MOC Qualification Form for QI Initiatives

MOC Qualification Form for QI Initiatives

QI Project Title*

QI Project Start Date:*

End date:*

Submitter Name*

Submitter Email Address*

QI Project Leader Name (if different than Submitter)

QI Project Leader Email (if different than Submitter)

Select up to 5 relevant topics for this quality improvement Activity:*

Select or enter value

If you selected Other, please add topic.

ABMS Boards*

We are able to work with the following specialty boards to grant MOC credit for eligible QI projects. Please select all specialty boards MOC program you are seeking MOC credit for.

Select

Aim Statement (read requirements)*

Provide the Aim Statement. The Aim Statement should include: (1) a specific and measureable improvement goal, (2) a specific target population, and (3) a specific target date/time period.

Aim Statement Template – We will [improve, increase, decrease] the [number, amount, percent] of [the process] from [baseline rate] to [target rate] by [date].

Example – “We will increase the rates in high blood pressure screening of adult patients from 62%, on July 1, 2019, to 80% by June 30, 2020.”

I attest that the aim statement includes the required elements listed above.*

Primary Quality Measure - Only one quality measure should documented here.

Patient population*

What is the specific patient population for this quality measure?

Measure Name*

Measure Source*

Select or enter value

Measure Calculation: Specify the numerator and denominator. For example - If the project aim is to increase discharge naloxone prescribing from 9% to 25% for any person who receives opioids from his/her inpatient team upon discharge, your measure numerator would be “# of patients who received opioids who also received naloxone” and denominator would be “# of patients who received opioids.”

Numerator*

Denominator*

Baseline Rate*

Target Rate*

Interventions - Describe an intervention or a planned intervention for at least one cycle of improvement. Only one intervention is required for this application.

Describe Intervention*

e.g., We have a checklist that prints from our EMR for adult PCP visits; we worked with IT to have hypertension screening added to that

How will this impact individual practice?*

e.g.,Will lengthen physician visit time for every patient who screens.

How will this impact patient care?*

e.g.,This change ensures that every patient 18+ who is seen at least annually is screened for hypertension regardless of the type of visit

Physicians/PAs will engage in this QI work in the following way(s) (select all that apply):*

Provide direct/consultative patient care.

Oversee clinical delivery activities that provide opportunities for improvement.

Serve as a QI/PS lead, coach, or a resident/student advisor, or other leadership role.