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					                               General Information
AMA Definition of CME
CME consists of educational activities which serve to maintain, develop, or increase the
knowledge, skills, and professional performance and relationships that a physician uses to
provide services for patients, the public or the profession. The content of CME is the body of
knowledge and skills generally recognized and accepted by the profession as within the basic
medical sciences, the discipline of clinical medicine, and the provision of health care to the
public [AMA House of Delegates policy #300.988].

Physician’s Recognition Award of the AMA
The American Medical Association (AMA) Physician’s Recognition Award (PRA) has
recognized physician participation in continuing medical education (CME) for more than 35
years. Established in 1968, the AMA PRA certificate and the related AMA PRA credit
system recognize physicians who, by participating in CME activities, have demonstrated their
commitment to staying current with advances in medicine. AMA PRA credit offers a system
to measure and track physician participation in certified CME activities. AMA PRA credit is
recognized and accepted by hospital credentialing bodies, state medical licensure boards and
medical specialty certifying boards.

For further information regarding the AMA/PRA, visit the http://www.ama-assn.org
website.

Categories of CME Credit
There are two categories of Continuing Medical Education (CME) credit outlined by the
AMA.

Category 1: To be designated for AMA PRA Category 1 Credit, educational activities must
be planned by an accredited provider. Providers must assure that their activities:

   Conform to the AMA definition of CME.
   Present content appropriate in depth and scope for a physician audience.
   Conform to both the relevant CEJA opinions, as well as the ACCME Standards for
    Commercial Support, and are non promotional in nature.
   Address demonstrated educational needs.
   Communicate a clearly identified educational purpose and/or objectives.
   Use learning methodologies and format(s) appropriate to the activity’s educational
    purpose and/or objectives.
   Use evaluation mechanisms to assess an activity’s quality and relevance to its purpose
    and/or objectives.
   Include a means for the provider to record the actual credits claimed by each physician
    participant (physicians are ethically obligated to only claim credit consistent with the
    extent of their participation in a CME activity).
   Are designated for AMA PRA Category 1 Credit in advance; activities cannot be
    retroactively designated for Category 1 credit.



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   Include the Designation Statement in any activity materials that reference CME, with the
    exception of “save the date” or similar notices.

Accredited providers may designate the following types of activities for AMA PRA Category
1 Credit. All activities must comply with the AMA PRA Category 1 Credit requirements
detailed previously.

       Live activities
       Enduring materials
       Journal-based CME
       New procedures
       Test item writing
       Manuscript review (for journals)
       Performance improvement
       Internet point of care learning
       Other activities

Assigning Credit for Learner Participation in Live Activities
   Sixty minutes of physician participation (i.e., formal interaction between faculty and the
    physician audience) in a certified live activity equals one (1) AMA PRA Category 1
    Credit.
   Activities may be designated for, and credit awarded to physicians in, 15 minute or 0.25
    credit increments; in both cases providers or physicians may round to the nearest quarter
    hour.
   Simultaneous certified sessions within a live activity can only be counted once toward the
    designated maximum.
   If sections of a designated activity do not fit the AMA definition of CME, and are non
    promotional, then these sections must be clearly identified in the activity materials and
    excluded from the designated maximum amount of credit.

Providers may also award AMA PRA Category 1 Credit to their faculty for teaching at the
provider’s designated live activities. This credit acknowledges the learning associated with
the preparation for an original presentation.

Assigning Credit for Teaching at Category 1 Live Activities
   Faculty may be awarded two (2) AMA PRA Category 1 Credits for each hour they present
    at a live activity designated for such credit.
   Faculty may not claim simultaneous credit as physician learners for sessions at which they
    present; however, they may claim participant credit for other sessions they attend as
    learners at a designated live activity.
   Credit may only be claimed once for repeated presentations.

Category 2: AMA PRA Category 2 Credit is defined as all educational activities not
designated for Category 1 that: comply with the AMA definition of CME; comply with the
AMA ethical opinions on Gifts to Physicians from Industry and on Ethical Issues in CME
(i.e., are not promotional); and a physician finds to be a worthwhile learning experience
related to his/her practice. Accredited providers do not designate activities for AMA PRA
Category 2 Credit.

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Physicians may claim AMA PRA Category 2 Credit for such learning activities as: teaching
residents, medical students or other health professionals; unstructured online searching and
learning (i.e., not Internet PoC); reading authoritative medical literature; or participating in
live activities not designated for AMA PRA Category 1 Credit. Other examples include:

      Consultation with peers and medical experts
      Small group discussions
      Self assessment activities
      Medical writing
      Preceptorships
      Research

In each case, the physician individually determines the educational value of those AMA PRA
Category 2 activities in which he or she participates.

