THE UNIVERSITY OF TENNESSEE HEALTH SCIENCE CENTER POLICIES AND PROCEDURES FOR PLANNING AND IMPLEMENTING CONTINUING MEDICAL EDUCATION ACTIVITIES INTRODUCTION The University of Tennessee College of Medicine recognizes a commitment to create opportunities for lifelong learning for physicians and other health professionals of the state and region. The University of Tennessee is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor CME for physicians. POLICIES 1. Continuing medical education (CME) is considered by the dean, department chairmen and faculty as an integral part of the teaching program of the college and of the teaching responsibilities of the Faculty of the College. As such, the participation of faculty in planning and presenting CME programs will be considered in the determination of academic promotion and salary. 2. All CME courses presented by The University of Tennessee College of Medicine and its departments shall be either solely sponsored or jointly sponsored by the UT College of Medicine through the office of continuing medical education. 3. The Office of Continuing Medical Education is responsible for coordinating the College's efforts in providing continuing medical education for physicians and other health professionals. This responsibility includes the following: 1) maintaining national accreditation; 2) monitoring all programs presented by the College of Medicine and its departments to assure fulfillment of stated objectives and maintenance of high quality; 3) approving continuing education credit for CME programs; and 4) coordinating all programmatic and financial responsibilities associated with continuing medical education offerings. 4. The Continuing Medical Education Advisory Committee shall advise regarding policy and procedures for CME and assist in the development of continuing education. 5. The departments of the College of Medicine with support from the office of continuing medical education are responsible for assessing the needs of their specialties, developing and presenting CME programs based on these needs and evaluating program effectiveness. The office of continuing medical education may additionally develop programs that are not predominately taught by any single department, but involve multiple departments. 6. Joint sponsorship with outside groups and professional associations is permitted and encouraged in order to fulfill the public service commitment by the University and to reduce course duplication and scheduling conflicts. All such courses must reflect UT College of Medicine involvement and conform to UT College of Medicine's office of continuing medical education guidelines. The office of continuing medical education shall negotiate any sharing of program deficits and revenues after expenses prior to joint sponsorship agreement. 7. All programs offered by The University of Tennessee College of Medicine and its departments must be reviewed by the Continuing Medical Education Advisory Committee. Programs must be presented for review early enough so all necessary requirements for development can be met. 8. The University department sponsoring the CME program will assume financial responsibility for all losses after expenses of the course have been met. Any income after expenses will be shared equally by the Office of Continuing Medical Education and the sponsoring department. A final accounting of income and expenses of each program will be made by the Office of Continuing Medical Education and shared with the sponsoring department. Both the individual departments and the Office of Continuing Medical education are encouraged to generate financial support for continuing education programming and development. 9. The office of continuing medical education will record CME credits issued by the College of Medicine and will maintain an official transcript for CME participants. 10. CME programs cannot be sponsored or jointly sponsored by a commercial firm. Commercial firms may provide an educational grant to the University to support an activity. The University will assume total responsibility for the content and quality of the program. The University is committed to presenting programs which are objective, accepted by the medical community. PROCEDURES FOR CONTINUING EDUCATION PROGRAMS I. ASSESSMENT OF NEEDS A. One of the major prerequisites for a successful continuing education activity is the ability to recognize and fulfill the needs of the physicians. The academic departments are to participate in assessing the needs of the members of the profession. B. The determination of these needs can best be met through a continuous information gathering system. This may include: 1. Surveys of potential participants or national surveys of specialties targeted for the program. 2. Practice Data such as practice profiles, medical audits, professional review, organization reports, material consensus reports. 