Physicians seeking MOC
Part IV credit for QI project involvement must complete the CUSOM MOC Part IV Credit Application Form. This
form requires a description of the QI effort detailing the performance measures
and objectives, improvement cycles and outcomes. The CUSOM MOC Quality Projects Review Board
will review the documentation in applications to determine that the project has
been carried out with appropriate QI methods and expected engagement of
The CUSOM MOC Program
has outlined the criteria for project approval with the below requirements:
1. Approval for MOC Part IV credit is
usually granted at the conclusion of the
project. However, the MOC Part IV Credit Application can be used for the following scenarios:
(for beginning stage projects)
Part IV Credit Approval (for completed projects)
Progress Report (for approved projects)
For long-term projects, please consult the CUSOM MOC Program
determine if a project is eligible for MOC Part IV credit before the conclusion
of the project. For projects already
completed, they are eligible for CUSOM MOCPAP review if there was project activity in 2012 or later.
2. Data may be collected and reported
as often as necessary, but we will expect that projects should be eligible
for approval after ≥ 6 months of
sequential rapid cycles of improvement and data collection. Shorter
cycles that can be days/weeks to a month or two generally are advisable to
enable and support rapid improvements in care. The use of one-time
pre-and post-data collection does not meet the standards for MOCPAP approval and
is not consistent with quality improvement principles of sequentially testing
multiple interventions to improve care.
team should possess sufficient and appropriate resources to support the
successful planning, implementation, and sustainable conclusion of the project
without needing 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. According
to our national standards, commercial support may not be used to support
honoraria for faculty or the expenses of faculty participating in the
development/delivery of the QI project.
Commercial support may be used to support the delivery of QI efforts
(e.g., marketing, publicity, IT support, etc.) by the Sponsor Organization
4. The project must address an area of
high importance to patient care based upon:
a. Evidence from published literature.
b. Use of systemic analysis of systems
or processes of care (e.g., a process map or root cause analysis to identify interventions,
a logic diagram or key driver diagram to explain rationale for change).
5. Have a specific, measurable, relevant, and time-appropriate aim for improvement.
6. Include plans for appropriate and
repetitive data collection and reporting of data to support assessment of the
impact of interventions. There must be:
sample size to
minimize the impact of random variability and permit reasonable decision-making
regarding subsequent project steps.
b. Use of relevant outcome, process, and/or balancing measures to effectively
assess the impact of interventions and potential unintended consequences (see
c. Use of appropriate charting or reporting tools to document performance over time (e.g., annotated run charts,
control charts, etc.).
7. The project should address care the physician can influence in one or
more of the following Institute of Medicine (IOM) dimensions of quality patient
care: safety, effectiveness, efficiency, equity, timeliness,
8. Use of any or all of the following quality 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
Measures – Evaluation
of new problems that may occur as a result of the intervention (e.g., % of
patients with hypoglycemia complications).
9. QI efforts should be sustained,
involving no fewer than two
linked cycles of improvement efforts (e.g., Plan, Do, Study, Act (PDSA)
cycles). Following baseline data, an improvement cycle should address the
identified problem, general goals/aims within a measurable timeframe for
achievement, the main underlying root causes of the problem, interventions or
countermeasures to address causes, and operational plans to implement the
a. The first improvement cycle should consist of:
i. Appropriate data collection relevant
to the identified problem.
ii. Analysis and review of data to
identify underlying cause(s) of problem.
iii. Intervention likely to help address
underlying cause(s) and improve system performance.
b. Subsequent cycles should consist of:
i. Post-intervention data collection to
assess impact of intervention.
ii. Adjustment(s) / second
intervention(s) to address underlying cause(s).
iii. Post-adjustment data collection to
assess impact of intervention.
10. Must implement standardized
processes to ensure the sustainability of the improvement and outcomes.
MOC IV Credit
Application forms must be submitted to
the CUSOM MOC Program by October 15th of the current year in order for us
to review your project and report the awarding of credit to your
ABMS specialty board for the current calendar year.