MOC Part 4 Requirements

Maintenance of Certification Part 4 Requirements

APPENDIX B. American Board of Pediatrics Requirements for Maintenance of Certification (MOC)
Part 4 Portfolio Sponsor – American Academy of Pediatrics

The following project guidelines apply to projects with participating physicians who are board certified in General Pediatrics and/or in subspecialties certified by the American Board of Pediatrics:

Adolescent Med
Ped Emergency Med
Ped Infectious Dis
Ped Pulmonary Med
Ped CardiologyPed EndocrinologyMedical ToxicologyPed Rheumatology
Child Abuse PedsPed GastroenterologyNeo-Perinatal MedSleep Medicine
Ped Critical CarePed Hem/OncPed NephrologySports Med
Devel & Behav PedsHospice & Palliative MedNeurodevelopmental DisabilitiesTransplant Hepatology

MOC Portfolio LogoTo be approved for credit for MOC Part 4, a QI project must include the following components:

  • Impact on one or more of the Institute of Medicine quality dimensions: safety, effectiveness, timeliness, equity, efficiency, and patient-centeredness.

  • Use of accepted quality improvement methods, including:

    • Aim statement (target population, desired numerical improvement, timeframe)

    • Performance measures, collected over time, preferably nationally endorsed; if not, must have documentation of the evidence base, measure specifications, and development process

    • At least one balancing measure, to indicate unintended consequences of changes

    • Comparison of performance to benchmarks

    • Use of a systematic sampling strategy and appropriate sample size

    • Include a minimum of 10 data points in each cycle (projects with larger samples [eg, hand hygiene] should use larger sample sizes)

    • Systematic implementation of changes

    • Use of data for improvement; analysis of measures over time

    • At minimum, 1 baseline and 2 follow-up data cycles

    • Reporting data in graphical display over time

    • Monitoring data quality – clear measure definitions and adequate data validation

  • Regular reporting of project-wide and physician- or practice/unit-level data to all participants (typically, monthly) and executive leaders/sponsors and other key stakeholders (at least bi-annually and at project completion)

  • Development of physicians' demonstrated competency in quality improvement methods, by including training and educational resources on QI methods (e.g. seminars by QI experts, coaching by QI consultants, web-based curriculum)

  • A documented organizational structure including a project leader, who is responsible for adjudicating any disputes regarding participation and MOC credit and use of Local Leaders, for multi-site collaboratives. Also to include institutional governance, specified start date, appropriate staffing and financial support, documented policies and procedures for management of project, system to track physician participation, and HIPAA compliance.

  • A process for collecting, reviewing, and signing Attestation Forms, and resolving disputes

  • A system to maintain up-to-date documentation and retain the documentation for 7 years after the project's completion (to include project results; methods; participation monitoring, including completion data tracking; local leader acknowledgement forms if applicable)

  • Demonstrate improvements in care – score of at least 3.0 (modest process improvements) on the ABP's Improvement Progress Scale

Physician Meaningful Participation Requirements for QI projects approved for MOC Part 4 include:

  • Demonstrate/document active participation as determined by the project completion requirements (length of participation)

  • 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

  • Participate during current certificate period or MOC cycle

Project Leader responsibilities include:

  • Designing a project that addresses the above components for MOC Part 4

  • Determining if the project is research and obtaining appropriate IRB approval if it is

  • Completing and submitting an AAP MOC Application form to the Quality Cabinet (via MOC Manager)

  • Establishing a process to work with an associated AAP group to provide oversight to the project (eg, Section, QuIIN, QIDA, etc)

Once the project is approved:

  • Creating a system to track and monitor physician participation; monitoring physician participation to ensure the above standards are met

  • Providing feedback data reports to the physician participants on a regular basis

  • Collecting and retaining Local Leader Acknowledgement Forms if appropriate

  • Attesting for physician participants by signing their Attestation Forms; handling any disputes that arise in the attestation process

  • Sending physician completion data to the MOC Manager using the Completion Data Tracking spreadsheet

  • Completing reports associated with project approval including bi-annual reports that will be reviewed by the Quality Cabinet; a final report at the close of a project; and, if selected by the ABP for an annual review, an annual report.

  • Maintaining all project documentation for 7 years (including methods, results, participation, and leadership)

Affiliated AAP Group responsibilities include (eg, Section, QuIIN, QIDA, etc)

  • Ensuring projects follow ABP standards throughout the planning and project implementation period

  • Reviewing projects to determine the strength of QI (ie, Does the project know what they are trying to improve [QI aim statement], do the measures provide information to participants about whether or not they are seeing an improvement, and do the measures relate back to the QI aim)? Work with project leaders to develop sound QI protocols.

  • Serving as an appeal process for unresolved disputes with attestations.

  • Signing Project Leader attestation forms, to attest that they met the project leader requirements set forth by the ABP (ie, materially involved in the design and implementation of the project, involved for minimum of 12 months, understands principles of QI).

  • Note: AAP Groups do not need to conduct the projects, but must be meaningfully involved in the design and ongoing implementation/monitoring of the project.

A project meeting the above criteria may be eligible for, and may request inclusion in, AAP's MOC Project Portfolio by completing an AAP MOC Part 4 Application. Submit completed applications to Jill Healy, MS, Manager, Quality Improvement and Certification Initiatives at or fax 847/434-8000.

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