Policy Manual

Please click a subheading below to expand that portion of the policy manual.

 

  • Mission Statement 

    Purpose
    In keeping with the mission of Bon Secours St. Francis Health System, Inc., the Continuing Medical Education (CME) Program is dedicated to providing physicians and other health care professionals with educational experiences that enhance their ability to provide excellent patient care, through increased competence and performance and improved patient outcomes. The program seeks to improve healthcare through learning designed to advance quality, cost-effective and safe care of patients and the public. The CME Program is also committed to fostering a life long learning environment in which health care professionals seek advances in the knowledge, skills and competencies relevant not only to their clinical practice but also to research and medical professionalism.

    Target Audience
    CME activities are primarily designed and presented to serve the professional and educational needs of physicians who are credentialed to practice medicine at Bon Secours St. Francis Health System, Inc. Although the content and strategy of the CME is determined by the needs and interests of these physicians, other interested physicians/professionals may also attend CME sessions.

    Content
    The CME program provides educational activities that meet the criteria established by the Accreditation Council of Continuing Medical Education and other standards established by the South Carolina Medical Association on Continuing Medical Education. The content of programs address areas such as risk management, public health, the practice environment, leadership and administration, public policy and tools for performance improvement. The CME Program provides a forum for the exchange of information and ideas on current practice trends, evidence-based medicine advances in clinical medicine and research and the delivery of high quality, equitable and cost effective care. The content is based on the identification and analysis of the targeted audience’s continuing medical education needs as articulated by participants, department chairs, executive leadership and/or quality improvement initiatives.

    Objectives for each session are clearly stated and the effectiveness of each program subsequently evaluated. Speakers may include highly qualified physicians and other prominent leaders from academic medicine, industry, government, hospital leaders and clinical professionals. It is expected that the content presented will be objective, ethical and balanced. CME sessions that receive commercial support are so acknowledged in all announcements and at the beginning of the CME program.

    Types of Activities
    Bon Secours St. Francis Hospital CME Program will sponsor, co-sponsor or jointly sponsor CME activities utilizing current technologies and methodologies appropriate for adult learners in a variety of formats including but not limited to on-going weekly and monthly activities such as Tumor Conferences, and free-standing one-time programs such as lectures, conferences, seminars, symposium, etc. Also, the Healthstream Computerized Learning Center further supports self-directed learning by providing opportunities for electronic modules available at the learner’s desktop.

    Expected Outcomes
    As a result of participating in CME activities, it is expected that participants will report on post-activity evaluations that learning objectives have been met and/or that the learner intends to make a change in practice. In addition to post-activity evaluations, a comprehensive evaluation of the CME program as a whole will be conducted annually to guide on-going improvements in the CME program Activity evaluation summaries are made available to presenters to help them improve their educational skills. Finally, CME activities are reported to the Medical Executive Committee. An annual summary report is submitted to executive leadership, the Quality Board, and the Board of Directors.

  • Accreditation Statement

    1. Bon Secours St. Francis Health System, Inc. CME Coordinator/Committee is responsible for informing participants when they have designated an activity for credit, and the number of hours offered upon its completion. This is done through publication of the accreditation statement and the credit designation statement, both of which must appear on program announcements and brochures distributed to potential participants by accredited providers. The accreditation statement indicates that the organization is accredited and by whom it is accredited. The credit designation statement indicates the number of AMA PRA credits for which it is designated.

    2. All entities who require BSSFHS to provide CME AMA PRA Category 1 Credit for an educational activity are required to include the below accreditation and credit designation statement with it’s exact wording on activity announcements and registrations.

    Accreditation and Credit Designation Statements For Activities Designated for AMA PRA Category 1 Credit™

    For Directly Sponsored Activities

    Accreditation Statement: Bon Secours St. Francis Health System, Inc. (BSSFHS) is accredited by the South Carolina Medical Association (SCMA) to provide continuing medical education for physicians.

    Credit Statement: BSSFHS designates this educational activity for a maximum of (number of credits) AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Statements on promotional materials to the affect that CME credit is “pending” or “applied for” are PROHIBITED by the American Medical Association and Bon Secours St. Francis Health System, Inc.
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  • American Disabilities Act

    The ACCME has received this brief explanation from its legal counsel of the ADA requirements as it applies to CME activities:

    Under Title III of the Americans with Disabilities Act, entities that meet the statutory definition of “places of public accommodation”1,2 (which includes educational institutions such as ACCME accredited providers) are prohibited from discriminating against individuals on the basis of disability in the full and equal enjoyment of their services and privileges, and they must accommodate persons with disabilities by modifying their policies and practices, removing structural and communications barriers and providing auxiliary aids and services to ensure “effective communication” at no charge to the individual.

    The requirement for equal access and enjoyment precludes the use of separate facilities or methods that do not allow people with disabilities to participate fully in the service or activity. Furthermore, the Analysis4 to the regulations clarifies that Congress “expects that public accommodations will consult with the individual with a disability before providing a particular auxiliary aid or service.”

    There are limited exceptions to the requirement to provide modifications, removal of barriers and auxiliary aids: Such measures are not required if they would

    a) fundamentally alter the nature of the service, or

    b) would constitute an undue burden or expense, i.e., the overall financial impact on the entity as a whole would be too great.

    Auxiliary aids for deaf and hard-of-hearing people that are specifically listed in the regulations5 include: “qualified interpreters, note takers, computer-aided transcriptions services, written materials [and other] effective methods of making aurally delivered materials available to individuals with hearing impairments.” The regulations go on to state that a “qualified interpreter” is someone “…who is able to interpret effectively, accurately and impartially both receptively and expressively, using any necessary specialized vocabulary.”

    1) 1 Places of public accommodations include entities that do business with or serve the public, such as hotels, theaters, restaurants, shopping malls, stores, office buildings and private social service agencies. 42.U.S.C. 12181;29 C.F.R. 36.303(b)(4)

    2) 2 The specific definition of “public accommodation,” found at 42 U.S.C. Section 12181, is as follows:

    The following private entities are considered public accommodations for purposes of this subchapter, if the operations of such entities affect commerce—

    a) an inn, hotel, motel, or other place of lodging, except for an establishment located within a building that
    b) contains not more than five rooms for rent or hire and that is actually occupied by the proprietor of such
    c) establishment as the residence of such proprietor:
    d) a restaurant, bar, or other establishment serving food or drink;
    e) a motion picture house, theater, concert hall, stadium, or other place of exhibition or entertainment;
    f) an auditorium, convention center, lecture hall, or other place of public gathering;
    g) a bakery, grocery store, clothing store, hardware store, shopping center, or other sales or rental establishment;
    h) a Laundromat, dry-cleaner, bank, barber shop, beauty shop, travel service, shoe repair service, funeral parlor, gas station, office of an accountant or lawyer, pharmacy, insurance office, professional office of health care provider, hospital, or other service establishment;
    i) a terminal, depot, or other station used for specified public transportation;
    j) a museum, library, gallery, or other place of public display or collection;
    k) a park, zoo, amusement park, or other place of recreation;
    l) a nursery, elementary, secondary, undergraduate, or postgraduate private school, or other place of education;
    m) a day care center, senior citizen center, homeless shelter, food bank, adoption agency, or other social service center establishment; and
    n) a gymnasium, health spa, bowling alley, golf course, or other place of exercise or recreation.”

    3 42 U.S.C. Section 12182
    4 56 Fed. Reg. At 35567
    5 29 C.F.R. 36.303 (b)(1)
    6 29 C.F.R. 36.303 (b)(1)

  • Attendance and Record Keeping

    Credit for attendance will be granted when the following conditions apply:

    1) Sign-in on the appropriate attendance form. After the activity, sign-in sheets are collected and the CME Coordinator uses them to track activity attendance, enter medical staff members’ credits into a hospital database and prepare credit certificates.

    2) In the activities where pre and post testing is required to show competence improvement, attendees are required to turn in tests in prior to receiving credit. Post test must include passing grade prior to attendee receiving certificate. In the event the participant does not pass, a letter will be sent from the CME office with another post test. The participant has the opportunity to review his/her materials and retake the post test to be awarded credit.

