UNM CME Application

UNM CME Application

We are here to help. For support or questions, please call 505-272-3942 or email hsc-cpl@salud.unm.edu. Only completed applications will be reviewed.

The CME educational planning process consists of several essential steps:

Plan the activity --> Apply for CME credit --> Implement the activity --> Report outcomes

UNM RSS activities are accredited for free. Accreditation fees for other activity types will be assessed. Contact our office for rate and fee information.

1. Activity Information

CME Activity Name:*

Department or Organization Name:*

Select

Department Address:*

Department City:*

Department State:*

Select

Calendar Year of Activity:*

Select or enter value

First Date of Activity:*

End Date of Activity:*

(repeat first date if only one day)

Estimate the number of credit hours for your activity and how you determined the value.*

CPL staff will review the agenda and verify the credits.

Location of activity:*

Will you be applying for MOC/CC credit for your activities?*

Yes

If "yes" choose which Board you will apply for:*

CPL can only authorize and report MOC/CC for these boards
CPL will send you more information on setting up MOC/CC credit

American Board of Anesthesiology (ABA)

American Board of Internal Medicine (ABIM)

American Board of Otolaryngology - Head and Neck Surgery (ABOHNS)

American Board of Orthopaedic Surgery (ABOS)

American Board of Pathology (ABPath)

American Board of Pediatrics (ABP)

American Board of Surgery (ABS)

American Board of Thoracic Surgery (ABTS)

Is this activity organized by UNM?*

Yes (Direct Provider)

No (Joint Provider)

Is this activity supported by funds by an ACCME-defined ineligible company, such as a drug/device manufacturer, healthcare service provider?*

Yes

If "Other" support type, please specify:*

Commercial support source:*

Monetary value of support:*

2. Education Planners

Attending Physicians, Nonphysician healthcare professionals (e.g. APPs, nurses, pharmacists, CNMs, etc.)

Attending Physician 1:

First and Last name of Attending Physician

Attending Physician 1: Position

Attending Physician 1: Email

Attending Physician 2:

First and Last name of Attending Physician

Attending Physician 2: Position

Attending Physician 2: Email

Attending Physician 3:

First and Last name of Attending Physician

Attending Physician 3: Position

Attending Physician 3: Email

Nonphysician healthcare professionals 1: (e.g. APPs, nurses, pharmacists, CNMs, etc.)

First and Last name of Nonphysician healthcare professional

Nonphysician healthcare professional 1: Position

Nonphysician healthcare professional 1: Email

Nonphysician healthcare professionals 2: (e.g. APPs, nurses, pharmacists, CNMs, etc.)

First and Last name of Nonphysician healthcare professional

Nonphysician healthcare professional 2: Position

Nonphysician healthcare professional 2: Email

Nonphysician healthcare professionals 3: (e.g. APPs, nurses, pharmacists, CNMs, etc.)

First and Last name of Nonphysician healthcare professional

Nonphysician healthcare professional 3: Position

Nonphysician healthcare professional 3: Email

Learners (students, residents, or fellows) 1:

First and Last name of Learner

Learners (students, residents, or fellows) 1: Position

Learners (students, residents, or fellows) 1: Email

Learners (students, residents, or fellows) 2:

First and Last name of Learner

Learners (students, residents, or fellows) 2: Position

Learners (students, residents, or fellows) 2: Email

Learners (students, residents, or fellows) 3:

First and Last name of Learner

Learners (students, residents, or fellows) 3: Position

Learners (students, residents, or fellows) 3: Email

Other Planners 1:

First and Last name of Other Planners

Other Planners 1: Position

Other Planners 1: Email

Other Planners 2:

First and Last name of Other Planners

Other Planners 2: Position

Other Planners 2: Email

Other Planners 3:

First and Last name of Other Planners

Other Planners 3: Position

Other Planners 3: Email

Coordinator/Administrative Staff support person*

Coordinator/Administrative staff Email:*

Coordinator/Administrative staff Phone Number:*

Coordinator/Administrative staff Position/Department:*

3. Activity Type

Select your activity type:*

Regularly Scheduled Series-Grand Rounds, Journal Club, M&M and Tumor Board (RSS)

Live course (in-person, virtual or both (LC)

On demand/self paced web learning (EM)

Combining live and asynchronous-online learning (BOL)

Other

Select

If "Other", please describe:*

CPL will review the content, please provide:*

URL:

Username/password for access:*

Accreditation Fee

UNM RSS activities are CME-approved for free. Accreditation fees will be assessed for other activity types (e.g., live course, online asynchronous learning, combined online and in-person learning).

