ACCME Performance-in-Practice Structured Abstract

Please Note: Attachments are not included with
this sample document. All applicable attachments
will be required during the accreditation process.
ACCME Performance-in-Practice Structured Abstract
A tool for preparing and demonstrating compliance through performance-in-practice
Instructions: Complete this form for each activity selected for the ACCME’s performance-in-practice review. Complete all sections applicable for the activity,
and assemble attachments, marking each attachment with the appropriate number. If submitting material electronically, assemble a single PDF file that
includes this form and the required attachments with each attachment bookmarked. Submit the abstract/attachments to the ACCME as instructed.
ACCME
Provider ID:
0000000
Activity Title:
XYZ Annual Scientific Meeting
Activity Date
(mm/dd/yyyy):
3/15/2014
Provider Name:
Activity
Type:
XYZ Medical Specialty Society
Course
Providership:
Commercial Support
Received:
Direct
Yes
1) Early-practice physicians struggle to apply clinical reasoning to
management of challenging cases.
2) We have implemented a new virtual library. (No one knows how to use it!)
3) Our members have difficulty integrating information from new research to
State the professional practice gap(s) of your learners on which
clinical practice.
the activity was based (maximum 100 words). (C2)
4) Physicians do not have adequate time to train on integrating new
technology into their practice.
5) As a specialty, we continue to struggle to apply evidence-based medicine to
improve clinical practice.
need to understand the features of our new virtual library
Knowledge need and/or
State the educational need(s) that you
need for strategies to approach challenging cases as well as strategies to
determined to be the cause of the
Competence need and/or
integrate new knowledge and technology to practice
professional practice gap(s)
(maximum 50 words each). (C2)
Performance need and/or
need to integrate evidence-based information into patient care
This meeting was designed to provide new strategies for learners across
State what this CME activity was designed to change in terms of
several specialty-specific clinical areas so that they can access and integrate
learners’ competence or performance or patient outcomes
new information, treatment protocols, and therapies within their scope of
(maximum 50 words). (C3)
practice and apply that information to patient care.
This multi-format meeting uses lectures, panel Q&A, group demonstrations,
Explain why this educational format is appropriate for this
poster presentations, technology labs, and small journal groups to teach
activity (maximum 25 words). (C5)
strategies then reinforce learning via practice.
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Indicate the desirable physician attribute(s) (i.e., competencies) this activity addresses. (C6)
ACGME/ABMS Competencies
Institute of Medicine Competencies
Patient Care and Procedural Skills
Medical Knowledge
Practice-based Learning and Improvement
Interpersonal and Communication Skills
Professionalism
Systems-based Practice
Provide patient-centered care
Work in interdisciplinary teams
Employ evidence-based practice
Apply quality improvement
Utilize informatics
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Interprofessional Education
Collaborative Competencies
Values/Ethics for Interprofessional Practice
Roles/Responsibilities
Interprofessional Communication
Teams and Teamwork
Other Competency(ies) (specify):
For all INDIVIDUALS IN CONTROL OF CONTENT for the activity …
Complete the table below. If you have this information already available electronically, then simply include it as part of Attachment 2. For each
individual in control of content, list the name of the individual, the individual’s role (e.g., planner, editor, content reviewer, faculty) in the activity,
the name of the ACCME-defined commercial interest with which the individual has a relevant financial relationship (or if the individual has no
relevant financial relationships), and the nature of that relationship.
(Note: please ensure that when you are collecting this information from individuals, that you are using the most current definitions of what constitutes a relevant
financial relationship and ACCME-defined commercial interest.) (C7 SCS 2.1, 2.2, 2.3)
Name of individual
Individual’s role in activity
Name of commercial interest
Nature of relationship
Example: Jane Smythe, MD
Course Director
None
---
Example: Thomas Jones
Faculty
Pharma Co. US
Research grant
Rob Forrest, MD
Planning Committee Chair,
Presenter
None
N/A
Jill Rhoades, MD
Planning Committee, Presenter
None
N/A
©2014 by the Accreditation Council for Continuing Medical Education; all rights reserved
ACCME ® Example 5 Performance in Practice Structured Abstract
For non-commercial educational use only
Page 1 of 3
650_20140918
Sameer Patel, MD
Planning Committee, Presenter
None
N/A
Mike Walters, MD
Planning Committee
ABC Medical Device, Inc.