    Record keeping for participation in CME activities:
    1) Computerized transcripts are available by request made to the CME Coordinator.
    2) Records of attendance are maintained in a database for no less than 6 years.
    3) A Certificate of Attendance or Credit is awarded and mail to the attendee after the activity.
    4) The certificate indicates the maximum number of credits designated for Category 1, the title of the program, start date and the name of the participant with the number of credits claimed.
    5) The signature of the CME Committee Chairman appears on the certificate.

    Records Retention

    Specific CME activity records must be maintained by all accredited providers. Records retention requirements relate to the following two topics: Physician Participation and Activity Documentation.

    Physician Participation: An accredited provider must have mechanisms in place to record and, when authorized by the participating physician, verify participation for six years from the date of the CME activity. The accredited provider is free to choose whatever registration method works best for their organization and learners. The ACCME does not require sign-in sheets.

    Activity Documentation: An accredited provider is required to retain activity files/records of CME activity planning and presentation during the current accreditation term or for the last twelve months, whichever is longer. Maintenance of this documentation enables the provider to, at the time of re-accreditation, to show how the activities it provided during its current term of accreditation were compliant with all ACCME Essential Areas and Elements (including the Standards for Commercial Support) and Accreditation Policies.

  • CME Committee Membership

    The committee is comprised of physicians who have active privileges at Bon Secours St. Francis Health System, Inc. and therefore have a vested interest in improving quality outcomes in patient care. Committee members will develop, design education opportunities and monitor the quality of the BSSFHS sponsored activities. Physician issues dealing with CME are also discussed and acted upon by the committee. The cornerstone of an effective CME committee is strong physician support and this is ensured by the following:

    1. Identification of physicians who have an interest in education and encourage appointment to the CME Committee.

    2. Selection of Committee members who represent the major clinical department will be encouraged.

    3. The seated committee will recommend new committee members with final approval coming from the BSSFHS CMO.

    4. The CME Committee consist of:
    • Co-Chairman
    • Co-Chairman
    • Physician
    • Chief Medical Officer
    • Chief Nursing Officer
    • CME Coordinator

    Responsibilities

    The CME Committee oversees all continuing medical education activities. Committee members:
    • Designate CME activities for Category 1 credit.
    • Help formulate policies and procedures pertinent to CME
    • Participate in long and short term planning efforts according to the Accreditation Council for Continuing Medical Education Essential Elements and Element(s) and abide by the Standards for Commercial Support to ensure independence of all CME activities.
    • Participate in individual activity development
    • Assist in CME needs assessment and review
    • Assist in CME evaluation
    • Provide a liaison between CME staff, departmental staff and hospital administration.
    • Agreement to the Disclosure of Relevant Financial Relationships Statement
    • Attendance of bi-monthly one-hour committee meetings

    Email Voting
    When CME Committee members are emailed issues for approval prior to a scheduled committee meetings, it is that 80% of the committee respond before action can be taken or resolved. Should less than 80% of CME Committee members respond; issues will be taken to the following CME Committee for discussion and/or approval.

  • CME Mission Statement Policy

    Element 1.1: The provider must have a written statement of its CME mission that includes the CME purpose, content areas, target audience, type of activities provided, and expected results of the program.

    Element 1.2: Demonstrate how the CME mission is congruent with and supported by the mission of the parent organization, if a parent organization exists.

    To incorporate the organization’s philosophy regarding continuing medical education, the Mission Statement embodies the fundamentals and scope of what the CME program will provide. It serves to guide the program along its intended path, protect against the manipulation of the program into educational situations, or otherwise adverse situations, not endorsed by the policies.

    The most important reason for any health care organization to establish a program of continuing medical education is the desire to enhance high quality medical care. The physician must be involved as a participant and student in the active process of learning.

    In order to apply the guidelines of the Mission Statement, the CME committee considers the following criteria:
    • What does this program expect to accomplish? (Purpose)
    • What major content areas will be the focus of the program? (Content Areas)
    • For whom will the educational activity be intended? (Target Audience)
    • What type of activities will be provided? (Activities) What are the expected results of the program? (Results)

    The Mission Statement is reviewed and revised annually by the CME committee.

  • Commercial Support

    If commercial support is obtained for the payment of speaker(s) honorarium and/or travel expenses, catering, or any part of the directly or jointly sponsored activity, an initial meeting is held with the contributing sponsor to discuss responsibilities and activity content. At this time, forms to be completed are reviewed and guidelines are explained. Commercial sponsors are asked to follow the Standards for Commercial Support of CME and are monitored by the CME Coordinator to insure that all guidelines are complied with on the day of the activity.

    A Grant Request Letter and Letter of Agreement including terms, conditions and purpose of the educational grant is composed and given to the representative. The Letter of Agreement must either be signed and returned by the representative or forwarded to his/her home office for completion. A copy of the Standards for Commercial Support of CME must accompany the Letter of Agreement. The CME Coordinator is responsible for obtaining the completed forms and coordinating all financial transactions.

    At this time, it is clearly explained to the commercial company representative that all funds collected are used for the sole purpose of the planned educational activity and documentation of use will be available to the company after the activity has been completed.

    After the signed Letter of Agreement is received by the CME Coordinator, any checks received from the company are deposited and credited to the hospital’s account (checks must be made payable to Bon Secours St. Francis Health System, Inc.). Speaker(s) honorarium and/or travel expenses, catering, facility rental and printing costs will be paid out of the hospital account.

    Commercial companies can offer assistance in the initial process of speaker selection by offering the CV of possible candidates. The CV is forwarded to the CME Coordinator for review and consideration by the CME Committee. Once the activity is being planned, acknowledgement of commercial support is noted on any marketing materials and also on the Activity Packet given out prior to the presentation on the day of the activity.

    Commercial companies are not allowed to distribute any materials during the activity without the authorization of the CME Coordinator. If authorization is granted, the commercial companies are allowed to set up exhibit space outside of the actual meeting room. This material must not contain any bias information related to their products or company.

    The CME Coordinator establishes and maintains relationships with commercial companies in order to gain information about new drugs, innovative equipment and procedures, national speakers, and physician interest. The key to these relationships is the control and supervision that is maintained by the CME Coordinator and the CME Committee to insure that activities are physician driven.

  • Conflicts of Interest

    In order to meet the Standards for Commercial Support the provider must have a mechanism in place to identify all relevant financial relations with any commercial interest, determine whether these relationships create a conflict of interest with the individual’s control of content, and if so have a mechanism to resolve all conflicts of interest prior to the education activity.

    1) Bon Secours St. Francis Health System, Inc. requires that all individuals involved in planning, authoring, or presenting a CME activity complete the form “Disclosure of Relationships, Identifying and Resolving Conflict of Interest in CME.”

    2) All presenters are given information describing “content validation” and the expectation that their presentation will be compliant. This is clearly stated on the “Disclosure of Relationships” form.

    3) When significant relationships are disclosed and when the content may be influenced by such a relationship, a conflict of interest is determined to exist.

    4) Conflicts of interest forms will be reviewed prior to the CME activity by the CME Coordinator and the appropriate course of action will be determined. This may include review by the activity planning committee, CME Committee, and/or the specific department.

    5) Conflicts of interest can be resolved by:
    a) Altering the financial relationships. Individuals may change their relationships with commercial interests (e.g. discontinue contracted services). This way, no duty, loyalty, or incentive remains to introduce bias into the CME content. 

    b) Altering control over CME content. An individual’s control of CME content can be altered in several ways to remove the opportunity to affect content related to the products and services of a commercial interest. These include the following:
    • Choosing someone else to control that part of the content
    • Change the focus of the CME activity
    • Change the content of the person’s assignment so that it is no longer about products or services of the commercial interest.
    • Limit the content to a report without recommendations by limiting it to data and results of research, and assigning someone else to address broader implications and recommendations.
    • Request a peer review to validate content. This is to ensure that all scientific research referred to, reported or used in CME in support or justification of patient care recommendations conforms to the generally accepted standards of experimental design, data collection and analysis.

    c) Disqualifying the speaker, author or planner and select a replacement.

    6) Disclosure of all relationships and the resolution of conflicts of interest will be provided to the CME participants.

  • Criteria for Category 1 Credit Designation

    CME consists of educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships a physician uses to provide services for patients, the public, or the professional. The content of CME is that body of knowledge and skills generally recognized and accepted by the profession as within the basic medical sciences, the discipline of clinical medicine, and the provision of health care to the public.

