TUFTS UNIVERSITY SCHOOL OF MEDICINE - OFFICE OF CONTINUING EDUCATION

TUFTS UNIVERSITY SCHOOL OF MEDICINE - OFFICE OF CONTINUING EDUCATION Tufts University School of Medicine (TUSM) Office of Continuing Education (OCE) is pleased to work with you on continuing education (CE) for your activity. As an accredited provider, we strive to uphold rigorous national standards for quality CE that improves clinician performance and care for patients and communities. Using this planning form and other supporting documentation, TUSM OCE will lead you through an effective educational planning process. In doing so, we will highlight the quality standards required of CE providers and educational partners by the following national CE oversight and accrediting bodies: The American Medical Association (AMA) and the Accreditation Council of Continuing Medical Education (ACCME). Please submit the attached planning form to TUSM OCE via Box.com by June 30, 2017. Forms WILL NOT be accepted after this date and we cannot offer CME retroactively. Please see our reference manual for information on completing this planning form and for examples of best practices. eeds Also, we would like to inform you about an online tool, eeds (electronic education documentation system) which some departments have purchased and we highly recommend. This electronic documentation system can help record participant attendance, track evaluation data, etc. For more information including fees, please contact TUSM OCE directly. We look forward to working with you on this educational initiative! TUSM OCE Staff

TUFTS UNIVERSITY SCHOOL OF MEDICINE - OFFICE OF CONTINUING EDUCATION Planning Form Documentation Checklist Upload by June 30, 2017 (Forms WILL NOT be accepted after this date) Completed/Signed RSS Planning Form (completed by RSS administrator or Course Director) Verification of Identified Learner Needs (one form of documentation required) Disclosure Forms for Course Director and Planning Committee Members Estimated budget (not required if there will be no expenses or funding for series/sessions) NOTE: TUSM OCE must submit all educational grant requests to potential funders. If your department wants to submit a grant request directly, you may do so as an activity not offered for CME (TUSM OCE will not offer credit(s) for those sessions). There will be fees associated with each grant request TUSM OCE directly submits and manages. Please contact TUSM OCE if you would like further details. Monthly Session Upload Submission Month to be Monitored: July August September October November December Upload Schedule by: June 16th July 14th August 18th September 15th October 13th November 17th Month to be Monitored: January February March April May June Upload Schedule by: December 15th January 19th February 16th March 16th April 20th May 18th Post-Series Checklist Upload by August 13, 2018 Attendance & Credit Tracking Spreadsheet (download and use our required template) Final budget (if any income and/or expenses apply) Impact of Education on Outcome* *If using a follow-up survey, please use our survey template or view our instructions on how to set it up on Survey Monkey. Please note the Session Specific Requirements that must be met to comply with accreditation requirements and for certificates at end of series (see next page). Our forms are PDF fillable and we require that forms are sent to us electronically via box.com. All forms are available on our website, please click HERE. NOTE: Sessions are subject to periodic audit by TUSM OCE and/or the ACCME. pg. 2

TUFTS UNIVERSITY SCHOOL OF MEDICINE - OFFICE OF CONTINUING EDUCATION RSS Session Specific Required Documentation Checklist Please UPLOAD the following documentation to TUSM OCE within 5 business days post-session*: BEFORE the session complete: Obtain Speaker s Disclosure Form Obtain Speaker s presentation slides or a bulleted outline of session content Review Content and Disclosure forms NOTE: If the course director or designated reviewer has relevant financial relationships with a commercial interest, then they are not an appropriate reviewer. You must choose another reviewer with no relevant financial relationships. Complete Required Content Review/Resolving Conflicts of Interest (RCOI) form NOTE: To be completed by an appropriate reviewer, course director or assigned reviewer; not the speaker. Update Sign-In Sheet Disclosure/Accreditation Information and/or Accreditation slides DURING the session complete: Display Sign-In Sheet for Participants to Sign-In Communicate Accreditation/Disclosure Information (Verbally and/or display OCE Accreditation slides/sign-in Sheet) Distribute Monthly Evaluation to participants (if using paper version) AFTER the session complete: Collect Sign-in Sheet(s) Distribute Monthly Evaluation (if using electronic version) Complete Monitor Verification Form (completed by designated person present at session; attesting accreditation requirements met) Update Attendance & Credit Tracking Spreadsheet (OCE template required - NOTE: this document is submitted post-series) Complete Practice Gap Summary Form for all M&M, Case Conference, and Tumor Board sessions (if applicable) *Our forms are PDF fillable and we require that all session documentation be uploaded to Box.com, a free cloud-based service hosted by Tufts University. This will ensure that quality data is being recorded, forms are filled out completely and correctly, and that all documents required for receiving credit are submitted in a timely manner.. All forms are available on our website, please click HERE. NOTE: Sessions are subject to periodic audit by TUSM OCE and/or the ACCME. pg. 3

