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Performance Improvement Continuing Medical Education (PI CME)

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This webpage is intended to provide physicians, accredited CME providers and others with information about the Performance Improvement Continuing Medical Education (PI CME) learning format. If you have additional questions after reading this information, you are encouraged to contact [email protected].

What is PI CME?

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 develops a long-term, 3-stage process during 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.

History and Background

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 3 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.

AMA Format Specific Requirements

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

  • Meet all AMA core requirements for certifying an activity. The core requirements (that must be met for every activity certified for AMA PRA Category 1 Credit™) can be found on page 4 of the AMA PRA booklet (PDF).
  • Have an oversight mechanism that assures content integrity of the selected performance measures. These measures must be evidence based and well designed (e.g., clearly specify required data elements, ensure that data collection is feasible).
  • Provide clear instructions to the physicians that define the educational process of the PI CME activity (documentation requirements, timelines, etc.).
  • Provide adequate background information so that physicians can identify and understand the performance measures that will guide their PI CME activity, and the evidence base behind those measures.
  • Validate the depth of physician participation by a review of submitted PI CME activity documentation.
  • Consist of the following 3 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. Participating physicians must be actively involved in the analysis of the collected data to determine the causes of variations from any desired performance and identify appropriate intervention(s) to address these.

    Stage B: Learning from the Application of PI to Patient Care
    Implement the intervention(s) based on the results of the analysis in Stage A, 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) in Stage B, by comparing to the assessment done in Stage A and using the same performance measures. Summarize any practice, process and/or outcome changes that resulted from conducting the PI CME activity.

Designating and Awarding Credit for Participation in a PI CME Activity

  • Accredited CME providers should designate each PI CME activity for 20 AMA PRA Category 1 Credits™.
  • Physicians that complete only Stage A or stages A and B should be awarded 5 AMA PRA Category 1 Credits™ for each stage that was completed. Completion of the full PI CME activity should be encouraged.
  • Physicians completing, in sequence, all 3 stages (A-C) of a structured PI CME activity should be awarded 20 AMA PRA Category 1 Credits™. This acknowledges that the best learning is associated with completing the entire 3-stage PI CME activity.

FAQ Specific to PI CME

View frequent CME provider questions specific to PI CME (PDF).

AMA PI CME Activities

The AMA currently has 2 active PI CME activities for which the AMA is the accredited CME provider:

Search for Courses and Events

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.

Performance Measures

PI CME activities certified for AMA PRA Category 1 Credit™ must include the use of one or more evidence-based performance measures.

Definition of a Performance Measure

There are 2 commonly used definitions of a clinical performance measure:

  • A mechanism that enables the user to quantify the quality of a selected aspect of care by comparing it to a criterion (Institute of Medicine, 2000)
  • A mechanism to measure the degree to which a provider competently and safely delivers clinical services that are appropriate for the patient in the optimal time period (National Quality Measures Clearinghouse)

Types of Performance Measures

There are 3 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.

Performance Measure Levels

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

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

Performance Measure Composition

There are typically 3 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.

How to Calculate Measure Performance

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

Performance Measures

There are several organizations that have been involved in developing or approving evidence-based performance measures. Visit these websites to see what may be available:


View a list of articles (PDF) linking Quality Improvement and Continuing Medical Education from a PubMed search on Aug. 25, 2014.

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