    Formally planned AMA PRA category 1 educational activities must be developed by the organizations that satisfy all accreditation standards, and cover specific and scientifically valid topics. More specifically, the activity must:
    • address a physician audience in both the depth and scope of its content
    • be sponsored by a US based, ACCME accredited provider or by a state medical society accredited provider or, in Canada, where special rules apply, by a medical school accredited by the Council on Accreditation of Canadian Medical Schools (CACMS)
    • conform to the AMA definition of CME
    • conform to AMA ethical opinions on Gifts to Physicians from Industry and on Ethical Issues in CME as well as the ACCME Standards for Commercial Support of CME
    • address demonstrated educational needs
    • include clearly stated educational objectives
    • have content which will help physician learners meet the stated objectives
    • use learning methodologies appropriate to the activity’s content and format
    • define evaluation mechanisms with which to assess program quality and relevance to the stated objectives of the activity
    • include a means for the provider to record the actual credits claimed by each physician participant

    Content Validation
    1) All recommendations involving clinical medicine in a CME activity must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.

    2) All scientific research referred to, reported or used in CME in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection and analysis.

    3) Providers are not eligible for SCMA/ACCME accreditation or reaccreditation if they present activities that promote recommendations, treatment or manners of practicing medicine that are not within the definition of CME, or known to have risks or dangers that outweigh the benefits or known to be ineffective in the treatment of patients.

    References: AMA Physician’s Recognition Award Information Booklet for CME Providers, August 2002 ACCME Policy Compendium, 2002-B-09

  • Disclosure Policy

    It is the policy of Bon Secours St. Francis Health System, Inc. to ensure balance, independence, objectivity in all its educational programs. All CME Committee Members, activity planners, speakers, as well as, anyone else in a position to control the content of an activity are expected to disclose to the program audiences any real or apparent conflict of interest related to the content of their presentation or if they intend to reference off-label or investigational use of drugs or products. Disclosure details will be presented at the beginning of each CME presentation. Any individual who refuses to disclose relevant financial relationships will be disqualified from being a CME Committee member, CME planning committee member, teacher, or an author of CME, and cannot have control of, or responsibility for, the development, management, presentation or evaluation of the CME activity.

  • Education Planning and Needs Assessment

    Element 2.1: The provider must use a planning process(es) that links identified educational needs with a desired result in its provision of all CME activities.

    Element 2.2: The provider must use needs assessment data to plan CME activities.
    1) A learning needs survey is conducted annually to identify educational needs perceived by the physicians as well as to evaluate performance of the continuing medical education department of Bon Secours St. Francis Health System, Inc. (BSSFHS). This data is then summarized used in the planning of the educational activities.

    2) Identified needs from multiple sources are used to initiate and support the planning process. Need documentation is the first step in planning a CME activity. BSSFHS may use needs assessment data generated in a variety of ways: Quality Department recommendations to the CME Committee, activity needs assessment surveys, community/global health concerns, specialty groups, annual program surveys and/or hospital departments and administration.

    3) Each source of need requires a supporting document to use in setting methodology, design, objectives, and evaluation of the CME activity.

    4) After suggestions have been received and educational needs have been identified, activity topics are reviewed and analyzed by the CME Committee, CME Committee Chairperson and/or a CME Committee member to ensure that the proper procedures for identifying needs have been met.

    Procedures for Planning Directly Sponsored and/or Jointly Sponsored Activity
    BSSFHS is accredited by the South Carolina Medical Association (SCMA) to provide continuing medical education (CME) for physicians. In this role, BSSFHS is responsible for fulfilling requirements as set forth by the SCMA’s Essential Areas and their Elements, including the Standards for Commercial Support of CME and the Accreditation Policy Compendium. Jointly sponsored activities will also adhere to BSSFHS’s Joint Sponsorship Policy. BSSFHS must be integrally involved from activity conception to completion with documentation of involvement in planning, implementation, administration and evaluation of directly and jointly sponsored activities.

    The following planning steps are used in the order they appear for directly and jointly sponsored activities. These steps are explained in further detail:
    1. Activity Concept and Planning
    2. Speaker
    3. Faculty Disclosure
    4. Learning Objectives
    5. Commercial Support
    6. Marketing
    7. Meeting Space/Facility Rental, Catering and Media Equipment Needs
    8. Activity Packet
    9. Pre- and Post Testing
    10. Activity Evaluation
    11. Record of Attendance

    Types of Directly Sponsored Course Activities:
    Single Lectures by Guest Speakers - Lectures are held addressing the needs of the primary care physicians and other interested specialists. There is no attendance requirement.

    Types of Directly Sponsored, Regularly Scheduled Series Activities:
    Departmental Medical Staff Meetings
    Breast Cancer Conferences - Weekly conferences are held every Thursday morning. There is no attendance requirement at this time.
    Gastrointestinal Cancer Conferences - Monthly conferences are held every 3rd Tuesday morning. There is no attendance requirement at this time.
    General Cancer (formerly Tumor Board) Conferences - Monthly conferences are held every 1st, 2nd and 4th Tuesday morning. There is no attendance requirement at this time.
    Cancer Conferences - Monthly conferences are held every 2nd Wednesday morning. There is no attendance requirement at this time.

    Types of Jointly Sponsored Course Activities: BSSFHS has not yet jointly sponsored an event. At that time, BSSFHS will follow the guidelines the SCMA’s Essential Areas and their Elements for Jointly Sponsored Activities.

    1. Activity Concept and Planning
    Quality Gap Data: CME Committee receives quality gap data from the Quality Assurance Department and the Nursing Quality Department. This data identifies quality gaps in practice or a potential need for practice improvement. Quality gaps are usually identified through the hospital review processes and other combative report generated through state reporting agencies or national quality reporting agencies.

    Needs Assessment Data: BSSFHS may use needs assessment data generated in a variety of ways: Quality Department recommendations to the CME Committee, activity needs assessment surveys, community/global health concerns, specialty groups, annual program surveys and/or hospital departments and administration.

    CME Committee Review: After suggestions have been received and educational needs have been identified, activity topics are reviewed and analyzed by the CME Committee, CME Committee Chairperson and/or a CME Committee member to ensure that the proper procedures for identifying needs have been met. The committee discusses the potential speakers according their expertise and requests potential topics as related to the need. Learning objectives are discussed by the committee and given to the speaker for planning of their activity.

    Activity Checklist, Planning Notes and Activity File: Once needs assessment data has been gathered and the CME Committee has reviewed and analyzed the identified educational needs, the CME Coordinator must begin planning the activity. Documentation of activity planning must be maintained in the activity file.

    The CME Coordinator creates and manages a file for each activity. From activity conception to completion, copies, checklists and required forms and letters are kept in this file. Throughout the activity planning process, the CME Coordinator is responsible for communicating with the Activity Director and Speaker(s). The CME Coordinator is also responsible for receiving and reviewing the completed forms, requested signatures and presentations/handouts (if applicable) and testing questions (if applicable) from the speaker in a timely manner.

    Once the activity has occurred, the Activity Completion Checklist is used as a tool to ensure that all remaining steps are completed (ex. final reports (tallied activity evaluations, tallied assessments and tallied testing results showing improvement in competence) to speaker, activity director and CME Chairperson, credit letter distribution, check requests, etc.). The file is then scanned and saved on the CME shared folder. At the minimum, BSSFHS will retain activity files during the current accreditation period and attendance records for minimum of six years.

    Activity Certification: Once activity details are gathered, the application along with any supporting documentation is submitted to the CME Committee for approval or denial of category I credit.

    2. Speaker

    3. Faculty Disclosure
    After a speaker(s) has been confirmed for a directly or jointly sponsored activity, a copy of the Standards for Commercial Support of CME is sent to the speaker(s), along with a Faculty Disclosure Statement Form. The speaker is required to return the completed form to the CME department for our records. The CME Coordinator will discuss the inappropriateness of conveying or alluding to an affiliation with a commercial organization during an activity with the speaker either via telephone or in person prior to the activity. Whether significant support or substantial financial relationships between a presenter and commercial entity exists or not, a written statement is printed in the Activity Packet that is distributed to activity attendees.

    The speaker(s) must also verbally disclose such information to attendees prior to his/her presentation. If slides are available prior to the activity, the disclosure slide is added to the beginning of the presentation. A representative of BSSFHS who was in attendance at the time of the verbal disclosure must attest, in writing: a) that verbal disclosure did occur; and b) itemize the content of the disclosed information; or that there was nothing to disclose; or that the speaker(s) had refused to disclose via the Verbal Disclosure Statement Documentation Form. Documentation of this action must be recorded in the activity file.

