on this activity to the Office of Community and Continuing Medical

Education (OCCME) throughout the approval period as required by the OCCME.

Signature of Activity Director Date

As the Department Chairperson, I attest that this CME activity has the sponsorship and support of the

department.

Signature of Department Chairperson or Equivalent Date