TUFTS UNIVERSITY SCHOOL OF MEDICINE - OFFICE OF CONTINUING EDUCATION Regularly Scheduled Series Planning Form - July 1, 2017 June 30, 2018 All sections of this form must be fully completed in order to receive approval. General RSS Activity Information RSS Title RSS Start Date (no earlier than 7/1/17) RSS End Date (no later than 6/30/18) Anticipated # of sessions per year (minimum of 4) Session Start & End Time RSS Location Hospital/Institution (Joint Provider) Department/Division Administrative Contact Name Email Telephone Course Director Name Email Telephone RSS Category New RSS (TUSM OCE will contact you to schedule a training session required for new series) Repeat RSS RSS Type Grand Rounds (if you will integrate periodic M&M sessions into this series, please select M&M too) M&M (please choose one option below) All sessions are M&M Case Conference (specific cases discussed per session) Tumor Board Only some sessions are M&M, #: Journal Club Frequency Weekly Bi-weekly Other: Days Monthly Quarterly Monday Tuesday Wednesday Thursday Friday Other: Type of Continuing Education (check all that apply) AMA PRA Category 1 Credit Risk Management Credit Please see requirements at the end of this planning form. NOTE: TUSM OCE cannot grant AMA PRA Category 1 Credit to speakers for their original presentations, but they may claim credit directly from the AMA. Please visit the AMA for more information. Educational Format(s) Identify primary teaching method(s) that will help the target audience achieve the learner objectives. Lecture/discussion Video/teleconference Demonstration/hands-on workshop Case presentation/discussion Slide/film/video/audiotape Simulation/hands-on lab Panel presentation/discussion Small group workshop Other, please describe: Target Audience (check all that apply) Physicians, please specify specialty below: Nurses Pharmacists Residents/Fellows Medical Students Other: Budget Will there be any expenses and funding related to this series? No expenses or funding related to this series General Support: Registration Fees Dept/Institution Funds Yes, please select what type of funding from options below: Federal/public/private grant(s)/donation(s) Commercial Support from commercial interest(s)*: Monetary Grant Support In-Kind Support (non-monetary, e.g., equipment) Please note that TUSM OCE must submit all educational grant requests to potential funders. If your department wants to submit a grant request directly, you may do so as an activity not offered for CME (TUSM OCE will not offer credit(s) for those sessions). There will be fees associated with each grant request TUSM OCE directly submits and manages. Please contact TUSM OCE if you would like to discuss further details. Promotional Support: Exhibitors Other Source of Funding: please specify: * A commercial interest is defined as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. pg. 4

Planning Process ACCME Criterion 7 High quality continuing education activities depend on thoughtful and rigorous planning. To this end, the following sections ask you to describe and demonstrate how this activity will directly contribute to health care improvement while meeting the current CE guidelines/requirements of the ACCME. Course Director and Planning Committee Members NOTE: Please obtain disclosure forms from planning committee members to fully complete this section. Name Degree(s) Role on Area of *Conflict of Interest with Committee 1. 2. 3. 4. Expertise/Specialty a commercial Interest? Course Director Planner Yes No Course Director Planner Yes No Course Director Planner Yes No Course Director Planner Yes No Who will identify the speakers and topics for this series? Check all that apply. Course Director Planning Committee Members Other(s) (please specify): Will there be any input from pharmaceutical and/or medical device manufacturer employees, including suggesting speakers and/or topics? NO YES, please explain: *How will you resolve conflict(s) of interest noted above by planning committee members? Check all that apply. Not applicable since planning committee members do not have any conflicts of interest Will ensure that the focus of the activity will be away from the conflict(s) of interest Will revise the role of the individual with conflict of interest so that the relationship(s) is no longer relevant to the activity Active Learning Strategies How will you engage the learner audience before, during and after the activity? Check all that apply. Q&A Discussion Pre- & Post-Test Case Presentation(s) Pre-course study materials Educational Reinforcement Tools (optional) ACCME Criterion 17 What mechanism(s) will be available to the learner audience to help them retain what they ve learned in this activity? Post-activity, please provide a sample or a web link for any selected reinforcement tool(s). Patient/health care professional reminders and materials Information posted online (web link): Follow-up emails Pocket guides Alignment with TUSM OCE s Mission ACCME Criterion 3 The mission TUSM OCE is to enhance clinician knowledge and competence; improve clinician performance; and promote lifelong learning for Tufts-affiliated physicians, nurses, pharmacists, and for other health practitioners.the ultimate goal of this endeavor is to improve patient care and health outcomes. Please indicate how this RSS will align with TUSM OCE s mission noted above (Check all that apply) Designed to address gaps in quality Designed to disseminate evidence-based knowledge and skills Designed to improve patient health status/metrics Designed to promote teamwork among health professionals by including an inter-professional audience Other, please explain: pg. 5

