QI Activity Requirements
Maintenance of Certification at BCM
For questions, please contact: BCM MOC Program
In order for a QI activity/project to qualify for Maintenance of Certification (MOC) Part 4 credit consideration, it must be met and submitted in accordance with stated ABMS Portfolio Program™ QI Activity Requirements, as described below.
Additionally, a physician's or physician assistant's participation in the activity must meet stated ABMS Portfolio Program™ Meaningful Participation Requirements.
The American Board of Medical Specialties Portfolio Program™ (ABMS Portfolio Program™) operates through a national network of health care organizations that serve as ABMS Portfolio Program Sponsors and with participating ABMS Member Boards and the National Commission on Certification of Physician Assistants (NCCPA) to award credit to eligible physicians and physician assistants.
Baylor College of Medicine (BCM) is an approved and recognized ABMS Portfolio Program Sponsor (Program Sponsor). This achievement was coordinated through the BCM Institute for Continuing Professional Development in Quality Improvement and Patient Safety (I-QIPS), which oversees all Program Sponsor responsibilities, as conducted through the BCM Maintenance of Certification Program (BCM MOC Program), operated under the I-QIPS.
As a Program Sponsor, BCM works directly with the ABMS Portfolio Program™ to help BCM and BCM-affiliated physicians/PAs earn MOC Part 4 credit/MOC points for their work in eligible QI efforts that promote the College's quality and safety aims. This is done through the BCM MOC Program, where physicians/PAs can request credit consideration via streamlined and facilitated processes. In coordination with the physician/PA, the BCM MOC Program prepares and submits on their behalf the necessary paperwork for credit consideration through the ABMS Portfolio Program™, ultimately resulting in less paperwork and more time for physicians and PAs to focus on delivering quality care to their patients.
Updated: June 2021
Eligible Activities
Eligible QI activities/projects can address many facets of the health care continuum, including, but not limited to, the following areas:
- Processes (e.g., access to care, discharge planning, advanced directives)
- Clinical care (e.g., cardiovascular disease, depression, opioid treatment)
- Administration/systems (e.g., efficiency, resource allocation, EMR use)
- Population health (e.g., childhood obesity, food safety, motor vehicle injury)
Activity Requirements
To qualify for MOC Part 4 credit consideration through the ABMS Portfolio Program™, a QI activity/project must meet ALL of the following requirements:
- Include an oversight process that ensures adherence to meaningful participation criteria.
- Have measurable, relevant, and time-appropriate aims for improvement.
- Incorporate appropriate, relevant and (when available) evidence-based measures and interventions*.
- Document data collection* pre- and post-intervention.
Intervention Examples
Types of interventions are too numerous to list, but some examples of typical interventions include 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
Note: Any commercially supported QI efforts/activities or education-related interventions (that offer AMA PRA Category 1 Credit™) are deemed acceptable IF compliant with ACCME Standards for Integrity and Independence in Accredited Continuing Education (effective 01/01/2022), which replaced the former ACCME Standards for Commercial Support.
As such and for those physicians/PAs seeking MOC Part 4 credit and to which 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.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 used 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