Process, Standards & Guidelines

Qualifying QI Initiatives

Project Leads are responsible for ensuring the project meets the following standards to be eligible for MOC Part 4 credit for all participants. The MOC Program can provide assistance to physicians during the project development phase to help ensure the project will meet the criteria.

Qualifying projects are those that:

• Have leadership and management at the initiative level that will ensure adherence to the participation criteria
• Address care the physician can influence in one or more of the six Institute of Medicine quality dimensions (safety, effectiveness, timeliness, equity, efficiency and/or patient-centeredness) and one or more of the ACGME/ABMS competencies (Practice-based Learning and Improvement; Patient Care and Procedural Skills; Systems-based Practice; Medical Knowledge; Interpersonal and Communication Skills; and Professionalism)
• Have specific, measurable, relevant and time-appropriate aims for improvement
• Use appropriate, relevant and evidence-based (when available) performance measures that include measurement at the appropriate unit of analysis (physician, clinic, care team, etc.); use national measures when available
• Use a recognized, valid, established quality or performance improvement methodology
• Include appropriate prospective and repetitive data collection and reporting of performance data so that participants access, reflect on and act upon the data at least three times (including at baseline and at the conclusion of the activity) during the course of their meaningful participation in a quality initiative designated for MOC Part 4
• Implement an improvement into routine care, or disseminate or spread and sustain an existing improvement into practice
• Possess sufficient and appropriate resources to develop, support and conclude the activity without real or perceived conflict of interest (industry funding)

Meaningful Participation

In order to be eligible for MOC Part 4 credit, the physician’s participation must be meaningful. Physician participation in an approved quality improvement effort is considered meaningful when:

• The activities within initiatives are directly related to the physician’s clinical practice or organizational/leadership role in improving care.
• The physician is actively involved throughout the entire specified activity in order to understand and experience basic QI/PI principles. Involvement MAY include at least one of the following:
  • Provision of direct patient care as an individual or a member of the care team
  • Being involved from the conceptualization, design, implementation, overall assessment/evaluation and evolution of the QI/PI initiative
  • Supervised residents or fellows throughout the entire initiative as noted in the Standards and Guidelines for MOC Qualifying Initiatives
• The physician is able to verify and will attest that they have participated throughout the entire specified QI/PI initiative, met with others involved in the improvement activities, reviewed their performance data, helped develop and/or implement changes to the activities and personally reflected on the impact of the initiative on their practice or organizational role. Reflection on further improvements, barriers to improvement and sustaining achieved improvement is strongly encouraged.