MDCMA CME Joint Providership Application

Our goal is to help you deliver CME that promotes a measurable change in physician competency and performance, with the ultimate goal of improving health outcomes.

Click here to read our Joint Providership Program FAQs.

It is strongly advised that you save your application.
To do so, click the "Save" button at the bottom of the page (before closing your browser screen) and click the "Get Draft Link" then save a copy of this link so you may later access your working application.

APPLICANT ORGANIZATION NAME:*

ADDRESS:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PHONE NUMBER:*

Please enter a valid phone number.

DATE(S) OF ACTIVITY:*

ANTICIPATED NUMBER OF CREDITS/HOURS TO BE PRESENTED:*

TITLE OF ACTIVITY/PRESENTATION:*

ACTIVITY LOCATION:*

Name of facility

ACTIVITY ADDRESS:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

ACTIVITY DIRECTOR:*

*The DCMA Committee on CME requires this person to be a physician.

ACTIVITY DIRECTOR EMAIL:*

example@example.com

ACTIVITY DIRECTOR PHONE:*

Please enter a valid phone number.

ACTIVITY COORDINATOR:*

ACTIVITY COORDINATOR EMAIL:*

example@example.com

ACTIVITY COORDINATOR PHONE:*

Please enter a valid phone number.

DO YOU WISH THE MDCMA TO REPORT YOUR LEARNERS' CME CREDITS TO THEIR SPECIALTY BOARD?*

YesNo

*If you select "No" your learners can still self-report their credit hours to their specialty boards.

Please note: If you would like the MDCMA to report learner credits to a specialty board you must include the proper disclosures to learners in your announcements (website, emails, flyers, etc.) and program.

Please click here for a list of the required disclosures.

The MDCMA can report learners' credits to the following specialty boards. If you wish the MDCMA to report, please select which boards (you may select one or multiple boards):*

American Board of AnesthesiologyAmerican Board of PathologyAmerican Board of SurgeryAmerican Board of Orthopaedic SurgeryAmerican Board of Thoracic Surgery

IF YOUR PROGRAM IS LOCAL TO THE SOUTH FLORIDA AREA, DO YOU WISH THE MDCMA TO SHARE YOUR ACTIVITY INFORMATION WITH HEALTHCARE PROFESSIONALS OUTSIDE OF YOUR ORGANIZATION VIA THE MDCMA WEBSITE?*

YesNo

Professional Practice Gap

All educational activities should attempt to address and potentially change some aspect of the learner’s knowledge, competence or performance, and result in improved patient care.

Who is the primary target audience for this activity?*

All physiciansCertain physician specialistsOther members of the healthcare teamOther professionals

please specify certain physician specialists:*

please specify other members of the healthcare team:*

please specify other professionals:*

What is the target audience’s problem(s) in practice that will be addressed by this activity?
Identify the Professional Practice Gap (i.e. State the educational opportunity or the difference between current practice and best practice on which this activity was based:

Professional Practice Gap:*

How do you know about these problems? What brought these problems to your attention?*

Focus panels or RoundtablesSurvey of targeted learnersPeer-reviewed literatureInterviews with experts or thought leaders in the areaPrevious evaluation/outcomes measurement summariesNational guidelines or specialty society guidelines

Why are you offering this activity?*

Knowledge need: To reinforce knowledge and competence that the target audience already has or should have.Performance need: To share new ideas, strategies and/or technologies with the target audience that will hopefully result in a change in practice.Competence need: To convince members of the target audience to adopt a new approach or strategy that will potentially result in improved patient outcomes.

Objectives - Link the gaps/needs listed above to the content to be presented.

State what this CME activity was designed to change in terms of learners' competence or performance:

Objectives/Outcomes #1*

Objectives/Outcomes #2*

Objectives/Outcomes #3

Objectives/Outcomes
1. Objective 1*
2. Objective 2
3. Objective 3

What formats are best to achieve the learning objectives?*

Please specify the format if "Other" was selected:*

Taking into account the educational objectives, why are the educational format(s) you selected appropriate for this activity?*

Content Verification: CME content must be developed within the context of "desirable physician attributes” or competencies. Indicate the desirable physician attribute(s) (i.e. competencies) this activity addresses: (select all that apply)*

Patient care - Provide care that is compassionate, appropriate, and effective treatment for health problems.Medical knowledge - Demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and apply this knowledge to patient care.Practice-based learning and improvement - Investigate and evaluate patient care practices, appraise and assimilate scientific evidence, and improve practice.Interpersonal and communication skills - Demonstrate skills that result in effective information exchange and teaming with patients and their families and with professional colleagues.Professionalism - Demonstrate a commitment to carrying out professional responsibilities, adhering to ethical principles, and being sensitive to diverse patient populations.System-based practice - Demonstrate an awareness of and responsibility to a larger context and system of health care. Be able to call on system resources to provide optimal care.

