POLICIES AND PROCEDURES
FOR CME ACCREDITATION OF
REGULARLY SCHEDULED SERIES
(GRAND ROUNDS)

A Manual for Series Chairs and Coordinators

Updated 4/15/13

DEFINITION OF REGULARLY SCHEDULED SERIES:

Regularly Scheduled Series (RSS) are defined as:

  1. A series with multiple sessions that
  2. Occur on an ongoing basis (offered weekly, monthly or quarterly) and
  3. Are primarily planned by and presented to the professional staff of the UCLA Health System,
  4. Held on campus or at an affiliated institution, and at
  5. No charge to participants

At UCLA, RSSs are tracked by calendar year. Therefore, prior to each January 1, the Course Chair must submit the Application Form in which he/she identifies professional practice gaps, writes the justification for practice gaps identified, and develops learning objectives.

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ACCME CRITERIA FOR ACCREDITING RSSs:

Regularly scheduled series must be planned using the following criteria:

  1. C.2. Incorporate into the series the educational needs (knowledge, competence, or performance) that underlie the professional practice gaps of your learners.
  2. C.3. Generate a series that is designed to change competence, performance, or patient outcomes as described in the Office of CME mission statement.
  3. C.4. Generate a series around content that matches the learners' current or potential scope of professional activities.
  4. C.5. Choose educational formats for your series that are appropriate for the setting, objectives and desired results of the series.
  5. C.6. Develop your series/educational interventions in the context of desirable physician attributes (e.g., IOM competencies, ACGME Competencies).
  6. C.7. Develop your series independent of commercial interests.
  7. C.8. Appropriately manage commercial support (if applicable).
  8. C.9. Maintain a separation of promotion from education.
  9. C.10. Actively promote improvements in health care and NOT proprietary interests of a commercial interest.

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PART 1: INSTRUCTIONS FOR COURSE CHAIRS

To receive accreditation for a Regularly Scheduled Series, course chairs must complete the CME Application Form for Regularly Scheduled Series and submit it to the Office of CME. The information required on the form is obtained through a four-part planning process that includes:

  1. Identifying professional practice gaps to be addressed
  2. Planning topics and speakers who will address those gaps
  3. Linking the practice gaps identified to your learners (needs assessment)
  4. Writing goals and objectives

These items are described in more detail below.

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PROFESSIONAL PRACTICE GAPS TO BE ADDRESSED

Each year, when planning your series, you will need to identify four or five professional practice gaps that your series will address. These will form the basis of your needs assessment and will guide you as you select appropriate topics and speakers for your series. (See examples of how practice gaps should be written.)

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PLANNING YOUR TOPICS AND SPEAKERS

Each Regularly Scheduled Series has to have a minimum of four or five sessions that are based on your learners' identified professional practice gaps. At a minimum, one of these sessions should be held each quarter (i.e., January-March, April-June, July-September, October-December).

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JUSTIFICATION OF PRACTICE GAPS IDENTIFIED (NEEDS ASSESSMENT)

A connection between the identified gaps and your own learners must be established as part of your needs assessment. This is best accomplished by evaluation of individual or group performance measures, including:

  • Patient care audit
  • Quality assurance data
If this cannot be done, you will need to:
  1. Provide evidence that a professional practice gap exists (you should use at least one of the following in your needs assessment):
    • Presentation of new techniques or technology
    • Literature review
    • State legislation
    • National trend data
    • State level data
    • IOM-identified practice gap
    • NIH-identified practice gap
    • Professional society-identified practice gap
    • Evaluations of prior series
  2. AND

  3. Demonstrate prospectively that it is applicable to your audience by conducting:
    • a survey of your learners that is administered prior to the beginning of your series or
    • an evaluation of the competency or performance of your learners in the identified areas

An example of a needs assessment justification follows:

The primary target audience for UCLA Family Medicine Grand Rounds is the faculty members and residents of the UCLA Department of Family Medicine as well as community primary care practitioners. Although designed with the original intent to comply with the ACGME program requirements for residency training in family medicine, the content of Family Medicine Grand Rounds fulfills the ongoing need of primary care physicians to remain current on the assessment and management of medical problems and issues seen in clinical practice and to maintain awareness of important legal and public health issues that impact their practice. In addition, an educational objective of the 2013-2014 curriculum is to narrow identified physician practice gaps in at least four areas of clinical practice. The four identified areas are:

(1) recognition and management of major depression: this gap was identified in the National Co-morbidity Survey Replication which found that less than 1/3 of patients with major depression seen in clinical practice were adequately managed (Kessler et al, JAMA 2003;289:3095-3105)

(2) management of asthma: asthma was identified by the Institute of Medicine in 2003 as one of the 20 top health care priority conditions needing improvement. (Adams K, Corrigan JM, eds. Priority Areas for National Action: Transforming Health Care Quality. Washington, DC: Institute of Medicine National Academies Press; 2003.)