Verification of Identified Learner Needs ACCME Criterion 2 Select one method from any category below by which you identified the need for the activity. NOTE: Please do not select methods for which you cannot submit DETAILED DOCUMENTATION. Learner Identified Needs Needs Assessment Survey (highly recommended) - A pre-scanning of the registered or anticipated audience to determine what topics or gaps in knowledge the audience is most interested in addressing. Please submit a summary of results along with a statement explaining how the results were used for determining the topics for this educational activity. Learner Feedback suggestions for topics/content from learners of a prior activity s evaluation results or outcomes follow-up survey results. Please submit a statement that clearly identifies what the feedback was and how it will be incorporated in the agenda for this educational activity. Expert Identified Needs Changes in National or Specialty Society Guidelines - Submit a copy of the guidelines with a statement indicating the specific change along with any recommendations on education addressing these changes. Current Research/ Peer-reviewed literature Submit the journal article(s)/current research that were reviewed along with a statement that explains the educational needs of the learner derived from the articles. Planning/Advisory Committee/Department Chair/Leadership - Submit a written statement by the Course Director, Department Chair/Leader or other Course Planner indicating the educational needs of the learner and how they were determined. Data-based Observations - Please DO NOT include patient confidential information. QA/QI Data or Dashboards/Metrics - Submit a summary of the data along with an explanation of how the data demonstrates area(s) in need of improvement. Publicly Reported Performance Data - Submit a copy of the data along with an explanation of the areas that need improvement that will be addressed by this activity. Professional Practice Gap (Learner Needs) ACCME Criterion 2 Continuing education activities should be developed to address and change some aspect of the learners knowledge, competence, or performance that will result in improved patient care and/or patient outcomes. Please indicate the specific educational needs of the targeted audience that this activity will address. What are the problems/educational needs that you are trying to address in this series? What questions in practice are you having that you are not getting answers to? What patient problems or patient challenges are you not able to address appropriately or to your satisfaction? What problems are your patients reporting to you that need more attention or more follow-up? It is assumed that practitioners need to keep current with regulatory requirements including ACGME, ABMS & MOC. The identified practice gap should meet learner needs that go beyond those regulatory requirements. NOTE: Do not complete this section if this series is an M&M, Case Conference or Tumor Board since the practice gaps (learner needs) are identified at the actual sessions during discussion and reflection. For these series types, please complete a Practice Gap Summary Form after each session. pg. 6