Planners/Faculty Info

For all individuals in control of content for the activity:

Each planner and speaker/faculty MUST complete the MDCMA Disclosure Form.
If you would like a custom disclosure form link that you can share with your planners and speakers so they may complete the form electronically, please email us. The results of these completed disclosures will automatically be sent to you and the MDCMA.

Planners and faculty who identify relevant relationships with ineligible companies will trigger the MDCMA’s mitigation process.

Disclosure Forms:*

I will be uploading completed disclosure forms for all of my planners and speakers.I will use the electronic disclosure form link provided by the MDCMA.

PLANNER/SPEAKER DISCLOSURES: Copies of each MDCMA Disclosure Form completed by Planners and Faculty.*

Planners/Faculty Form:

The Activity Coordinator must complete the Planners/Faculty Form below or if a list is available electronically(e.g., in Excel), indicate that below and upload the file (Click here for a sample Excel spreadsheet).
- List each individual in a position to control content, that individual’s role in the activity (activitydirector, planner or faculty), and the name of the ACCME-defined ineligible company with which the individual has a relevant financial relationship or if the individual has no relevant financial relationship.
Planners and faculty listed on this log who identify relevant relationships with ineligible companies will trigger the DCMA’s resolution of conflict of interest (COI) process.

How will you provide the Planners/Faculty Form?*

I'm including an attached Excel spreadsheet of speakers.I will fill out the Planners/Faculty Form below.

Please click below to upload your Excel spreadsheet of speakers:*

Planners/Faculty Form*

	Name of Individual	Individual's role in activity (e.g., Activity Director, Planner, Faculty)	Name of ineligible company	Nature/type of relationship. Choose one of the following that best describes the relationship: Grant/Research support, Consultant, Speakers Bureau, Stockholder, Other financial/material support.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Communication of Disclosure & Accreditation Information:

Communicate disclosure information collected to learners in a tangible way in advance of the activity(e.g.: on the flyer in the Final Program, or with some other written documentation). MDCMA must retain a copy of this evidence.

Please click here to see a sample flyer showing communication of planner and speaker disclosure information, accreditation statements, and more. Please also review the MDCMA CME Marketing Guidelines found here.

ACTIVITY TOPICS/CONTENT: (for example: agenda, brochure, program book, or announcement) NOTE: All promotional materials and Final Program must be pre-approved by MDCMA before dissemination. MDCMA staff is looking for correct accreditation/designation statements, communication of planner and speaker disclosure information, proper acknowledgment of commercial support (if applicable), and MDCMA & FMA logo.*

PLEASE NOTE:
PowerPoint presentations may be requested if relevant financial relationships with ineligible companies are identified.

HONORARIA POLICY:
Please click here to view the MDCMA Honoraria Policy. The DCMA expects its joint providership partners to employ similar parameters when determining the amount of speaker honoraria.

Commercial Supporters Info

Commercial support is financial or in-kind (e.g. products) contributions given by a ineligible company (any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients) which is used to pay all or part of the costs of a CME activity.

This does not include fees paid by vendors for an exhibit booth or companies which pay corporate sponsorships in exchange for ads, booth space or other tangible benefits.

Will you be seeking COMMERCIAL SUPPORT for this activity?

YesNo

Click here to download the Commercial Supporters Form and upload the completed form below.

Commercial Supporters Form*

Each supporter listed on the Commercial Supporters Form must have a Letter of Agreement for Commercial Support executed for this activity. This is due before the program can be approved. Please upload these below.

Letter of Agreement for Commercial Support*

If you are seeking commercial support for this activity, please complete the following attestations:*

I attest that our organization will notify the MDCMA of all commercial support for which we apply.I attest that our organization will submit a signed Commercial Agreement form for each financial or in-kind contribution (grant) that we receive from a commercial interest. Either the LOA generated by the supporter’s online grant system or I will use the MDCMA’s Commercial Agreement.I attest that we will not allow ineligible companies to give any funds directly to planners, faculty, attendees, or other individuals involved in the execution of this activity, or to pay any activity expenses directly nor will we use commercial support to pay for the expenses of non-faculty members directly.I attest that we will acknowledge commercial supporters in our promotional materials or Final Program SEPARATELY from Exhibitors or Corporate Partners or Sponsors of social events.

Exhibitor and Corporate Support

Will your meeting include the opportunity for companies to pay fees or corporate sponsorships in exchange for ads, booth space or other tangible benefits?*

YesNo

Please explain an affirmative answer:*

Do you plan to provide the names and contact information of your learners to these companies?*

YesNo

*You must explain to learners that you intend to share their information with an ineligible company. You can do that at registration; however, the learner must have the ability to opt out and still register for your activity. The consent statement must be clearly visible. If the statement is hidden in a long list of terms and conditions, that would not meet the expectation.

