Process, Standards & Guidelines

Quality or Process Improvement (QI/PI) projects sponsored by the Children’s Heath℠ MOC Portfolio Program will have a focus healthcare in pediatric and adolescent patient populations. While projects must be physician-centered for approval, Interdisciplinary collaboration among the healthcare team is encouraged. Ongoing QI/PI projects in your division or clinic may be eligible MOC credit. Please review the criteria for qualifying QI initiatives and meaningful participation below to ensure the project meets the necessary standards and guidelines.

Project Application Form

Only ongoing or completed* initiatives may be submitted for project approval. Initiatives still in the planning and/or baseline data collection phase can contact the MOC Program for feedback to ensure the project will meet the requirements for MOC Part 4 credit. The application review and approval process may take up to 90 days to complete.

*Children’s Health became a portfolio sponsor in November 2015. Projects that began prior to this may not be eligible for submission by Children’s Health. Please contact the MOC Portfolio Program for questions.

Qualifying QI Initiatives

Project Leads are responsible for ensuring the project meets the following standards to be eligible for MOC Part 4 credit for all participants. The MOC Program can provide assistance to physicians during the project development phase to help ensure the project will meet the criteria.

Qualifying projects are those that:

Have leadership and management at the initiative level that will ensure adherence to the participation criteria
Address care the physician can influence in one or more of the six Institute of Medicine quality dimensions (safety, effectiveness, timeliness, equity, efficiency and/or patient-centeredness) and one or more of the ACGME/ABMS competencies (Practice-based Learning and Improvement; Patient Care and Procedural Skills; Systems-based Practice; Medical Knowledge; Interpersonal and Communication Skills; and Professionalism)
Have specific, measurable, relevant and time-appropriate aims for improvement
Use appropriate, relevant and evidence-based (when available) performance measures that include measurement at the appropriate unit of analysis (physician, clinic, care team, etc.); use national measures when available
Use a recognized, valid, established quality or performance improvement methodology
Include appropriate prospective and repetitive data collection and reporting of performance data so that participants access, reflect on and act upon the data at least three times (including at baseline and at the conclusion of the activity) during the course of their meaningful participation in a quality initiative designated for MOC Part 4
Implement an improvement into routine care, or disseminate or spread and sustain an existing improvement into practice
Possess sufficient and appropriate resources to develop, support and conclude the activity without real or perceived conflict of interest (industry funding)

Meaningful Participation

In order to be eligible for MOC Part 4 credit, the physician’s participation must be meaningful. Physician participation in an approved quality improvement effort is considered meaningful when:

The activities within initiatives are directly related to the physician’s clinical practice or organizational/leadership role in improving care.
The physician is actively involved throughout the entire specified activity in order to understand and experience basic QI/PI principles. Involvement MAY include at least one of the following:
- Provision of direct patient care as an individual or a member of the care team
- Being involved from the conceptualization, design, implementation, overall assessment/evaluation and evolution of the QI/PI initiative
- Supervised residents or fellows throughout the entire initiative as noted in the Standards and Guidelines for MOC Qualifying Initiatives
The physician is able to verify and will attest that they have participated throughout the entire specified QI/PI initiative, met with others involved in the improvement activities, reviewed their performance data, helped develop and/or implement changes to the activities and personally reflected on the impact of the initiative on their practice or organizational role. Reflection on further improvements, barriers to improvement and sustaining achieved improvement is strongly encouraged.