In addition:
     Providers should be aware of those activities that are available to physicians on a
        direct credit basis; i.e., providers do not designate them for credit, physicians claim the
        credit directly from the AMA.
     Accredited providers do not designate activities for AMA PRA Category 2 Credit™ .

Documentation: self documented; physicians should self claim credit for appropriate AMA
PRA Category 2 activities on their AMA PRA certificate application form.

Credit assignment: as with live activities, physicians may self claim one (1) AMA PRA
Category 2 Credit for each 60-minute hour engaged in the learning activity. Physicians may
claim credit in 15 minute, or 0.25 credit increments, and round to the nearest quarter hour.




Note: For additional information as it relates to the AMA PRA go to www.ama-
assn.org.


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                              Accreditation Process
Initial Application
If your CME program is an intra-state program, you may apply for accreditation from the
Missouri State Medical Association, 113 Madison Street, P.O. Box 1028, Jefferson City,
Missouri 65102. Telephone (573) 636-5151. The initial applicant will complete and submit a
pre-application to determine accreditation eligibility. Once eligibility has been determined
the provider will proceed with the application process.
It will take considerable time and thought to complete the application; it should be a joint
effort of the individuals involved in planning and administering the CME activities.
Please Note: Initial applicants are required to participate in two joint sponsorships prior to
submitting an application for accreditation.
If your CME program is interstate (a program where more than 30% of the registrants are
from beyond bordering states), you should apply for accreditation directly from the
Accreditation Council for Continuing Medical Education, 515 N. State Street, Suite 1801,
Chicago, IL 60654, (312)527-9200.

Review of Initial Application
Completed applications are carefully reviewed by the MSMA staff to ensure that all required
information was submitted and to determine whether the CME program is sufficiently
developed to merit a site survey. The application, with any staff comments, is then forwarded
to members of the Missouri State Medical Association’s Commission on Continuing
Education.
If this review indicates that additional data is needed or that the applicant needs more time to
properly meet standards, further processing will be delayed. During the first stage of
application, it is the policy of the Commission on Continuing Education to help applicants
bring their programs up to standards through informal written critiques and personal visits.

Formal Survey
When the Commission has determined that the CME program is ready for a formal survey,
the applicant is notified well in advance. The survey team will consist of an MSMA
Commission member and a staff member from the MSMA. The team will meet live or via
telephone with the CME coordinator and a physician member of the hospital’s CME
Committee to discuss the application in detail and review the educational records.

If a facility is applying for initial accreditation, the survey team will also observe a CME
activity planned by the facility the day of the formal survey or shortly thereafter.

Following the formal survey, the survey team will make a recommendation to the
Commission on Continuing Education. The Commission will vote on the recommendation
and forward it to the MSMA Council.

Decision Outcomes
The following decisions can be made by the Commission:



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Provisional – 2 years                             C with at least C1 – C3, C7 – C12
Accreditation – 4 years                           C with C1 – C15
Accreditation with Commendation – 6 years         C with C1 – C22
Accreditation with a progress report – 4 years    transition underway but NC in 1 or more
                                                  Criterion
Probation – No more than – 4 years with no        egregious; system failure; failure to transition
more than 2 years of probation
Non Accreditation from Initial                    NC with C1 – C3 or C7 – C12

    Provisional Accreditation: This type of accreditation is used only for new applications
    from institutions and organizations that meet the Essentials. Provisional accreditation is
    granted for a one- or two-year period.
    Restrictions: Provisionally accredited institutions may NOT jointly sponsor CME
    activities with non-accredited entities.
    Accreditation: This type of accreditation is granted to institutions/organizations that are
    already accredited or have provisional or probationary accreditation, and for which there
    is evidence that they fully meet the Essentials. Full accreditation is granted for a four-year
    or six-year period.
    Probationary Accreditation: This type of accreditation is granted to an accredited
    institution or organization that has a deficiency or deficiencies of sufficient degree that
    accreditation in accordance with the Essentials is jeopardized. During the probationary
    period, the accredited institution/organization shall take the necessary steps to correct the
    identified deficiency or deficiencies via a progress report and/or focused or full survey.
    Probationary accreditation is granted for a two-year period.
    Restrictions: Institutions under probationary accreditation may NOT jointly sponsor with
    non-accredited entities. Upon the first re-survey, provisional accredited institutions must
    be given full accreditation or non-accreditation. They may NOT be placed on probation.
 Non-Accreditation: This action applies in cases where the applicant has been unable to
  comply with the Essentials, for whatever reason. The institution/ organization will be
  provided with the reasons for the non-accreditation and will be apprised of appeal
  procedures.

