UCSF
MOC PartIV
IV: Project Design Charter
MOC
Part
SECTION A: Quality Improvement Project Description
1.
Project Title:
2.
Submission Date:
3.
Department/Division(s):
4.
QI Project Leader(s) (up to two)
Name (First, Last, Middle Initial)
Email
Phone #
Name (First, Last, Middle Initial)
Email
Phone #
5.
Estimated Start date of the QI effort (mm/dd/yyyy):
6.
Estimated End date of data collection for the quality improvement effort (mm/dd/yyyy):
(If the project has no end date, please indicate ‘continuous’ for the date above)
7.
Estimated date when first two quality improvement cycles will be complete (one cycle includes collection and
review of baseline data, an intervention, re-measurement, and reflection on impact):
1st Cycle Begin Date (mm/dd/yyyy):
2nd Cycle Begin Date (mm/dd/yyyy):
8.
What is the approximate number of physicians who have participated or who are anticipated to participate in
this quality improvement effort? (Please check one box below)
1-10
9.
1st Cycle End Date (mm/dd/yyyy):
2nd Cycle End Date (mm/dd/yyyy):
11-50
51-100
101-1000
Over 1000
What relationship(s) do participants of this MOC IV QI activity have with UCSF?
Physicians employed or contracted by the organization (e.g., Moffit-Long, LPPI, Mount Zion, Mission Bay,
or SFGH)
Physicians in the organization's health system or network (e.g., Children’s Hospital Oakland, Family
Medicine Center at Lakeshore, or VA medical center)
Physicians affiliated with the organization (e.g., Private Practice Group that supervises UCSF students/
house staff)
If affiliated, please describe the affiliation:
FORM VERSION 6.9 – 12.09.14
1
UCSF
MOC PartIV
IV: Project Design Charter
MOC
Part
10.
What is/are the location(s)/setting(s) for this activity? (i.e., inpatient ward at Moffitt; outpatients clinic at SFGH,
etc.)
LPPI
Moffit-Long
Mount Zion
VA
SFGH
Children’s Hospital Oakland
Mission Bay
Community Practice with Volunteer Clinical Faculty
Physicians in the organization's health system or network (i.e., Oakland Childrens’ employee)
Other – Please describe:
11.
Select one or more relevant topics for this quality improvement effort:
Access to care
Efficiency
Patient Safety
Asthma
Hand hygiene
Prescriptions
Cancer
Health Literacy
Preventive care
Cardiovascular
HIV
Readmissions
CLABSI
Hypertension
Satisfaction
Communication
Immunizations/Vaccinations
Sepsis
Compliance
Length of stay
Surgical site infections
Diabetes
Medical home
Teamwork
Documentation
Obesity
Transitions of care
Other – Please describe:
12.
Select Medical specialties addressed as part of this quality improvement effort:
Allergy and Immunology
Obstetrics and Gynecology
Preventive Medicine
Anesthesiology
Orthopaedic Surgery
Psychiatry and Neurology
Dermatology
Otolaryngology
Radiology
Emergency Medicine
Ophthalmology
Surgery
Family Medicine
Pathology
Thoracic Surgery
Internal Medicine
Pediatrics
Other – Describe:
Medical Genetics
Physical Medicine and Rehabilitation
FORM VERSION 6.9 – 12.09.14
2
UCSF
MOC PartIV
IV: Project Design Charter
MOC
Part
13.
How is the quality improvement effort funded?
Internal
Non-commercial grant
Pharma or device funding (UCSF does NOT provide MOC IV credit for commercially funded activities)
Other – Please describe:
14.
What is the specific aim of the quality improvement effort? Note: An aim answers the questions how much
improvement and by when. The response should indicate a measurable goal within an identified timeframe.
15.
Briefly describe the quality improvement effort. Include the identified problem that resulted in the development
of this project. Note: This description may be displayed on the Boards' websites and/or or the Portfolio Program
site. This response should be different from the aim provided above.
16.
What is the specific patient population for this quality improvement effort?
17.
Select one or more IOM Quality Dimensions addressed as part of this quality improvement effort:
Effectiveness
Efficiency
Equity
Patient-Centeredness
Safety
Timeliness
18.
Indicate how results are captured and displayed over time.
Annotated Run Chart
Other – Please describe format(s) and provide your reason(s):
FORM VERSION 6.9 – 12.09.14
3
UCSF
MOC PartIV
IV: Project Design Charter
MOC
Part
SECTION B: Quality Measures (If you have more than one measure, complete the following for each measure.)
1.
Measure Name:
2.
Measure Type:
3.
Calculation (Indicate the denominator and numerator for the measure):
4.
Exclusions (What data, if any, are excluded from the calculation?):
5.
Data Source (Note – If patient surveys are used, they must be provided to the ABMS for approval. Please attach
any patient surveys to this application.):
Outcome
Chart review
Electronic Health Record
Process
Balancing
Nationally Endorsed?
Yes
No
Prospective at point of care
Patient Survey (Please attach to application)
6.
Has pre-intervention data been collected to inform this initiative? What does this baseline data show?
7.
What is the performance goal or target? Is this based on any standard benchmark? If so, please describe.
If additional measures are being tracked, please provide the information for each additional measure. Measure
questions above can be copied and pasted here:
FORM VERSION 6.9 – 12.09.14
4
UCSF
MOC PartIV
IV: Project Design Charter
MOC
Part
SECTION C: Meaningful Physician Participation Requirements
IMPORTANT: Each physician who wishes to claim credit must submit a Physician Attestation Form. That form will
require a description of the physician’s involvement in the QI project, and a reflection statement of the impact of the
QI Project on their practice.
For physicians to claim credit, they must participate meaningfully in the project by involvement with at least 2
quality improvement cycles and active participation in 2 of the following 4 standards.
a) Project Design: The physician is actively involved in the initial project design, including but not limited
to identifying the gap in quality, development of primary outcome measures and target improvement,
and development of plans for intervention.
b) Implementation of Interventions: The physician is actively involved in the implementation of strategies
and interventions.
c) Data collection: The physician is actively involved in the data collection
d) Intervention Analysis: The physician actively participates in the problem analysis / development of
interventions and compares post-intervention results to pre-intervention results.
The physician needs to participate in at least 2 cycles of implementation of interventions, data collection, or
intervention analysis.
As a Project Lead(s), I (we) will receive all Physician Attestation forms and review the reflection
statements of participating physicians. It is my (our) responsibility as a Projects leader to ensure that each
participant has met the criteria for meaningful participation.
Project Lead 1 Signature:
____________________________________
(Please note: Your initials can be used as an electronic signature.)
Date:
Project Lead 2 Signature: (Optional)
____________________________________
(Please note: Your initials can be used as an electronic signature.)
Date:
Submit completed Project Design Form to the UCSF MOC Project Manager
joey.bernal@ucsf.edu.
FORM VERSION 6.9 – 12.09.14
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