OFFICE of
CONTINUING
MEDICAL EDUCATION
Certification Request
for Sponsorship of a CME
Performance Improvement
(PI) Activity and AMA PRA
Category 1 Credit(s)TM
Introduction
The Wake Forest School of Medicine is accredited by the Accreditation Council for Continuing Medical Education
(ACCME) to provide continuing medical education for physicians.
The ACCME requires that accredited Providers maintain high standards of quality and documentation in the
development and provision of continuing medical education (CME). This Certification Request is intended for faculty,
departments, and organizations developing PI CME activities who agree to support and abide by these standards.
The Office of Continuing Medical Education (OCME) is responsible for maintaining the CME accreditation granted to
Wake Forest University Health Sciences (WFUHS)/Wake Forest School of Medicine (WFSM). Activities for which CME
sponsorship or joint sponsorship is sought must be reviewed and approved by the institutional Continuing Medical
Education Committee. Appropriate CME credit is awarded if sponsorship/joint sponsorship is approved. Credit can be
withdrawn from previously certified activities if actions by the faculty, staff, planning committee members, or
teachers/authors threaten the accreditation of WFUHS/WFSM.
As set forth in the core mission statement of WFSM, the OCME is committed to providing superior, ethical, timely CME
to healthcare professionals, specifically physicians, thereby supporting them in constant self-evaluative improvement and
lifelong learning of biomedical knowledge and better enabling them to provide optimal, safe patient care leading to the
improved health and well-being of the general public. All certified CME activities must help fulfill this mission.
According to the AMA’s 2010 Physician’s Recognition Award & Credit System Booklet, “PI CME is a certified CME activity in
which an accredited CME provider structures a long-term three-stage process by which a physician or group of
physicians learn about specific performance measures, assess their practice using the selected performance measures,
implement interventions to improve performance related to these measures over a useful interval of time, and then
reassess 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 has defined the following stages that when integrated together develop a complete, structured PI CME activity:
 Stage A: Learning from current practice performance assessment:
Assess current practice using 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 will receive guidance on appropriate parameters for applying the intervention(s).
 Stage C: Learning from the evaluation of the PI CME effort:
Re-assess 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.
The Wake Forest School of Medicine designates this PI CME activity for a maximum of 20 AMA PRA Category 1 CreditsTM.
Physicians should claim only the credit commensurate with the extent of their participation in the activity. (Physicians
that complete only one or two stages will be awarded 5 AMA PRA Category 1 CreditsTM for each stage that was completed.
Completion of the full PI cycle is not required but encouraged. Physicians completing in sequence all three stages of a
structured PI CME activity will be awarded 20 AMA PRA Category 1 CreditsTM. This credit allocation acknowledges that
the best learning is associated with completing the entire three-stage PI CME activity.) Completion of this process meets
most board recertification requirements.
Instructions
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Contact/meet with an OCME Program Coordinator in order to plan the PI CME activity.
After the initial planning meeting, complete Stage A of the Certification Request and return it to the OCME with
the required supporting documentation and payment.
Complete Stage B and Stage C as appropriate and submit within two weeks of completion of that stage.
The cost is $1500 per Certification Request, which includes up to 10 hours of OCME staff support/technical
assistance and $10/credit.
Joint Sponsorship
For CME activities proposed by organizations outside WFUHS/WFSM:
 The proposed activity must be consistent with the overall CME mission and policies of WFUHS/WFSM and
follow all ACCME Essential Areas, Policies, and Updated Accreditation Criteria, including the 2004 ACCME
Standards for Commercial Support.
 A full time WFSM faculty member with expertise in the appropriate specialty as well as a member of the
OCME staff must participate in planning and executing the PI CME activity, which includes up to 10 hours of
technical assistance, e.g. activity design, documentation, etc.
 WFSM must be listed as a joint sponsor of the activity.
 All costs must be paid by the applicant/outside organization.
Tips for Success
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A successful project that results in lasting improvement requires teamwork. Involve clinical and
administrative employees.
The PI CME project will take an estimated 15 hours to complete over a period of months.
Start small. Choose an area of focus and one outcome to assess.
