Designating MOC for QI (ABMS Part IV, NCCPA PI-CME)

Processes involved in designating and receiving MOC (ABMS Part IV, NCCPA PI-CME) for participation in a QI project include:

1. Identifying a QI activity appropriate for MOC designation.
2. Outlining the QI activity to check eligibility for QI MOC and other planning related to the project:
     a. Concepts and vocabulary to describe QI activities
         (1) Structured problem solving - logic underlying a proposed initial cycle
         (2) Performance measurement and presentation
         (3) A timeline for the two linked cycles of improvement
    b. Preliminary worksheet outlining activities that will meet requirements
    c. Other issues
        (1) Enrolling participants who want their participation documented
        (2) Whether AMA PRA Category 1 credit™ is also sought for physicians who participate
        (3) Planning for presentation/publication of results
3. Submitting a report on the completed QI project for QI MOC to be approved.
4. Individual participants attesting to their participation on the QI project.

Each of these steps is described briefly below with links to relevant information and resources.

1. Identifying a QI activity appropriate for QI MOC designation.

Several factors should be considered in selecting a QI project to be designated for MOC. A list of factors is presented in SELECTING A QI PROJECT FOR QI MOC DESIGNATION (PDF). Some of the factors are highlighted below.

Participate in improving patient care. To qualify for QI MOC through the ABMS Multi-specialty Portfolio Program, participants must be engaged in a systematic effort of reviewing and improving some aspect(s) of care or care delivery for their patients.

Sustained QI cycles. The QI effort must be sustained, involving at least two or more linked cycles of performance review and improvement effort. The post-intervention data and review from one cycle become the baseline data and planning for the next cycle. Starting with a suspected or actual problem with care:

1st QI cycle Baseline data collection, analysis/review, identify underlying cause(s) Intervention(s) to address underlying cause(s)
Post-intervention data collection, analysis/review, identify remaining underlying cause(s)

2nd QI cycle Post-intervention data collection, analysis/review, identify underlying cause(s) (same as above) Adjustment(s) / second intervention(s) to address underlying cause(s) Post-adjustment data collection, analysis/review, identify remaining underlying cause(s)

Periodic opportunities. Physicians and physician assistants need QI MOC periodically, so clinical leaders should plan ahead for selecting QI projects for the additional documentation effort required for designating QI MOC.

2. Outlining the QI project to check eligibility for MOC and Other Planning Related to the Project.

The lead of the QI project should check with a member of the UMHS QI MOC Program staff regarding whether the design of a project is eligible for MOC and to address other planning issues. This discussion is greatly simplified by the project lead considering in advance:

    a. Concepts and vocabulary to describe QI activities
        (1) Structured problem solving - logic underlying a proposed initial cycle
        (2) Performance measurement and presentation
        (3) A timeline for the two linked cycles of improvement
    b. Preliminary worksheet outlining activities that will meet requirements
    c. Other issues
        (1) Enrolling individuals who want their participation documented
        (2) Whether AMA PRA Category 1 credit™ is also sought for physicians who participate
        (3) Planning for presentation/publication of results

Each of these activities is explained below.

a. Concepts and vocabulary to describe QI activities

     (1) Structured problem solving - logic underlying a proposed initial cycle.

Planning an improvement cycle involves identifying:

  • Problem to address
  • General goal and specific aim(s) (measurable and timeframe for achievement)
  • Main underlying (root) causes of the problem
  • Interventions (countermeasures) that address major causes
  • Operational plans to implement the interventions

A framework for describing these elements of a plan and their relationships is presented in the planning tool: STRUCTURED PROBLEM SOLVING LOGIC DIAGRAM FOR A PROPOSED IMPROVEMENT CYCLE (PDF).

Figure 1 illustrates the conceptual linkage for structured problem-solving.

Figure 2 presents an example of a completed logic diagram for the plan for the first cycle of an actual improvement project.

Table 1 presents for each logical step some questions to help think through the step and tools that may be useful in addressing it.

Figure 3 illustrates how the information is often formatted when the planning is more complex and therefore described in a more detailed A3 two-page proposal used in "Lean Thinking."