3. Epidemiological Data 4. Literature review and expert recommendations 5. Expressed interest of target audience from consultation, past course evaluation, letter of request or some other form. II. COURSE APPROVAL A. Each department in the College of Medicine should develop a systematic approach to the development of CME activities. The time frame allotted will depend on the scope and location of the program. Generally, programs should be scheduled 6-12 months in advance to allow ample time for program development and promotion. An involved faculty member must submit all programs sponsored by The University of Tennessee College of Medicine with approval by a department chairman. The program should be developed based on the following guidelines: 1. Clear the proposed dates through the Office of Continuing Medical Education; 2. Complete a "Course Approval Form" from the CME office; 3. Designate the faculty director of the course; 4. Define the course objectives/purpose statement and program content; 5. Identify professional groups as target audience; 6. Secure the approval from the appropriate departmental chairman with his/her signature on the approval form; 7. Include the recommended honorarium for visiting faculty; 8. Insure evaluation procedures; 9. Include tentative or final schedule; 10. Include the names and titles of UT faculty, local professionals, and outside faculty who will present; 11. Satisfy ACCME requirements for Continuing Medical Education credit; 12. Indicate any specialty group accreditation requirements applicable to the intent of the program; 13. Include proposed methodology to be used; 14. Submit the above information to the Office of Continuing Medical Education for presentation to the CME Advisory Committee, assignment of credit hours and approval of continuing education credit. B. Professional associations or other outside groups that request joint sponsorship from the University of Tennessee College of Medicine, will first request approval from the appropriate department chairman through the faculty member participating in the program. The program must then be reviewed by the Office of Continuing Medical Education as a jointly sponsored effort between University of Tennessee College of Medicine and the professional association or group. Such review is to insure that the proposed program coincides with the essentials of ACCME. Programs offered for joint sponsorship with UT Health Science Center must be developed and presented in concert with appropriate department as represented by its faculty member who will: 1. Participate in the planning and development of each cosponsored CME activity; 2. Assume responsibility for the overall quality of the program being cosponsored; 3. Assure that the name of the University of Tennessee College of Medicine is placed on the program as a bona fide joint sponsor, and that the name(s) and titles of participating faculty and speakers are complete and proper; 4. Determine that the program is appropriately evaluated, and that the evaluations are made available to the Office of Continuing Medical Education; 5. Establish in consultation with the Office of Continuing Medical Education any financial arrangements prior to the completion of the joint sponsorship agreement. C. Grand Rounds and Ongoing Programs Departments requesting approval of ongoing programs such as rounds must complete a "Course Approval Form" annually outlining the objectives, tentative or final schedule, faculty and evaluation method for the upcoming year. These should be submitted in June of each year for the new fiscal year beginning July 1. A contact person in each department should be identified to assure proper attendance records are completed and returned to the CME Office for recording. Evaluations should be summarized and sent to the Office of Continuing Medical Education. Additional information concerning these activities is available. Please contact the CME office for specifics. III. COURSE EVALUATION All participants in continuing education courses are required to evaluate program content and presentation. A summary of the evaluation results are made available to: 1. Course Director; 2. Department Chairman; 3. Chairman, Continuing Education Committee. Individual evaluations of course faculty will be made available to course faculty upon request. IV. SCHEDULING AND IMPLEMENTATION The approval process involves judgments by the faculty regarding programmatic content. Scheduling and implementation represents a collaborative effort between the faculty and support staff in carrying out the judgment of the faculty. Logistical and administrative functions shift to the Office of Continuing Medical Education with content development remaining the responsibility of the faculty. A. Immediately following approval and acceptance (but no later than six months prior to implementation) a complete and comprehensive course outline together with objectives and a projected list of participating faculty should be presented to the CME office by the faculty course director. B. A budget for the course listing all expenses and anticipated income should then be prepared by the CME office in cooperation with the faculty course director. C. Confirmation of speakers, resources staff, honoraria, travel expenses, space reservation, and other arrangements are to be processed by the CME office. D. The CME office is to coordinate preparation of brochures for printing and distribution and provide a copy of the proof for review by faculty course director. E. Where a course warrants video or audio taping, such costs must be provided for in the course budget. The preparation of slides, videotapes, transparencies, and other similar materials, is the responsibility of the faculty or their department. F. The chairman and/or his designee reviews and approves recommended courses as to the needs for the offerings, course objectives, course content, method of presentation, faculty and scheduling. G. For those cases where no identifiable department exists, the continuing medical education committee and/or Assistant Dean for Continuing Medical Education and/or his designee