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).
The physician is actively involved in the QI
effort, including participation in a minimum
of 3 of the 4 activities:
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
physician is actively involved in the implementation of strategies and
physician is actively involved in the data collection and/or analysis to assess
the impact of the interventions, making appropriate course corrections in 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.
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.
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.