    4. Learning Objectives
    Learning/Activity Objectives are 3-4 main objectives that the committee has determined to be necessary to expand on the requested topic. The learning objectives can be obtained by the Activity Director, the committee, the speaker(s), or a combination. Once the general objectives are given, the CME Coordinator will request the speaker(s) develop more specific objectives. The learning objectives for sponsored activities are stated in all marketing materials. The learning objectives are also inserted in the Activity Packet on the day of the presentation, along with an Activity Evaluation Form that clearly states the objectives.

    5. Commercial Support
    If commercial support is obtained for the payment of speaker(s) honorarium and/or travel expenses, catering, or any part of the activity, an initial meeting is held with the contributing sponsor to discuss responsibilities and activity content. At this time, forms to be completed are reviewed and guidelines are explained. Commercial sponsors are asked to follow the Standards for Commercial Support of CME and are monitored by the Activity Director and CME Coordinator insuring that all guidelines are complied with on the day of the activity.

    A Grant Request Letter and Letter of Agreement including terms, conditions and purpose of the educational grant is composed and given to the representative. The Letter of Agreement must either be signed and returned by the representative or forwarded to his/her home office for completion. A copy of the Standards for Commercial Support of CME must accompany the Letter of Agreement. The CME Coordinator is responsible for obtaining the completed forms and coordinating all financial transactions.

    At this time, it is clearly explained to the commercial company representative that all funds collected are used for the sole purpose of the planned educational activity and documentation of use will be available to the company after the activity has been completed.

    After the signed Letter of Agreement is received by the CME Coordinator, any checks received from the company are deposited and credited to the hospital’s CME account (checks must be made payable to Bon Secours St. Francis Health System, Inc.). Speaker(s) honorarium and/or travel expenses, catering, facility rental and printing costs will be paid by the BSSFHS CME Program.

    Commercial companies can offer assistance in the initial process of speaker selection by offering the CV of possible candidates. The CV is forwarded to the CME Coordinator for review and consideration. Once the activity is being planned, acknowledgement of commercial support is noted on the Activity Invitation and also on the Activity Packet given out prior to the presentation on the day of the activity. z

    Commercial companies are not allowed to distribute any materials during the activity without the authorization of the CME Committee. If authorization is granted, the commercial companies are allowed to set up exhibit space outside of the actual meeting room. This material must not contain any bias information related to their products or company.

    The CME Coordinator establishes and maintains relationships with commercial companies in order to gain information about new drugs, innovative equipment and procedures, national speakers, and physician interest. The CME program and, in turn, the hospital can benefit financially from educational grants provided by commercial companies. The key to these relationships is the control and supervision that is maintained by the Activity Director and/or CME Coordinator to ensure that activities are physician driven.

    6. Marketing
    Once the target audience has been identified for an activity, the CME Coordinator designs all marketing materials. The appropriate accreditation and credit hour designation statements must be included on all marketing materials for all activities. The invitation/flyers/brochures includes registration information.

    7. Meeting Space/Facility Rental, Catering, and Media Equipment Needs
    The CME Coordinator coordinates the facility/room reservation(s), catering, and media (audiovisual) equipment needs for each activity. 8. Activity Packet The CME Coordinator creates an informational Activity Packet. This information is given to each activity participant for their review and evaluation completion. The Activity Packet includes: Title Page (acknowledgement of commercial support, if applicable), Activity Objectives, Faculty Disclosure Status Statement, Notes Page, Pre and Post Tests (if applicable) Activity Evaluation Form, and Needs Assessment Survey Form. The pre and post tests, evaluation and survey forms are collected from participants at the end of each activity and the results are tabulated by the CME Coordinator.

    9. Pre- and Post testing
    • Where activities are planned that do not generate a means of measuring physician competence levels, such as in data obtainable through hospital, state or national agencies, it has been determined by the BSSFHS CME Committee to institute pre and post testing.
    • Post tests must be passing by 70%.
    • Any physician requesting CME credits must complete these tests and turn into the CME Coordinator.
    • Pre and post tests are graded by the CME Coordinator.
    • Tallied results of the overall competence levels pre and post testing are sent to the Speaker, Activity Director, CME Chairman and the participant.
    • The participant also receives copies of their pre and post tests as a means of correcting any answers which were marked wrong as a means of review.
    • Letters of approval or denial of credit, CME certificates and test results are mailed to the attendees and speakers. 10. Activity Evaluation
    • The CME Coordinator distributes Pre and Post tests (if applicable), Activity Evaluation Forms and any other handouts at the start of each presentation to be completed by participants. The Activity Evaluation asks participants to evaluate and rate various topics including:
    o overall activity
    o presenter’s overall performance
    o presenter’s knowledge of subject area
    o effectiveness of the meeting room
    o learning aids
    o were learning/activity objectives met
    • Completed evaluations, tests and surveys are collected at the end of the activity and are tabulated by the CME Coordinator. The results are reported to the CME Committee and a copy is sent with the Speaker’s Thank-You Letter. If applicable, a copy of the tabulated results is also mailed to any commercial support representative(s).

    11. Record of Attendance
    The CME Coordinator creates sign-in sheets that are placed on a table outside the classroom(s) prior to the activity. After the activity, sign-in sheets are collected and the CME Coordinator uses them to track activity attendance, enter medical staff members’ credits into a hospital database and prepare credit certificates for attendees. Credit certificates and letters are mailed promptly after each activity and include: activity title, speaker, activity date, and designated number of credits.

  • Educational Evaluation

    Element 2.4: The provider must evaluate the effectiveness of its CME activities in meeting identified educational needs.

    Element 2.5: The provider must evaluate the effectiveness of its overall CME program and make improvements to the program. The CME Coordinator distributes Pre and Post tests (if applicable) Activity Evaluation Form and Needs Assessment Survey Form (included in the Activity Packet) at the start of each presentation to be completed by participants. The Activity Evaluation asks participants to evaluate and rate various topics including:
    • overall activity
    • presenter’s overall performance
    • presenter’s knowledge of subject area
    • effectiveness of the meeting room and learning aids
    • whether the learning/activity objectives were met
    • effect on the practice of the physician The Needs Assessment Survey asks participants for program improvement suggestions and other statistical data (i.e. participation in AMA’s PRA, yearly CME credit hour requirements, etc.).
    • Completed evaluations, tests and surveys are collected at the end of the activity and are tabulated by the CME Coordinator.
    • The results are reported to the CME Committee and a copy is sent with the Speaker’s Thank-You Letter.
    • If applicable, a copy of the tabulated results is also mailed to any commercial support representative(s). 3. The overall CME program is evaluated regularly by the CME committee with review of its mission and activities of the previous fiscal year.
    • Annual review of the CME program is included in the annual needs survey by feedback from physicians.
    • Annual review of the CME Mission Statement by the CME Committee to make sure the mission aligns with the mission of the organization
    • Improvements are made in the CME program by incorporating suggestions of the CME committee into the operating policies CME department.
    • Outcomes in physician behavior which influence the health of the population are measured when applicable by repeated surveys or statistical review of morbidity data.

  • Education Objectives

    Element 2.3: The provider must communicate the purpose or objectives of the activity so the learner is informed before participating in the activity.
    1) Based upon the identified needs, objectives are developed for each CME activity. Learning/Activity Objectives are 3-4 main objectives that the committee has determined to be necessary to expand on the requested topic.

    2) The learning objectives can be obtained by the CME Coordinator, Activity Director, the committee, the speaker(s), or a combination.

    3) Once the general objectives are given, the CME Coordintator will request the speaker(s) develop more specific objectives.

    4) Learning outcomes in terms of knowledge, skills, and/or attitudes are indicated and communicated to the learner. The learning objectives for activities are stated in all marketing materials.

    5) Learning objectives are also inserted in the Activity Packet on the day of the presentation, along with an Activity Evaluation Form that clearly states the objectives.

    6) The target audience is identified and stated in all learning materials.

    7) The purpose or objectives of the activity describe learning outcomes in terms of physician performance or patient health and are consistently communicated to the learner

  • Enduring Materials

    DEFINITION 1) The ACCME defines CME enduring materials as a non-live CME activity that "endures" over time. 2) The learning experience by the physician can take place at any time in any place, rather than only at one time, and one place, like a live CME activity.