Areas for Improvement and Learner Objectives ACCME Criterion 3 INSTRUCTIONS: 1. Please check off the area(s) of improvement that this activity will address. NOTE: It is assumed that knowledge is an area of improvement for all CE activities. Use this section to indicate if the activity is designed to achieve a change in competence or competence and performance. 2. Provide a minimum of 2 overall learner objectives. If you would like to use measurable action verbs not listed below, you may just write it in the text box. Please refer to our Verb Worksheet for a list of acceptable verbs. Competence (what learners need to know how to do) Performance (what learners need to do) As a result of this educational activity, learners will be able to: Choose one measurable verb below: Assess Integrate Outline Evaluate Distinguish Select Choose Compare Explain Complete objective here: As a result of this educational activity, learners will be able to: Choose one measurable verb below: Develop Apply Perform Interpret Show Diagnose Implement Use Practice Complete objective here: As a result of this educational activity, learners will be able to: As a result of this educational activity, learners will be able to: Choose one measurable verb below: Assess Integrate Evaluate Distinguish Choose Compare Complete objective here: Choose one measurable verb below: Develop Apply Interpret Show Implement Use Complete objective here: Outline Select Explain As a result of this educational activity, learners will be able to: Choose one measurable verb below: Assess Integrate Outline Evaluate Distinguish Select Choose Compare Explain Complete objective here: Perform Diagnose Practice As a result of this educational activity, learners will be able to: Choose one measurable verb below: Develop Apply Perform Interpret Show Diagnose Implement Use Practice Complete objective here: Quality Improvement ACCME Criterion 21 Is this series a quality improvement project or process? NO YES, please explain: Patient/Systems-level Outcomes Is your series designed to change Patient and/or Systems-level Outcomes? NO YES, please explain: pg. 7

Competencies ACCME Criterion 6 Identify one primary and up to two secondary ACGME/ABMS competencies that this activity is designed to address with a check in the appropriate column. Primary (select only one) Secondary (select up to two) ACGME/ABMS Competencies Patient Care and Procedural Skills Including: compassionate, appropriate and effective treatment of health problems and/or health promotion. Medical/Clinical Knowledge Including: established and/or evolving biomedical, epidemiological, socialbehavioral knowledge as it applies to clinical medicine. Practice-Based Learning and Improvement Including: appraisal of one s own care patterns, knowledge, expertise, and gaps; setting goals addressing gaps in one s own practice and implementing; changes with the goal of practice improvement ;information mastery: locating, appraising, and assimilating evidence from; scientific studies to apply in own practice Interpersonal and Communication Skills Including: effective communication with patients, families, other health professionals; effective collaboration/leadership in a healthcare team. Professionalism Including: adherence to ethical principles; integrity; respect for others; responsiveness to patient needs; sensitivity and responsiveness to diverse populations. Systems-Based Practice Including: coordination of patient care within a healthcare system, with appropriate and effective use of system resources; system-based quality assessment and improvement Please identify if this series will address any of the following IOM Competencies. Check all that apply: Provide patient-centered care Work in interdisciplinary teams Employ evidence-based practice Utilize informatics in patient care, clinical decision-making; error reduction, and/or knowledge management Apply quality improvement pg. 8

Identified Barriers ACCME Criterion 18 What factors do you predict will prevent the learner audience from incorporating new knowledge, competence, and/or performance gained through this activity? Check all that apply. Clinician Barriers Lack of time to assess or counsel patients Lack of consensus on professional guidelines Clinician allegiance to old standards/old habits Lack of time to assimilate large amounts of new knowledge Insufficient cultural competence Lack of reinforcement of new professional guidelines Clinician fear of punishment/malpractice litigation Patient-Based Barriers Insufficient adherence to treatment plan Insufficient clinical staff Insufficient technical resources Insufficient interdepartmental communication/uniform level of care between departments/sub-specialties Insurance/reimbursement issues System Barriers Communication/Language Barriers Insufficient administrative support/resources Policies Institutional Barriers/ Departmental Barriers Insufficient data Organizational culture/disorganized systems Cost of treatment Insufficient accessibility/availability of treatment Please specify: Other Not Applicable No perceived barriers ACCME Criterion 19 Will this activity address those options noted in the above section? Not applicable no perceived barriers as noted above. Not able to address barrier(s) identified above through this activity. Activity content will address the identified barriers. pg. 9

Learner Evaluations ACCME Criteria 12-15 Learner feedback (evaluation) is conducted immediately post-session to measure the learners' intent to change. NOTE: This is not the same as the outcomes measurement tool noted below, which is conducted at the end of the series and is designed to measure actual changes made to practice. Participant evaluations must be distributed MONTHLY (at minimum) per series. Completion of evaluations by participants is optional, but encouraged. Impact of Education on Outcomes ACCME Criterion 11 The purpose of this tool is to determine the impact that the education had on clinician practice. Submitted results should demonstrate impact through survey results and/or a narrative explaining the findings using hard data. In some cases, it may be discovered that the education had little to no impact on the learner. This should be a consideration when planning the series for the following year. Identify how you will measure the relevance and impact of your series on practice application, clinician performance and/or health outcomes. Please select carefully. You are required to submit results for all of the selections made. Only ONE measurement tool is required. Knowledge/Competence Follow-up surveys (Instructions on how to create your survey using Survey Monkey and the survey template are available on OCE s website) Please distribute by June 30, 2018, submit results to TUSM OCE no later than August 13, 2018. Customized pre- and post-test Learner reports on changes made as a result of the CE activity Performance Participant focus group about actual change in practice Certification exam outcome with analysis of results Chart Audits with analysis of results Case-based studies Track and ID new practices or policies as a result of your series Data Monitoring/Patient Outcomes Other Quality assessment data/review (departmental, institutional, external) with analysis of results Patient satisfaction survey Claims data/review with analysis of results Morbidity/ Mortality data with analysis of results Please specify: pg. 10

