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
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
Identify interventions appropriate for MOC Part IV to be
tested for improvement.
Focus on improved patient care.
Provide evidence from published literature.
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).
Select evidence-based or consensus-driven measures to
support team’s effort to improve clinical outcome.
Address one or more IOM dimensions of quality patient
care: safety, effectiveness, efficiency, equity, timeliness,
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
Plan for repetitive data collection and reporting to support
assessment of impact of interventions over time (e.g., annotated
run charts or control charts).
Identify participating physicians.
Select project leader(s) and assign MOC Part IV
requirements (QI project application, physician
participation confirmation, and report submissions).
Consider specialty board variations in MOC Part IV
credit requirements for group projects.
QI project must be related to the physician’s clinical
practice and benefit the physician’s patients.
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
QI Project Credit Application Section I must be submitted for review
by the UKHC CECentral MOC Part IV Review Committee.
This review provides the QI project team guidance to assure that
their approach is consistent with requirements for approving MOC Part
Section I review feedback is typically given to the QI project
leader by the Review Committee within 5 business days
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
QI projects should involve no fewer than 2 linked cycles of
change including data collection and analysis.
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
QI projects should be eligible for approval after 2-3 months
of sequential rapid cycles of change and data collection depending upon
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:
Appropriate data collection relevant to identified
Analysis and review of data to identify cause(s) of the
Intervention proposed to help address the problem as well as the cause(s) and
Subsequent cycles should include:
Post-intervention data collection to assess impact of
Adjustment(s) or additional intervention(s) addressing underlying
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
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
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.
QI Project Credit Application Section II feedback is typically
given by the UKHC CECentral MOC Part IV Review Committee within 4
weeks following submission.
MOC Part IV Credit Process
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.
Project leader submits email including verified participant names (MOC and PI CME)
to the UKHC CECentral MOC Program.
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.
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:
Initial project design, including practice gap identification,
primary outcome measures development, target for improvement, and
Implementation of strategies and intervention
Data collection and/or analysis to assess the impact of the
intervention and recommendation of appropriate course corrections
in the QI project
Meetings with team to continue the process for improvement with
QI projects should involve no fewer than 2 linked cycles of change including data collection and analysis to receive MOC Part IV approval.