(3) effective management of hypertension: the National Institutes of Health reported in JNC-VII that 30 percent of hypertensive patients remain undiagnosed and that 2/3 of the patients treated for hypertension are not controlled to levels below 140/90 mm Hg (http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf)

(4) screening for Chlamydia trachomatis infection: this was identified by the UCLA CPN (Community Physician Network) as one of the clinical performance measures on which UCLA physicians performed most poorly during the past year (CPN data 2008)

These practice gaps for our learners were confirmed on a survey conducted in October, 2010.

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GOALS AND OBJECTIVES

Your goals and objectives should include the educational goals and objectives the series will address, the target audience, the instructional content, and the learning outcomes. Goals and objectives statements characteristically describe what participants can expect to learn or achieve as a result of the program, how their attitudes are expected to change as a result of the program, and how the goals and objectives relate to patient care and/or other professional activities. Your goals and objectives statement should link to your professional practice gaps and needs assessment.

The following is an example of a well-written goals and objectives statement:

UCLA Family Medicine Grand Rounds represent a three-year longitudinal curriculum composed of weekly lectures designed to improve the competency and performance of family medicine faculty and other primary care physicians in the management of common clinical problems or issues seen in their clinical practice as well as to augment the clinical experiences of family medicine residents. Areas that will be addressed include:

  • The recognition, diagnosis, and management of common clinical problems arising in the areas of medicine, pediatrics, obstetrics and gynecology, surgery, and psychiatry
  • Important psychosocial, legal, and public health issues likely to be encountered in a clinical practice
  • Disease prevention and health promotion

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DESIRABLE PHYSICIAN ATTRIBUTES

As you plan your topics and speakers for your grand rounds series, be mindful of the ACGME competencies and try to include sessions that address as many of the following as possible:

  • Patient Care
  • Medical Knowledge
  • Practice-Based Learning and Improvement
  • Systems-Based Practice
  • Professionalism
  • Interpersonal and Communication Skills

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DEVELOPMENT OF PRE- AND POST-SURVEYS

For sessions that have been designated as addressing one of the identified practice gaps, a written pre- and post-survey must be generated and distributed to the learners just before the start of the lecture and at the conclusion of the lecture. The results of both the pre- and post-surveys must be tallied.

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PART 2: INSTRUCTIONS FOR SERIES COORDINATORS

CME programs are tracked by calendar year. Therefore, each January 1 we begin anew—the course chair needs to submit the Application Form in which he/she identifies professional practice gaps, writes the justification for the gaps identified, and develops goals and objectives. The series coordinator must obtain new course director and planning committee conflict of interest forms for the coming year and close out the previous year's program by providing the Office of CME with an Excel file report of previous year's participants.

Specifically, the series coordinator will be responsible for the following tasks:

  1. Approval Form
  2. Session Schedule
  3. Course Directors and Planning Committee Members Conflict of Interest Disclosure Forms
  4. Faculty Disclosure Forms
  5. Resolution of Conflicts Process
  6. Disclosure of the Conflict(s) of Interest to the Audience
  7. Correct Accreditation Statement on Fliers
  8. Sign-in at Each Session
  9. Distribution of Information on Cultural Competency
  10. Distribution of Pre- and Post-Surveys
  11. Session Evaluations
  12. Maintenance of Accurate Attendance Records
  13. Submission of Attendee List
  14. Site Visit
  15. Industry Support Regulations

These items are described in more detail below.

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APPROVAL FORM

Once your application is approved the CME Office will send the necessary forms for your specifi topics and speakers. An Approval Form must be completed prospectively each month, quarter or year with a series schedule for that time period attached. If your department organizes its series at the beginning of the year for the entire year, then only one form needs to be submitted. If your department organizes its schedule monthly, then a form needs to be completed each month and submitted during the previous month. Forms may not be submitted more frequently than monthly. Make a copy of the form and schedule you are submitting for your file.

The Department Chair must sign the form on the appropriate line. The other three signatures will be obtained by the CME Office. Once all approvals have been received, the original copy of the form will be sent back to the department to keep in the department CME files.

The Approval Form together with the schedule must be received in the CME office at least one week before the first scheduled session.

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SESSION SCHEDULE

A schedule must accompany the Approval Form. The schedule must contain the following information:

  • Date of each session
  • Topic
  • Speaker
  • Speaker affiliation

The topic must be specific. For example, "Patient presentation", "Case presentation," "Chief rounds," and "Morbidity and Mortality"are not acceptable because they do not tell us what the specific content will be.

