IMQ/CMA Continuing Medical Education
Accreditation Program
Application for CME Accreditation
Please refer to these resources when preparing your Application:
 IMQ Instructions for Preparing the Application for CME Program
Accreditation
 IMQ/CMA Accreditation Criteria and Policies for Continuing
Medical Education

IMQ/CMA and ACCME Notes for CME Accreditation
CME Accreditation Program of the
California Medical Association and the
Institute for Medical Quality
Institute for Medical Quality
180 Howard Street, Suite 210
San Francisco, CA 94105
415.882.5182
IMQ CME Accreditation Application
PROGRAM OVERVIEW
1. Briefly describe the history of your continuing medical education (CME) Program.
2. Describe the current leadership and organizational structure of your CME program and how
it fits within the overall structure of your organization. Describe the role of the physicians
and staff involved. For example do you have a CME coordinator, CME chair, and CME
committee? Are there other committees, departments, staff or organizations that
contribute to your CME program? If your organization is a health system, briefly describe
how each entity interfaces with the CME program. For example, are there other
committees, departments, staff or organizations that contribute to your CME program?
Please attach an organizational chart.
3. Do you conduct CME activities through joint providership (formerly known as joint
sponsorship)? Yes or No
If yes, briefly describe this component of your program.
4. Does your organization accept commercial support (financial or support-in-kind)? Yes or No
5. Check all of the ACCME Activity Types/AMA Formats used for your CME activities:
 Course/Live Activity
 RSS/Live (i.e. tumor board, case conferences, M &M, journal club etc)
 Internet Enduring Material
 Enduring Material (other)
 Internet Live Course/Live
 Internet Point of Care or Internet Searching & Learning
 Learning from Teaching/Teaching at a Live Activity/Teaching Medical Students and
Residents (Faculty Credit/Live)
 Performance Improvement CME (must also meet specific AMA requirements)
 Journal-based CME (Reminder: Not the same as Journal Club)
 Test Writing
 Manuscript review
 Other_____________________
Criterion 1: CME MISSION
6. Attach or insert your CME mission statement. Please highlight the Expected Results that
articulate the changes in physician competence, performance, or patient outcomes
intended for your CME program.
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Criteria 2-6: CME ACTIVITY PLANNING
The following questions are designed to gather information on the components of your
planning process that serve as a basis for a CME activity. Briefly describe:
7. How you identify the Professional Practice Gaps (PPGs) for your learners. Include in your
description the data sources and/or types information that used to identify PPGs. (C2)
8. How you incorporate into activities, the educational needs that underlie the PPGs of your
learners. Indicate if needs are related to lack of knowledge and/or competence and/or
performance. (C2)
9. How you design activities to change physician competence, and/or performance, and/or
patient outcomes. (e.g. learning objectives/expected results) (C3)
10. How you select educational format(s) that are appropriate to your setting and/or expected
results for an activity. (C5)
11. The desirable physician attributes/core competencies (e.g., ABMS/ACGME Competencies,
IOM Competencies) you consider when planning an activity. (C6)
Provide two examples from educational activities that demonstrate compliance with each of
the following. You may use a detailed planning form as documentation. (See IMQ Instructions
for Preparing the Application for CME Program Accreditation regarding selecting examples)
a. Professional practice gap(s) for your learners. Include data sources and/or types
information you used to determine the PPGs. (C2)
b. Educational need(s) underlying the PPGs. Indicate if the needs were related to
knowledge and/or competence and/or performance deficiencies. (C2)
c. Changes in physician competence and/or performance and/or in patient
outcomes expected from the activity. (e.g., learning objectives or expected
results). (C3)
d. Appropriate format for the setting and/or the expected results. (C5)
e. Relevant core competencies or desirable physician attributes. (C6)
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Criterion 7: Independence (SCS 1); Identification Relevant Financial
Relationships and Resolution of COI (SCS 2); Disclosure to Learners (SCS 6)
NOTE: You must respond to this section regardless of whether or not your organization accepts
commercial support.
12. Describe how your organization ensures independence from commercial interests in the
CME planning process, including the identification of needs; determination of educational
objectives; selection and presentation of content; selection of all persons and organizations
in a position to control the content; selection of educational methods; and evaluation of the
activity (SCS 1)
13. Describe the following:
a. how you collect information about financial relationships with commercial interests that
occurred in the past 12 months, covers spouse/partners and uses correct definition of
commercial interest (e.g. disclosure form) for everyone in a position to control educational
content, including faculty, planners, authors and reviewers. Include if your organization
disqualifies individuals who refuse to disclose. (SCS 2.1-2.2).
b. how you identify Relevant Financial Relationships (RFRs) from the collected disclosure
information.
