Maintenance of Certification Portfolio Approval Program
Program
CUSOM Maintenance of Certification Part IV Credit Quality Improvement Project:
MOC Part IV Credit Application Form
Project Approval Criteria:
1.
Approval for MOC Part IV credit is usually granted at the conclusion of the project.
However, this application can be used for following scenarios:
a. Pre-Approval (for beginning stage projects)
b. MOC Part IV Credit Approval (for completed projects)
For long-term projects, please contact the CUSOM MOC Program manager to determine if
a project is eligible for MOC Part IV credit before the conclusion of the project. For
projects already completed, they are eligible for CUSOM MOCPAP review if there was
project activity in 2012 or later.
2.
Data may be collected and reported as often as necessary, but we will expect
that projects should be eligible for approval after ≥ 6 months of sequential rapid
cycles of improvement and data collection. Shorter cycles that can be days/weeks to
a month or two generally are advisable to enable and support rapid improvements in
care. The use of one-time pre-and post-data collection does not meet the
standards for MOCPAP approval and is not consistent with quality improvement
principles of sequentially testing multiple interventions to improve care.
3.
The team should possess sufficient and appropriate resources to support the successful
planning, implementation, and sustainable conclusion of the project without needing external
funding that could create a conflict of interest. To the extent that resources are needed they
should be identified within the department or hospital division’s budgets. According to our
national standards, funding from industry may be used to support implementation of a QI
initiative that has been developed by the Sponsor Organization (CUSOM) independent of
industry input. In instances where industry support (e.g., marketing, publicity, IT support, etc.)
has been used by the Sponsor Organization (CUSOM) to support the delivery of a project, the
organization must provide a statement on any materials that are used in association with or to
promote the activity that clearly delineates what specifically has been supported and clearly
states that no support has been provided for the development of content.
4.
The project must address an area of high importance to patient care based upon:
a. Evidence from published literature.
b. Use of systemic analysis of systems or processes of care (e.g., a process map or
root cause analysis to identify interventions, a logic diagram or key driver diagram
to explain rationale for change).
5.
Have a specific, measurable, relevant, and time-appropriate aim for improvement.
6.
Include plans for appropriate and repetitive data collection and reporting of data to
support assessment of the impact of interventions. There must be:
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a. Sufficient sample size to minimize the impact of random variability and permit
reasonable decision-making regarding subsequent project steps.
b. Use of relevant outcome, process, and/or balancing measures to effectively
assess the impact of interventions and potential unintended consequences (see
criterion #7).
c. Use of appropriate charting or reporting tools to document performance
over time (e.g., annotated run charts, control charts, etc.).
7.
The project should address care the physician can influence in one or more of the Institute of
Medicine (IOM) dimensions of quality patient care: safety, effectiveness, efficiency,
equity, timeliness, patient-centeredness. The project should also address one or more of the
ACGME/ABMS competencies: communication/interpersonal skills, medical knowledge,
patient care & procedural skills, professionalism, practice based-learning and improvement,
systems-based practice.
8.
Use of any or all of the following quality measures where applicable:
a. Outcome Measures - Evaluation of the results of an activity, plan, process or
program and their comparison with the intended or projected results (e.g., % of
diabetics with hemoglobin A1c less than 7mg/dl).
b. Process Measures – Evaluation of the performance of a process. Measuring the
results of process changes will indicate if care is improving (e.g., % of diabetics who
have hemoglobin A1c measured).
c. Balancing Measures – Evaluation of new problems that may occur as a result of
the intervention (e.g., % of patients with hypoglycemia complications).
9.
QI efforts should be sustained, involving no fewer than two linked cycles of
improvement efforts (e.g., Plan, Do, Study, Act (PDSA) cycles). Following baseline data,
an improvement cycle should address the identified problem, general goals/aims within a
measurable timeframe for achievement, the main underlying root causes of the problem,
interventions or countermeasures to address causes, and operational plans to implement
the interventions.
a. The first improvement cycle should consist of:
i. Appropriate data collection relevant to the identified problem.
ii. Analysis and review of data to identify underlying cause(s) of problem.
iii. Intervention likely to help address underlying cause(s) and improve system
performance.
b. Subsequent cycles should consist of:
i. Post-intervention data collection to assess impact of intervention.
ii. Adjustment(s) / second intervention(s) to address underlying cause(s).
iii. Post-adjustment data collection to assess impact of intervention.