Please indicate on the schedule which of the presentations, if any, addresses the practice gaps that are being addressed for that year. A minimum of one presentation per quarter must address the practice gaps.

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COURSE DIRECTORS AND PLANNING COMMITTEE MEMBERS CONFLICT OF INTEREST DISCLOSURE FORMS

At the beginning of each year, the Course Chair and members of the Planning Committee must complete a UCLA Faculty Disclosure Form. This should be submitted with the first Approval Form of the year. The CME Office will resolve any potential conflicts of interest of your course chair and/or planning committee members.

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FACULTY DISCLOSURE FORMS

Prior to a speaker's presentation, he/she must complete a UCLA Faculty Disclosure Form. The faculty member must disclose for him/herself and his/her spouse/partner any honoraria; grants; royalties; consultant roles; speaker's bureau membership; stock ownership; or other special relationships with the activity's commercial supporter or to any company who sells a product linked to the presentation's topic. If the speaker has a potential conflict, he/she must indicate on the form how he/she plans to resolve the conflict. If a speaker does not return the form in advance of the presentation, he or she may not speak or the audience needs to be told that CME credit will not be given for that session.

Completed disclosure forms must be kept on file in the department whether or not a conflict exists.

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RESOLUTION OF CONFLICTS

If a conflict of interest exists, it must be resolved before the individual can be confirmed as a speaker. The Disclosure Form contains a list of options for the speaker to indicate how he/she will resolve the stated conflict of interest. When the speaker declares a conflict, the series organizer/chair must review the form and complete an Identification and Management of Conflict of Interest form. This must be done prior to the speaker's lecture and maintained in the file. If the conflict is not resolved, CME credit for the presentation will be withdrawn.

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DISCLOSURE TO THE AUDIENCE

The presenter's declaration on the conflict of interest form and a statement that it was resolved, if a conflict existed, must be disclosed prior to the start of the activity to the audience (even if the presenter does not have a conflict of interest) in one of the three following ways:

  1. it must be announced prior to the presentation by the person introducing the speaker;
  2. a written announcement of the conflict of interest must be clearly visible at the sign-in desk; or
  3. it must be printed in program material distributed to all members of the audience.

If a presenter does not return the conflict of interest form, he/she may not participate in the activity.

View the sample disclosure statements. Your disclosures should use the same language used in these sample statements.

Disclosure should also be made of any industry support received by the department for the particular session.

If the disclosure is made verbally to the audience at the beginning of the session, a memo must be inserted in the CME file describing the details of the announcement, including who announced it, the nature of the conflict of interest and how it was resolved, and/or that no conflict of interest exists. If a written announcement is posted at the sign-in desk, a copy of what was posted must be maintained in the files. If the conflict of interest and resolution are described in material that is handed out to the audience, a copy of this material must be kept on file. If disclosure is not made to the audience, CME credit for the presentation will be withdrawn.

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ACCREDITATION STATEMENT ON FLYERS

The following paragraphs must be included on your series announcements, flyers and promotional materials or brochures. This includes all materials sent electronically.

Accreditation

The Office of Continuing Medical Education, David Geffen School of Medicine at UCLA is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Office of Continuing Medical Education, David Geffen School of Medicine at UCLA designates this live activity for a maximum of __ AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The number that is to be inserted in the second paragraph is the number of hours of education that are presented on each flyer. For example, if you have a weekly one-hour series, you produce a monthly flier, and there are five sessions that particular month, you would fill in the number 5. You must send the CME Office a copy of each flyer you produce for our files.

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SIGN-IN AT EACH SESSION

A sign-in notebook must be maintained by the department. Sign-ins must take place at each session. We recommend developing a sign-in sheet which has the names of "regular attendees" already typed on it to avoid difficulties in deciphering signatures and have developed a Sign-In Sheet template you can modify for your series. Sign-in sheets should have a mechanism for person to indicate whether they are an M.D. or non-M.D.

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CULTURAL COMPETENCY

Recent legislation that was passed in the state of California (AB1195) requires that continuing medical education courses with patient care components include curricula in the subject of cultural and linguistic competency. It is the intent of the bill to encourage physicians and surgeons to meet the cultural and linguistic concerns of a diverse patient population through appropriate professional development. To meet this mandate for regularly scheduled series, we require the following:

  1. Have handouts available at your sign-in table that explain relevant federal and state laws and regulations regarding linguistic access (available at Linguistic.pdf) as well as a list of cultural competency resources (available at http://cme.ucsd.edu/docs/uccme_cultural_competency_resources.doc.pdf). Please announce that these materials are available.
  2. As appropriate, ask your faculty to include content related to cultural competency in their presentations. Such content might include:
    1. Epidemiology and risk factors specific to cultural groups
    2. The impact of a subject's culture on the clinical presentation of a disorder
    3. The relevance of the patient's ethnicity as it relates to the management plan
    4. The role ethnicity plays in the pathophysiology of the disorder discussed
  3. As appropriate, ask your faculty to include content related to linguistic competency. Such content might include:
    1. Assessment of the patient's literacy
    2. Working effectively with an interpreter
    3. Development of medically focused CME-based second language training
  4. If appropriate, schedule at least one speaker each academic year in your series on the topic of cultural competence in medicine.

