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Part IV Effort Approval Criteria

Physicians seeking MOC Part IV credit for QI effort involvement must complete the following forms:

  1. UR Medicine MOC Part IV credit registration form to indicate intent to request consideration for approval of QI efforts during the current calendar year. This should be completed as early in the year as possible but no later than August 1 of the calendar year in which one is seeking MOC Part IV credit.
  2. UR Medicine MOC Part IV QI Effort approval form which requires a description of the QI effort detailing the performance measures and objectives, improvement cycles and outcomes. The first cycle information can be submitted prior to the commencement of the effort but must also be submitted at the completion of three improvement cycles. Forms submitted after August 15 may not make it through the review process in time to apply to the current calendar year.
  3. UR Medicine MOC Part IV physician attestation form is required by the Multi-Specialty MOC Portfolio Approval Program and must be completed prior to submitting any application for credit. This form must be submitted no later than November 15 to ensure review in time for consideration for the current calendar year.

The UR Medicine MOC Quality Effort Review Board (MOC QERB) will review the documentation in applications to determine that the project has been carried out with appropriate QI methods and expected engagement of participating physicians.

The UR Medicine MOC Program has outlined the criteria for project approval with the below requirements:

  1. The effort must address an area of high importance to the UR Medicine clinical enterprise as evidenced by the relationship to the Quality and Safety goals in the Management Plans of any of the UR Medicine hospitals, URMFG, and/or AHP.
  2. Data may be collected and reported as often as necessary, but we will expect that projects should be eligible for approval after ≥ 3 months of sequential rapid cycles of improvement and data collection. Shorter cycles that can be days/weeks to a month or two generally are advisable to enable and support rapid improvements in care. The use of one-time pre-and post-data collection does not meet the standards for MOC Portfolio Approval Program and is not consistent with quality improvement principles of sequentially testing multiple interventions to improve care.
  3. The team should possess sufficient and appropriate resources to support the successful planning, implementation, and sustainable conclusion of the effort without needing external funding that could create a conflict of interest. To the extent that resources are needed they should be identified within the department or hospital division’s budgets.
  4. Have a specific, measurable, relevant, and time-appropriate aim for improvement.
  5. Include plans for appropriate and repetitive data collection and reporting of data to support assessment of the impact of interventions. There must be:
    1. Sufficient sample size to minimize the impact of random variability and permit reasonable decision-making regarding subsequent project steps.
    2. Use of relevant outcome, process, and/or balancing measures to effectively assess the impact of interventions and potential unintended consequences.
    3. Use of appropriate charting or reporting tools to document performance over time (e.g., annotated run charts, control charts, etc.).
  6. The project should address care the physician can influence in one or more of the Institute of Medicine (IOM) dimensions of quality patient care: safety, effectiveness, efficiency, equity, timeliness, patient-centeredness.
  7. Use of any or all of the following quality measures where applicable:
    1. Outcome Measures - Evaluation of the results of an activity, plan, process or program and their comparison with the intended or projected results (e.g., % of patients readmitted with 30 days).
    2. Process Measures – Evaluation of the performance of a process. Measuring the results of process changes will indicate if care is improving (e.g., % of patients with a follow-up appointment scheduled before discharge).
    3. Balancing Measures – Evaluation of new problems that may occur as a result of the intervention (e.g., median LOS of patients).
  8. QI efforts should be sustained, involving no fewer than three linked cycles of improvement efforts (e.g., Plan, Do, Study, Act (PDSA) cycles). Following baseline data, an improvement cycle should address the identified problem, general goals/aims within a measurable timeframe for achievement, the main underlying root causes of the problem, interventions or countermeasures to address causes, and operational plans to implement the interventions.
    1. The first improvement cycle should consist of:
      1. Appropriate data collection relevant to the identified problem.
      2. Analysis and review of data to identify underlying cause(s) of problem.
      3. Intervention likely to help address underlying cause(s) and improve system performance.
    2. Subsequent cycles should consist of:
      1. Post-intervention data collection to assess impact of intervention.
      2. Adjustment(s)/second intervention(s) to address underlying cause(s).
      3. Post-adjustment data collection to assess impact of intervention.
  9. Must implement standardized processes to ensure the sustainability of the improvement and outcomes.
  10. For long-term efforts, please contact the UR Medicine MOC Program Manager to determine if a project is eligible for MOC Part IV credit before the conclusion of the project. For projects already completed, they are eligible for UR Medicine MOC QERB review if there was activity in the current calendar year.

For any questions/comments, please contact the UR Medicine MOC Program Manager at