Baylor College of Medicine Logo

Meaningful Participation Requirements

Maintenance of Certification at BCM

For questions, please contact: BCM MOC Program

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


Updated: June 2021

Physician/PA participation in a QI Activity 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.


In participating in their QI Activity, 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 that meets all of the following guidelines:

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

Physician Assistants: With respect to PAs, the QI Activity 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, 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. Meeting Participation
    • Actively participate in project meetings.

At the completion* of the QI Activity, the physician/PA must reflect on project outcomes to determine whether the intervention(s) resulted in any improvement. If no improvement occurred after a given intervention, the physician/PA is asked to include in their reflection why no improvement occurred.

*The physician/PA also must attest to meeting all of the above requirements by completing, signing, and submitting a QI Activity - Physician (or PA) Attestation & Reflection Form by its indicated deadline.