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DISTRIBUTION OF PRE- AND POST-SURVEYS

For the presentations that have been designated as meeting one of the identified practice gaps, a written pre- and post-survey must be conducted. The results of the survey must be tallied and submitted to the CME Office at the time that the attendance records are submitted.

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SESSION EVALUATIONS

Evaluations must be completed by the attendees at least twice per year. We have developed a sample evaluation form that you can adapt to your needs. The following four questions must be included in your evaluation forms:

  1. On a scale of 1 to 5, please rate how well the program provided you information or strategies that you can apply to your practice. (5 = strongly agree; 1 = strongly disagree)
  2. This program taught me new important information and/or verified important information for me. (5 = strongly agree; 1 = strongly disagree)
  3. Please list 3 changes that you will make in your practice as a result of your participation in this series.
  4. Do you feel any part of this series was promotional and not educational? If your answer is yes, please explain your reasons.

Evaluation forms must be kept on file in the department. They should be tallied on a regular basis and the results reported back to the series organizers and to the department's CME Committee, if one exists. Information obtained from evaluations should be used in planning future presentations.

We recommend that an evaluation be done at each presentation so that the information gathered can be used by faculty and departments and included in faculty dossiers.

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MAINTENANCE OF ACCURATE ATTENDANCE RECORDS

It is important that you develop an efficient method of keeping accurate attendance records derived from your sign-in sheets and completed evaluation forms. Maintaining and updating these records after each session will save you the enormous effort of trying to reconstruct an entire year's attendance at the end of the year. Records must be kept for six years.

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SUBMISSION OF ATTENDEE LIST AT END OF ACADEMIC YEAR

At the end of the academic year, a report must be submitted to the CME Office utilizing the Excel spreadsheet template provided. Required information for each person who attended one or more sessions in the series includes:

  • Last name
  • First name
  • Degree
  • Address to which certificate should be sent
  • Last 4 digits of Social Security Number (optional if participant declines to provide)
  • Dates of sessions attended
  • Total number of hours of credit earned for the year

This information will be input into the CME Office database where it will be kept for six years or more as required by the Accreditation Council for Continuing Medical Education. When called upon, we will verify CME units for your participants for all years except the year in progress. Each participant will receive a CME certificate for the credits earned at the conclusion of the calendar year, upon receipt of the complete attendee list. Please remind your participants that we provide this service free of charge and therefore at times there may be delays in processing certificates due to high volume of office activity.

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SITE VISIT

Sometime during the subsequent year after the previous year's file is in order, the coordinator should make an appointment with the Co-Director of the Office of CME to review departmental CME files. Using a checklist, verification will be made that files are complete and orderly. Both the reviewer and the departmental regularly scheduled series coordinator will sign off on the checklist. Follow-up will be made to ensure that missing information is obtained and that improvements are made when deficiencies have been identified.

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INDUSTRY SUPPORT

We understand that industry can play a positive role in supporting speakers and regularly scheduled series. The following guidelines should be followed when agreeing to accept industry support:

  • Supporting an Outside Speaker: Industry representatives may not make recommendations on topics or speakers for regularly scheduled series. If industry wishes to support the travel and honorarium of an outside speaker whom you have already invited, they may do so by making an unrestricted educational grant to the Office of CME and signing a Letter of Agreement. The Office of CME will then generate the travel reimbursement and honorarium for the speaker. The Letter of Agreement must be kept on file in the department and a copy sent to the CME office. Acknowledgement of this grant should be included in the disclosure information disseminated as described above.
  • Supporting a Member of the Clinical Faculty (Uncompensated): The same procedure as "Supporting an Outside Speaker" should be followed.
  • Meals: Per University of California policy and David Geffen School of Medicine at UCLA guidelines, industry representatives may not provide meals for regularly scheduled series. Meals during the session must be paid for by the division or department. Companies wishing to support a series may provide an unrestricted educational grant to the department or division, provided they sign a Letter of Agreement. The department/division must purchase the food. Copies of these transactions should be kept in the CME notebook. If the series is open to the public, representatives from the company that is providing support may attend the presentation. Before entering the presentation venue, they must remove name badges or other material displaying the name of the company. Detailing is strictly forbidden in or around the CME activity.

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