Maintenance of Certification

Name Name * First Last
QI activity name *
Start date Start date * / MM / DD YYYY
(Anticipated) End date (Anticipated) End date * / MM / DD YYYY
QI Leader name QI Leader name * Title First Last Suffix
QI Leader email *
QI Leader phone number QI Leader phone number * - ### - ### ####
Select up to 5 relevant topics for this quality improvement activity *

Select up to 5 relevant topics for this quality improvement activity Access to care Asthma Burnout/clinician wellbeing Cancer Cardiovascular Career sustainability Choosing wisely/High value care/Cost of care CLABSI Communication (patient-clinician) Compliance (regulatory) COVID-19 Diabetes Documentation Efficiency/timeliness of care Hand hygiene Health literacy HIV Hypertension Immunizations/vaccinations Length of stay Medical home Obesity Opioid use Patient-centered care Patient safety/harm reduction Prescriptions Preventative care Procedural skills Professionalism Provider resilience Re-admissions Resource stewardship, utilization, value and/or cost of care Satisfaction Sepsis Surgical site infections Teamwork/team-based care Transitions of care Other Other
View subspecialty information pertaining to the question below.
Select one or more medical specialties addressed as part of this Quality Improvement Activity *

Select one or more medical specialties addressed as part of this Quality Improvement Activity American Board of Anesthesiology American Board of Dermatology American Board of Emergency Medicine American Board of Family Medicine American Board of Internal Medicine American Board of Medical Genetics and Genomics American Board of Obstetrics and Gynecology American Board of Ophthalmology American Board of Otolaryngology American Board of Pathology American Board of Pediatrics American Board of Physical Medicine and Rehabilitation American Board of Psychiatry and Neurology American Board of Radiology American Board of Surgery American Board of Thoracic Surgery American Board of Urology National Commission on Certification of Physician Assistants
Is this QI Activity part of NCQA recognition? *

Is this QI Activity part of NCQA recognition? Yes No

ABD – In addition to Sponsors submitting completions to the Portfolio program, diplomates must claim credit on their MOC tables through their physician portal (self-report).
Funding for this QI activity meets ABMS Portfolio Program requirements *

Funding for this QI activity meets ABMS Portfolio Program requirements Yes No N/A
Aim Statement

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

Example aim statement

We will [improve, increase, decrease] the [number, amount, percent] of [the process/outcome] from [baseline measure] to [goal measure] by [date].
What is the specific aim of the Quality Improvement Activity? *

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

Add a row for each measure used in the QI activity, if known.

Note: You must complete, at minimum, the patient population at this point.

It is desirable, though not required, to have at least one outcome, process, and balancing measure.
Patient population *
Measure title
Measure type
Measure source
Numerator
Denominator
Baseline rate
Target rate
Benchmark and source (as available)
Were additional measures used in this QI activity? *

Were additional measures used in this QI activity? Yes No
Additional measures *
Interventions/Tools

Describe the types of interventions and tools that are being, were, or will be used by participants in the QI Activity and describe how each is expected to impact individual practice and patient care, if known.

You must complete, at a minimum, the impact on patient care and individual practice at this point. If you do not know interventions/tools at this point, indicate “Unknown at this time”.
Intervention/tool type and description?
How will this impact individual practice? *
How will this impact patient care? *
Would you like to add additional interventions/tools? *

Would you like to add additional interventions/tools? Yes No
List additional interventions/tools used *
Physicians/PAs will engage in this QI work in the following way(s), select all that apply

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 QI/PS lead, coach, or a resident/student advisor, or other leadership role.
Individual participants in this QI activity will complete the following:
- - Identify and/or acknowledge a gap(s) in outcomes or in care delivery.
- - Identify and/or review data related to the gap(s).
- - Identify or acknowledge appropriate intervention(s) designed to improve the gap(s), OR participate in the planning and selection of intervention(s) designed to improve the gap(s).
- - Implement intervention(s) for a timeframe appropriate to addressing the gap(s), OR monitor and manage implementation of intervention(s) for a timeframe appropriate to addressing the gap(s).
- - Review data related to the gap(s).
- - Reflect on outcomes to determine whether the intervention(s) resulted in improvement. If no improvement occurs after an intervention, diplomats must reflect on why no improvement occurred.
Attest to meeting the above requirements and obtain the attesting signature of the project leader or person in a position of authority. *

Attest to meeting the above requirements and obtain the attesting signature of the project leader or person in a position of authority. Yes No
By submitting this QI Activity, you are agreeing to share project level information (Aim Statement, Measures, and Interventions) with other Portfolio Sponsors. No outcomes data will be shared without express permission from you.

By submitting this QI Activity, you are agreeing to share project level information (Aim Statement, Measures, and Interventions) with other Portfolio Sponsors. No outcomes data will be shared without express permission from you. I agree to share project level information. I do NOT wish to share project level information about this QI Effort.
Attach any relevant files regarding the Quality Improvement Activity that you wish to share with the Portfolio Program reviewers.

Attach Files

Maintenance of Certification

Maintenance of Certification

Aim Statement

Interventions/Tools

Individual participants in this QI activity will complete the following: