QI Activity Requirements

Eligibility

Eligible QI activities/projects can address many facets of the health care continuum, including, but not limited to, the areas indicated below. The scope of the activities can be large (e.g., to address systemic and clinical issues) or small (e.g., to improve a specific area of practice).

1. Processes (e.g., access to care, discharge planning, advanced directives)
2. Clinical care (e.g., cardiovascular disease, depression, opioid treatment)
3. Administration/systems (e.g., efficiency, resource allocation, EMR use)
4. Population health (e.g., childhood obesity, food safety, motor vehicle injury)

Qualifications

To qualify for MOC Part 4/NCCPA Category 1 PI-CME credit consideration, the QI activity/project¹ must meet all of the following requirements:

1. Includes an oversight process that ensures adherence to meaningful participation criteria.
• The QI activity/project must be supported by appropriate leadership and management at the initiative level to ensure adherence by physician/PA project participants to stated meaningful participation requirements.

2. Has a specific, measurable, achievable, relevant, and time-bound (SMART) aim for improvement.
• The aim statement/SMART goal of the QI activity/project must address at least one (1) IOM Quality Dimension.
3. Uses appropriate, relevant, and (when available) evidence-based performance measures and interventions.¹
• Includes process and/or outcomes measures that also focus on one (1) or more IOM Quality Dimensions AND one (1) or more ABMS/ACGME Core Competencies.
• Includes measurement at the appropriate unit of analysis (e.g., clinic, care team, physician, etc.).
• Uses national measures when available.
• Uses recognized, valid, and established quality improvement methodology.
4. Documents data collection pre- and post-intervention.¹
• Includes appropriate prospective and repetitive data collection and reporting of performance data that reflects the completion of at least one (1) full improvement cycle (not including baseline data collection).¹
• Demonstrates qualified meaningful participation, project participants should assess, reflect on, and act upon the data at least two (2) times (e.g., including at baseline and at the conclusion of the project) during the term of the QI activity.¹
5. Possess sufficient and appropriate resources to develop, support, and conclude without real or perceived conflict of interest (e.g., industry funding).²

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.

¹Some certifying bodies (including the American Board of Internal Medicine (ABIM) may not accept projects that were completed in prior calendar years. Further, some may require the completion of more than one improvement cycle (not including baseline collection). For example, the American Board of Pediatrics (ABP) has other requirements (Table 2), in addition to those described above.

Refer to stated credit translations and requirements (see Tables 1 and 2) for more information regarding project and/or participation standards relevant to your respective certifying body(ies). See below for examples of acceptable interventions and data sources.

²Any commercially supported QI activities/projects or education-related interventions that offer AMA PRA Category 1 Credit™ are deemed acceptable IF compliant with current ACCME Standards for Integrity and Independence in Accredited Continuing Education. Where relevant, the BCM MOC Program is required to document adherence to these standards.

As such and for those physicians/PAs to whom this applies, the physician/PA is responsible for contacting the BCM MOC Program to discuss their intended QI effort in ensuring their understanding of and compliance with current ACCME standards, as well as for including all related and required documentation in this regard (per ACCME standards) when submitting QI activity/project information to the BCM MOC Program for their attention and processing for credit consideration.

Intervention Examples

Examples of typical interventions include, but are not limited to, the following:

• Redesign of subprocesses in a clinical process
• Alerts and reminders in an Electronic Health Record (EHR) system
• Checklist(s) guiding healthcare professionals’ practice (may also be a component of an EHR modification)
• Utilization of phone calls/reminders/posters and other sources of patient education and compliance information
• Implementation of standing orders for evidence-based intervention(s)
• Education of team members addressing practice-changing evidence
• Kaizen events or similar team-based quality improvement or patient safety events

Data Source Examples

A wide array of data are available and appropriate to drive improvement. When available, improvement work should incorporate appropriate, relevant, and evidence-based performance measures. The use of national measures may be applied if appropriate. The best data sources are those that are the most accessible to providers.

Examples of common data sources include the following:

• Practice-level metrics
• System-level metrics
• Employer-gathered information or outcomes
• Survey-generated information
• Accountable Care Organization (ACO)-required metrics
• Electronic Health Record (EHR)-produced reports