Standard 2 of the Standards for Integrity and Independence in Accredited Continuing Education specifies that accredited continuing education must protect learners from commercial bias and marketing.

The accredited provider must ensure that all decisions related to the planning, faculty selection, delivery, and evaluation of accredited education are made without any influence or involvement from the owners and employees
of an ineligible company.
Accredited education must be free of marketing or sales of products or services. Faculty must not actively promote or sell products or services that serve their professional or financial interests during accredited education.
The accredited provider must not share the names or contact information of learners with any ineligible company (any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on,
patients) or its agents without the explicit consent of the individual learner.

If you answered yes to one or both of the above questions, please complete the following attestations:*

I attest that our organization will observe the guidelines outlined above.I attest that no promotional activity will occur within the confines of the educational space (including sale of books or materials by faculty).I attest that our organization will provide evidence that learner consent has been obtained if applicable.I attest that our organization will not share the names or contact information of learners with any ineligible company or its agents without the explicit consent of the individual learner. *

How will you determine the effectiveness of your CME activity? (Evaluations are a simple method to determinewhether the result you intended has actually been achieved).*

Post Activity Evaluation Form - with questions that address what learners might do differently as a result of attending the activity. (minimum requirement/use MDCMA template) MDCMA must receive a SUMMARY of this data (not copies of individual forms).*Pre- and Post-Testing utilizing paper tests - MDCMA must receive a SUMMARY of the aggregate test data (not a copy of each individual test).Pre- and Post-Testing utilizing audience response technology - MDCMA must receive a SUMMARY of the aggregate test data.Assimilation of knowledge and/or clinical strategies via questions incorporated in presentation utilizing audience response technology - MDCMA must receive a SUMMARY of the aggregate data.

*MDCMA can provide you with a custom post activity evaluation form link you can send to your learners to complete online. This method will allow the results to be received automatically by the MDCMA.

Ten days after the activity the below follow-up materials are due. What is this date?*

Must be 10 days after your activity concludes.

1. Attendance Credits Worksheet with participants’ names, medical license numbers, and the number of credits earned.
- One Topic Meeting Sample
- Multi-Day Meeting Sample
- Monthly/Quarterly Meeting Sample

2. A set of meeting materials as distributed to participants on site including meeting program, agenda, worksheets, etc.

3. Budget Report: The income and expense statement for this activity that details the receipt and expenditure of all of the commercial support. (sample budget report).

4. Director’s Evaluation Letter (sample)

Joint Providership Agreement Attestation

I hereby certify that the information provided in this application is complete and accurate to the best of my knowledge. In the event any information changes or the CME Activity descriptions are no longer accurate, I agree to notify MDCMA at cpope@cobbemanagement.com. In addition, I agree that our organization will fulfill the expectations and obligations as set forth by the MDCMA, including the submission of requested compliance documentation and payment of all fees within the time frames specified and understanding that the failure to do so can result in the assessment of a late fee or termination of services.

Signature*

Date*

Date

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance

DEFINITION OF TERMS:

Activity Director: Physician charged with oversight of the educational activity.
Activity Coordinator: Primary contact with the MDCMA and individual responsible for administrative tasks.
Planner: Anyone involved in choosing speaker, topic, or content, this includes the Activity Director; it may/may not include the ActivityCoordinator depending on her/his role in planning the activity.
Commercial Support: Educational grants (monetary or in-kind) received from commercial interests such as pharmaceutical companies.
Ineligible Company: is defined as any entity whose primary business is producing, marketing, re-selling, or distributing health care goods orservices used by or patients. Entities that provide clinical service directly to patients are exempted.
Competence: Knowing how to do something, application of knowledge and skills
Relevant Financial Relationships: are those in any amount occurring within the past 24 months where the planner or speaker has the opportunity to influence CME content that relates to the products or service lines of the ineligible company with which he/she has a financial relationship. The MDCMA as the accredited provider is obligated to determine relevance. And the MDCMA as the accredited provider is obligated to mitigate all financial relationships determined to be relevant.
Desired Results: What physician learners should be able to do after participating in this course.
Knowledge: Having the necessary information, skills or facts.
Mechanism to resolve Conflicts of Interest: The MDCMA CME Committee policy to ensure that content is objective and free of commercial bias is to perform an in-depth review of the content to be presented. All speakers who disclose a relevant financial relationship with an ineligible company must provide a copy of their PowerPoint. A member of the MDCMA CME Committee, specialist, or designee will review the slides with regard to objectivity and an absence of commercial bias for or against any company or product.
Problem/Professional Practice Gap: What physician learners need to know or know how to do, strategies that they are not using that should beincorporated into their practice, the difference between actual practice and ideal practice. What a learner is doing now as compared to what s/he would do if they had the requisite knowledge, skills and strategies.

JOINT PROVIDERSHIP APPLICATION