Skip to main content
Sign In

Maintenance of Certification Portfolio Approval Program

Project Approval Criteria


MOC Part IV Credit – Project Approval Criteria

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 participating physicians.
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, this application can be used for following scenarios:
a.    Pre-Approval (for beginning stage projects)
b.    MOC Part IV Credit Approval (for completed projects)
For long-term projects, please contact the CUSOM MOC Program manager to 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.
3.      The 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, funding from industry may be used to support implementation of a QI initiative that has been developed by the Sponsor Organization (CUSOM) independent of industry input. In instances where industry support (e.g., marketing, publicity, IT support, etc.) has been used by the Sponsor Organization (CUSOM) to support the delivery of a project, the organization must provide a statement on any materials that are used in association with or to promote the activity that clearly delineates what specifically has been supported and clearly states that no support has been provided for the development of content.
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:
a.    Sufficient 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 criterion #7).
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 Institute of Medicine (IOM) dimensions of quality patient care: safety, effectiveness, efficiency, equity, timeliness, patient-centeredness.  The project should 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, systems-based practice.
8.      Use of any or all of the following quality measures where applicable:
a.    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).
b.    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).
c.    Balancing 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 interventions.
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.
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 participating physicians.  The QPRB review process will take approximately 2-4 weeks. MOC IV Credit Application forms must be submitted by October 31st 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.  
Some projects and some forms of patient data use may require Colorado Multiple Institutional Review Board (COMIRB) review, or at CHCO review by the Organizational Research Risk and Quality Improvement Review Panel (ORRQIRP) for approval. Based on the department within the hospital, the UCH Clinical Excellence and Patient Safety (CEPS) Department or the CHCO Quality and Patient Safety (QPS) Department may need to be involved in the project.
For any questions/comments, please contact the CUSOM MOC Program manager at