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Maintenance of Certification Portfolio Approval Program

Meaningful Participation Criteria

MOC Part IV Credit – Physician Attestation to Meaningful Participation  

MOC Part IV QI projects can be done by individuals, a group of individuals, or department. There is no limit to the number of physicians that may participate in the QI effort.  All physicians seeking MOC Part IV credit must complete the Physician Attestation Form.  The purpose of the attestation is to show the physician has met the criteria for “meaningful participation”.  Attestations may be submitted at the time of project review, or anytime after project approval if the QI effort is ongoing.
The CUSOM MOC Program has defined the criteria for “meaningful participation” with the below requirements.   
1.    The QI effort must provide clear benefit to the physician’s patients and/or be directly related to the physician’s clinical practice (for leaders in non-caregiving roles). 
2.    The physician is actively involved in the QI effort, including participation in a minimum of 3 of the 4 activities:
a.     The physician is actively involved in the initial project design, including but not limited to identifying the gap in quality, development of primary outcome measures and target improvement, and development of plans for intervention. 
b.    The physician is actively involved in the implementation of strategies and interventions.
c.     The physician is actively involved in the data collection and/or analysis to assess the impact of the interventions, making appropriate course corrections in the improvement effort. 
d.    The physician actively participates in meetings to continue the process for improvement. Documentation of meeting attendance must be available upon request; meeting minutes are encouraged, but not required. 
3.    At a minimum, the activities must be of sufficient duration to allow for physician participation in at least two full cycles of data assessment and planning of an improvement intervention, the implementation of a change process and re-assessment of the results (e.g., PDSA cycle) for at least six months duration.
4.    The physician is able to personally reflect on the activity, describing the change that was performed in their practice and how it affected the way care is delivered.
The timely submission of attestation forms is essential for physicians whose certification period will end in the year that the project ends.  Attestation forms must be submitted to the CUSOM MOC Program by December 5th in order for us to report credit to your ABMS specialty board and have your credit count for that year.  
For any questions/comments, please contact the CUSOM MOC Program manager at