    POLICY 1) Enduring materials require the same planning guidelines as any other CME activity.
    • General CME information – including the accreditation statement, credit designation statement, target audience, all special enduring material statements (see “Implementation”), and disclosure of financial relationships enduring material.

    IMPLEMENTATION 1) The following information must be included in the CME Information section of enduring materials sponsored by the provider at the beginning of the activity:
    • Sponsorship Statement
    • Accreditation Statement
    • Credit Designation Statement
    • Acknowledgment of Commercial Support
    • Sponsor and Faculty Financial Relationships Disclosure
    • Release Date, Review Date, Expiration Date, Estimated Time to Complete the Activity

    EVALUATION AND POST-TEST 1) A set of test questions will be developed which address the material presented. 2) These questions should be developed with the activity objectives as a guide. 3) In addition, an evaluation will be included with each enduring material. 4) Tests will be graded by the staff and returned to the participant along with their CME certificate. A score of at least 70% or higher must be attained to receive credit.

    INSTRUCTIONS FOR PARTICIPATING IN THE ACTIVITY AND SECURING CME CREDIT 1) Clear instructions describing how participants can participate in the activity and receive CME credit, including completion of test questions and methods of returning them for scoring will be included in the enduring materials. 2) Tests should be mailed to the provider per the instructions in the enduring material, prior to the published expiration date.

  • Internet CME Materials

    1) All CME activities developed and/or delivered for Internet usage will be in compliance with ACCME Essential Areas, Elements, and Policies.

    2) BSSFHS CME will NOT post any of its CME activities on the website of pharmaceutical or device manufacturers.

    3) If BSSFHS CME chooses to allow links to the pharmaceutical and device manufacturers’ product websites, then clear notification must be provided that the learner is leaving the educational website.

    4) Product website links are permitted BEFORE or AFTER the educational content of a CME activity, but shall not be imbedded in the educational content of the activity.

    5) Advertising of any type is prohibited within the educational content of CME activities on the Internet including, but not limited to, banner ads, subliminal ads, and Pop-up window ads.

    6) Each Internet activity will indicate in the beginning, the hardware and software required for the learner to participate.

    7) The Internet activity will have a mechanism in place that allows the learner to contact the provider if there are questions about the activity.

    8) The BSSFHS CME policy on privacy and confidentiality will be communicated to the learner and will be adhered to throughout CME activities on the Internet.

    9) BSSFHS CME will document copyright ownership, or permission granted for use of all copyrighted materials contained within the Internet CME activity.

  • Internet Policy

    PURPOSE To provide guidance for on the implementation of the ACCME’s Policy for CME Delivered Via the Internet.

    POLICY
    1) Bon Secours St. Francis Health System, Inc., CME fully supports and adopts the ACCME Policy for CME Delivered Via the Internet (Policy #2002-A-11) as recommended by the Strategic Plan Implementation Task Force.

    2) CME activities provided by BSSFHS must be planned and implemented in compliance with the Essential Areas, Elements and policies of the ACCME.

    3) All continuing medical education Internet activities sponsored by BSSFHS shall maintain separation of promotion from education by ensuring the following:
    • Internet CME activities cannot reside on a pharmaceutical or device manufacturer’s website;
    • There must be clear notification that a learner is entering and leaving the educational website;
    • Links from the website of an ACCME-accredited provider to a pharmaceutical and device manufacturer’s website are only permitted before or after the educational content of a CME activity, but shall not be embedded in the educational content of a CME activity;
    • Advertising of any type is prohibited within the educational content of CME activities on the Internet, including but not limited to, banner advertisements, subliminal advertisements, and pop-up window advertisements.

    4) BSSFHS will operate its Internet CME products and services in accordance with high levels of business and management integrity – as they relate to human resources, financial affairs and legal obligations – so that its obligations and commitments are met.

    5) Prior to registering for an Internet CME activity, BSSFHS will inform the learner about the hardware and software needed to participate in its CME activities;

    6) BSSFHS will have a mechanism (including telephone, fax, and email contact information) for the learner to contact the provider with questions about their Internet CME activities;

    7) For Internet CME activities, BSSFHS will post on its website information regarding privacy and confidentiality of information; and compliance with copyright law.

    IMPLEMENTATION
    1) When planning an Internet CME activity complete the Internet CME Checklist to assure compliance with this policy.

    2) The completed Internet Checklist will be affixed to the CME activity file.

    3) Internal or external web designers must obtain approval by the CME Manager that the Internet CME activity has complied with this policy.

    4) Other enduring material requirements of BSSFHS Policy on Enduring Materials must be adhered to in an Internet CME activity (e.g., expiration date, length of time to complete the activity, etc).

    5) BSSFHS will assure that the commercial support of an Internet CME activity complies with the requirement not to have a credited activity reside on the supporter’s website, including a visual inspection of how hyperlinks are used to refer physicians to the site.

    CME INTERNET CHECKLIST Internet CME activity does NOT reside on the commercial supporter’s website. Learner is notified when entering or departing the educational website. If there is a link to the supporter’s website, it is done before or after the entrance to or exit from the educational content area. There is no advertising whatsoever within the educational content area of the website (includes banner, subliminal and pop-up window advertisements). Information included as to type of hardware and software needed to participate in the activity. Mechanism for learner to contact the provider is posted on the website. If the activity is hosted on a joint or co-sponsor’s website, a hyperlink is established to the sponsor’s website.

  • Joint Sponsorship

    Bon Secours St. Francis Health System, Inc. is accredited by the South Carolina Medical Association (SCMA) to provide continuing medical education (CME) for physicians. In this role, BSSFHSI is responsible for fulfilling requirements as set forth by the SCMA. On a regular basis, non-accredited sponsors of CME activities or a group of physicians will seek out an accredited provider to facilitate the planning and delivery of educational activities. By doing this, and providing AMA PRA Category I Credit™, BSSFHSI is participating in the process of joint sponsorship.

    BSSFHSI must ensure the entire activity is in compliance with the Essential Areas and Elements adopted by the SCMA, the Standards for Commercial Support of CME and the BSSFHSI CME Faculty Disclosure Policy. This means that BSSFHSI must be integrally involved from conception to completion with documentation of such involvement in planning, implementation, administration and evaluation of the activity. BSSFHSI is also responsible for ensuring all activity announcements, brochures and/or other written publicity indicate the appropriate accreditation and credit hour designation statements.

    BSSFHSI will enter into joint sponsorship if the need for such CME activity is “physician-driven” – meaning the idea for the activity, content/topic(s) and the choice of speaker(s) should be chosen according to the needs of the physicians being served (the “audience”) and rigorous compliance with the following criteria is established:

    Activity Application and Activity Director

    1. An Activity Director will be assigned for jointly sponsored activities.
    2. The Activity Director reviews and approves the needs assessment, the Joint Sponsorship Application for Activity Certification, the speaker selection, the learning objectives, the development of the activity and other pertinent issues as they arise.
    3. Typically, the Activity Director is the CME Committee Chairperson, a CME Committee member, BSSFHSI medical staff member or a member of hospital administration.
    4. Once an Activity Director has been assigned, the Joint Sponsorship Application for Activity Certification is completed and serves as a summary of the jointly sponsored activity being planned.
    5. Once activity details are gathered, the application is completed, sent to the non-accredited sponsor for review and returned to the CME Coordinator along with any supporting documentation (ex. speaker’s curriculum vitae, learning objectives, etc.).
    6. After documentation has been received and educational objectives have been identified, the information is submitted to the Activity Director and CME Committee Chairperson for approval or denial (ex. insufficient time to plan, etc.) of AMA PRA Category I Credit™.
    7. If the request is denied, the non-accredited sponsor is directed to the SCMA for assistance with accreditation.

