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
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
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
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
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.).
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
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
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:
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