1.Project Title (must be less that 50 characters):
2.Submission Date:
3.Department/Division(s):
4.QI Project Leader(s) (up to two)
Name (First, Middle Initial, Last) Email Phone #
Name (First, Last, Middle Initial) Email Phone #
5.Select the methodology that most closely represents the methods used in this QI effort:
Continuous Quality Improvement (CQI) / Model for Improvement (PDSA/PDCA) / Other – Please describe:IHI Collaborative Model / Six Sigma (DMAIC)
LEAN / Total Quality Management
6.Start date of the QI effort (mm/dd/yyyy):
7.End date of the QI effort if project is completed (mm/dd/yyyy):
(If project is in process or end date is unclear, please indicate ‘ongoing’ for the date above)
8.Dates for first two quality improvement cycles (one cycle includes collection and review of baseline data, planning and implementing an intervention, re-measurement, and reflection on impact):
1st Cycle Begin Date (mm/dd/yyyy): 1st Cycle End Date (mm/dd/yyyy):
2nd Cycle Begin Date (mm/dd/yyyy): 2nd Cycle End Date (mm/dd/yyyy):
Please note: 1st Cycle Begin Date and 2nd Cycle Begin Date may be the same day.
9.Indicate the approximate number of participating physicians?
1-10 11-50 51-100 101-1000 Over 1000
10.What relationship(s) do participants of this MOC IV QI activity have with UCSF?
Physicians employed or contracted by UCSF (e.g., Moffit-Long, LPPI, Mount Zion, Mission Bay, or SFGH)
Physicians in UCSF’s health system or network (e.g., Children’s Hospital Oakland, Family Medicine Center at Lakeshore, or VA medical center)
Physicians affiliated with UCSF (e.g., Private Practice that supervises students/house staff)
If affiliated, please describe the affiliation:
11.What is/are the location(s)/setting(s) for this activity?
LPPI / SFGHMoffit-Long / Children’s Hospital Oakland
Mount Zion / Mission Bay
VA / Other – Please describe:
12.Select one or more relevant topics for this quality improvement effort:
Access to care / Efficiency / Patient SafetyAsthma / Hand hygiene / Prescriptions
Cancer / Health Literacy / Preventive care
Cardiovascular / HIV / Readmissions
CLABSI / Hypertension / Satisfaction
Communication / Immunizations/Vaccinations / Sepsis
Compliance / Length of stay / Surgical site infections
Diabetes / Medical home / Teamwork
Documentation / Obesity / Transitions of care
Other – Please describe:
13.Select Medical specialties addressed as part of this quality improvement effort:
Allergy and Immunology / Obstetrics and Gynecology / Plastic SurgeryAnesthesiology / Orthopaedic Surgery / Preventive Medicine
Dermatology / Otolaryngology / Psychiatry and Neurology
Emergency Medicine / Ophthalmology / Radiology
Family Medicine / Pathology / Surgery
Internal Medicine / Pediatrics / Thoracic Surgery
Medical Genetics / Physical Medicine and Rehabilitation / Other – Describe:
14.How is the quality improvement effort funded?
Internal
Non-commercial grant
Pharma or device funding (Commercially funded activities are not eligible)
Other – Please describe:
15.What is the specific aim of the quality improvement effort? The aim statement should include the following:
a)Specific improvement goal – this can be stated as one amount to another, OR as an overall amount of improvement desired
b)Specific target audience
c)A specific date, or in a given period of time, in which the improvement goal should be reached
e.g. – Improve hand-washing in providers seeing patients on the 5th floor from 75% to 90% in 6 months.
16.Briefly describe the quality improvement effort. Include the identified problem and also rationale for your improvement goals. This response should be different from the aim provided above.
17.Describe how physicians meaningfully participate in the QI effort. You should answer the following questions in your response.
a)How physician’s patients are directly impacted by this effort.
b)The physician role within his/her care team as it relates to this effort.
c)The physician role in data collection, measurement and/or analysis throughout this effort.
d)How physicians implement interventions and assess if adjustments are needed throughout this effort.
e)The approximate length of time expected for an individual physician participant to reach his/her goal(s), as per the aim statement.
f)How physician participation in this effort impacts medical practice and/or the care provided.
18.What is the specific patient population for this quality improvement effort?
19.Select one or more IOM Quality Dimensions addressed as part of this QI effort
Patient-Centeredness / Safety / Timeliness
20.Select one or more ACGME/ABMS competencies addressed as part of this QI effort:
Practice-based Learning andImprovement / Patient Care and Procedural Skills / Systems-based PracticeMedical Knowledge / Interpersonal and Communication Skills / Professionalism
21.Indicate how results are captured and displayed over time.
Annotated Run Chart
Other – Please describe format(s) and provide your reason(s):
1.Measure Name:
2.Measure Type: Outcome Process Balancing
3.Nationally Endorsed? Yes No
4.Calculation (Indicate the denominator and numerator for the measure):
5.Exclusions (What data, if any, are excluded from the calculation?):
6.Data Source (Note – If patient surveys are used, they must be provided to the ABMS for approval. Please attach any patient surveys to this application.):
Chart review / Prospective at point of careElectronic Health Record / Patient Survey (Please attach to application)
7.Has pre-intervention data been collected to inform this initiative? What does this baseline data show?
8.What is the performance goal or target? Is this based on any standard benchmark? If so, please describe.
If additional measures are being tracked, please provide the information for each additional measure. Measure questions above can be copied and pasted here:
SECTION C: Outcomes1.Attach results for the quality improvement showing data over time.Note:The attached file should contain an annotated run chart.
2.Describe the interventions that were implemented to achieve the quality improvement effort goals. Explain the rationale and dates of implementation for each intervention.
3.Describe how these interventions are/were expected to improve patient care.
4.How will improvements from these interventions be sustained and spread?
5.Please make sure to attach your results as an annotated run chart. If another format is used for reporting, please explain why.
SECTION D: Lessons Learned
Please respond to each question below with at least one or two sentences.
1.What was the difference, if any, between what was planned and what actually happened?
2.What lessons (positive or negative) were learned through the improvement effort that can be used to prevent future failures and mishaps or reinforce a positive result?
3.What changes were made or processes standardized as a result of this project —a document, procedure, policy, structure, budget, etc.?Did you adopt your intervention, make additional adaptations or did you take a new approach altogether and what was it?
4.Are you willing to share information about this QI effort among other physicians and administrators that are participating in this program (the multispecialty portfolio program)? Yes No
SECTION E: Meaningful Physician Participation RequirementsIMPORTANT: The physician claiming MOC Part IV credit must verify and attest that they have participated throughout the entire QI effort, which includes reviewing, reflecting on, and acting upon project data at least three times during the course of their meaningful participation in a quality initiative. Physicians must also reflect on further improvements, barriers to improvement, and sustaining improvement.
As a Project Lead(s), I (we) will receive all Physician Participation forms and review the reflection statements of participating physicians. It is my (our) responsibility as a Projects leader to ensure that each participant has met the criteria for meaningful participation.
Project Lead 1 Signature:______ Date:
(Please note: Your initials can be used as an electronic signature.)
Project Lead 2 Signature: (Optional)______ Date:
(Please note: Your initials can be used as an electronic signature.)
Submit completed Project Design and Outcomes Report to the UCSF MOC Program Manager .
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FORM Version 7.0 – 3.24.15