- Data may be collected and reported as often as necessary, but we will expect that a project should be eligible for approval after at least 6 months of sequential rapid cycles of improvement and data collection. Shorter cycles (e.g., kaizen event or 1-2 months) are advisable to support rapid improvements in care. The use of one-time, pre- and post-data collection does not meet criteria for approval and is not consistent with quality improvement principles of sequentially testing multiple interventions to improve care.
- Projects must use demonstrated quality improvement methodologies including, but not limited to:
- LEAN
- Six Sigma (DMAIC)
- Continuous Quality Improvement (CQI)
- Total Quality Management (TQM)
- Model for Improvement (PDSA/PDCA)
- Projects must have at least two linked cycles of improvement (e.g., Plan-Do-Study-Act). Following baseline data, an improvement cycle should address the identified problem, general goals/aims within a measurable time frame for achievement, the main underlying root causes of the problem, interventions or countermeasures to address causes and operational plans to implement the interventions.
- Projects must address care physicians can influence in one or more of the Institute of Medicine (IOM) dimensions of quality patient care: safety, effectiveness, efficiency, equity, timeliness or patient-centeredness. The project must 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 or systems-based practice.
- Projects must have a clear aim statement describing how much improvement is expected and by when.
- Project interventions should be directly linked to project aims. Improvement changes must include a process change in addition to any educational interventions. Education-only interventions will not meet approval criteria.
- Projects should include plans for appropriate and repetitive data collection and reporting of data to support the assessment of the impact of interventions. There must be:
- Sufficient sample size to minimize the impact of random variability and permit reasonable decision-making regarding subsequent project steps.
- Use of relevant outcome, process, and/or balancing measures to effectively assess the impact of interventions and potential unintended consequences (see criterion #8).
- Use of appropriate charting or reporting tools to document performance over time (e.g., annotated run charts, control charts, etc.). A visual representation of data including three data points (e.g., baseline, post-intervention 1, post-intervention 2) is required for approval.
- Projects must use one or more of the following quality measures where applicable:
- 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).
- 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).
- Balancing Measures – Evaluation of new problems that may occur as a result of the intervention (e.g., % of patients with hypoglycemia complications).
- The team should possess sufficient and appropriate resources to support the successful planning, implementation, and sustainable conclusion of the project without the need for 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. Funding from industry may support implementations of a QI initiative that has been developed by the Sponsor Organization (CUSOM) independent of industry input.
- Each physician seeking MOC Part IV credit (including project leaders) must complete the Physician Attestation Form to ensure their level of involvement meets the criteria for meaningful participation.
The MOC Quality Projects Review Board (QPRB) will review applications to determine if the project has been carried out with appropriate quality improvement methods and expected engagement of participating physicians. The QPRB meets monthly to review projects and will respond to applicants within 1-2 weeks after review. The MOC Part IV point designation is decided by the specialty boards, please view each board's credit designation definition (these are subject to change). It is important to note that a single project may not fulfill a diplomates' entire Part IV requirements.
MOC Part IV Credit Application forms must be submitted by September 30th of the current year to be counted for credit in the same year. Please note, some specialty boards (e.g., ABIM) do not accept projects older than the current calendar year. If you have questions, you may contact the MOC Program Manager. You may also visit our program website for more background on MOC, sample applications, project examples, approved project listings and program information.
