Spokane County

MEDICAL SOCIETY

1101 West College Avenue, Suite 355 • Spokane, WA 99201-2037 • (509) 325-5010 • Fax (509) 325-5409

REQUEST FOR JOINT SPONSORSHIP (ACCREDITATION) OF MEDICAL EDUCATION PROGRAMS

(Application must be received in the SCMS office at least two weeks prior to being reviewed by the CME Committee & 60 days in advance of the program)

TITLE OF PROGRAM: _____________________________________________________________________________

_____________________________________________________________________________

DATE(S)/TIME(S): __________________________________

CONTACT HOURS: _________________________

(TO THE NEAREST 1/2 HOUR)

LOCATION(S): ___________________________________________________________________________________

___________________________________________________________________________________

PROGRAM DIRECTOR (LOCAL MD): _________________________________________________________________

PROGRAM COORDINATOR): _______________________________________________________________________

ADDRESS: _______________________________________________________________________________________
_____________________________________________________	PHONE: ______________________

PROVIDOR*: _____________________________________________________________________________________

*NOTE: Application will be rejected where commercial entities do any of the following; determine the need for, create objectives, or select faculty of a program. Monies that have been donated to CME joint sponsors to underwrite seminars are acceptable as long as needs, objectives, curriculum and faculty have been determined by the joint sponsor.

NEEDS ASSESSMENT/OBJECTIVES OF THIS PROGRAM: See Attached

LIST NAMES/POSITIONS OF PLANNERS: _____________________________________________________________

_________________________________________________________________________________________________

DATE PLANNING BEGAN: _________________________________

ANTICIPATED ENROLLMENT: ___________

FACULTY (LIST NAME, SPECIALTY AND SUBJECT ON A SEPARATE SHEET OF PAPER):

METHOD OF TEACHING BY CONTACT HOUR:

Case Presentation	_____	Lectures	_____	Videotapes	_____
Group Discussions	_____	Other	_____	TOTAL	_____

PLAN OF EVALUATION OF LEARNING MUST ACCOMPANY APPLICATION. Your evaluation must show that you measure the extent to which your educational objectives are being met by your faculty. Furthermore, please demonstrate that evaluation data are used in planning future CME activities.

Program Director ________________________________________M.D.

Date _____________________

NEEDS ASSESSMENT

Every application must be accompanied by supporting Needs Assessment documents.

(A needs assessment comes from the needs of the learner, the body of knowledge and the experts in the field. An adequate needs assessment must go beyond you or your organization's perceived need for this program.)

1. WHAT IS THE REASON FOR INITIATING THIS PROGRAM? (STATE THE PROBLEM)

WHAT WOULD A PHYSICIAN HOPE TO GAIN FROM THIS PROGRAM?

2. HOW WAS THE NEED FOR THIS PROGRAM IDENTIFIED? (PLEASE ENCLOSE DATA)

_____	QA/CQI Data	_____	Morbidity/Mortality	_____	State PRO Data
_____	Peer Review	_____	Objective Methods	_____	New Developments in Medicine
_____	Surveys	_____	Interviews	_____	New Laws
_____	Self Assessment Exams	_____	Epidemiological Data	_____	Health Care Statistics
_____	Patient Care Audits	_____	Current Literature	_____	JCAHO, NCQA, HEDIS
_____	Consensus of Experts	_____	Panel of Experts	_____	Licensure Requirements
_____	Hospital Data (P&T, IC)	_____	Malpractice Data	_____	Other ___________
_____	Focus Groups

3. WHAT OTHER DATA AND/OR SOURCES OF INFORMATION SUPPORT THE NEED FOR THIS PROGRAM?

_____	Anecdotal	_____	Personal Observation
_____	Community Need	_____	Other ________________________

4. DESCRIBE YOUR TARGET AUDIENCE - INCLUDE POSSIBLE NUMBERS (I.E. RURAL PHYSICIANS PRACTICING CARDIOLOGY)

5. HOW MANY REQUESTS DID YOU HAVE FOR THIS PROGRAM?

_____

0 - 2

_____

3 - 5

_____

5 - 10

_____

Over 10

WHAT OTHER SOURCES OF INFORMATION/RESOURCES ON THE PROBLEM ARE LOCALLY AVAILABLE TO PROSPECTIVE PARTICIPANTS?

_____	Other Programs	_____	Texts	_____	Videos	_____	WWW
_____	Journals	_____	Speakers	_____	Other	_____	Consultants

OBJECTIVES

STATE THE EDUCATIONAL NEED(S) WHICH THIS ACTIVITY ADDRESSES:

INDICATE THE PHYSICIANS FOR WHOM THE ACTIVITY IS DESIGNED:

LIST ANY SPECIAL BACKGROUND REQUIREMENTS OF YOUR PROSPECTIVE PARTICIPANTS:

FOR YOUR PROPECTIVE LEARNER, PLEASE DESCRIBE THEIR EXPECTED LEARNING OUTCOMES IN TERMS OF KNOWLEDGE, SKILLS AND/OR ATTITUDES (WHAT WILL THE PROSPECTIVE LEARNER BE ABLE TO DISCUSS, DEFINE, DEMONSTRATE, ACCEPT OR AGREES/VALUES AT THE END OF THIS PROGRAM). THERE MUST BE AT LEAST ONE OUTCOME PER SPEAKER.

DESCRIBE ANY OTHER OUTCOMES YOU EXPECT YOUR PARTICIPANTS TO BE ABLE TO ACCOMPLISH:

OTHER THAN STATING YOUR LEARNING OBJECTIVES ON YOUR BROCHURE, HOW ARE YOU MAKING YOUR EDUCATIONAL CONTENT AND METHODS KNOWN TO YOUR PROSPECTIVE PARTICIPANTS? (FOR EXAMPLE: LISTED ON MEETING AGENDA, THE EVALUATION OR IN OTHER COURSE MATERIALS)

EDUCATIONAL DESIGN

BRIEFLY DESCRIBE HOW THIS PROGRAM IS RESPONSIVE TO THE EDUCATIONAL CHARACTERISTICS OF YOUR PROSPECTIVE PARTICIPANTS. SUCH AS: KNOWLEDGE LEVELS, PROFESSIONAL EXPERIENCE AND PREFERRED LEARNING STYLES.

DOCUMENT THE USE OF SYSTEMATIC PLANNING PROCEDURES (INCLUDE MINUTES OF PLANNING COMMITTEE MEETING(S) / CONVERSATIONS AND CORRESPONDENCE WITH FACULTY & DEPARTMENT CHAIRS TO ACHIEVE YOUR STATED OBJECTIVES).

FINAL EVALUATION QUESTIONAIRE

HOW WILL YOU USE YOUR EVALUATION DATA TO PLAN FUTURE CME ACTIVITIES?

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