Contact CPL for rate and fee information.

4. Commendable inclusion of learners as planners & presenters

It is commendable to include learners (students, residents, fellows) as planners and presenters.

Learners listed as planners in part 2?

Yes

Learners also presenters?*

If so, indicate names, if known, or write “TBA”

5. Gap(s)

State the difference between the current and desired state of learner competence, performance, and/or patient/trainee/student outcomes.

Gap(s) Examples:*

Surveys of attending’s and trainees indicate insufficient knowledge and skill in collecting and analyzing health/practice data to teach residents about healthcare improvement.
Emerging changes in guidelines for treatment require updating to maintain high standards of care.
NM DOH data show that fewer than 15% of patients with an alcohol use disorder get treatment and we want to raise that to at least 50% in our division.

What sources did you use to determine these gaps?*

NM Department of Health Reports

Mortality/morbidity statistics

Survey/request from target audience

QI dashboards/patient care data; e.g. Vizient (recommended)

Learning environment reports

Department/division priorities

Other

If "Other" sources, please describe:*

6. Needs: What do participants need to know or do to close the gap?

Examples:

Clinicians need to know anatomy and physiology of the joints and best practices for evaluating joint symptoms.
Clinicians need to demonstrate skills in creating respectful and professional learning climates.
Clinicians need to apply standard oncologic clinical care protocols for optimal management of patients diagnosed with solid tumors.

Select and describe one or more needs related to your gap (your educational activity may not address all of these needs).

Knowledge Need: gaining knowledge

Competence Need: knowing what to do with knowledge; knowing what to do if given the opportunity to do it

Performance Need: applying new knowledge to practice (performance)

7. Competencies addressed in your activity

One or more applicable competencies are required.

The list below includes the Competencies of: ACGME/ABMS, Institute of Medicine, and Interprofessional Education Collaborative, or you may enter other competencies recognized by your organization.

If your activity addresses other competencies, list them here along with the source citation:

8. Learning Objectives:

What participants will be able to do as a result of this activity (2-3 recommended).

Examples:

Participants will use clinical cases to guide quality improvement
Participants will correctly apply splints to simple extremity fractures
Participants will be able to design small-group-learning opportunities
Participants will adopt tools to promote professional wellbeing

For guidance to write learning objectives, click on this link:

https://app.box.com/s/ovhujesupmmo62cqxaw9o8ulbygxh046

Learning objective 1: Participants will...*

Learning objective 2: Participants will...*

Learning objective 3: Participants will...

Learning objective 4: Participants will...

9. Learning formats and methods:

For guidance on most effective and engaging formats, click on this link:

https://hsc.unm.edu/medicine/education/cpl/_cpl-docs/learning-formats.pdf and choose "Learning formats and methods".

If "Other", describe:

10. Intended and evaluated outcomes

Check all where change is intended.

At least one change OTHER THAN KNOWLEDGE must also be evaluated. Evaluated outcomes should align with learning objectives (section 8) and evaluation plan.

Change in participants' knowledge intended:*

Yes

Will you evaluate knowledge change with your activity?*

Yes

Will you evaluate knowledge: Objectively*

Test (pre and post, or post only)
Audience response quiz (identifying learner)

Yes

Will you evaluate knowledge: Subjectively*

Retrospective pre/post survey

Yes

At least one of the changes below must be objectively and/or subjectively evaluated.

Change in participants' competence (ability to do if given the opportunity) intended*

Yes

Will you evaluate competence change with your activity?*

Yes

Will you evaluate competence: Objectively*

Test (pre and post, or post only)
Audience response quiz (identifying learner)
Practice observation during event (preferably with rubric or checklist)

Yes

Will you evaluate competence: Subjectively*

Retrospective pre/post survey
Commitment-to-change statements
Retrospective pre/post survey and Commitment-to-change statements

