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Meaningful Participation Criteria

All physicians seeking MOC Part IV credit must complete the Physician Attestation Form. This form will include a description of the QI effort detailing the improvement cycles and how it is directly related to the physician’s practice, and a reflection statement describing the change that was performed in his/her practice affecting the way care is delivered. The purpose of the attestation is to show the physician has met the criteria for “meaningful participation”. Attestations may be submitted at the time of the effort review, or any time after effort approval if the QI effort is ongoing.

The UR Medicine MOC Program has defined the criteria for “meaningful participation” with the below requirements. For any questions, please contact the MOC Program Manager.

  1. The QI effort must provide clear benefit to the physician’s patients and/or be directly related to the physician’s clinical practice (for leaders in non- caregiving roles).
  2. The physician is actively involved in the QI effort as evidenced by documented participation in meetings on this QI effort and meeting the following criteria:
    1. The physician participated in the “plan” phase –including, but not limited to, identifying the gap in quality, development of primary outcome measures and target improvement, and development of plans for intervention.
    2. The physician participated in the “do” phase – implementing strategies and interventions.
    3. The physician participated in the “study” phase-assessing the impact of interventions through data collection and/or analysis and making appropriate course corrections in the improvement effort.
    4. The physician participated in the “act” phase - ensuring implementation of sustainable interventions in their practice, department, and/or across the institution.
  3. At a minimum, the activities must be of sufficient duration to allow for physician participation in at least three full cycles of data assessment and planning of an improvement intervention, the implementation of a change process and re-assessment of the results (e.g., PDSA cycle) for at least three months duration.
  4. The physician is able to personally reflect on the activity, describing the change that was performed in their practice and how it affected the way care is delivered.

The timely submission of attestation forms is essential for physicians whose certification period will end in the year that the effort ends. Attestation forms must be submitted to the UR Medicine MOC Program by November 15th in order for us to report credit to your ABMS specialty board and have your credit count for that year.