must review proposed offerings for approval. V. COURSE CREDIT A. All programs presented under the auspices of The University of Tennessee College of Medicine Continuing Education Committee are approved for appropriate AMA/PRA Category credit and for CEUs for The University of Tennessee. Only the Office of Continuing Medical Education is permitted to assign credit hours to a continuing medical education activity. B. Other specialty accreditation’s will be submitted by the CME office as the programs require. The American Academy of Family Physicians forbids the use of any reference to Family Practice credit before it has granted the credit. Statements such as "AAFP credit has been applied for" must NOT be placed in the brochure. Therefore, if AAFP credit is requested, the application must be made at least 30 days prior to brochure printing. Other specialty groups have similar requirements; consult the CME office in this regard. C. The approved credit statement for AMA Category 1 and the joint sponsorship statement with the University MUST be noted on the brochure; therefore, the brochure copy must be reviewed by the CME office prior to printing and mailing to insure compliance with these regulations. VI. REGISTRATION FEES The continuing education director must establish a firm registration fee, in cooperation with the respective program director at the time the budget for the course is prepared. The fee will be collected through advance registration and on site registration by the Office of Continuing Medical Education. Appropriate receipts and confirmations will be provided to course participants. The fee for the course should cover all the expenses of the course. 1. Registration fees may be reduced or waived for regular full time faculty, staff, residents and students of UT Health Science Center provided: a. Space is available b. And the course director and/or Assistant Dean approves the same. 2. In all instances of waiver of registration fees, the recipient is responsible for the cost of meals, handout materials, fees to record credit and any extra curricular activities. 3. Course fees for certain individuals may be waived at the discretion of the continuing education course director and the Director of Continuing Medical Education and shall be documented with appropriate justification. VII. HONORARIA A. UT faculty continuing education involvement is a recognized commitment of the University of Tennessee College of Medicine. Thus, participation in continuing education programs will be considered in faculty appointment, promotion, tenure and merit raises. Therefore, UT faculty will not receive an honorarium for CME activities with the exception of selected outreach activities. The Office of Continuing Medical Education will provide the appropriate department head with a periodic report on faculty continuing education productivity within the College of Medicine. Travel expenses for participation in continuing medical education will be paid within University guidelines. B. Non-UT Personnel 1. The setting of honoraria for outside faculty participating in continuing education courses is the responsibility of the director of continuing medical education in consultation with the course director. This fee will be established at the time the budget for the course is prepared. 2. The honorarium is to be based upon the University daily maximum plus expenses unless exception are approved by the CME committee and/or the Assistant Dean for Continuing Medical Education. 3. All travel expenses authorized must be in accord with UT policy regarding these matters. 4. The number of outside faculty should be appropriate to the mission of the course. VIII. CREDIT RECORDS A. The UT Health Science Center Continuing Medical Education Office will maintain a permanent record of attendance at all continuing education courses, in accordance with the requirements established by the Higher Education Commission and accreditation agencies. B. The CME office will be responsible for providing needed reports to various agencies, including the sponsoring agencies, and the Tennessee Higher Education Commission. IX. CONTINUING EDUCATION OUTREACH PROGRAMS A major responsibility of the statewide CME program is to set up outreach continuing education programs throughout the state and in surrounding patient referral areas. These programs may take the form of: 1. Providing a speaker for a hospital or medical society meeting, 2. Developing seminars or workshops of varying lengths to meet local needs, 3. And providing a travel circuit of medical/surgical presentations. A. Hospitals and/or medical societies which request the program will be encouraged to pay travel expenses and if possible an honorarium or gift to the faculty member. B. Each faculty member who participates in the outreach network should be an individual who is either employed by or who supports the goals and mission of The University of Tennessee College of Medicine. He/she must indicate to the audience that he/she represents the University and University hospitals when presentations on behalf of the University. C. The Office of Continuing Medical Education will be responsible for setting up the outreach programs and will conduct an annual needs assessment and evaluation of these programs. D. Attendance records for Grand Rounds and similar ongoing programs will be forwarded to the CME Office by the academic departmental office. E. The CME Office will provide transcript service to individuals who have established records.