10. Must implement standardized processes to ensure the sustainability of the improvement
and outcomes.
The CUSOM MOC Quality Projects Review Board will review the documentation in applications to
determine that the project has been carried out with appropriate QI methods and expected
engagement of participating physicians. The QPRB review process will take approximately 2-4 weeks.
MOC IV Credit Application forms must be submitted by November 1st of the current year in order
for us to review your project and report the awarding of credit to your ABMS specialty board for the
current calendar year.
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MOC Part IV Credit Application:
The Project Leader(s) must complete the information below to submit their QI project for MOC Part IV
credit. Only one application form per project is necessary, despite the number of participating
physicians. This form may be submitted at any time during the project, though we highly
recommend seeking pre-approval to ensure the project is carried out with appropriate methodology
for approval.
Questions and/or completed forms should be sent to the CUSOM MOC Program Manager at
heather.hallman@ucdenver.edu.
Submission Date:
I am using this application form to request:
Pre-approval of my project design [Complete sections I – IV only]
MOC Part IV Credit for a completed project [Complete full application]
Title of QI Project:
I. PROJECT PERSONNEL
A. QI Project Lead(s):
Name:
Academic Title:
Department/Clinic:
Address:
Phone:
Email:
Name:
Academic Title:
Department/Clinic:
Address:
Phone:
Email:
B. What is the approximate number of physicians who have participated or who are
anticipated to participate in this quality improvement effort?
1 – 10
11 – 50
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100+
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C. Participating physicians are affiliated with the CU School of Medicine through:
Children’s Hospital Colorado
University of Colorado Hospital
Clinical (Volunteer) Faculty
Veteran’s Affairs Hospital
Denver Health Medical Center
Non-CUSOM Affiliated Participant
D. Please list the specific facility/location(s) of the quality improvement effort.
E. Please provide the numbers, as available, of health care team members who did/will
participate in this quality improvement effort (e.g., PA’s, Nurses, Residents, MA’s).
F. Is this project associated with any of the following CU School of Medicine programs?
Institute for Healthcare Quality, Safety & Efficiency (IHQSE) Certificate Training Program (CTP)
UCH Clinical Effectiveness and Patient Safety (CEPS) Small Grants Program
CHCO Clinical and Operational Effectiveness and Patient Safety (COEPS) Small Grants Program
N/A
II. PROJECT DESCRIPTION
A. Duration of Project:
Project Status:
Not yet started
Completed
Ongoing
Project Start Date (or anticipated):
Project End Date (if complete, or anticipated):
B. Funding Resources: [Check all that apply]
Internal sources, please list:
External sources (i.e. grant, national funding), please list:
Other, please explain (if no funding, select this option):
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C. What is the identified problem(s) in quality that resulted in the development of this
quality improvement effort?
D. What is the project aim(s) regarding the problem in quality? Please note, an aim should
address how much improvement will occur and by when. The response should indicate a
measurable goal within an identified timeframe.
E. Is the project associated with any larger UCH or CHCO initiatives or national initiatives?
No
Yes, please explain:
F. What patient population does this project address? What is the approximate sample size?
G. Which of the Institute of Medicine (IOM) Quality Dimension(s) of Patient Care is/are
addressed in this quality improvement effort? [Check all that apply, must check at least one]
Safety
Equity
Timeliness
Effectiveness
Efficiency
Patient-Centeredness
H. Which of the ACGME/ABMS competencies is/are addressed in this quality improvement
effort? [Check all that apply, must check at least one]
Medical Knowledge
Patient Care
Systems-Based Practice
Professionalism
Practice-Based Learning
Communication/Interpersonal Skills
I. Please list any additional relevant topics for this quality improvement effort. [Check all
that apply]
Access to Care
Communication
Compliance
Documentation
Immunizations
Length of Stay
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Cost of Care
Prescriptions
Preventative Care
Re-admissions
Reduction of Harm
Satisfaction
Teamwork
Transitions of Care
Waste Reduction
J. Please list the ABMS medical specialties addressed as part of this quality improvement
effort. [Check all that apply]
Allergy & Immunology
Obstetrics & Gynecology
Plastic Surgery
Anesthesiology
Orthopaedic Surgery
Preventative Medicine
Dermatology
Otolaryngology
Psychiatry & Neurology
Emergency Medicine
Ophthalmology
Radiology
Family Medicine
Pathology
Surgery
Internal Medicine
Pediatrics
Thoracic Surgery
Medical Genetics
Physical Medicine & Rehab
Urology
III. PROJECT MEASURES AND DATA
A. Identification of Primary Underlying Cause(s):
1. What were/are the primary underlying cause(s) for the problem(s) that the project
addresses? Causes may be communications or behaviors of people, processes, information
infrastructure, equipment, environment, etc. List each primary cause separately. These may be
shown here or refer to attachment.
