QI Project Preliminary Worksheet for Part IV MOC Eligibility
Basic components of an eligible project are outlined below. Briefly highlight plans for each step. If not yet known, enter “TBA.” Review the overview with either of the followingindividuals for suggestions to facilitate completing the formal application for Part IV credit.
Grant Greenberg, MD, UMHS Part IV Program Lead, 763-232-6222,
R. Van Harrison, PhD, UMHS Part IV Program Co-Lead, 763-1425,
1. Date:2. Key individuals
a. Project leader:
b. Clinical leader to whom project leader reports regarding project:
3. Title of QI project:
4. Patients involved:
5. Physician specialties / subspecialties involved and number:
PLAN / 6. General purpose
a. Problem with patient care:
b. Project goal:
(Data 1) / 7. Baseline measures of performance
a. What is measured?
b. What time period will be included?
c. By when will the data be collected and reported?
8. Review results, considering underlying causes,and planning
a. Who is involved?
b. How will they meet(e.g.,clinic staff meeting)?
c. Approximately when will this occur?
d. What underlying causes are identified?
DO / 9. Intervention(s)
a. What is the intervention?
b. When (date(s))is the intervention implemented?
CHECK
(Data 2) / 10. Post-intervention measures of performance
a. What is measured?
b. What time period will be included?
c. By when will the data be collected and reported?
ADJUST –
REPLAN / 11. Review results, considering underlying causes,and planning
a. Who is involved?
b. How will they meet(e.g.,clinic staff meeting)?
c. Approximately when will this occur?
d. What underlying causes are identified?
REDO / 12. Further intervention
a. What is the intervention?
b. When (date(s)) is the further intervention implemented?
RECHECK
(Data 3) / 13. Post-adjustment measures of performance
a. What is measured?
b. What time period will be included?
c. By when will the data be collected and reported?
READJUST
PLAN / 14. Review results, considering underlying causes,and planning
a. Who is involved?
b. How will they meet(e.g.,clinic staff meeting)?
c. Approximately when will this occur?
d. What underlying causes are identified?
PHYSI-
CIANS / 15. How physicians are involved (summary):
a. Interpreting baseline data, considering underlying causes, and planning intervention:
b. Implementing intervention:
c. Interpreting post-intervention data, considering underlying causes, and planning changes:
d. Implementing further intervention/adjustments:
e. Interpreting post-adjustment data, considering underlying causes, and planning changes:
16. How will you provide a list of physicians who plan to participate as described in # 15?
Have participants individually enroll through an online form provided by the UMHS Part IV Program
Other:
17. Are you applying also to have “Performance Improvement” CME credit (20 AMA PRA Category 1 credits) designated for physicians participating in this QI project?
Yes No
18. Are you planning to present this QI project and its results in a:
Yes No Formal report to clinical leaders?
Yes No Presentation (verbal or poster) at a regional or national meeting?
Yes No Manuscript for publication?
1