Notification and Public Recognition
A certificate of accreditation shall be provided to an institution or organization that is granted
accreditation. The certificate shall specify the years for which accreditation is granted.

The accredited organizations are authorized to plan and designate CME programs as meeting
the criteria for category 1 of the Physician’s Recognition Award (PRA) of the AMA.

The provider may publicize its accreditation status.

Re-Accreditation Procedures
The same general policies and survey procedures will apply to organizations that have been
accredited. During re-surveys, team members will examine educational progress since the
last survey and efforts made to correct any previously noted problems.



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MSMA’s Process of Accreditation:

       Data Collection           Data Review & Analysis   Decision      Notification

               Pre-application
               and Initial
               Application or                         Commission on
               Reaccreditation          Survey         Continuing            Provider
 Program       Application              Team            Education
               Site Survey                                            (Within four weeks)
               Monitoring




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                            Accreditation Overview
Purpose
The major purposes of accreditation are to ensure quality and integrity of accredited providers
by:
  Establishing criteria for evaluation of educational programs and their activities,
  Assessing whether accredited organizations meet and maintain standards,
  Promoting organizational self-assessment and improvement, and
  Recognizing excellence.

Definition
Accreditation is official recognition by the Missouri State Medical Association or the
Accreditation Council for Continuing Medical Education that an institution’s overall program
of physician CME meets established criteria for educational planning and quality.

The ACCME
The Accreditation Council for Continuing Medical Education is composed of representatives
from the following organizations: American Hospital Association; American Medical
Association; Council of Medical Specialty Societies; American Board of Medical Specialties;
Federation of State Medical Boards of the U.S., Inc.; Association of American Medical
Colleges; and the Association for Hospital Medical Education.

The ACCME:
 Sets and administers standards and criteria for providers of quality CME for physicians
  and related professionals,
 Certifies that accredited providers are capable of meeting the requirements of the
  Essential Areas,
 Relates CME to medical care and the continuum of medical education,
 Evaluates the effectiveness of its policies,
 Assists providers in continually improving their programs, and thereby
 Assures physicians, the public, and the CME community that CME programs meet the
  ACCME’s criteria for compliance with the Essential Areas.

The MSMA:
The Missouri State Medical Association is recognized by the ACCME Committee on Review
and Recognition (CRR) as the Missouri accreditor of intra-state CME sponsors.
In accordance with ACCME criteria, MSMA’s Commission on Continuing Education:
   Sets Missouri standards and guidelines for the accreditation of CME sponsors.
   Accredits institutions providing state or locally promoted CME activities.

Purpose of the MSMA Accreditation Program
National trends indicate that physicians are most interested in practice-based, patient-related
continuing medical education activities. CME activities developed by institutions in the local
community can effectively assist in fulfilling these needs.



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The MSMA Accreditation Program was initiated in 1976 to:
 Assist institutions in developing high quality CME programs,
 Increase physicians’ access to quality practice-based CME in the local community; and
 Identify and accredit Missouri entities whose overall CME programs substantially meet or
  exceed the accreditation standards of the Missouri State Medical Association. These
  standards are called the “Essentials and Guidelines for the Accreditation of CME
  Sponsors.”

Who/What is Accredited?
The MSMA does not accredit individual CME activities, but does accredit institutions or
organizations based on their implemented overall program of CME. The overall program
consists, at least in part, of one or more educational activities that have been developed in
accordance with the Essential Areas and policies and are available for review by MSMA.

Benefits of Accreditation

To the CME Process
 Provides uniform criteria for assessment of CME programs.
 Legitimizes CME as an integral aspect of the medical profession.
 Enhances respect for life-long learning.
 Increases the quantity of experienced CME providers.
 Combats inappropriate marketing conducted under the guise of CME.

To the CME Participant
 Enhances program relevance.
 Increases quality CME opportunities locally, thus reducing travel costs and time away
  from the medical practice.
 Enhances physician performance in the optimum care and management of patients.

To the Accredited Provider
 Enhances CME program credibility.
 Distinguishes the institution as a quality CME provider.
 Improves program attendance.
 Provides formal evaluation of the CME effort.
 Provides consultation with accreditation experts.
 Legitimizes support and funding requests.
 Improves planning, delivery, and evaluation of the CME program.