B. Performance Objectives:
1. What was/is the overall performance level(s) at baseline? These may be displayed in a data
table, bar graph, run chart, or other method; these may be shown here or refer to attachment.
2. What were/are the targets for performance and the timeframe for achieving the targets?
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3. How were the performance targets determined (e.g. regional or national benchmarks)?
Please list the benchmark sources; internally developed benchmarks are acceptable.
C. Performance Measures:
1. Please list the quality measures used in this effort? It is desirable, though not required, to
have at least one outcome, process and balancing measure. See MOC Part IV Project Approval
Criteria (item 8) for a description of quality measures.
Measure Title
Measure Type
Measure Source
Numerator
Denominator
(e.g., Outcome,
Process, Balancing)
(e.g., Internally
developed, JCAHO, AMA,
NCQA, Choosing Wisely)
(e.g., Pts. with
documented screening)
(e.g., Pts. seen in
last 12 months)
2. What was/is the source of data for the measures (e.g., medical records, billings, patient
surveys)? What methods were/will be used to collect the data (e.g., abstraction, data
analysis)?
3. How were/will data analyzed over time (e.g., simple comparison of means, statistical tests)
and how frequently (e.g., weekly, monthly, quarterly)?
IV. PROJECT IMPROVEMENT CYCLES
A. Select the methodology that most closely represents the methodology being used in this
quality improvement effort:
Continuous Quality Improvement (CQI)
IHI Collaborative Model
LEAN
Model for Improvement (PDSA/PDCA)
Six Sigma (DMAIC)
Total Quality Mngmt.
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B. Select the type of intervention(s) and/or tools that were/will be used by participants in
this quality improvement effort. [Check all that apply]
Education
Reminders
(daily, weekly, etc.)
Use of a Checklist
Use of a Registry
Survey
Other
New Clinic
If other, please explain:
C. Please describe how each intervention is expected to impact patient care and/or
physician practice?
D. Please describe the improvement cycles (noting the dates for each cycle), including how
the intervention(s) addresses the identified underlying cause(s), who was involved in the
intervention(s), overall performance level(s) after the intervention(s), any new underlying
causes identified through this process and/or any new targets or countermeasures for
performance.
For projects not yet started, please note your plans for the intervention(s). Please limit
responses to 600 – 800 words, excluding tables or graphs. These can be displayed in a data table, bar
graph, run chart, or other method; these may be shown here or refer to attachment.
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V. OUTCOMES
A. Project Impact:
1. Please describe the overall outcome of the quality improvement project, including data
that demonstrate the impact of the project. These may be shown here or refer to attachment.
2. What standardized processes will be implemented to maintain improvements that
resulted from this project?
B. Lessons Learned:
1. What barriers were observed in this effort and how were they resolved?
2. In future improvement cycles, do you intend to make any changes to avoid pitfalls?
VI. REFLECTION STATEMENTS
Each physician involved in the project must submit a Physician Attestation Form at the completion of
the project. This form will include a description of the QI project detailing how it is directly related to
the physician’s practice, and a reflection statement describing the change that was performed in
his/her practice affecting the way care is delivered.
The Project lead(s) will receive all Physician Attestation forms and review the reflection statements of
participating physicians. It is the Project lead’s responsibility to ensure each participating physician
has met the criteria for meaningful participation (see Meaningful Participation Criteria for full details).
Project Lead Signature:
Date:
Project Lead Signature:
Date:
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