1 Start 2 Complete Name of CE Activity * Start Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2025202620272028 End Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2025202620272028 Contact Person * What is the official name of your organization? * Contact Email * Link to live or enduring activity webpage, if available. (ex: event registration page, course overview page, organization website, etc) Course Director * Nurse Planner Target Audience * Dentists Nurses Nurse Practitioner Pharmacists Physicians Physician Associate Psychologists Social Workers Optometrists Other... Target Audience Other... Upload agenda Files must be less than 2 MB.Allowed file types: gif jpg jpeg png pdf doc docx. COLLABORATIONS AND PARTNERSHIPS Will there be commercial support for this activity? * Yes No Please list potential supporters: * GAPS AND NEEDSThe Needs Assessment needs to include the following. If these are not included in your needs assessment, please click NO.Professional practice gap of your learners on which the activity will be based. (maximum 100 words)Educational needs that you determined to be the cause of the practice gaps: (maximum 50 words each)Must have at least one need identified: KNOWLEDGESKILLS/STRATEGY means the ability to apply knowledge to practicePERFORMANCE means actual implementation in practiceWhat the activity will be designed to change in terms of learners' skills/strategy or performance of the healthcare team or patient outcomes: (maximum 50 words) Needs assessment completed? * Yes No Upload needs assessment * Files must be less than 2 MB.Allowed file types: gif jpg jpeg png pdf doc docx. State the professional practice gap of your learners on which the activity will be based: (maximum 100 words) * State the educational needs below that you determined to be THE CAUSE OF THE ABOVE PROFESSIONAL PRACTICE GAPS: (maximum 50 words each)Must have at least ONE "need" identified: KNOWLEDGESKILLS/STRATEGY means the ability to apply knowledge to practicePERFORMANCE means actual implementation in practice Knowledge need: Skills/Strategy need: Performance need: State WHAT THE ACTIVITY WILL BE DESIGNED TO CHANGE in terms of learners' skills/strategy or performance of the healthcare team or patient outcomes: (maximum 50 words) * Explain how this activity matches the healthcare team’s current or potential scope of professional activities. (maximum 25 words) * Explain why this educational format is appropriate for the setting, objectives and desired results of this activity. (maximum 25 words) * CORE COMPETENCIES Institute of Medicine Competencies * Provide patient-centered care Work in interdisciplinary teams Employ evidence-based practice Apply quality improvement Utilize informatics Interprofessional Collaborative Practice * Values/Ethics for Interprofessional Practice Roles/Responsibilities Interprofessional Communication Teams and Teamwork ACGME/ABMS Competencies * Patient Care and Procedural Skills Medical Knowledge Practice-based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-based Practice List the objective(s) for this activity that address the target audience(s) identified above. List 1-2 objectives for each anticipated hour of learning.E.g. Complete this phrase: “Upon completion of this activity, the learner will ……..” CLICK HERE FOR A LIST OF APPROPRIATE VERBS. Objective 1: * Objective 2: * Objective 3: * Upload additional objectives: (if applicable) Files must be less than 2 MB.Allowed file types: gif jpg jpeg png pdf doc docx. QUALITY IMPROVEMENT: Is there a performance improvement project within your institution that we can develop CME in response to an issue you may want to address? * Yes N/A Please explain: * BARRIERS TO CHANGE: Are there any actual or perceived barriers to physician change that this activity can address? * Yes N/A Please explain: * ANCILLARY TOOLS TO ENHANCE LEARNING OUTCOMES: Describe one or two ancillary tools you envision making available to learners in this activity: [e.g., algorithms, patient handouts, checklists, guides, etc.] * QUALITY FRAMEWORK FOR THIS ACTIVITY: If this activity will be based on or incorporate a relevant clinical guideline or standard of care, indicate what that guideline or standard will be and its source: * Purpose of activity? (1-2 sentences; disregard if included in needs assessment) Leave this field blank