Speakers' Bureau
Anita Mann, DO
Planning Committee, Presenter
Pharma Co, US
Speakers' Bureau
Richard Richards, MD
Planning Committee
None
N/A
Melissa Mitchell, M.Ed.
Planning Committee (Staff)
None
N/A
C.J. Singh
Planning Committee (Staff)
None
N/A
Devon VanBuren, DO
Poster Reviewer
ABC Medical Device, Inc.
Stockholder
Joan DeSarno
Poster Reviewer
East Coast Pharma
Research Grant
Gerardo Juarez, MD
Poster Reviewer
None
N/A
Linda Thomas, MD
Poster Reviewer
None
N/A
*See attached list
Presenters & Authors
(If there are additional individuals in control of content for the activity, please attach a separate page using the same column headings.)
If the activity was COMMERCIALLY SUPPORTED …
Complete the table below. If you have this information already available electronically, then simply include it as part of Attachment 8. List the
names of the commercial supporters of this activity and the $ value of any monetary commercial support and/or indicate in-kind support (C8 SCS
3.4-3.6).
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Name of commercial supporter
Example: XYZ Pharma Company
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Amount of monetary commercial support
$5,000
In-kind
Example: ABC Medical Device Company
XYZ Pharmaceutical
West Coast Pharma
National Pharma, Inc.
XYZ Medical Devices, LLC
ABC Diagnostics
☐
☒
$15,000.00
$15,000.00
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$10,000.00
$8,000.00
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(If there are additional commercial supporters, please attach a separate page using the same column headings.)
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ATTACHMENTS Please Note: Attachments are not included with this sample document.
All applicable attachments will be required during the accreditation process.
Attachment 1
Attachment 2
Attachment 3
Attachment 4
Attachment 5
Attachment 6
The activity topics/content, e.g., a genda, brochure, program book, or a nnouncement. (ACCME Definition of CME)
The form, tool, or mechanism used to identify relevant financial relationships of a l l i ndividuals i n control of content.
(C7 SCS 2.1) (NOTE: See instructions on page 1 – i nclude table or a ttachment with relevant fi nancial relationships of a ll
i ndividuals i n control of content for this a ctivity.)
Evi dence that you i mplemented your mechanism(s) to resolve conflicts of interest for a l l individuals in control of
content prior to the start of the activity. (C7 SCS 2.3)
The di sclosure information as provi ded to l earners about the relevant financial relationships (or a bsence of relevant
fi nancial relationships) that each individual i n a position to control the content of CME di sclosed to the provider. (C7
SCS 6.1-6.2, 6.5)
The da ta or information generated from this a ctivity a bout changes a chieved in l earners’ competence or performance
or pa ti ent outcomes. (C11)
The ACCME a ccredi tation statement for this a ctivity, as provided to learners. (Appropriate Accreditation Statement)
If the activity was COMMERCIALLY SUPPORTED …
The i ncome and expense s tatement for this activity that details the receipt a nd expenditure of all of the commercial
Attachment 7
s upport. (C8 SCS 3.13)
Attachment 8
Ea ch executed commercial s upport a greement for the a ctivity. (C8 SCS 3.4-3.6)
©2014 by the Accreditation Council for Continuing Medical Education; all rights reserved
ACCME ® Example 5 Performance in Practice Structured Abstract
For non-commercial educational use only
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650_20140918
Attachment 9
The commercial support disclosure information as provided to learners. (C7 SCS 6.3-6.5)
Note: If this activity is an enduring material, journal-based CME, or Internet CME, please include the actual CME product (or a
URL and access code – if applicable) with your performance-in-practice.
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©2014 by the Accreditation Council for Continuing Medical Education; all rights reserved
ACCME ® Example 5 Performance in Practice Structured Abstract
For non-commercial educational use only
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650_20140918