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Project Guidelines

The following project guidelines apply to projects with participating physicians who are board certified in General Pediatrics and/or in subspecialties certified by the American Board of Pediatrics:
Adolescent Medicine Ped Emergency Med Hospitalist Ped Neurology
All Specialties Ped Endocrinology Ped Inf Diseases Ped Pulmnology
Ped Cardiology General Pediatrics Medical Toxicology Ped Rheumatology
Child Abuse Peds Ped Gastroenterology Neo-Perinatal Med Sleep Medicine
Ped Critical Care Ped Hem/Onc Ped Nephrology Sports Medicine
Devel & Behav Peds Hospice & Palliative Care Neurodevel Disabilities Transplant Hepatology

To be approved to confer credit for MOC Part 4, a QI project must include the following components
  • Impact on one or more of the Institute of Medicine quality dimensions: safety, effectiveness, timeliness, equity, efficiency, and patient‐centeredness.
  • Use of accepted quality improvement methods, including:
    1. Aim statement (target population, desired numerical improvement, timeframe) S.M.A.R.T. Aim
    2. Performance measures, collected over time, preferably nationally endorsed; if not, must have documentation of the evidence base, measure specifications, and development process
    3. At least one balancing measure, to indicate unintended consequences of changes
    4. Comparison of performance to benchmarks
    5. Use of a systematic sampling strategy and appropriate sample size
    6. Include a minimum of 10 data points in each cycle (projects with larger samples [eg, hand hygiene] should use larger sample sizes)
    7. Systematic implementation of changes
    8. Use of data for improvement; analysis of measures over time
    9. At minimum, 1 baseline and 2 follow‐up data cycles
    10. Reporting data in graphical display over time
    11. Monitoring data quality – clear measure definitions and adequate data validation
    • Regular reporting of project‐wide and physician‐ or practice/unit‐level data to all participants (typically, monthly) and executive leaders/sponsors and other key stakeholders (at least bi‐annually and at project completion)
    • Development of physicians’ demonstrated competency in quality improvement methods, by including training and educational resources on QI methods (e.g. seminars by QI experts, coaching by QI consultants, web‐based curriculum)
    • A documented organizational structure including a project leader, who is responsible for adjudicating any disputes regarding participation and MOC credit and use of Local Leaders, for multi‐site collaboratives. Also to include institutional governance, specified start date, appropriate staffing and financial support, documented policies and procedures for management of project, system to track physician participation, and HIPAA compliance.
    • A process for collecting, reviewing, and signing Attestation Forms, and resolving disputes
    • A system to maintain up‐to‐date documentation and retain the documentation for 7 years after the project’s completion (to include project results; methods; participation monitoring, including completion data tracking; local leader acknowledgement forms if applicable)
    • Demonstrate improvements in care – score of at least 3.0 (modest process improvements) on the ABP’s Improvement Progress Scale

Physician "Meaningful Participation" Requirements for QI projects approved for MOC Part 4
  • Participate during current certificate period or MOC cycle
  • Plays an active role in the project over an appropriate period of time.
  • Active role means that the pediatrician must:
  1. Provide direct or consultative care to patients as part of the QI project.
  2. Be intellectually engaged in planning and executing the project.
  3. Implement the project’s interventions (the changes designed to improve care)
  4. Collect, submit and review data in keeping with the project’s measurement plan.
  5. Collaborate actively by attending at least four project meetings.
  • Appropriate Period of participation means:
  1. ABP looks at the project leader to set requirements for length of participation based on the nature and needs fo the project
  2. Most MOC approved projects have required 6-12 months of participation

Project Leader's responsibilities
  • Designing a project that addresses the above components for MOC Part 4
  • Determining if the project is research and obtaining appropriate IRB approval if it is
  • Completing and submitting an Project Leader MOC Application form to the Part 4 Portfolio IRC
  • Establish a process to work with MCHS/NCH Portfolio Sponsor IRC (Internal Review Committee) to provide oversight to the project
  • On Approved Projects:
    1. Provide feedback data reports to the physician participants on a regular basis
    2. Collect and retain Local Leader Acknowledgement Forms if appropriate
    3. Attest for physician participants by signing their Attestation Forms; and handle any disputes that arise in the attestation process
    4. Send physician completion data to the MCHS/NCH MOC Manager (Dr. Gereige)
    5. Complete the reports associated with project approval including bi-annual reports that will be reviewed by the IRC, a final report at the close of a project; and, if selected by the ABP for an annual review, an annual report.

Portfolio Sponsor Institutional Responsibility on Approved Projects
  • 􀂉Creating a system to track and monitor physician participation; monitor physician participation to ensure the above standards are met 
  • Maintaining all project documentation for 7 years (including methods, results, participation, and leadership)

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