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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      
Determine if other credits will be offered      
Identify an appropriate QI project      
Identify Project Leand and/or Co-Leads      
Review the Conflict of Interest (COI) Management process      
If the Project Lead has a COI, identify a Conflict of Interest Manager      
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      
Complete the CME application      
Ensure all conflicts of interest (COI) are reviewed and appropriately managed      

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