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Costs of Accreditation
To obtain information on current fees, contact the MSMA, 113 Madison Street, P.O. Box
1028, Jefferson City, Missouri 65102, (573) 636-5151, www.msma.org.
The Commission, however, may evaluate an institution’s accreditation status before its
designated date for re-survey if information indicates that the institution has undergone
substantial changes or may no longer be in compliance with the Essentials.
This information about status changes may come from the MSMA’s CME Commission, the
institution itself, or outside sources. In such cases, additional non-standard re-survey fees
may apply.




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                   Eligibility for MSMA Accreditation
Eligible Institutions and Entities
Institutions and organizations located in Missouri and developing and/or presenting a program
of CME for physicians on a regular and recurring basis will be considered for eligibility to
apply for accreditation by the MSMA. An organization is not eligible to apply for
accreditation if, in the judgement of the MSMA, its program is devoted to advocacy on
unscientific modalities of diagnosis or therapy. The MSMA reserves the right to make
decisions on eligibility for accreditation based on information provided in the pre-application.
The MSMA is the body that accredits the following institutions for the provisions of CME
(when and if they choose to seek accreditation):
     Community hospitals,
     County medical societies,
     State or local specialty societies,
     Voluntary health organizations,
     State agencies, and
     Other entities which sponsor CME activities on a regular or recurring basis.

Advocation of Unscientific Modalities of Treatment
An institution is not eligible for CME accreditation by the Missouri State Medical Association
if its program is devoted to unscientific modalities of diagnosis or treatment.
Unscientific modalities are defined as methods of diagnosis or treatment, which are not
subject for instruction in most medical school programs accredited by the Liaison Committee
on Medical Education.

Eligibility Criteria
To be eligible for accreditation by the Missouri State Medical Association, institutions must
meet the following criteria:
       - At least 70 % of the registrants must be from Missouri or surrounding states.
       - Be located within the state of Missouri.
       - Demonstrate an overall organizational commitment to the continuing medical
           education program, including budget support, staffing, and record-keeping
           resources.
       - Demonstrate the capacity to substantially comply with the MSMA Essentials and
           Guidelines for the Accreditation of CME sponsors as outlined in this publication.
           This must be accomplished through doing a jointly sponsored CME program with
           an accredited provider.
       - Offer a formal, planned program of continuing medical education that includes
           fifteen or more organized educational offerings per year.

Separate Departments of Units within an Institution
Since eligibility for accreditation requires full institutional commitment to the CME program,
individual departments or units within a hospital or institution should seek internal support for
accreditation of the institution as a whole.




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      Additional Responsibilities of Accredited Providers
MSMA Annual Reporting
All accredited institutions must submit an annual report for their CME program. Reporting
will be completed on the ACCME’s website by the end of March.

Institutions that do not submit the annual report by the deadline will be mailed a letter of
notification stating: 1) the institution’s accreditation status will be re-evaluated if the report is
not received within two weeks, and 2) the institution will be assessed a $200 late fee.

If no response is received within the two week timeframe, the Commission will have the
discretion to place the institution on probation or suspend the institution from providing AMA
PRA Category I CME. If the institution is suspended from accrediting CME activities, it may
be required to submit a new application for accreditation.

If after reviewing an annual report, the Commission decides the information provided in the
annual report warrants additional scrutiny a site visit may be scheduled. The decision to
schedule a site survey will be based upon such factors as the provider’s past stability,
accreditation history, review recommendations, and information received during follow-up on
the annual report.

If a site survey is warranted, the institution will be responsible for reimbursement of travel
expenses incurred by members of the site survey team.

Provider Maintenance Fee
All MSMA accredited providers will receive an invoice for an annual maintenance fee
annually. The maintenance fee will be due by March 31st .

Provider Marketing Pieces
The following accreditation statements must appear on all announcements, brochures, and
fliers:

Accreditation Statement for Directly Sponsored Activities and Co-sponsored
The accreditation statement identifies which MSMA accredited organization is responsible for
demonstrating the CME activity’s compliance with all MSMA Essential Areas and Elements
(including the Standards for Commercial Support) and Accreditation Policies. The
accreditation statement must appear on all CME activity materials and brochures distributed
by accredited organizations, except that the accreditation statement does not need to be
included on initial, save-the-date type activity announcements. Such announcements contain
only general, preliminary information about the activity like the date, location, and title. If
more specific information is included, like faculty and objectives, the accreditation statement
must be included.