Describing the full logic for an improvement cycle typically occurs after the problem is identified and baseline data are collected. After baseline data are collected and discussed, the aims, underlying causes, interventions, and operational plans can be specified.

The report documenting required activities for QI MOC asks for a description of each of the elements illustrated in Figure 1. For projects with two linked cycles, the initial intervention will likely alter the underlying causes to be addressed in the second cycle. Therefore, the elements are described separately for the planning of each cycle. Three sequential plans for improvement will eventually be developed and described:

  • Plan for initial interventions developed from reviewing baseline data
  • Plan for adjustments (second interventions) developed from reviewing post-intervention data
  • Plan for further adjustments (third interventions) developed from reviewing post-adjustment data

Project leaders can use the figure as the basis for developing and updating plans at each stage. Although the description in the report will be in narrative text, project leaders can use the "Logic Diagram" planning tool to outline content, organize, and simplify writing the narrative description.

    (2) Performance measurement and presentation. Thinking through the logic underlying an improvement effort includes identifying a measure (or measures) that reflect relevant performance. Data to calculate the measure will be collected repeatedly over time to assess progress toward the goal. Three common types of measures and their calculations (numerator and denominator) are:

  • Percent - how frequently is a criterion met (yes or no) over the number of instances observed? For example, percent of diabetic patients with HbA1c measured. Calculation is: numerator = the number of instances where the criterion is met, denominator = the total number of instances.
  • Mean - what is the average level of occurrence? For example, the average waiting time for patients. Calculation is: numerator = the sum of value across instances, denominator = the number of instances.
  • Frequency - how often does something occur in a time period? For example, number of errors reported over a period of two weeks. Report descriptively: the number of instances (numerator) in the observation period (denominator).

In selecting measures, you need to:

  • Identify the population eligible for measurement. In most instances, the study population is the eligible population. However, a specific aspect of performance may apply only to a subpopulation.
  • Determine the measure(s) of performance. One performance measure is required (you may have more), but it must be assessed at least three time periods: baseline, post-intervention, and post-adjustment.
  • Determine how data for measures will be collected. Common ways to collect data include keeping a special record or┬átally of events, someone abstracting data from medical records, or a programmed report produced from electronic medical records. QI projects aligned with institutional efforts may have a higher priority among requests for institutional help with data collection.
  • Decide how to present results on measures of performance The ABMS Multi-specialty MOC Program requires that data be presented in graphic form, e.g., a table, bar graph, or run chart (line graph) that facilitates assessing change in performance over improvement cycles. Several EXAMPLES OF GRAPHIC PRESENTATIONS OF PERFORMANCE RESULTS illustrate possibilities.

Formal statistical analysis is not required. However, statistical tests of reliability can always be performed and are usually expected if results are to be shared widely or published.

The above considerations are elaborated in PERFORMANCE MEASUREMENT AND REPORTING.

    (3) Timeline draft for two linked cycles of improvement. After thinking through the logic and plan to initiate the first improvement cycle, project leaders will want to lay out an overall timeline for the entire two cycles of the project. Sequencing several interrelated activities over many months requires careful thought regarding how long each activity will likely take. The TIMELINE DRAFT FOR A QI PROJECT WITH TWO LINKED CYCLES (PDF) is planning tool helps project leaders list the time frame for each major project activity. To the right of each major activity is space to note the relevant date or time period for the project being planned. An example of a completed timeline draft is EXAMPLE COMPLETED TIMELINE DRAFT (PDF). This listing of relevant dates and time periods will be needed to complete the more detailed project worksheets (see immediately below).

b. Preliminary worksheet outlining activities that will meet requirements. With the logic for the first cycle of improvement and the timeline for major project activities in mind, the project leader can outline an overview of the plan for the overall project. Major activities and their time frames should be briefly described on the form QI PROJECT PRELIMINARY WORKSHEET FOR MOC ELIGIBILITY - DOC. [Use browser other than Internet Explorer for this link to work properly.] Some of the specific activities for the second improvement cycle may not be known. For preliminary purposes it is sufficient to note when later activities will occur. For example, if the initial intervention has not yet occurred, for underlying causes at the beginning of the second cycle, note "To be determined after post-intervention data are collected." The purpose of the Worksheet form is to show that the project is structured with appropriate activities over two linked cycles of improvement. An example of an adequately completed preliminary worksheet is EXAMPLE COMPLETED PRELIMINARY WORKSHEET (PDF).