    Budget, Finance, and Disclosures
    8. BSSFHSI may assign responsibility to the non-accredited sponsor(s) to secure meeting space/facility rental, catering, media equipment needs and speaker(s) travel accommodations.
    9. In doing so, the non-accredited sponsor must provide the CME Coordinator with an itemized list detailing such plans (see also Payment of Expenses)
    10. As indicated by the BSSFHSI CME Faculty Disclosure Policy, all faculty, speakers, authors and/or planners who are in a position to control the content of a CME activity are expected to disclose to BSSFHSI and the audience any real or apparent conflict of interest that may have a direct bearing on the subject matter of the educational activity.
    11. To this end, the joint sponsor representative and speaker(s) will be required to complete a Disclosure of Relevant Financial Relationships Form.
    12. Whether significant support or substantial financial relationships exists or not, a written statement is printed and distributed to all physician participants (see Activity Evaluation).
    13. The speaker(s) must also verbally disclose such information to attendees prior to his/her presentation. A representative designated by BSSFHSI, who will be in attendance at the time of the verbal disclosure, must attest in writing that verbal disclosure did occur, itemize the content of the disclosed information or that there was nothing to disclose.
    14. After a speaker(s) is confirmed for the jointly sponsored activity, they are sent required documentation detailing the activity date, location, learning objectives, disclosure of relevant financial relationships information and other activity details.
    15. Once completed forms are received by the CME Coordinator, discussion follows regarding the inappropriateness of conveying or alluding to an affiliation with a commercial organization during an activity with the speaker either via telephone or in person prior to the activity.

    Marketing
    16. The non-accredited sponsor(s) is responsible for creating and distributing all advertisement for the activity, but it must be sent to the CME Coordinator first for pre-approval.
    17. In some instances, the CME Coordinator will create printed materials for distribution. All marketing materials (ex. invitations, brochures and/or other written or printed publicity) must contain the appropriate accreditation and credit hour designation statements and learning objectives, as well as acknowledgement of commercial support (if applicable).

    Activity Evaluation
    18. After the activity, evaluations and needs assessment survey forms must be completed by physician participants, collected and will be picked up by or may be mailed to the CME Coordinator.
    19. These results are promptly tabulated (1-2 weeks post-activity) and a copy of the results is mailed to the non-accredited sponsor(s) and/or commercial company representative(s) for review.

    Record of Attendance
    20. Prior to or on the day of the activity, the CME Coordinator will deliver sign-in sheets to be used for recording physician attendance.
    21. After the activity, the original sign-in sheets will be picked up by or may be mailed to the CME Coordinator.
    22. Promptly after the activity (1-2 weeks post-activity), the CME Coordinator will record attendance into the hospital CME database and prepare credit and attendance certificates.
    23. Certificates include: activity title, activity date, location and designated number of AMA PRA Category I Credit™.

    Commercial Support (if applicable)
    24. If the non-accredited sponsor(s) is seeking commercial support for the payment of speaker(s) honorarium and/or travel expenses, catering and/or any part of the jointly sponsored activity, BSSFHSI is responsible for coordinating the educational grant request. BSSFHSI will compose and submit a grant request letter and Written Agreement for Commercial Support including terms, conditions and purposes of the educational grant to the commercial interest representative(s).
    25. A copy of the BSSFHSI CME Program Mission Statement and the Standards for Commercial Support of CME will also accompany the grant request.
    26. The CME Coordinator is responsible for obtaining the completed forms and the non-accredited sponsor(s) must produce, as documentation, a full accounting of the funds within a reasonable period after activity completion.
    27. Under no circumstances is a commercial interest allowed to pay directly for services related to a CME activity.

    Payment of Expenses
    28. The non-accredited sponsor(s) can pay all expenses (including honoraria, facility rental, catering, etc.) through their organization, but an itemized list of all the expenses that were paid and/or received (including registration fees and/or educational grant monies) should be sent to the CME Coordinator within 2 weeks after activity completion.

    BSSFHSI CME Joint Sponsorship Fees
    29. At the time of application for joint sponsorship, the applying organization or group will provide the approved Joint Sponsorship application fee.

    Fee Schedule
    Application and 1st hour of credit - $100.00
    2nd and 3rd Hour of Credit - $400.00
    Each Additional Hour of Credit - $300.00

  • Planning and Design

    CONTENT DESIGN
    1) Bon Secours St. Francis Health System, Inc. (BSSFHS) is accredited by the South Carolina Medical Association (SCMA) to provide continuing medical education (CME) for physicians.
    2) In this role, BSSFHS is responsible for fulfilling requirements as set forth by the SCMA’s Essential Areas and their Elements, including the Standards for Commercial Support of CME and the Accreditation Policy Compendium.
    3) BSSFHS must be integrally involved from activity conception to completion with documentation of involvement in planning, implementation, administration and evaluation of directly and jointly sponsored activities.
    4) Promotional brochures or flyers are mailed to the target audience, and posted as appropriate in the physician lounges.
    5) The following planning steps are used in the order they appear for planning and executing activities. These steps are explained in further detail:
    • Activity Concept and Planning
    • Speaker
    • Faculty Disclosure
    • Learning Objectives
    • Commercial Support
    • Marketing
    • Meeting Space/Facility Rental, Catering and Media Equipment Needs
    • Activity Packet
    • Pre- and Post Testing
    • Activity Evaluation
    • Record of Attendance

    BUDGET
    1) All expenditures and revenue are documented on the activity financial worksheet.
    2) Guests speakers may receive reasonable honoraria in addition to hotel, meals, and transportation reimbursement.
    3) Program expenses may include meals or light refreshments for the participants.

    A. Activity Concept and Planning
    1. Quality Gap Data
    • CME Committee receives quality gap data through from the Quality Assurance and Nursing Quality Department.
    • This data identifies quality gaps in practice or a potential need for practice improvement.
    • Quality gaps are usually identified through the hospital review processes and other combative report generated through state reporting agencies or national quality reporting agencies.

    2. Needs Assessment Data
    • BSSFHS may use needs assessment data generated in a variety of ways: Quality department(s) recommendations to the CME Committee, activity needs assessment surveys, community/global health concerns, specialty groups, annual program surveys and/or hospital departments and administration.

    3. CME Committee Review
    • After suggestions have been received and educational needs have been identified, activity topics are reviewed and analyzed by the CME Committee, CME Committee Chairperson and/or a CME Committee member to ensure that the proper procedures for identifying needs have been met.
    • The committee discusses potential speakers according their expertise and requests potential topics as related to the need(s).
    • Learning objectives are discussed by the committee and given to the speaker for planning of their activity.

    4. Activity Checklist, Planning Notes and Activity File
    • Once needs assessment data has been gathered and the CME Committee has reviewed and analyzed the identified educational needs, the CME Coordinator must begin planning the activity.
    o Documentation of activity planning must be maintained in the activity file.
    • The CME Coordinator creates and manages a file for each activity.
    o From activity conception to completion, copies, checklists and required forms and letters are kept in this file.
    o Throughout the activity planning process, the CME Coordinator is responsible for communication.
    o The CME Coordinator is also responsible for receiving and reviewing the completed forms, requested signatures and presentations/handouts (if applicable) and testing questions (if applicable) from the speaker in a timely manner.
    • Once the activity has occurred, the Activity Completion Checklist is used as a tool to ensure that all remaining steps are completed (ex. final reports (tallied activity evaluations, tallied assessments and tallied testing results showing improvement in competence) to speaker, activity director and CME Chairperson, credit letter distribution, check requests, etc.).
    o The file is then scanned and saved on the CME shared folder. At the minimum, BSSFHS will retain activity files during the current accreditation period and attendance records for minimum of six years.

    5. Application for Activity Certification
    • Once activity details are gathered, the application along with any supporting documentation is submitted for approval or denial of category I credit.

    B. Speaker
    • Speaker suggestions are obtained from the CME Committee members, Quality department(s) representatives, Hospital Administration, BSSFHS medical staff members and specialty groups.
    • Speaker(s) curriculum vitae (CV) are obtained by the CME Coordinator and provided to the CME Committee for approval.
    • A copy of the chosen speaker’s CV is kept in the activity file.
    • The speaker is contacted by the CME Coordinator, an activity date is chosen, and compensation and travel arrangements (if necessary) are discussed along with other activity details including:
    o requested topic and learning objectives
    o time
    o location
    o activity title
    o target audience
    o media equipment needs
    • A Speaker Form is then sent to the selected speaker for completion, including Activity Objectives Form, Faculty Disclosure Statement Form and Standards for Commercial Support of CME.

