Maintenance of Certification Part IV Program

QI Effort Submission Deadline: October 1st, 2017


How Does the UKHC CECentral MOC Part IV Program Approval Process Work?

MOC Part IV QI projects may be completed by a UK HealthCare-affiliated individual, group or department.

The UKHC CECentral MOC Part IV Review Committee recommends that a potential physician applicant briefly discuss the QI project initially with a committee member before completing Sections I and II of the QI Project Credit Application Form. (See Resources for a list of committee members.)

If the QI project is already underway, some steps below may not be necessary. For projects that are completed, skip to Step 4. To be eligible for MOC Part IV credit, projects must be completed after UK HealthCare CECentral’s approval as a Portfolio Sponsor on June 1, 2013.

Step 1: Selection of QI Project and Project Team
  1. Identify interventions appropriate for MOC Part IV to be tested for improvement.
    1. Focus on improved patient care.
    2. Provide evidence from published literature.
    3. Use systemic analysis of systems or processes of care. (e.g., process map or root cause analysis to identify interventions and a logic diagram or key driver diagram to explain rationale for change).
    4. Select evidence-based or consensus-driven measures to support team’s effort to improve clinical outcome.
    5. Address one or more IOM dimensions of quality patient care: safety, effectiveness, efficiency, equity, timeliness, and patient-centeredness.
  2. Sufficient and appropriate resources must be available to support QI project planning, implementation and reporting. Commercial support is not permitted for any component of the project.
  3. Plan for repetitive data collection and reporting to support assessment of impact of interventions over time (e.g., annotated run charts or control charts).
  4. Identify participating physicians.
    1. Select project leader(s) and assign MOC Part IV requirements (QI project application, physician participation confirmation, and report submissions).
    2. Consider specialty board variations in MOC Part IV credit requirements for group projects.
    3. QI project must be related to the physician’s clinical practice and benefit the physician’s patients.
    4. Physicians must actively participate in the QI project by:
      • Working with team members to plan and implement interventions
      • Interpreting performance data assessing impact of interventions
      • Making appropriate course corrections in the project
      • Reflecting on ways the interventions changed their performance in practice and care delivery
Step 2: Review of QI Project Credit Application Section I by UKHC CECentral MOC Part IV Review Committee
  1. QI Project Credit Application Section I must be submitted for review by the UKHC CECentral MOC Part IV Review Committee.
  2. This review provides the QI project team guidance to assure that their approach is consistent with requirements for approving MOC Part IV credit.
  3. Section I review feedback is typically given to the QI project leader by the Review Committee within 5 business days following submission.

Note: Some QI projects and forms of patient data use may require review by the UK Medical Institutional Review Board.

Step 3: Data Collection and Intervention
  1. QI projects should involve no fewer than 2 linked cycles of change including data collection and analysis.
  2. Shorter cycles are advisable to support rapid improvements in care. One-time pre-post data collection is not consistent with QI principles of sequentially testing multiple interventions to improve care.
  3. QI projects should be eligible for approval after 2-3 months of sequential rapid cycles of change and data collection depending upon results.
  4. Appropriate charting and reporting tools should be used to document performance over time (e.g., annotated run charts and/or statistical process control charts).

First improvement cycle should include:

  1. Appropriate data collection relevant to identified problem
  2. Analysis and review of data to identify cause(s) of the problem
  3. Intervention proposed to help address the problem as well as the cause(s) and improve performance

Subsequent cycles should include:

  1. Post-intervention data collection to assess impact of intervention
  2. Adjustment(s) or additional intervention(s) addressing underlying causes
  3. Data collection following adjustment(s) or additional intervention(s) to assess impact
Step 4: Review of QI Project Credit Application Section II, Approval and Report
  1. Project leader submits the completed QI Project Credit Application Section II to the UKHC CECentral MOC Program for review by the UKHC CECentral MOC Part IV Review Committee. The Committee determines that appropriate QI methods were used and physicians actively participated.
  2. QI project approval may be granted at the conclusion of a QI project or during long-term projects after sufficient cycles of improvement and data collection have been completed. Discuss an ongoing project with the UKHC CECentral MOC Program to determine MOC Part IV credit eligibility.
  3. QI Project Credit Application Section II feedback is typically given by the UKHC CECentral MOC Part IV Review Committee within 4 weeks following submission.
  4. MOC Part IV Credit Process
    1. Following approval of Credit Application Sections I and II, CECentral will provide access to each participating physician to complete the online QI Project Participation Attestation Form and apply for 20 PI CME AMA PRA Category 1 Credits ™. The completed form is then emailed to the QI project leader to verify the physician’s meaningful participation in the QI project.
    2. Project leader submits email including verified participant names (MOC and PI CME) to the UKHC CECentral MOC Program.
    3. UKHC CECentral MOC Program completes and forwards UK HealthCare MOC Part IV Physician Data Form(s) to the Multi-Specialty MOC Portfolio Approval Program for submission to each represented certifying ABMS specialty board.
    4. The time period from submission of QI Project Participation Attestation Forms to credit being recorded by the certifying ABMS specialty board(s) is typically 4-6 weeks.

QI Project Participation Attestation Forms must be submitted to the UKHC CECentral MOC Program by November 15 so that physician MOC Part IV data can be reported to ABMS specialty boards in sufficient time for credit to be included in that calendar year.

Step 5: Physician Attestation of Meaningful Involvement

Each physician involved in a QI project requesting MOC Part IV credit must complete the online QI Project Participation Attestation Form verifying that he/she has met criteria for meaningful participation. Access to the online form will be provided after Credit Application Sections I and II have been approved.

Physicians must be actively involved in the following criteria, with participation documented in meeting notes, to receive MOC Part IV approval:

  1. Initial project design, including practice gap identification, primary outcome measures development, target for improvement, and intervention planning
  2. Implementation of strategies and intervention
  3. Data collection and/or analysis to assess the impact of the intervention and recommendation of appropriate course corrections in the QI project
  4. Meetings with team to continue the process for improvement with attendance documented
  5. QI projects should involve no fewer than 2 linked cycles of change including data collection and analysis to receive MOC Part IV approval.