Yes

Change in participants' performance IN ACTUAL PRACTICE intended*

Yes

Will you evaluate performance change with your activity?*

Yes

Will you evaluate performance: Objectively*

Observation in actual practice
Audit and feedback
Analysis of medical records

Yes

Will you evaluate performance: Subjectively*

Survey of participants' transfer of learning to practice examples

Yes

Change in patient health intended*

Yes

Will you evaluate patient health with your activity?*

Yes

Will you evaluate patient health: Objectively*

Analysis of medical records

Yes

Will you be evaluate patient health: Subjectively*

Survey of participants' knowledge of changes in patient outcomes

Yes

Change in community/population health intended*

Yes

Will you evaluate community/population health within 1-6 months after the activity?*

Yes

Will you evaluate community/population health: Objectively*

Consult CPL for guidance

Yes

Will you evaluate community/population health: Subjectively*

Consult CPL for guidance

Yes

Change in learning outcomes for residents/students intended*

Yes

Will you evaluate learning outcomes for residents/students within 1-6 months after the activity?*

Yes

Will you evaluate learning outcomes for residents/students: Objectively*

Analysis of changes in learners' performance (course grades, board-exam scores) before and after learned intervention

Yes

Will you evaluate learning outcomes for residents/students: Subjectively*

Survey of participants' knowledge of changes in learner outcomes

Yes

11. Policy acknowledgments:

Financial Disclosure Process:

Each presenter and program planner must complete an online Relevant Financial Relationship Disclosure form prior to the activity. If presenters or planners do not complete a disclosure statement prior to the activity, they will be disqualified from presenting, or the activity/event will not be certified for CME credit. The disclosure information needs to be provided to the audience in writing, whether the planners/presenters have a financial relationship or not. If there is a conflict of interest, contact CPL staff, so we can provide you with guidance to resolve the conflict.

Evaluation and learning by attendees:

Please see sample Learning & Feedback Forms (L&FF) for the expected CME questions and options. You are encouraged to add items to evaluate your activities that are specific to the goals of your program. L&FF or equivalent MUST be completed by each learner in order to obtain CME credit.

Reporting:

Evaluation Summaries of your L&FF or equivalent data must be compiled and uploaded to CPL at least twice per year (July for January-June; January for July-December).

Outcome Summary analyzing gap closure and other committed change measurements are due after the activity concludes or by the last day of February of the following year.

Attendance Process:

Learners are responsible for signing in with the provided sign-in link from the departments/ organizations. QR code or Bit.ly link and L&FF to be provided at the last 5-10 minutes of the activity. Sign-in and L&FF competition must take place at the end of the live activity. Retroactive credit for later sign in will not be awarded.

I understand UNM RSS activities are accredited for free. Accreditation fees for other activity types may be assessed (such as LC-Live Courses). I will contact CPL for rate and fee information.*

I have read and understand the policies regarding financial disclosures, evaluation, attendance, and reporting, and understand that if these processes are not followed that CME credit may not awarded.*

Clinical Content Policy: This activity includes content related to patient care, research supporting patient care, or other topics relevant to clinical work for health care providers.*

Yes

All recommendations for patient care in my approved continuing education activity must be based on current science, evidence, and clinical reasoning, while giving a fair and balanced view of diagnostic and therapeutic options.*

All scientific research referred to, reported, or used in my approved continuing education activity in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection, analysis, and interpretation.*

Although my continuing education activity is an appropriate place to discuss, debate, and explore new and evolving topics, these areas need to be clearly identified as such within the program and individual presentations. It is my responsibility to facilitate engagement with these topics without advocating for, or promoting, practices that are not, or not yet, adequately based on current science, evidence, and clinical reasoning.*

I as planner and presenters in my approved activity cannot advocate for unscientific approaches to diagnosis or therapy, or recommendations, treatment, or manners of practicing healthcare that are determined to have risks or dangers that outweigh the benefits or are known to be ineffective in the treatment of patients.*

Name of Educational Planning Faculty acknowledging these policies:*

Attachments:

When you submit your application, you will also attach the following documents (PDF preferred):

A Sample Announcement that includes the disclosure statement & accreditation statement.

Sample Learning & Feedback Form or your evaluation and learning assessment tool.

If the activity duration is greater than one hour, include an agenda that lists the speaker(s), the presentation titles and the start/end time for each session of your activity (including breaks and meals).

File Upload

Drag and drop files here or

Deadlines:

Applications must be received at least 30 days prior to the first day of the activity.
First time applications with the CPL office, we suggest 45 days prior to the first day of the activity.

A rush fee will be assessed for incomplete applications at the 30-day deadline.

If contracting CPL Event Planning Services, the application must be submitted prior to the first event-planning steps.

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