Use electronic health records, spreadsheets, and other database tools to collect and tabulate information.
Choose an initial sample size for the assessment and continue to add to the database over the course of the
project.
After the assessment, utilize best evidence from published trials to plan changes in practice. Quality indicators
should be evidence-based, measurable, and changeable. The best process to target is one that is easily changed
and has the greatest impact on patient care.
July 2006
Revised July 2007, June 2011, June 2012
Office of Continuing Medical Education
Certification Request for Sponsorship of a PI CME Activity and
AMA PRA Category 1 Credit(s)TM
Date Form Completed:
Name:
Degree/Credentials & Specialty:
□
□
Home
Office
Last 4 Digits of Social Security #:
Address:
Phone:
Fax:
E-Mail:
Application Fee Payment Options (due at the time of application submission and charged following review):
Mail in the form of a check or money order (payable to Wake Forest University Health Sciences)
Charge the following credit card:
MasterCard
Visa
American Express
Card #:
Expiration Date:
Name of Credit Card Holder:
Deduct from the following WFUHS Chartfield:
Complete Full Disclosure Statements and Resolution of Conflict Forms and return them with Stage A of the Certification Request
along with the required $1500 Certification Request fee.
Planning Committee Structure*:
In addition to the above individual, list all persons responsible for planning, designing, developing, and implementing this CME
activity. Include names, degrees, titles, and affiliations. No employee of a commercial interest may serve on the planning
committee nor be allowed to influence educational content (nuanced or direct). All decisions must be free of the control of
commercial interests including: (a.) identification of needs; (b.) the determination of educational objectives; (c.) the selection and
presentation of content; (d.) the selection of all persons and organizations in a position to control the content; (e.) the selection of
educational methods; and (f.) the evaluation of the activity. (Criterion 7 and the Standards for Commercial Support)
WFSM Faculty Member:
Name:
Name:
Name:
Name:
Title/Department:
Title/Affiliation:
Title/Affiliation:
Title/Affiliation:
Title/Affiliation:
Stage A:
1.
Describe the process that was used to assess your current practice. List identified performance measures and
describe your role in data collection.
2.
Describe the results and discuss the processes or practices that will be targeted for improvement. Describe why
each area for improvement is needed and what your role will be.
3.
Describe any assistance you are going to need in future stages of assessment.
July 2006
Revised July 2007, June 2011, June 2012
4.
A CME activity should be developed in the context of desirable physician attributes. (Criterion 6) Indicate which
of the Institute of Medicine (IOM), Accreditation Council for Graduate Medical Education (ACGME), and/or
American Board of Medical Specialties (ABMS) core competencies you will address (check all that apply).
Quality Improvement
Use of Informatics
Evidence and Practice-Based Learning & Improvement
Working in Interdisciplinary Teams
Patient-Centered Care
Interpersonal Communication Skills
Medical Knowledge
Professionalism
Systems-Based Practice
Stage B:

Describe the specific practice or processes that were undertaken or modified for the purpose of achieving the
improvements cited in Stage A. Explain any tracking tools that were used and attach any examples/copies of
clinical guidelines, policies, procedures, clinical tools, chart forms, or other supporting data.
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Describe the outcome/result.
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Discuss any obstacles encountered.
Stage C:
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Summarize any lessons learned. What practice changes will you make as a result of this PI CME activity?
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Describe any unexpected outcomes for your patients, your practice, or you.
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Do you expect any future obstacles?
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If you could begin this PI CME activity again, what changes would you make?
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What were your initial objectives for this process and did you achieve them?
By submitting this Certification Request, all involved parties understand that the proposed PI CME activity must be
consistent with the overall CME mission and policies of WFUHS/WFSM and follow all ACCME Essential Areas, Policies, and
Updated Accreditation Criteria, including the 2004 ACCME Standards for Commercial Support.
OFFICE USE ONLY
Date Received: ________
Date Reviewed: ________ OCME Program Coordinator: _________
Approval Date: ______________ Approved for _____AMA PRA Category 1 Credit(s)TM
Activity #: __________________________________________________
Disapproved (description): _________________________________________________________________________________