appropriate interventions to be tested for improvement.
to improving patient care.
from published literature.
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).
a rule, there should already be an evidence based or consensus driven set of
processes that will support the team’s effort to improve a clinical outcome, as
opposed to the project being established to identify and/or prove that a new treatment
or therapy is better than the current standard care.
should address one or more of the following Institute of Medicine (IOM dimensions of quality patient care: safety, effectiveness, efficiency,
equity, timeliness, patient-centeredness.
2. 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. For the CUSOM MOC Program, no
commercial support is permitted for any component of a project.
3. Include plans for appropriate and repetitive
data collection and reporting of data to support assessment of the impact of
a. Use of relevant outcome, process,
and/or balancing measures to effectively assess the impact of interventions and potential
b. Sufficient sample size to minimize
the impact of random variability and permit reasonable decision-making regarding subsequent project steps.
c. Timely feedback reports to allow for
frequent, rapid improvement cycles.
d. Use of appropriate charting or
reporting tools to document performance over time (e.g., annotated run charts,
control charts, etc.).
4. Identify participating physicians.
a. Identify project leads and assign
additional requirements (e.g., project application, participation confirmation,
report submissions, etc.).
b. Requirements for MOC Part IV credit may
vary by specialty and should be taken into consideration for group or
departmental QI efforts.
c. Consider whether the QI project should benefit the
physician’s patients and be related to the physician’s clinical practice (Circumstances where this is not the case should be reviewed in advance with the CUSOM MOC Program manager).