Form Instructions
The New QI Effort Notification form should be used by Portfolio Managers when a new quality
improvement effort has been determined to meet the standards and guidelines of the Portfolio
Program
One QI Effort Notification is equivalent to one approved QI effort by the Portfolio Sponsor.
Find help on completing this form by visiting www.mocportfolioprogram.org/mocamsubmitting-a-new-qi-effort-notification/
* Denotes a required field
* QI Effort Title:
* Organization Name:
Show in my Portfolio?
1. * Type of quality improvement effort:
2. * Status of the quality improvement effort at the time of submission:
Note: If the status of the quality improvement effort is "continuous," the start date and end
date are assumed to be equal to the approval period of the Portfolio Sponsor.
* Start Date:
* End Date:
3. * What is the approximate number of physicians who have participated or who
are anticipated to participate in this quality improvement effort?
4. * QI leader name:
* QI leader email:
QI leader phone number:
5. * Medical specialties addressed as part of this quality improvement effort:
Allergy and Immunology
Anesthesiology
Dermatology
Emergency Medicine
Family Medicine
Internal Medicine
Medical Genetics
Obstetrics and Gynecology
Otolaryngology
Pediatrics
Physical Medicine and Rehabilitation
Preventive Medicine
Psychiatry and Neurology
Surgery
Thoracic Surgery
Relevant Anesthesiology subspecialties:
All Anesthesiology Subspecialties
Critical Care Medicine
Hospice and Palliative Medicine
Relevant Dermatology subspecialties:
Pain Medicine
Pediatric Anesthesiology
Sleep Medicine
All Dermatology Subspecialties
Dermatopathology
Pediatric Dermatology
Relevant Emergency Medicine subspecialties:
All Emergency Medicine Subspecialties
Emergency Medical Services
Hospice and Palliative Medicine
Internal Medicine – Critical Care Medicine
Medical Toxicology
Pediatric Emergency Medicine
Sports Medicine
Undersea and Hyperbaric Medicine
Relevant Family Medicine subspecialties:
All Family Medicine Subspecialties
Adolescent Medicine
Geriatric Medicine
Hospice and Palliative Medicine
Sleep Medicine
Sports Medicine
Relevant Internal Medicine subspecialties:
All Internal Medicine Subspecialties
Adolescent Medicine
Adult Congenital Heart Disease
Advanced Heart Failure and Transplant
Cardiology
Cardiovascular Disease
Clinical Cardiac Electrophysiology
Critical Care Medicine
Endocrinology, Diabetes and Metabolism
Gastroenterology
Geriatric Medicine
Hematology
Hospice and Palliative Medicine
Infectious Disease
Interventional Cardiology
Medical Oncology
Nephrology
Pulmonary Disease
Rheumatology
Sleep Medicine
Sports Medicine
Transplant Hepatology
Relevant Medical Genetics subspecialties:
Clinical Biochemical Genetics
Clinical Cytogenetics
Clinical Genetics (MD)
Clinical Molecular Genetics
All Medical Genetics Subspecialties
Medical Genetics Subspecialties
Molecular Genetic Pathology
Relevant Obstetrics and Gynecology subspecialties:
All Obstetrics and Gynecology
Subspecialties
Critical Care Medicine
Female Pelvic Medicine and
Reconstructive Surgery
Gynecologic Oncology
Relevant Otolaryngology subspecialties:
Hospice and Palliative Medicine
Maternal and Fetal Medicine
Reproductive
Endocrinology/Infertility
All Otolaryngology Subspecialties
Neurotology
Pediatric Otolaryngology
Plastic Surgery Within the Head
and Neck
Sleep Medicine
Relevant Pediatric subspecialties:
All Pediatric Subspecialties
Adolescent Medicine
Child Abuse Pediatrics
Developmental-Behavioral Pediatrics
Hospice and Palliative Medicine
Medical Toxicology
Neonatal-Perinatal Medicine
Neurodevelopmental Disabilities
Pediatric Cardiology
Pediatric Critical Care Medicine
Pediatric Emergency Medicine
Pediatric Endocrinology
Pediatric Gastroenterology
Pediatric Hematology-Oncology
Pediatric Infectious Diseases
Pediatric Nephrology
Pediatric Pulmonology
Pediatric Rheumatology
Pediatric Transplant Hepatology
Sleep Medicine
Sports Medicine
Relevant Physical Medicine and Rehabilitation subspecialties:
All Physical Medicine and Rehabilitation
Subspecialties
Brain Injury Medicine
Hospice and Palliative Medicine
Neuromuscular Medicine
Pain Medicine
Pediatric Rehabilitation Medicine
Spinal Cord Injury Medicine
Sports Medicine
Relevant Preventive Medicine subspecialties:
All Preventive Medicine Subspecialties
Clinical Informatics
Medical Toxicology
Undersea and Hyperbaric Medicine
Relevant Psychiatry and Neurology subspecialties:
All Psychiatry and Neurology
Subspecialties
Addiction Psychiatry
Brain Injury Medicine
Child and Adolescent Psychiatry
Clinical Neurophysiology
Epilepsy
Forensic Psychiatry
Geriatric Psychiatry
Hospice and Palliative Medicine
Neurodevelopmental Disabilities
Neuromuscular Medicine
Pain Medicine
Psychosomatic Medicine
Sleep Medicine
Vascular Neurology
Relevant Surgical specialties and subspecialties:
General Surgery
Vascular Surgery
All Surgical Subspecialties
Complex General Surgical Oncology
Hospice and Palliative Medicine
Pediatric Surgery
Surgery of the Hand
Surgical Critical Care
Relevant Thoracic Surgery subspecialties:
All Thoracic Surgery Subspecialties
Congenital Cardiac Surgery
6. * How is the quality improvement effort funded?
Grant
Internal
Pharma or device funding (Describe the use:
)
Subscription
Other (Describe the source:
)
7. * What is the specific aim of the quality improvement effort?
Note: an aim answers questions about how good and by when? The response should indicate a
measurable goal.
8. * Participation in this quality improvement effort is limited to:
Physician members of the society/collaborative/association
Physicians employed or contracted by the organization
Physicians in the organization’s health system or network
Physicians affiliated with the organization (Define the affiliation:
)
9. * Briefly describe the quality improvement effort.
Note: The brief description may be displayed on the Boards’ websites and/or the Portfolio
Program site. This response should be different from the aim provided above.