14. Provide the mechanisms your organization uses to resolve Conflicts of Interest (COI) prior to
an activity. (e.g. your COI resolution process/policy) (SCS 2.3)
15. Describe how you disclose to learners prior to the activity any RFRs, and/or lack thereof, for
all persons in a position to control educational content. If applicable, describe how you
disclose to learners the source of any commercial support. (SCS: 6.1-6.5)
Provide two examples from educational activities that demonstrate compliance with each of
the following. (See IMQ Instructions for Preparing the Application for CME Program
Accreditation regarding selecting examples)
a. List of all CME planners, committee members, faculty, staff, reviewers, and others that are
in a position to influence CME content. (SCS 2.1)
b. Disclosure information/forms for all individuals on list. Disclosure information must
(1) identify financial relationships with commercial interests that occurred in the past 12
months, (2) include financial relationships of spouse/partners and (3) use correct definition
of commercial interest. Identify if anyone was disqualified for refusal to disclose. (SCS 2.2)
c. If a relationship was determined to be a relevant financial relationship (RFR), submit
documentation that you implemented a mechanism to resolve any Conflict of Interest (COI)
prior to the activity. State if you have only one or no examples of COI. (SCS 2.3)
d. Documentation of disclosure to learners made prior to the activity of the presence or
absence of relevant financial relationships for all who controlled content (SCS 6.1, 6.2, 6.5).
Documentation can include a copy of slide, handout, or verbal attestation.
e. If applicable, documentation of your disclosure to the learners of commercial support
including “in-kind” support. Disclosure of commercial support must not include corporate
logo, trade name or product group message (SCS 6.3-6.5)
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Criterion 8 (SCS 3): Management of Commercial Support
NOTE: You must respond to this question, regardless of whether or not your organization
accepts commercial support.
16. Attach your written policies and procedures for honoraria and reimbursement of out-ofpocket expenses for planners, teachers, and/or authors. The policy should state:
a. the amount or range of honoraria and what expense are reimbursable (SCS 3.7)
b. that payment is made directly by the provider or designated education partner and not
by the commercial interest. (SCS 3.8-3.9)
NOTE: If your organization accepts commercial support respond to Questions 17 – 19. If not,
skip to Question 20.
17. Attach one written letter of agreement signed by provider and commercial supporter prior
to the activity, documenting terms, conditions, and purposes of commercial support and
specify the source of commercial support. (SCS 3.4-3.6)
18. Provide one example detailing the receipt and expenditure of commercial support.
(SCS 3.13)
19. Describe your process to appropriately manage commercial support, including how:
a. You make all decisions regarding the disposition and disbursement of both funds and inkind commercial support. (SCS 3.1).
b. You do not accept advice or services as a condition of receiving support (SCS 3.2)
c. All commercial support is given with your organization’s full knowledge and approval
(SCS 3.3)
d. Describe what process you employ to ensure that commercial support payment is made
directly by the provider or designated education partner and not by commercial
interest. (SCS 3.8)
e. No other payment is given to the director of the activity, planning committee members,
teachers or authors, joint provider, or any others involved in the activity (SCS 3.9)
f. If teachers and authors are presenting and participants, their expenses can only be
reimbursed as presenters and not as learners (SCS 3.10)
g. Social events do not compete with or take precedence over educational activities.
(SCS 3.11)
h. Commercial support is not used to pay honoraria or expenses for participants who are
not teachers or authors. (SCS 3.12)
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Criterion 9 (SCS 4): Management of Commercial Promotion
NOTE: You must respond to this section whether or not your organization accepts commercial
support or arranges for commercial exhibits or promotion in your activities.
20. Describe that you do not use a commercial interest as the agent providing a CME activity to
learners, e.g., distributing self study CME activities or arranging for electronic access to CME
activities (SCS 4.5)
NOTE: If your organization organizes commercial exhibits or arranges for advertisements in
association with any of your CME activities respond to Questions 21 – 22. If not, state “No” and
skip to Question 23.
21. Describe how your organization ensures that arrangements for commercial exhibits or
advertisements do not (1) influence planning or interfere with the presentation and (2) are
not a condition of the provision of commercial support for CME activities. (SCS 4.1)
22. Describe how your organization ensures that advertisements or other product-promotion
are kept separate from the education. In your description, distinguish between your
processes related to advertisements and/or product promotion in each of the following
types of CME activities: (1) print materials, (2) computer-based materials, (3) audio and
video recordings, and (4) face-to-face. Describe how you ensure that CME educational
materials (e.g. slides, abstracts and handouts) do not contain advertising, corporate logo,
trade name or product group message of a commercial interest (SCS 4.2-4.4)
Criterion 10 (SCS 5): Clinical Content Validation Policy and Activities without Bias
23. Describe how your organization ensures the following:
a. Content of CME activities does not promote the proprietary interests of any
commercial interest (i.e. there is no commercial bias). (SCS 5.1)
b. CME activities give a balanced view of therapeutic options. (SCS 5.2)
c. Clinical content of CME activities is in compliance with the IMQ/CMA Clinical
Content Validation Policy (see the IMQ Accreditation Manual)
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Criteria 11-13: Collecting Data for Evaluation and Improvement
24. Describe the tools and processes you use to evaluate activities and collect data about
changes in learners’ competence and/or performance and/or patient outcomes. (C11)
Provide two examples from educational activities that demonstrate compliance with each of
the following. (See IMQ Instructions for Preparing the Application for CME Program
Accreditation regarding selecting examples)
a. Example or description of the activity evaluation tool/process that measures changes in
learners’ competence and/or performance and/or patient outcomes.
