AAOS_SingleLineBlack 

 


Form #3: AAOS CME Project Planning Form for Joint Providership of Educational Activities

 

Date:  Click here to enter a date.

 

Activity Information

 

Activity Title: Click here to enter text. 

 

Activity Date(s):    Click here to enter a date.

 

Please describe the process used to develop this activity. 

For example, if the planning committee met fact-to-face or electronically to plan the meeting, describe the interactions.

Click here to enter text.

 

 

Activity Development Planning Committee

 

Faculty Contacts   

Chair Name:  Click here to enter text.

Contact Phone:   Click here to enter text.

Contact Email:  Click here to enter text.

Contact Mailing Address:  Click here to enter text.

Disclosure Updated?   Choose an item.         Click here to enter a date.

 

Activity Planning Committee or Faculty

            Name:  Click here to enter text.

Contact Phone:   Click here to enter text.

Contact Email:  Click here to enter text.

Contact Mailing Address:  Click here to enter text.

Disclosure Updated?   Choose an item.         Click here to enter a date.

 

Name:  Click here to enter text.

Contact Phone:   Click here to enter text.

Contact Email:  Click here to enter text.

Contact Mailing Address:  Click here to enter text.

Disclosure Updated?  Choose an item.         Click here to enter a date.

 

Name:  Click here to enter text.

Contact Phone:   Click here to enter text.

Contact Email:  Click here to enter text.

Contact Mailing Address:  Click here to enter text.

Disclosure Updated?   Choose an item.        

                       

Administrative Staff Contact

Name:  Click here to enter text.

Contact Phone:   Click here to enter text.

Contact Email:  Click here to enter text.

Contact Mailing Address:  Click here to enter text.

Disclosure Updated?   Choose an item.         Click here to enter a date.

 

Needs ASSESSMENT C2, C3, C5, C6

 

Describe the educational need or clinical practice gap that will be addressed by this activity.  C2

Click here to enter text.

 

What problem or problems are being addressed by this activity? C2

Click here to enter text.

 

Provide at least two data sources used to identify the educational need or clinical practice gap described above.  For the data source chosen, provide a brief description of the source and the data. C2

   Expert faculty opinion (provide names and description of their input)

   Literature review (provide summary)

   National or local clinical quality, safety or performance data

   Survey of target audiences

   Prior program evaluations

   New medical information

   External requirements such as the NCQA, JCAHO, CMS, Professional society, licensure or MOC requirement

   Legislative or regulatory or organizational changes affecting patient care

   Other:     Click here to enter text.

       

 

Educational Objectives C2
As a result of participation in this activity, participants will be able to:

Objective 1:   

Objective 2:

Objective 3:

Objective 4:

 

This activity is designed to accomplish which of the following outcomes?  Choose all that apply. C3

  Improve learner competence. 

  Improve learner performance in practice.
Should be documented through competency assessment, such as performance on case based problems or direct observation of competency.

  Improved patient outcomes.

          Should be documented through measurement of patient outcomes

 

How can this activity be used to help the learner improve their practice or patient outcomes?

Click here to enter text.

 

 

PLANNING

 

Target Audience(s)  

   Generalist orthopaedic surgeon

   Specialist            Specialty focus:  Click here to enter text.

   Resident

   Other    Click here to enter text.

 

Type of Activity  C5

   Internet Enduring

   Webinar Live

   Live Course

 

Educational Formats for This Activity C5

   Lecture

   Case study

   Interactivity

   Small group discussion

   Skills workshop

   Other        

 

Please describe the educational format of the activity. C5

Click here to enter text.


 

Please indicate which core competencies (as described by the ABMS) will be addressed. Choose all that apply.  C6

 

  Professionalism

Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations.

 

  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 sciences and their application in patient care.

 

  Practice-based Learning and Improvement
Able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence and improve their practice of medicine.

 

  Interpersonal and Communication Skills
Demonstrate skills that result in effective information exchange and teaming with patients, their families and professional associates (e.g. fostering a therapeutic relationship that is ethically sound, uses effective listening skills with non-verbal and verbal communication; working as both a team member and at times as a leader).

  Systems-based Practice
Demonstrate awareness of and responsibility to larger context and systems of healthcare. Be able to call on system resources to provide optimal care (e.g. coordinating care across sites or serving as the primary case manager when care involves multiple specialties, professions or sites).

 


 

Financial Information   C7, C8, C9, C10

Will this activity be receiving external support ,e.g., pharmaceutical or medical device company support?

 

____ Yes        ____ No

 

If yes, please describe the type of support and anticipated amount (if available):

    Commercial Support

Company Name

Amount

 

 

 

 

 

     Other Anticipated Financial Support

Source

Amount

 

 

 

 

    Is another organization co- sponsoring or developing this activity?

 

Organization

Role

 

 

 

Additional Information:   Click here to enter text.

 

 

 

Administration: Choose all that apply.

  The provider developed activities/educational interventions independent of commercial interests. (SCS 1, 2, and 6).  C7

 

  The provider appropriately managed commercial support (if applicable, SCS 3 of the ACCME Standards for Commercial SupportSM).  C8

 

  The provider maintained a separation of promotion from education (SCS 4). C9

 

  The provider actively promoted improvements in health care and NOT proprietary interests of a commercial interest (SCS 5). C10


 

Evaluation 

 

Course Evaluation

Based on the outcome determined above (competence, performance, or patient outcomes), indicate the evaluation method used to analyze changes in learners achieved as a result of the program's activities/educational interventions. 

 

Please describe and/or attach.  Choose all that apply. C11
   CME evaluation form

   Group problem solving exercises

   Practice audits or chart reviews

   Performance evaluation such as direct performance evaluation or assessment on case based problems before and after activity.

   Intent to change practice questionnaire

   Other         Click here to enter text.

 

 

Rev. 8.7.2014