Performance Improvement Continuing Medical Education (PI CME)

If you are a physician, accredited CME provider or just have questions about the Performance Improvement Continuing Medical Education (PI CME) learning format, the material presented on this page will provide the information and answers you need. If you need additional assistance, please contact [email protected]. 

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A PI CME activity is a process by which evidence-based performance measures and quality improvement (QI) interventions are used to help physicians identify patient care areas for improvement and change their performance. This type of CME activity differs in structure from other CME learning models that may also use PI/QI data (e.g., live activities, enduring materials).

The accredited CME provider structures a PI CME activity as a 3-stage process by which a physician or group of physicians learns about specific performance measures, assesses their practice using the selected performance measures, implements interventions to improve performance related to these measures over a useful interval of time and then reassesses their practice using the same performance measures.

A PI CME activity may address any facet (structure, process or outcome) of a physician’s practice with direct implications for patient care.

The AMA Council on Medical Education approved AMA PRA rules for PI CME activities in September 2004. The AMA Division of Continuing Physician Professional Development (CPPD) had directed a pilot project over the preceding three years in order to develop the guidelines, which offer CME providers and physicians a different way to think about CME activities. PI CME activities focus on the physician’s clinical practice. Performance measurement and improvement activities had already emerged as a mechanism for physicians to systematically assess their practice, and to some extent, their patient outcomes. The pilot project helped develop the processes by which this could be structured as an AMA PRA Category 1 Credit™ educational activity.

To be certified for AMA PRA Category 1 Credit™, a PI CME activity must:

• Have an oversight mechanism that assures content integrity of the selected performance measures. If appropriate, these measures should be evidence based and well designed. 
• Provide clear instruction to the physician that defines the educational process of the activity (documentation and timeline).
• Provide adequate background information so that physicians can identify and understand the performance measures that will guide their activity and the evidence base behind those measures (if applicable).
• Validate the depth of physician participation by a review of submitted PI CME activity documentation.
• Consist of the following three stages:

  Stage A: Learning from current practice performance assessment Assess current practice using the identified performance measures, either through chart reviews or some other appropriate mechanism. 

  Stage B: Learning from the application of PI to patient care Implement the intervention(s) based on the results of the analysis, using suitable tracking tools. Participating physicians should receive guidance on appropriate parameters for applying the intervention(s).

  Stage C: Learning from the evaluation of the PI CME effort Reassess and reflect on performance in practice measured after the implementation of the intervention(s), by comparing to the original assessment and using the same performance measures. Summarize any practice, process and/or outcome changes that resulted from conducting the PI CME activity.

• Each PI CME activity is designated for 20 AMA PRA Category 1 Credits™.
• Physicians completing Stage A are awarded 5 AMA PRA Category 1 Credits™; Stages A and B, 10 credits; A, B and C, 20 credits.

Search the AMA Ed Hub™ to find any current AMA sponsored PI CME activities and learn more about the frequently asked questions about PI CME (PDF).

Many CME courses are free or offered at a discount for AMA members and some are free for nonmembers. Some courses may require a login. 

There are three types of performance measures; measures of any type can be used in a PI CME activity as long as there is a direct implication for patient care:

• Structural measures: A measurement of some quality of the physical or organizational aspect of the organization. Structural measures can signify whether basic organizational constructs are in place.
• Process measures: A measurement of compliance with a specific procedure. Process measures can supply actionable feedback by illuminating if the prescribed procedure is being followed consistently
• Outcome measures: A measurement of product quality, based on the specifications. Outcome measures indicate whether or not the process is successful in reaching its goal.

Measures can be specified at different reporting levels. Typical levels include:

• Physician level
• Patient level
• System level
• Hospital level
• Physician group level
• Payer level

There are typically three parts to a fully developed performance measure:

• Numerator statement: The numerator includes the number of patients meeting the numerator criteria (Example: Number of patients in a physician’s practice that received the influenza vaccine).
• Denominator statement: The denominator includes the number of patients meeting the criteria for numerator inclusion (Example: Number of patients in a physician’s practice that meet the guidelines to receive the influenza vaccine).
• Denominator exclusions: There are valid reasons patients need to/should be subtracted from the denominator. Patients may be excluded from the denominator of an individual measure for:
  • Medical reasons/contraindications (Example: Patients that are allergic to eggs and therefore should not receive the influenza vaccine).
  • Patient reasons (Example: Patients who refuse the influenza vaccine).
  • System reasons (Example: There is a shortage of the influenza vaccine and it is not available).

These exceptions need to be identified in the medical record.

The method of calculation for performance follows these steps:

• Identify the patients who meet the eligibility criteria for the denominator
• Identify which of those patients meet the numerator criteria
• For those patients who do not meet the numerator criteria, determine whether an appropriate exclusion applies and subtract those patients from the denominator

There are several organizations that have been involved in developing or approving evidence-based performance measures:

• National Committee for Quality Assurance
• Agency for Healthcare Research and Quality (AHRQ) 
• CMS Quality Payment Program resource library
• The Joint Commission
• PubMED Search: View a list of articles linking Quality Improvement and CME (PDF)