b. Collected data from the activity
25. Provide a review or analysis of the collected data from your activities and determine if there
were changes in learners’ competence, performance, or patient outcomes achieved as a
result of your overall program’s activities. Note: This analysis should be conducted
periodically, but no less than once per accreditation cycle. You may provide documentation
of an analysis of the data for each activity and/or you may aggregate data/analysis from
groups of similar activities. You must provide a conclusion if there were changes in learners’
competence, performance, or patient outcomes achieved as a result of your overall
program’s activities. (C11)
26. Conduct a program-based analysis by using conclusions from the analysis of the collected
activity data (C11) and other information to determine if you achieved the expected results
stated in your CME mission. Note: This is also an opportunity to address other factors such
as resources, staff training, technology support, venues, etc, that might contribute to the
success of or impede your CME program in achieving its overall mission. (C12)
27. Using the results of your program-based analysis (C12) and other information, list a
minimum of two examples of program improvements you identified, planned and
implemented to help you better meet the expected results component of your CME
mission. (C13)
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Cultural and Linguistic Competency (CLC) Policy (Assembly Bill 1195)
28. Describe how for each CME activity with a clinical care focus, you identify cultural or
linguistic health disparities relevant to the PPGs of the targeted physician learners and/or
their patient community. Describe that you document when no CLC disparity is identified.
Provide two examples from educational activities that demonstrate compliance with each
of the following. Documentation may be shown on a detailed planning form. (See IMQ
Instructions for Preparing the Application for CME Program Accreditation regarding
selecting examples)
Documentation from a clinically focused CME activity that planners proactively identified
relevant CLC disparities and generated an educational component. Note: A planner may
work collaboratively with the faculty or speaker to identify one or more CLC disparity.
IMQ/CMA Policies
29. Describe the mechanism your organization uses to record and verify physician participation
for six years from the date of your CME activities.
Include one example that demonstrates your practice to record and verify physician
participation.
30. Describe how your organization retains educational activity files in accordance with
IMQ/CMA Policies for your current accreditation term or for the last 12 months, or
whichever is longer.
31. Include one example of correct use of IMQ/CMA Accreditation Statement and AMA Credit
designation statement.
32. If applicable, and you conduct activity types other than courses/live activities,
describe how you comply with the AMA and ACCME special requirements for these
other activity types. Please see ACCME and AMA requirement Summary documents
on the IMQ CME Provider portal.
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OPTIONAL: Accreditation with Commendation (Criteria 16-22)
NOTE: If your organization is applying for Accreditation with Commendation (6 year term),
complete the following questions. Include at least two examples for each Commendation
Criteria. If not applying for commendation then you may skip this section.
33. Describe how your organization integrates CME into the process for improving professional
practice. Include at least two examples of organizational practices that have been
implemented. (C16)
34. Describe how your organization utilizes non-education strategies to enhance change as an
adjunct to its educational activities. Include in your description an explanation of how the
non education strategies were connected to either an individual activity or group of CME
activities. Include at least two examples of non-education strategies that have been
implemented. (C17)
35. Describe how your organization identifies factors outside of its control that will have an
impact on patient outcomes. Include at least two examples of identifying factors outside of
your organization’s control that will have an impact on patient outcomes. (C18)
36. Describe how your organization implements educational strategies to remove, overcome, or
address barriers to physician change. Include at least two examples of educational
strategies that have been implemented to remove, overcome, or address barriers to
physician change. (C19)
37. Describe how your organization engages in collaborative or cooperative relationships with
other stakeholders. Include at least two examples of collaboration and cooperation with
other stakeholders. (C20)
38. Describe how your CME unit participates within an institutional or system framework for
quality improvement. Include at least two examples of your CME unit participating within
an institutional or system framework for quality improvement. (C21)
39. Describe your procedures and/or practices that position your organization to influence the
scope and content of educational activities. Include at least two examples of how your
organization is positioned to influence the scope and content of your educational activities.
(C22)
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