CME Planning Guide - CME Request Form

CME Request Form

Please complete this CME request form as the initial step in development of your accredited CME/CE activity. CME staff will follow up within ten business days with further instructions. The following minimum lead time is required for submission: 3 months before a live, webinar, or hybrid activity up to 2 hours in duration; 6 months for an instructional design online activity; 12-18 months before a symposium.

Accredited CME must meet the AMA definition of CME content which is education 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.

Expand each section below to review the required fields. After reviewing each section, please submit the CME Request Form.

Planning Team

Requestor Name *

Requestor Position/Company *

Requestor Email *

Requestor Phone Number *

Interprofessional Coordinator Name

Interprofessional Coordinator Email

Physician Leader Name *

Physician Leader Email *

Activity Details

Title Of Activity/Presentation *

Activity Date(s) *

Activity Location *

Anticipated Number of CME Credits (hours) *

Target Audience *

Who should—or is expected to—participate in this education? (Example: Specific physician specialty/ies, nurses, pharmacists, etc. For non-physician events, please reach out to Clinical Enterprise.)

Is this course a requirement for physicians? *

Yes

Will it be available to the entire Medical Staff and Community, or for a closed group? (If closed, please elaborate.) *

Open

Closed

Will it be available to the entire Medical Staff and Community, or for a closed group? (If closed, please elaborate.) Closed

Does your department have a budget to cover the expenses? *

Cost center is required for planning costs and expenses that are not budgeted.

Yes

Department Cost Center

BHSF Initiatives

Does this initiative support an Institute or Baptist Health initiative?

DNV Requirements

Systemness - Patient-centered, care, continuum of care, standardization of care

High-reliability tools - Patient safety, PI, QI

Implementing evidence-based data

Diversity & Inclusion

Public health factors - Health behaviors, socio-economic/environmental conditions, health disparities, etc.

Institute - MCI, MCVI, MNI, etc. (Specify the institute, if selected.)

Does this initiative support an Institute or Baptist Health initiative? Institute - MCI, MCVI, MNI, etc. (Specify the institute, if selected.)

Educational Needs

Identify the professional practice gap. *

State the educational opportunity or the difference between current practice and best practice on which this activity was based. (Ex: Improve care coordination, better communication with patients and families, team roles, medical knowledge, new protocol, etc.)

State the educational need(s) that you determined to be the underlying cause for the professional practice gap. *

What is/are the reason(s) for the gap? (Ex: “We need strategies to discuss difficult topics with family members.” or "We do not know the best ways to improve team collaboration."

Educational Needs *

Select all that apply.

Knowledge need - New technology or information that physicians need to know more about.

Competence need - Tools or strategies available that might help learners apply what they should already know.

Performance need - New technology or clinical information that necessitate learners assimilating new skills.

References to support the educational need or desired goal for the activity *

Provide evidence-based references (peer-reviewed journal articles links) that highlight the educational need (practice gap) and support the desired goal (what the activity is designed to change).

Designed to Change

What is the CME activity designed to change in terms of learners’ competence or performance? *

What commitments to change would you expect/anticipate the learners to be able to implement as a result of this educational intervention? *

Ex: "I will now utilize the 2024 American Heart Association Clinical Pracrice Guidlines for heart failure." or "I will now screen my perimenopausal patient according to ACOG imaging guidelines."

How will you determine the effectiveness of your CME activity? *

Baptist Health CME must receive a SUMMARY of the aggregated data, not copies of individual forms.

Post-activity evaluation form – Include questions that address what learners might do differently as a result of attending the activity.

Pre- and post-activity testing using paper tests.

Pre- and post-activity testing using audience response (ARS) technology.

Assimilation of knowledge and/or clinical strategies via questions incorporated in presentation utilizing audience response (ARS) technology.

Competencies

Indicate the desirable physician attribute(s) (i.e. competencies) this activity addresses *

Select all that apply.

Patient care – Provide care that is compassionate, appropriate, and effective treatment for health problems.

Medical knowledge – Demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and apply this knowledge to patient care.

Practice-based learning and improvement – Investigate and evaluate patient care practices, appraise and assimilate scientific evidence, and improve practice.

Interpersonal and communication skills – Demonstrate skills that result in effective information exchange and teaming with patients and their families and with professional colleagues.

Professionalism – Demonstrate a commitment to carrying out professional responsibilities, adhering to ethical principles, and being sensitive to diverse patient populations.

System-based practice – Demonstrate an awareness of and responsibility to a larger context and system of health care. Be able to call on system resources to provide optimal care.

Planner/Faculty Information

All planners, faculty and moderators will be required to complete a disclosure form.
NOTE: An employee of an ineligible company is not able to provide clinical recommendations related to the products or services manufactured and/or sold by their employer.

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CME Planning Guide - CME Request Form

CME Request Form