    C. Faculty Disclosure
    • After a speaker(s) has been confirmed acopy of the Standards for Commercial Support of CME is sent to the speaker(s), along with a Faculty Disclosure Statement Form.
    • The speaker is asked to return the completed form to the CME department for our records.
    • The CME Coordinator will discuss the inappropriateness of conveying or alluding to an affiliation with a commercial organization during an activity with the speaker either via telephone or in person prior to the activity.
    • Whether significant support or substantial financial relationships between a presenter and commercial entity exists or not, a written statement is printed in the Activity Packet that is distributed to activity attendees.
    • The speaker(s) must also verbally disclose such information to attendees prior to his/her presentation.
    • If slides are available prior to the activity, the disclosure slide is added to the beginning of the presentation.
    • A representative of BSSFHS who was in attendance at the time of the verbal disclosure must attest, in writing
    o that verbal disclosure did occur
    o itemize the content of the disclosed information
    o OR, that there was nothing to disclose; OR, that the speaker(s) had refused to disclose via the Verbal Disclosure Statement Documentation Form.
    • Documentation of this action must be recorded in the activity file

    D. Learning Objectives
    • Learning/Activity Objectives are 3-4 main objectives that the committee has determined to be necessary to expand on the requested topic.
    • The learning objectives can be obtained by the CME Coordinator, the committee, the speaker(s), or a combination.
    • Once the general objectives are given, the CME Coordinator will request the speaker(s) develop more specific objectives.
    • The learning objectives for sponsored activities are stated in all marketing materials.
    • The learning objectives are also inserted in the Activity Packet on the day of the presentation, along with an Activity Evaluation Form that clearly states the objectives.

    E. Commercial Support
    • If commercial support is obtained for the payment of speaker(s) honorarium and/or travel expenses, catering, or any part of the activity, an initial meeting is held with the contributing sponsor to discuss responsibilities and activity content.
    • At this time, forms to be completed are reviewed and guidelines are explained.
    • Commercial sponsors are asked to follow the Standards for Commercial Support of CME and are monitored by the CME Coordinator to ensure that all guidelines are complied with on the day of the activity.
    • A Grant Request Letter and Letter of Agreement including terms, conditions and purpose of the educational grant is composed and given to the representative. The Letter of Agreement must either be signed and returned by the representative or forwarded to his/her home office for completion. A copy of the Standards for Commercial Support of CME must accompany the Letter of Agreement. The CME Coordinator is responsible for obtaining the completed forms and coordinating all financial transactions.
    • At this time, it is clearly explained to the commercial company representative that all funds collected are used for the sole purpose of the planned educational activity and documentation of use will be available to the company after the activity has been completed.
    • After the signed Letter of Agreement is received by the CME Coordinator, any checks received from the company are deposited and credited to the hospitals account (checks must be made payable to Bon Secours St. Francis Health System, Inc.). Speaker(s) honorarium and/or travel expenses, catering, facility rental and printing costs will be paid out by BSSFHS the CME program.
    • Commercial companies can offer assistance in the initial process of speaker selection by offering the CV of possible candidates. The CV is forwarded to the CME Coordinator for review and consideration.
    • Once the activity is being planned, acknowledgement of commercial support is noted on any activity marketing materials and also on the Activity Packet given out prior to the presentation on the day of the activity.
    • Commercial companies are not allowed to distribute any materials during the activity without the authorization of the CME Coordinator. If authorization is granted, the commercial companies are allowed to set up exhibit space outside of the actual meeting room. This material must not contain any bias information related to their products or company.
    • The CME Coordinator establishes and maintains relationships with commercial companies in order to gain information about new drugs, innovative equipment and procedures, national speakers, and physician interest. The CME program and, in turn, the hospital has benefited financially from educational grants provided by commercial companies.
    • The key to these relationships is the control and supervision that is maintained by the CME Coordinator to insure that activities are physician driven.

    F. Marketing
    Once the target audience has been identified for an activity, the CME Coordinator designs all marketing materials. The appropriate accreditation and credit hour designation statements must be included on all marketing materials for all activities. The invitation/flyers/brochures includes registration information.

    G. Meeting Space/Facility Rental, Catering, and Media Equipment Needs
    The CME Coordinator coordinates the facility/room reservation(s), catering, and media (audiovisual) equipment needs for each activity.

    H. Activity Packet
    • The CME Coordinator creates an informational Activity Packet.
    • This information is placed in a folder and given to each activity participant for their review and evaluation completion.
    • The Activity Packet includes:
    o Title Page (acknowledgement of commercial support, if applicable)
    o Activity Objectives
    o Faculty Disclosure Status Statement
    o Notes Page
    o Handouts
    o Pre and Post Tests (if applicable)
    o Activity Evaluation Form
    o Needs Assessment Survey Form
    • The pre and post tests, evaluation and survey forms are collected from participants at the end of each activity and the results are tabulated by the CME Coordinator.

    I. Pre- and Post Testing
    • Where activities are planned that do not generate a means of measuring physician competence levels, such as in data obtainable through hospital, state or national agencies, it has been determined by the BSSFHS CME Committee to institute pre and post testing.
    • Post tests must be passing by 70%.
    • Any physician requesting CME credits must complete these tests and turn into the CME Coordinator.
    • Pre and post tests are graded by the CME Coordinator.
    • Tallied results of the overall competence levels pre and post testing are sent to the Speaker, Activity Director, CME Chairman and the participant.
    • The participant also receives copies of their pre and post tests as a means of correcting any answers which were marked wrong as a means of review.
    • Letters of approval or denial of credit, CME certificates and test results are mailed to the attendees and speakers.

    J. Activity Evaluation
    • The CME Coordinator distributes Pre and Post tests (if applicable), Activity Evaluation Forms and any other handouts at the start of each presentation to be completed by participants. The Activity Evaluation asks participants to evaluate and rate various topics including:
    o overall activity
    o presenter’s overall performance
    o presenter’s knowledge of subject area
    o effectiveness of the meeting room
    o learning aids
    o were learning/activity objectives met
    • Completed evaluations, tests and surveys are collected at the end of the activity and are tabulated by the CME Coordinator. The results are reported to the CME Committee and a copy is sent with the Speaker’s Thank-You Letter. If applicable, a copy of the tabulated results is also mailed to any commercial support representative(s).

    K. Records of Attendance
    The CME Coordinator creates sign-in sheets that are placed on a table outside the classroom(s) prior to the activity. After the activity, sign-in sheets are collected and the CME Coordinator uses them to track activity attendance, enter medical staff members’ credits into a hospital database and prepare credit certificates for attendees. Credit certificates and letters are mailed promptly after each activity and include: activity title, speaker, activity date, and designated number of credits.

  • Quality Improvement

    1) Bon Secours St. Francis Health System, Inc. Continuing Medical Education Program quality improvement strategy is to develop and support a comprehensive educational program that is coordinated and represents continuous efforts to monitor, improve patient outcomes and services provided.

    2) Quality improvement education is planned and systematic with an ultimate goal of achieving optimal outcomes through continuous, incremental improvements that are consistently representative of BSSFHS high standard of practice.

    3) The BSSFHS CME office will address quality, risk management, utilization and infection control in planning CME activities for BSSFHS professional staff.

    4) BSSFHS CME will develop CME opportunities in conjunction with identified physician needs based on physician performance through BSSFHS, or community quality data.

    5) BSSFHS CME office combines efforts with BSSFHS stakeholders to assist in maintaining, developing, or increasing knowledge, skills, professional performance and relationships utilized by physicians to provide quality services to improve the health and well being of the patient, the public, and the profession.

    6) BSSFHS CME works in conjunction with hospital quality initiative efforts and follows these efforts until satisfactory results are achieved.

  • Regularly Scheduled Series

    1) Definition Regularly Scheduled Series (RSS) are defined as medical education activities planned as a series with multiple sessions that occur on an ongoing basis (i.e., offered weekly, monthly, or quarterly). They are primarily planned by and presented to a department's professional staff. When reporting on RSS activities, each series equals one activity. Examples of RSS activities include, but are not limited to Tumor Board Conference, GI Conference, Breast Cancer Conference, Urology Conference and Journal Clubs. RSS activities carry Continuing Medical Education (CME) credit when, and only when, they have been approved by the CME Coordinator in accordance with the procedures indicated here.

    2) Educational Planning Process RSS activities must be planned by linking overall educational goals with identified learner needs or gaps in knowledge, competence, or performance. Further, departments must demonstrate success of their RSS in achieving such overall educational goals by providing outcomes evaluation data.