MA Risk Management Credit MA Risk Management Study means instruction in medical malpractice prevention, such as risk identification, patient safety, and medical error prevention. This activity may be eligible to receive MA Risk Management Credit if the activity meets the following criteria. If only specific sessions/presentations within the activity meet the criteria, these individual sessions/presentations may still receive Risk Management credit. Frequency of Risk Management Related Content Not applicable All sessions in the series meet the criteria (select applicable topics below) Only some of the sessions in this activity meet the criteria Please check off Risk Management Credit under the General RSS Information on page 4 of the planning form. As you update the Attendance & Credit Tracking Sheet, please indicate which sessions include Risk Management credit. Please indicate the Risk Management topic(s) that was addressed on the Monitor Verification Form. Risk Management Topics Please check off any areas noted below that will be applicable to this RSS activity. Risk identification Patient safety Loss prevention Medical ethics Medical-legal issues Patient relations End of life care studies Opioid and pain management Non-economic aspects of practice management Utilization review that directly relates to quality assurance/quality improvement Study of the MA Board of Registration in Medicine s Patient Care Assessment Regulations (243 CMR 3.01 et seq.) pg. 11

Joint Provider Collaboration Agreement As part of a collaborative relationship with TUSM OCE, the joint provider agrees to the following responsibilities: Adhering to pre-established submission timelines noted on the Planning Form Documentation. Adhering to all requirements and standards of the ACCME and AMA. Conducting a continuing education activity that focuses on health care improvements and does not in any way promote proprietary interests (maintaining total separation of all educational and promotional activities). Identifying the quality gap and need for this activity, and providing supporting documentation as requested. Reviewing and assuring quality of content and selection of faculty. Providing session documentation, including disclosure forms for all persons involved in content, as noted on the Session Specific Required Documentation Checklist. Notifying TUSM OCE if you will seek commercial support for the overall series or any sessions so that TUSM OCE can submit the grant requests directly to the commercial interest(s). Adhering to all ACCME Standards for Commercial Support and Promotion (exhibiting). See Standards for Commercial Support requirements Resolving of all potential conflicts of interest prior to delivery of the educational activity (please note that disclosure alone is insufficient). Ensuring appropriate peer review of content and course materials to ensure that content is scientifically valid, evidencebased, balanced, and free from any commercial bias (regardless of whether the activity itself receives any commercial support). Ensuring that learners are informed, prior to beginning the activity, of relevant financial relationships or lack thereof for all persons in control of content, all commercial support or lack thereof, and other format-specific accreditation information. Submitting all final post-series documentation as noted in the Post-Series Documentation Checklist. Implementing an Impact of Education on Outcomes Tool with activity participants after the series to assess the impact that the education had on clinician practice and/or patient outcomes. Additionally, I understand the following: If our department/division applies for an educational grant, TUSM OCE cannot offer continuing education credit for the funded sessions/series. Presenters for this activity may only receive AMA PRA Category 1 Credit for time spent preparing and presenting through direct application to the AMA. TUSM OCE will issue certificates for Series that comply with timely receipt of all required session and post-series materials. If a session or series is deemed non-compliant, TUSM OCE cannot issue certificates. All activities offered by TUSM OCE are subject to periodic audit by TUSM OCE and/or the ACCME. I have read and agree to the above noted responsibilities related to collaboration in this activity and attest that the information provided is complete and accurate. I agree to abide by the current ACCME and AMA accreditation requirements for planning, activity implementation and evaluation (including the Standards for Commercial Support) and TUSM OCE s RSS policies and procedures. Course Director Signature: Date: pg. 12