To be approved for credit for MOC Part 4, the application must include and describe the following:
☐ Target population.
☐ Desired numerical goal.
☐ Measures, collected over time, preferably nationally endorsed (process/outcome/balancing).
☐ At least one balancing measure, to indicate unintended consequences of changes.
☐ Comparison of performance to benchmarks, when available.
☐ Goal for each measure.
☐ Sampling strategy and appropriate sample size.
☐ Systematic implementation of changes (interventions).
☐ Data collection and reporting strategy that describes the regular reporting of project-wide and physician- or practice/unit-level data to all participants.
☐ Use of data for improvement; must include analysis of measures over time to track performance and test for effects of changes.
☐ Clear measure definitions and adequate data validation.
☐ Training and educational resources on QI methods to develop physician’s competency.
☐ Participation completion requirements/Criteria for meaningful participation in the project that defines the length of participation, number of data cycles, and number of meetings that must be attended in order to earn for MOC Part 4 points.
For MOC purposes, any physician participating in the project must, at a minimum:
Be intellectually engaged in planning and executing the project.
Implement the project's intervention (the changes designed to improve care).
Review data in keeping with the project's measurement plan.
Collaborate actively by attending team meetings
☐ Organizational structure that describes the framework of the QI project, including the use of Local Leaders for multi-site collaboratives and/or project planning group and oversight group roles/responsibilities.
☐ Physician Project Leader whom attests to participant and/or Local Leader participation
☐ Financial resources and staff to support the project.
☐ Specified start and end date.
☐ Documented policies and procedures for management and administration of project.
☐ System to track physician participation for purposes of approving attestations for MOC credit.
☐ Process for collecting, reviewing, and signing Attestation Forms, and resolving disputes.
☐ System to maintain up-to-date documentation and retain the documentation for 7 years after the project’s completion, including project results; methods; participation monitoring/completion data tracking; and local leader acknowledgement forms, if applicable.
Project must be HIPAA compliant.