    3) Application RSS activities must be approved each year by the CME Committee. Departments will be prompted to submit renewal applications. Completed applications must include appropriate documentation showing evidence of needs assessment. Careful consideration should be given by departments to identify an activity for CME credit considering the effort required for appropriate educational planning. Incomplete applications will be returned to the department without review and the RSS activity therein will NOT carry CME credit unless and until the application is completed by the department and approved by the CME Coordinator. Each RSS applicant will be notified of the status of its RSS certification within 30 days of the receipt of a completed application. Certification of RSS is prospective only. Sessions that predate certification will not carry CME credit.

    4) Commercial Support Each RSS is responsible for identifying and reporting all forms of commercial support for RSS activities on the annual application form. Commercial support is defined as financial or in-kind contributions given by a commercial interest, which is used to pay all or part of the costs of a CME activity. A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by or used on patients. In addition, departments are responsible for properly completing Letters of Agreement (LOA) with commercial supporters.

    5) Financial Disclosure Any financial relationship between a commercial interest and anyone in a position to influence the content of an RSS event must be documented and disclosed to the audience PRIOR to the event. This includes planners, speakers, and presenters. RSS are responsible for knowing correct and appropriate methods of making financial disclosures. The CME Coordinator can provide suggestions for doing so.

    6) Conflict of Interest Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of commercial interest which he/she has a financial relationship. If a conflict of interest is identified from a financial disclosure, the CME Coordinator must resolve the conflict. Resolution may include alteration of the financial interests, alteration of the control over content or independent content validation.

    7) Responsibilities of Program Director & Department Contact Each RSS must have an RSS Activity Director who assumes responsibility for completing the annual application and for complying with accreditation procedures and standards. An administrative contact person may be given responsibilities for file maintenance and communicating with the CME Coordinator. This includes sending announcements, disclosure forms, attendance rosters, and evaluations to the CME Coordinator at required intervals. RSS Activity Directors are responsible for maintaining up-to-date files with the CME Coordinator and for providing required documentation to the CME Coordinator as requested.

    8) Responsibilities of CME Coordinator The CME Coordinator is responsible for monitoring departments for compliance with RSS procedures, providing guidance/assistance with compliance issues, training on policies and procedures, and communication when noncompliance is discovered and requires intervention. (Please see consequences of failure to comply below.) The CME Coordinator is also responsible for documenting and storing RSS files in compliance with ACCME standards. Specifically, the CME Coordinator will assist departments in implementing the following Essential Elements with their RSS activities:
    • Needs assessment data that identify learning gaps and planning decisions
    • Planning process that links identified educational needs with desired results
    • Communication of the purpose and objectives of the RSS activity to develop informed and engaged learners
    • Content free from commercial bias and with appropriate acknowledgement of relevant financial relationships and commercial support

    Finally, the CME Coordinator will encourage departments to go beyond the minimum standards and be creative and innovative in its concept when conducting RSS activities. The CME Coordinator will offer its expertise in physician learning as a resource for integration of evidence-based approaches in all aspects of administering RSS activities.

    9) Consequences of Failure to Comply Additional consultation will be initially provided by the CME Coordinator to RSS Activity Directors who fail to comply with these policies and procedures. If such consultation is not effective in improving compliance, the RSS in question will enter a 3-month probationary period, and will have the opportunity to remedy the identified deficiencies. Further, the CME Coordinator will notify the activity director that they are in danger of losing CME certification of their RSS. If performance substantially improves by the end of the probationary period, the RSS will be restored to regular status. If performance does not improve during the probationary period, certification for the RSS activity will be revoked for the remainder of the year as enforced by the policies approved by the CME Committee. In these situations, CME certification may be re-applied for the following year, but must address the noncompliance problems in the new application including proposed remedial actions.

    10) Additional Resources: Accreditation Council for Continuing Medical Education The accrediting body for institutions and organizations offering continuing medical education. The Alliance for Continuing Medical Education accreditation, Codes and Guidelines.

  • Required Documentation

    BEFORE THE CME ACTIVITY
    1) Completed Application for Category 1 Designation
    2) Documentation of Need
    3) Topics, objectives, and speakers with time frames
    4) Curriculum vitae of all course presenters
    5) Proposed budget
    6) Full Disclosure Declaration for each speaker
    7) Full Disclosure of all persons who may control content of CME activity.
    8) Brochure, flyer, or other promotional material
    9) Speaker Curriculum Vitae or other professional record confirming professional expertise.
    10) Handout materials
    11) Planning notes and related correspondence
    12) Letter of Agreement for Commercial Support (if applicable)

    AFTER THE CME ACTIVITY  Due within 30 days
    1) Sign in form/Attendance record
    2) Participant Evaluation survey
    3) Participant Needs Assessment survey
    4) Pre and Post tests (if applicable)
    5) Complete budget/Accounting

  • Speaker Honoraria

    It is appropriate for faculty of conferences and enduring materials to accept reasonable honoraria and to accept reimbursement for reasonable travel, lodging and meal expenses. The amount of honoraria will not be influenced by representatives of industry or other financial contributors to the activity. Bon Secours St. Francis Health System, Inc., as an ACCME-accredited CME provider, should determine the amount of honoraria using the following criteria:
    1) Expertise of proposed faculty
    2) Market value (what faculty request)
    3) Status of proposed faculty – Bon Secours St. Francis Health System, Inc., staff, Bon Secours St. Francis Health System, Inc., member, professional consultant
    4) Amount of confirmed grant money
    5) Amount of registration fee that could be charged
    6) Number of expected participants

    The range of honoraria should fall between $0 and $2,000. However, honoraria outside of these limits can be granted in exceptional circumstances. The planning committee for each activity should determine specific guidelines for implementing this policy. The provider, the joint sponsor, or designated educational partner must pay directly any teacher or author honoraria or reimbursement of out-of-pocket expenses in compliance with the provider’s written policies and procedures (see below). No other payment shall be given to the director of the activity, planning committee members, teachers or authors, joint sponsor, or any others involved with the supported activity. If teachers or authors are listed on the agenda as facilitating or conducting a presentation or session, but participate in the remainder of the educational event as a learner, their expenses can be reimbursed and honoraria can be paid for their teacher or author role only.

  • Staff Development

    Bon Secours St. Francis Health System, Inc. is supportive of staff education for all employees.
    1) The CME Coordinator maintains membership in the Alliance for Continuing Medical Education (ACME) and shares knowledge with regional peers as well as the CME Committee.
    2) Workshops sponsored by the Accreditation Council for Continuing Medical Education
    3) (ACCME) shall be attended periodically by the CME Coordinator.
    4) CME Coordinator will attend quarterly and annual CME provider meetings held by the South Carolina Medical Association.
    5) DVD and Webinar presentations provided by reliable sources will be encouraged viewing by CME Coordinator and CME Committee members.
    6) Additional state and/or national workshops or conferences which serve to meet a specific learning need for the CME Coordinator will be recommended for attendance.

  • Testing

    1) All activities should be planned and produced in accordance with ACCME Essentials.
    2) A set of test questions will be developed which address the material presented.
    3) These questions should be developed with the activity objectives as a guide.
    4) Tests will be graded by the CME Coordinator and returned to the participant along with their CME certificate.
    5) Participants who answer 70% or more of the questions correctly will obtain credit.
    6) Once credit is received, the physician will receive a certificate of credit and a copy of a test with the correct answers.

  • Verbal Disclosures

    When information about faculty/provider relationships is disclosed to participants verbally, it is required that the file include verification that this disclosure to the learners actually occurred at the activity. The ACCME states the following:
    1) A representative of the provider CME Committee Member who was in attendance at the time of the verbal disclosure must attest in writing on the disclosure form:
    • That verbal disclosure did occur; and
    • Itemize the content of the disclosed information; or that there was nothing to disclose; or that the faculty member/speaker had refused to disclose.

    2) 2. The documentation that verifies that adequate verbal disclosure did occur must be completed within one month of the activity. Information to include in verbal disclosure:
    • Speaker’s name
    • Nature of the relationships (speakers’ list, grant recipient, stockholder, etc)
    • Entities with which he/she has a relationship
    • Or, if he/she had nothing to disclose or refused to disclose

    This policy applies to verbal disclosure only. Written disclosure requires verification within the presentation slides (where possible) and within the attendee forms.

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