Baylor College of Medicine Logo

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 and safety improvement activities being 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) in their practices and health care organizations to help them earn continuing certification (MOC) credit for their work.

The BCM MOC Program can contribute to organizational goals by encouraging and supporting physician/PA engagement in practice-level activities that result in improvement. Accepting improvement activities that are underway alleviates the need for physicians/PAs to seek out external pathways for continuing certification, which allows them to keep their focus on the care of their patients.

In order for a physician/PA project participant (including the Project Lead) to qualify for MOC Part 4 or NCCPA Category 1 PI-CME credit consideration, evidence of their participation in the QI activity/project must meet and be submitted in accordance with Meaningful Participation Requirements, as described below. Additionally, the respective QI activity/project must meet stated QI Activity Requirements.

To view a full description of the Project Lead's role and responsibilities (including those of the project participant and the BCM MOC Program), refer to the MOC Roles and Responsibilities list.


Updated: January 2024

Physician/PA participation in a QI activity/project must be meaningful, as defined by meeting ALL of the guidelines described below, which collectively allow the physician/PA to understand and experience the basic quality improvement/performance improvement principles that should be reflected in their QI activity/prjoect.


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.


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.


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

  1. 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).
      • 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).
  2. Implementation of Interventions
      • 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).
  3. Data Collection & Analysis
    • Review post-intervention data related to the gap(s).
  4. 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.

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.