FORM CMERSS-2
END OF YEAR REPORT AND CHECKLIST
RSS ACTIVITIES
(July 1, 2015 – June 30, 2016)
(This report is due in the CME office no later than July 18, 2016)
Please submit one hard copy of the report (with attachments) to the CME Office and email one electronic copy of the report
(only the report, not the attachments) in word format to [email protected]
Department:
Title of Activity:
Course Director:
Coordinator:
Location:
/ e-mail
/ e-mail
The following are required documentation for all WCMC RSS Activities:
Attached?
1.
2.
3.
4.
Attendance Summary (7/1/2015-6/30/2016)
Full List of Sessions (7/1/2015-6/30/2016)
Budget Summary (7/1/2015-6/30/2016)
Renewal Application – Form CMERSS-3 (7/1/2016-6/30/2017)
Yes
Yes
Yes
Yes
No
No
No
No
Course Director Section
I understand that I must retain activity records/files for all sessions for at least six years.
I have shared evaluation data with faculty for this activity.
I attest that sessions related to QA/UR issues were included in this RSS during this reporting period. I
verify that an assessment of Quality and Patient safety needs has been performed and that the
curriculum for this activity includes activities aimed at addressing deficiencies and closing quality gaps.
COURSE DIRECTOR’S Signature:
Print Name
Date
Signature
(By signing, you verify that you have reviewed and approved this CME report.)
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Core Competencies (select 1 at minimum)
CME activities should be developed in the context of desirable physician attributes. Please indicate which
American Board of Medical Specialties (ABMS)/Accreditation Council for Graduate Medical Education
(ACGME), Institute of Medicine (IOM) core competencies (as of July 2010) or Interprofessional Education
Collaborative were addressed in this activity.
Patient Care and Procedural Skills: 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 (e.g.
epidemiological and social behavioral) sciences and the application of this knowledge to patient care.
Practice-Based Learning and Improvement: involves investigation and evaluation of their own patient care practices,
appraisal and assimilation of scientific evidence, and improvements in patient care.
Interpersonal and Communication Skills: Demonstrate skills that result in effective information exchange and
teaming with patients, their families and professional associates.
Professionalism: Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical
principles and sensitivity to a diverse patient population.
System-Based Practice: actions that demonstrate an awareness of and responsiveness to the larger context and system
of health care and the ability to effectively call on system resources to provide care that is of optimal value.
Provide Patient-centered care: Identify, respect, and care about patients’ differences, values, preferences, and
expressed needs; 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 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, and participate 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 such as standardization and implications; continually understand and measure quality of care in terms of
structure, process and outcomes in needs; and 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 decisions making using
information technology.
Values/Ethics for Interprofessional Practice: Work with individuals of other professions to maintain a climate of
mutual respect and shared values.
Roles/Responsibilities: Use the knowledge of one’s own role and those of other professions to appropriately assess
and address the healthcare needs of the patients and populations served.
Interprofessional Communication: Communicate with patients, families, communities, and other health professionals
in a responsive and responsible manner that supports a team approach to the maintenance of health and the treatment of
disease.
Teams and Teamwork: Apply relationship-building values and the principles of team dynamics to perform effectively
in different team roles to plan and deliver patient-/population-centered care that is safe, timely, efficient, effective, and
equitable.
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ATTENDANCE SUMMARY
July 1, 2015 – June 30, 2016
A. Total # of sessions
B. Total # credits approved per session (e.g. 1, 1.5)
C. Total hours of instruction (A x B)
D. Total # of MD hours
Miultiply the number of MDs attending by the number of sessions attended.
(e.g. Dr. X attended 12 sessions for one hour each. This equals 12 attendee hours. Add totals for all
MD’s.)
E. Total # of NonMD hours
Multiply the number of nonMDs attending by the number of sessions attended.
(e.g. Dr. X attended 12 sessions for one hour each. This equals 12 attendee hours. Add totals for all
nonMD’s.)
Please attach a spreadsheet documenting the names of attendees, dates of attendance and total hours of
attendance for this activity for July 1, 2015 to June 30, 2016.
F. Spreadsheet attached?
Yes
No
Reviewed and approved by OCME: ________________________________________________
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APPENDIX A
Attendance Spreadsheet
Please attach here
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FULL LIST OF SESSIONS
July 1, 2015 – June 30, 2016
Total # of Sessions:
Date
Speaker
Topic
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BUDGET SUMMARY
July 1, 2015 – June 30, 2016
1. TOTAL REVENUE (INCOME)
Sources of Revenue/Income:
A.
Departmental Funding
B.
Other Support
$
$
TOTAL REVENUE/INCOME
$
2. TOTAL EXPENSES
A.
Speaker Honoraria (list each speaker):
$
$
$
$
$
TOTAL HONORARIA
B.
C.
D.
Faculty housing, travel, meals, misc.
Meals/Coffee Breaks
Other Expenses: (please list)
$
$
$
$
TOTAL EXPENSES
$
*
NET INCOME/LOSS............$
*
(Calculation: income minus expenses)
* Expense must be offset by either Departmental or other income.
* Negative balances are not acceptable.
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APPENDIX B
Renewal Application (Form CMERSS-3)
Please attach here
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