Meaningful Participation Requirements

Maintenance of Certification at BCM

For questions, please contact: BCM MOC Program

As an ABMS Portfolio Program Sponsor, the BCM MOC Program recognizes quality improvement and patient safety activities conducted by ABMS diplomates (physicians and medical specialists certified by participating ABMS Member Boards) and physician assistants (PA) (certified by the National Commission on Certification of Physician Assistants) within their practices and health care organizations. These activities help participants earn continuing certification (MOC) for their work.

The BCM MOC Program supports organizational goals by encouraging physician and PA engagement in practice-level improvement activities. Accepting ongoing improvement initiatives reduces the need for physicians/PAs to seek out external pathways for continuing certification, allowing them to focus on patient care.

To qualify for MOC Part 4/Improving Health and Health Care (IHHC) or NCCPA Category 1 PI-CME credit, physician/PA participants seeking credit (including the Project Lead if applicable) must independently demonstrate meaningful participation in the QI Activity/Project. Evidence of meaningful participation must meet and be submitted in accordance with the Meaningful Participation Requirements outlined below. Additionally, the QI Activity/Project itself must meet stated QI Activity Requirements.

For a full description of the roles and responsibilities of the Project Lead, Project Participant, and the BCM MOC Program, refer to the MOC Roles and Responsibilities page.

Affiliation Requirements

BCM AFFILIATION

As part of the eligibility requirements for participation in the BCM MOC Program for MOC Part 4/NCCPA Category 1 PI-CME credit consideration:

the Project Lead must be a current BCM or BCM-affiliated employee;
any Project Participant seeking credit must be a current BCM or BCM-affiliated employee; AND
the featured QI Activity must be conducted/implemented at a BCM or BCM-affiliated institution.

Further, any Project Lead or Project Participant seeking credit must be a physician or physician assistant (PA), who is currently certified by a participating ABMS Member Board or the National Commission on Certification of Physician Assistant (NCCPA).

Note: PhD Diplomates of the American Board of Medical Genetics & Genomics (ABMGG) also are permitted to participate in the BCM MOC Program for credit consideration.

NON-BCM EMPLOYEES

Currently (subject to change without notice), Project Leads and Project Participants who are not affiliated with BCM may request credit consideration through the BCM MOC Program only IF one (1) of the following conditions is met:

Condition 1: Neither the Project Participant or the Project Lead is affiliated with another ABMS Portfolio Program Sponsor organization.

Condition 2: Both the Project Participant and the Project Lead of the featured QI Activity are affiliated with another Program Sponsor organization, AND that organizaton currently does not offer the specific pathway (e.g., QI Activity, QI Poster) you are seeking for MOC Part 4 credit.
Important: If you are affiliated with another ABMS Portfolio Program Sponsor organization, please contact that organization directly to inquire about its available pathways (and associated requirements and processes) for requesting credit .

Be Advised: The BCM MOC Program generally cannot process credit requests for non-BCM physician/PA participants, particularly those affiliated with another ABMS Portfolio Program Sponsor organization. However, if that organization does not currently offer the specific pathway (e.g., QI Activity, QI Poster) you are seeking for MOC Part 4 credit, the BCM MOC Program may be able to assist in certain circumstances.

Note: This policy is subject to change, and services may be limited to BCM employees at any time without notice.

Meaningful Participation Requirements

Updated: January 2024

Physician/PA participation in a qualified QI activity/project must be meaningful, as defined by the criteria listed below.

To qualify, their individual participation must meet all of the guidelines as described, which together serve to ensure they gain a clear understanding of, and hands-on experience with, the fundamental principles of quality and performance improvement principles that should be reflected in their QI activity/project.

Role

In participating in their QI activity/project, the physician/PA must do so via at least one (1) of the following roles:

Provides direct or consultative patient care.
Oversees clinical delivery activities that provide opportunities for improvement.
Serves as a quality improvement/patient (QI/PS) safety coach, trainer, or resident/student QI advisor.
Leads an organization-wide QI/PS initiative.

Relevance

The physician/PA must participate in a QI activity/project that meets all of the following requirements:

Provides clear benefit to their patients.
Is directly related to their clinical practice or organizational/leadership role in improving care.

Physician Assistants: In addition to the above requirements, the QI activity/project ALSO must be conducted at BCM or a BCM-affiliated institution AND be team-based, reflecting an inter-professional project team that includes collaboration with one or more participating physician team members.

Continuity

The physician/PA must actively participate throughout the entire duration of their QI activity/project, completing all of the following project activities, as described:

Project Design

Identify and/or acknowledge a gap(s) in outcomes or in care delivery.
Identify and/or review data related to the gap(s).
AT LEAST ONE (1) OF FOLLOWING:
- Identify or acknowledge appropriate intervention(s) designed to improve the gap(s).
- Participate in the planning and selection of intervention(s) designed to improve the gap(s).

Implementation of Interventions

AT LEAST ONE (1) OF FOLLOWING:
- Implement intervention(s) for a timeframe appropriate to addressing the gap(s).
- Monitor and manage implementation of intervention(s) for a timeframe appropriate to addressing the gap(s).

Data Collection & Analysis

Review post-intervention data related to the gap(s).

Reflection

Reflect on project outcomes to determine whether the intervention(s) resulted in any improvement. Improvement is not required for credit consideration. If no improvement occurred after a given intervention, the physician/PA is asked to include in their reflection why no improvement occurred.

Attestation

At the completion of the QI activity/project, the physician/PA must attest to having met ALL of the above requirements by completing, signing, and submitting a QI Activity - Physician (or PA) Attestation & Reflection Form by its indicated deadline.