Designating Continuing Certification Credit for QI (ABMS IHHC, NCCPA PI-CME)

Processes involved in designating and receiving continuing certification credit (ABMS Improving Health and Healthcare [IHHC], NCCPA PI-CME, formerly known as Part IV maintenance of certification or MOC), for participation in a QI activity include:

1. Identifying a QI activity appropriate for Continuing Certification (MOC) designation.
2. Outlining the QI activity to check eligibility for QI Continuing Certificationand 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 improvement project
    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 activityt for QI continuning certification credit to be approved.
4. Individual participants attesting to their participation on the QI activity.

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

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

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

Participate in Improving Health and Health care. To qualify for QI continuning certification through the ABMS Multi-specialty Portfolio Program, participants must be engaged in a systematic effort of reviewing and improving some aspect(s) of health or healthcare delivery for their patients, have an organizational leadership role in quality improvement or patient safety, or serve as a quality improvement coach, trainer, or student/resident QI advisor.

Meaningful Participation Requirements
A physician/PA can receive continuing certification credit by fulfilling these requirements for meaningful participation:
    1. Identify and/or acknowledge a gap(s) in outcomes or in care delivery.
    2. Identify and/or review data related to the gap(s).
    3. Identify or acknowledge appropriate intervention(s) designed to improve the gap(s), OR participate in the planning and selection of intervention(s) designed to improve the gap(s).
    4. Implement intervention(s) for a timeframe appropriate to addressing the gap(s), OR monitor and manage implementation of intervention(s) for a timeframe appropriate to addressing the gap(s).
    5. Review post-intervention data related to the gap(s).
    6. Reflect on outcomes to determine whether the intervention(s) resulted in improvement. If no improvement occurs after an intervention, participants must reflect on why no improvement occurred.

Periodic opportunities. Physicians and physician assistants need QI continuing certification credit periodically, so clinical leaders should select and plan activities ahead, considering the additional documentation effort required for designating credit for IHHC.

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

The lead of the QI project should check with a member of the UMH QI Continuing Certification Program staff regarding whether the design of a project is eligible for continuning certification 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 improvement project
    b. Preliminary worksheet outlining activities that will meet requirements
    c. Other considerations
        (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 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
  • Intervention or 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).

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

The report documenting required activities for QI continuning certification asks for a description of each of the elements for structured problem solving.

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

Project leaders can use structured problem solving tools like the logic diagram as the basis for outlining content and developing and updating plans at each stage, although the description in the report will be in narrative text.

    (2) Performance measurement and presentation. Thinking through the logic underlying an improvement effort includes identifying a measure (or measures) that reflects relevant performance. Data to calculate the measure will be collected consistently 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, it is necessary to:

  • Identify the population or subpopulation eligible for measurement.
  • Determine the measure(s) of performance. One performance measure is required (you may have more), and it must be assessed at baseline and post-intervention.
  • Determine how data for measures will be collected. Common ways to collect data include keeping a special record or tally 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 Data must be presented in graphic form, e.g., a table, bar graph, or run chart (line graph) that facilitates assessing change in performance over time. Several EXAMPLES OF GRAPHIC PRESENTATIONS OF PERFORMANCE RESULTS illustrate possibilities.

The above considerations are elaborated in PERFORMANCE MEASUREMENT AND REPORTING.

    (3) Timeline draft for improvement. After thinking through the logic and plan to initiate the improvement cycle, project leaders will want to lay out an overall timeline for the entire project. The TIMELINE DRAFT FOR A QI PROJECT (DOC) is a planning tool that helps project leaders list the time frame for each major project activity. An example of a completed timeline draft is EXAMPLE COMPLETED TIMELINE DRAFT (PDF).

b. Preliminary worksheet outlining activities that will meet requirements. With the logic for the improvement cycle 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). The purpose of the Worksheet form is to show that the project is structured with appropriate activities.. An example of an adequately completed preliminary worksheet is EXAMPLE COMPLETED PRELIMINARY WORKSHEET (PDF).

Send a completed Preliminary Worksheet to UMH QI Continuning Certification Program ( One of the Program leads will follow up with the individual to discuss the proposed project and its potential appropriateness for designating continuning certification. Program leads will confirm for project leads that the QI project, if carried out as planned, will meet requirements for credit. [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 continuning certification requirement is to document participation in a specific QI activity. Therefore, for the purposes of designating continuning certification, points in time must be defined as the beginning (baseline) and the end of a specific QI project.]

c. Other considerations

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

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

The UMH QI MOC Program provides an online process for physicians to enroll to have their participation documented for continuning certification. 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 UMH QI Continuning Certification program 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 AMA PRA Category 1 credits™.

Project leads may choose to apply to have participation in QI projects that will meet requirements for Part IV continuning certification 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 continuning certification through the Portfolio Program.

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 Continuing Medical Education and Lifelong Learning under "Basics of CME" 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 Continuing Certification to be approved.

Report on a QI project eligible for Continuing Certification. Final confirmation of Continuing Certification (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 CONTINUING CERTIFICATION (DOC). [Before starting to complete the report, the eligibility of the project for continuning certification should have been checked by following the procedures described in #2 above, including completing and submitting a preliminary worksheet for review of eligibility.]

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

Approving QI projects for continuning certification credit. UMH QI Continuing Certification 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 continuning certification for physicians, send a notification of approval of the project to the ABMS Program.

An example of a completed application form EXAMPLE REPORT ON A QI PROJECT ELIGBLE FOR CONTINUING CERTIFICATION (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 continuning certification 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 Continuing Certification 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:

  • 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 credit.
    • 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 UMH Continuning Certification Program regarding the project lead and the organizational context in which the QI project occurs.

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, UMH 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 UMH QI Continuning Certification Program.

Project lead verifies. UMH QI Continuning Certification 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.

 Credit is usually awarded 4-6 weeks after submission of the attestation.