Send a completed Preliminary Worksheet to UMHS QI MOC Program ( One of the Program leads will follow up with the individual to discuss the proposed project and its potential appropriateness for designating MOC. Program personnel will confirm for project leads that the QI project, if carried out as planned, will meet requirements for MOC. [Note: Differentiating between an ongoing "QI program" and a specific QI project. Often a series of QI efforts are part of an ongoing program to improve care for a specific patient population or in a specific setting. However, the purpose of the QI MOC requirement is to document participation in a specific QI activity. Therefore, for the purposes of designating MOC, points in time must be defined as the beginning (baseline) and the end of a specific QI project to be documented for designating participation for MOC.]

c. Other issues

    (1). Enrolling participants who want their participation documented.

Identifying participants who want their participation documented for MOC helps the project lead assure these participants receive appropriate information and participate in required activities. While the majority of physicians and physician assistants participating in a qualified QI project want their participation documented for MOC, this documentation may not be important for those who are "lifetime certified," who have already met QI MOC requirements for their current certification cycle, or who know they will not be available to participate in all of the project's activities required for MOC.

The UMHS QI MOC Program provides an online process for physicians to enroll to have their participation documented for MOC. If the activity is also approved for AMA Category 1 CME credit (see below), this process also enrolls them for it.

An online survey is modified to function as an enrollment form. The TEMPLATE FOR ENROLLMENT (PDF) presents typical content and indicates information to be added for a specific project. An example of an enrollment form for a specific project is at EXAMPLE OF ENROLLMENT (PDF). Staff in the UMHS QI MOC work with a project lead to fill in information to create an enrollment form for a specific project. Staff prepares similar text for an email message that project leads can send to participants in the QI project. The message explains enrolling to have their participation documented and provides a link to the online enrollment form.

    (2). Having participation designated for 30 AMA PRA Category 1 credits TM.

Project leads may choose to apply to have participation in QI projects that will meet requirements for Part IV MOC also approved for CME credit. The American Medical Association recognizes continuing medical education occurring through participation in "performance improvement" activities (PI CME). The requirements for PI CME closely parallel those for Part IV MOC through the Portfolio Program. Physicians may receive 30 Category 1 Credits if they participate in two linked cycles of data-guided improvement. The 30 credits are the total of 5 credits each for:

  1. Reviewing baseline data, identifying root causes, and planning interventions
  2. Implementing interventions
  3. Reviewing post-intervention, identifying current root causes, and planning adjustments/additional interventions
  4. Implementing adjustments
  5. Reviewing post-adjustment data, identifying current root causes, and planning further adjustments/interventions
  6. Summarizing changes
Some additional requirements must be met for a QI activity to be designated for PI CME. These requirements are explained on the website for the University of Michigan Office of Continuous Professional Development under "Apply for Credit" HTTP://OCPD.MED.UMICH.EDU/CME/AMA-PRA-CATEGORY-1-CREDIT click on the "Performance Improvement CME" category. Important additional requirements include:
  • The application for PI CME must be submitted and approved before physicians begin a CME activity.
  • The disclosures of conflicts of interest must occur before physicians participate substantively in a CME activity.

If a project has reached the stage of participants reviewing the current/baseline data (i.e. they are participating substantively) before CME credit has been applied for and approved and disclosures have been shared, the project is not eligible for CME credit.

    (3) Planning for presentation/publication of results. Do you expect to present results of this QI project at national meetings or in a manuscript for publication? If so, see the tab on this site "PRESENTING/PUBLISHING QI." Your plans for using the information after the project is complete may affect some aspects of how the project is carried out (e.g., sample sizes and power to detect expected differences, records and documentation relevant for the audience). If you wait until the end of the project to consider plans for presentation/publication, you may have overlooked a crucial aspect or you may have to spend appreciable time and resources recovering information.

