Penn State College of Medicine
Department of Continuing Education
Mail Code G220
44 East Granada Avenue, Room 1108
Hershey, PA 17033
Tel: (717) 531-6483 Fax: (717) 531-5604
www.pennstatehershey.org/ce
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GRAND ROUNDS / LECTURE SERIES
Application for AMA PRA Category 1 Accreditation
Start Date: _____________________________ (2 –Year Period)
Department:
Division:
Series Name:
Series Type (choose one)
Grand Rounds
Lecture Series
Frequency to be offered:
Weekly =
MON
Weekly
Monthly ___________________
TUES
Other ____________________
WED
THURS
FRI
SAT
SUN
Quarterly _____________________
Series Location:
Start Time:
AM
PM
If online, web address:
End Time:
AM
PM
Will this series be teleconferenced to other locations?
Yes
No
If yes, where
Target Audience: ___________________________________________________________________________________________
Contact
Information
Course Director
Course Coordinator
Name, Credentials
Title
Phone Number
Fax Number
Email Address
Mail Code / Room#
Activity Planners: List everyone in a position to control or influence the content of this CME activity and attach their
faculty disclosure form
Planning Committee: (Completed and signed Disclosure Forms must be attached to application)
Name (please print)
Title
Organization
Attached with Application
Disclosure
Disclosure
Disclosure
Disclosure
Disclosure
Curriculum/Agenda:
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Do you have a set group of topics you plan to cover during this year’s Grand Rounds?
Yes
No
Please list the specific topics:
Planning Process:
How are topics chosen for each session?
Example: Planning committee meets each month, reviews department data, and bases topics on areas that need improvement.
How do you choose your speakers?
Example: National experts in the field
Practice Gaps:
What questions in practice are you having that you are not getting answers to?
What patient problems or patient challenges do you feel that you’re not able to address appropriately or to your
satisfaction?
Needs Assessment: A needs assessment is the process of identifying and analyzing data that reflect the need for a
particular CME activity.
Select all that apply: In the space provided below, please indicate which resources you used to determine the need for
this activity.
Expert Needs
Participant Needs
Observed Needs
Planning Committee
Previous Related Evaluation Summary
Analyses from Medical Records (DRGs)
Departmental Chair
Focus Groups/Interviews
Mortality / Morbidity Data
Activity Faculty
Epidemiological Data
Expert Panels
Needs Assessment Survey/
Questionnaire
Other Requests from Physicians
Peer-Reviewed Literature
Requested by Affiliated Groups
Specialty Society Guidelines
Research
Other (please specify)
Database Analyses
(e.g. Rx changes, diagnosis)
National Clinical Guidelines (NIH, etc)
Required By Government
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How do you plan to collect the above needs assessment data?
Are there quality improvement initiatives that your department is trying to achieve through the series?
Yes
No
If yes, how will the series help you achieve them? What strategy will be used to measure them?
Series Learning Objectives: Objectives are statements that clearly describe what the learner should be able to do
after participating in the series.
At the conclusion of this CME series, participants should be able to:
1.
________________________________________________________________________________________________
2.
________________________________________________________________________________________________
3.
________________________________________________________________________________________________
*use PERFORMANCE verbs, they are actionable and can be measured….examples of performance verbs:
Arrange
Conduct
Counsel
Enable
Estimate
Evaluate
Examine
Formulate
Hydrate
Interpret
Measure
Operate
Palpate
Predict
Prescribe
Promote
Provide
Record
Refer
Restore
Schedule
Select
Suture
Test
ACGME Competencies: In which of the following competency areas will participants improve as a result of this series?
Patient Care
Professionalism
Practice Based Learning
Medical Knowledge
System-based Practice
Communication Skills
Method: Please check which education formats will be used during this series (mark all that apply)
Case Presentation
Small Group Discussion
Lecture/didactic session
Panel discussion
Workshops
Simulation
Audio/Video Teleconference
Laboratory Experience
Other (specify)
Tools: Will any tools be provided to participants to assist with the changes in practice learned during the series?
(mark all that apply)
Patient Education
Provider Reminder System
Patient Reminder System
Provider Education
Audit and Feedback
Organizational Change
Other (specify)
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Evaluation: At the conclusion of the activity, how will you measure the effectiveness of the seriesl?
Use of pre- and post-test
Focus Group Evaluation (conducted annually)
Designated Evaluator (per session)
Faculty Disclosure: Prior to the educational activity, all participating faculty (speakers/authors, moderators, etc) in a PSCOM
sponsored activity must disclose to the audience all relevant financial relationships with any commercial interest. The ACCME defines
“’relevant’ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of
interest. Written disclosure documentation must be on file with the PSCOM Continuing Education Office prior to the activity taking
place and in sufficient time to resolve any identified conflicts of interest.
Please attach the following required documentation:
1. Disclosure Form for Course Director.
2. Disclosure Forms for anyone else involved in the planning process.
3. Any needs assessment documentation collected.
I hereby certify that this application was completed accurately and attest to the validity of the information contained
within. I agree to collaborate with the Department of Continuing Education to ensure that the planning and
implementation of the proposed CME activity are consistent with the policies and procedures of the ACCME..
________________________________________________________________________________________________
Course Director Signature
Date
________________________________________________________________________________________________
Course Coordinator Signature
Date
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