Performance Improvement CME for a Part IV Maintenance of Certification QI Project Timeline
What is a Performance Improvement activity for Part IV MOC?
A CME activity by which evidence-based performance measures and quality improvement (QI) interventions are used to help physicians identify patient care areas for improvement and change their performance.
Special considerations when applying for CME credit for approved MOC Part IV projects:
- Contact the Quality Department for guidance before developing a quality improvement project.
- An approved Preliminary Worksheet for Part IV Eligibility must be obtained prior to applying for performance improvement CME.
- A draft of the Enrollment Email Message must be submitted with the application.
- Applications must be submitted and approved before physicians begin their review of current/baseline data.
- Physicians who complete the project will receive 30 AMA PRA Category 1 credits.
Note: This page can be printed and used as a checklist throughout the planning process.
◉ Consult with Office of CME & Lifelong Learning and UMHS MOC Program for QI:
4 Months Prior
Initial consultation and assessment to determine if the activity aligns with departmental and institutional priorities, and that sufficient time is available for planning, approval, and promotion.
Key tasks include:
| Project Lead | UMHS MOC Program for QI | OCME&LL |
| ▢Review requirements for obtaining performance improvement credit for a CME activity | ▢Participate in consultation with Project Lead | ▢Participate in consultation with Project Lead |
| ▢Review requirements for having a quality improvement (QI) project designated for MOC |
▢Review the Mitigating Financial Relationships process |
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| ▢Determine if other credits will be offered | ||
| ▢Identify an appropriate QI project | ||
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▢If the Project Lead has any financial relationships, the OCME-LL Financial Relationship Mitigator will be notified |
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▢Consult with Department Chair for pre-approval and financial resources |
◉ Application Submission: 2 Months Prior
The application facilitates and documents the planning process.
NOTE: The CME application must be submitted and approved by OCME before physicians participate in their initial review and analysis of data.
Key tasks include:
| Project Lead | UMHS MOC Program for QI | OCME&LL |
| ▢Complete the QI Project Preliminary Worksheet for MOC Eligibility | Review and approve the QI Project Preliminary Worksheet for MOC Eligibility | Begin review of application within 2 business days of submission |
| ▢Develop a draft of the Enrollment Memo |
▢Ensure all Relevant Financial Relationships have been successfully mitigated |
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| ▢Complete the CME application |
◉ Participants Enroll: 1 Month Prior
Participants formally enroll in the project.
Key tasks include:
| Project Lead | UMHS MOC Program for QI | OCME&LL |
| ▢Distribute Enrollment Memo to potential participants |
★ Project Initiation
Physicians begin their initial review of data in the first of two linked performance improvement cycles.
Key tasks include:
| Project Lead | UMHS MOC Program for QI | OCME&LL |
| ▢Monitor project; address participant questions/concerns |
◉ Report Submission & Review: 1 Month After
Project-level reports are completed.
Key tasks include:
| Project Lead | UMHS MOC Program for QI | OCME&LL |
| ▢Submit the completed Report on a QI Project Eligible for Part IV MOC | ▢Review and approve the completed Report on a QI Project Eligible for Part IV MOC | ▢Review the completed Report on a PI CME / Part IV MOC Activity |
| ▢Submit the completed Report on a PI CME / Part IV MOC Activity |
◉ Participant Attestations & Awarding of Credit: Upon Report Approval
Participants attest to and reflect on their participation in the project. CME and Part IV MOC credit is awared to participants.
Key tasks include:
| Project Lead | UMHS MOC Program for QI | OCME&LL |
| ▢Distribute Attestation Forms to participants | ▢Award performance improvement CME credits to participants | |
| ▢Upload participant data to relevant Board | ||
| ▢Forward copies of final Report on a QI Project Eligible for Part IV MOC and completed attestation forms to OCME&LL |