3. Submitting a report on the completed QI Project for MOC to be approved.

Report on a QI project eligible for MOC. Final confirmation of MOC for a project occurs when the project is completed, documented by submitting the report, and approved as having met requirements. Project activities are documented by completing and submitting a REPORT ON A QI PROJECT ELIGIBLE FOR MOC-DOC. [Use browser other than Internet Explorer for this link to work appropriately. Before starting to complete the report, the eligibility of the project for MOC should have been checked by following the procedures described in #2 above, including completing and submitting a preliminary worksheet for review of eligibility.]

An example of a completed application form is EXAMPLE REPORT ON A QI PROJECT ELIGIBLE FOR MOC (PDF). No one example can illustrate all potential circumstances. However, this example reasonably illustrates the type (and brevity) of information that adequately documents a project for the purpose of MOC designation. An option for preliminary review of the report (highly recommended) is to complete the description of activities through the intervention phase and submit the partially completed report. Staff from the MOC Program will provide a preliminary review, checking that the information is sufficiently clear, but not overly detailed. This simplifies completion and review of descriptions of remaining activities when the fully completed report is submitted.

The types of information requested and how the information will be used. The information collected includes:

  • Measures - detail about the performance measures used.
  • Participation - who is involved in key steps and expectations for participants seeking MOC.
  • The description of the elements, logic and the results for each cycle of improvement (explained in Section 2, above).
  • Additional requirements that the ABMS Multi-specialty Portfolio Program would like to be described, including:
    • Participation - who is involved in key steps and expectations for participation to receive MOC.
    • Measures - some detail about the performance measures and data collection.
    • Lessons learned and how work from the project will be shared to help others.
  • Administrative information used by the UMHS MOC Program regarding the project lead and the organizational context in which the QI project occurs.

The Report on a QI Report is used by:

  • QI project leaders to guide the planning QI projects
  • UMHS MOC Program personnel and clinical leader to approve QI projects for MOC credit
  • Individuals participating in the project to review the entire completed project before describing their individual reflections regarding the project when completing the Attestation of participation.
  • QI project leaders who use the description of purpose, methods, and results to prepare scholarly products (presentations, posters, manuscripts) regarding the project.
  • Individuals within our institution and elsewhere who seek ideas for QI projects appropriate for MOC by looking at the "Approved UMHS Projects" on this website with links to the final reports.

The report form has been designed to assure that requirements of the ABMS Multi-specialty Portfolio Program are met for each UMHS QI project designated for MOC.

Approving QI projects for MOC credit. UMHS QI MOC Program personnel review the report to determine that the project has been carried out with appropriate QI cycles and methods and the expected engagement of participants. Project leads will be contacted regarding questions. Program personnel then approve the report of the project and, for projects involving Part IV MOC for physicians, send a notification of approval of the project to the ABMS Program.

4. Individuals attesting to their participation on the QI project.

Participation “attestation” form completed online. When the QI project has been completed, a final report submitted, and the final report approved, UMHS QI MOC Program personnel will send to each participant an email message that has a unique link to an online form to complete. The form includes the participant’s identifying information, an attestation of participating as required, and reflections about the project and changes in care that the participant provides. The information identifying the participant’s specialty varies for physicians who are already certified and physician assistants. Examples are ABMS CERTIFIED PHYSICIAN ATTESTATION (PDF) and PHYSICIAN ASSISTANT ATTESTATION (PDF). Program personnel work with project leads to prefill some standard sections of the form that apply to all participants in the specific project.

Participants complete forms. On the attestation form the participant documents personal reflections concerning the value of the project and future plans regarding QI efforts. After completing the form, participants click a “submit” button to send the responses to the UMHS QI MOC Program.

Project lead verifies. UMHS QI MOC program staff forward the information to the project lead. The project lead reviews the participant’s information and verifies to the Program that the individual participated as expected.