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The MSMA accreditation statement is as follows:
For directly sponsored activities: “The (name of accredited provider) is accredited by the
Missouri State Medical Association to provide continuing medical education for physicians.”
For jointly sponsored activities: “This activity has been planned and implemented in
accordance with the Essential Areas and policies of the Missouri State Medical Association
through the joint sponsorship of (name of accredited provider) and (name of non-accredited
provider). The (name of accredited provider) is accredited by the MSMA to provide
continuing medical education for physicians.”
There is no "co-sponsorship" accreditation statement. If two or more accredited providers are
working in collaboration on a CME activity, one provider must take responsibility for the
compliance of that activity. Co-sponsored CME activities should use the directly sponsored
activity statement, naming the one accredited provider that is responsible for the activity.
MSMA has no policy regarding specific ways in which providers may acknowledge the
involvement of other MSMA accredited providers in their CME activities.
Designation Statement
Example 1
The [name of accredited provider] designates this educational activity for a maximum of
[number of credits] AMA PRA Category 1 Credit(s)™. Physicians should only claim credit
commensurate with the extent of their participation in the activity.
Example 2
The [name of accredited provider] designates this educational activity for a maximum of
[number of credits] “AMA PRA Category 1 Credit(s)™.” Physicians should only claim
credit commensurate with the extent of their participation in the activity.
Example 3
The [name of accredited provider] designates this educational activity for a maximum of
[number of credits] AMA PRA Category 1 Credit(s)™. Physicians should only claim
credit commensurate with the extent of their participation in the activity.
Example 4
The [name of accredited provider] designates this educational activity for a maximum of
[number of credits] AMA PRA Category 1 Credit(s)™ . Physicians should only claim credit
commensurate with the extent of their participation in the activity.


         If the entire credit designation statement is in italics, or if the software does not allow
for italics, the credit phrase (AMA PRA Category 1 Credit ™) must otherwise be set-off from
the paragraph, such as by the use of bolding or quotation marks. More information regarding
the AMA credit designation statement and its proper use may be found on page 13 of the
AMA PRA booklet, available as a PDF online at www.ama-assn.org/go/prabooklet.

Activity Announcements
Activity announcements describe all materials (such as brochures), in both print and
electronic formats, that are designed to build awareness of the activity among the target
physician audience. These should feature an activity’s educational content, with advertising
for unrelated amenities playing a secondary role. Any announcement, if it references the



                                                                          CME Overview - Page 12
maximum number of credits for which the provider has designated the activity, must clearly
include the complete Designation Statement exactly as it is stated above.

A “save the date” announcement (such as a card mailer with limited space) may indicate that
AMA PRA Category 1 Credit will be provided without stating an exact amount, but only if
the provider has already certified the activity for AMA PRA Category 1 Credit. This
announcement may read, “This activity has been approved for AMA PRA Category 1 Credit.”

Providers may never publish or announce that “AMA PRA credit has been applied for.”

Records of Attendance
The provider must have a mechanism to record physician participation at CME activities.
Records of attendance should be maintained for a minimum of six years and made available
upon request of an attendee.

Activity Files
An accredited provider is required to retain activity files/records during the current
accreditation or for the last twelve months, whichever is longer.




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CME Certificates
AMA PRA category 1 certificates for physicians should read:

The [name of accredited provider] certifies that [name of physician] has participated in the
educational activity titled [title of activity] at [location, when applicable] on [date] and is
awarded [number of credits] AMA PRA Category 1 Credit(s)™ .

Attendance certificates for non-physician participants should read:

The (name of accredited provider) certifies that (name of the participant) has participated in
the educational activity titled (title of activity) at (location, when applicable) on (date). The
activity was designated for (number of credits) AMA PRA category 1 credit(s)™ .

Maintaining CME Committee Minutes
CME committee meeting minutes are the most important CME records an institution can
maintain. The primary objectives are to show that the committee:
    Has appropriate control and oversight of the overall CME program.
    Assesses and reviews CME needs.
    Assures that activities and their objectives are appropriate in context of the CME
     mission, needs assessment data, and the target audience.
    Assures that activities are appropriately designed and meet the Essentials.
    Reviews and utilizes evaluation data.
    Annually evaluates the accomplishment of the CME mission.

Minutes should fully reflect meeting attendance and discussions relative to CME planning,
implementation and review, not just motions and resulting action.

When needs are identified through medical audit, committee minutes should reflect the receipt
and use of this information, but should not compromise confidentiality or legal defense with
specific details or cases.




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