Multi-Specialty Portfolio Program - Application for QI Effort Approval

Prior to making application for project approval, please review the Standards and Guidelines for MOC Qualifying QI Initiatives (hyperlink) to make certain your QI Project meets these requirements, and additionally review the Standards and Guidelines for Meaningful Participation in Qualifying QI Initiatives and communicate these requirements to physician members of the team.

Description of QI Effort

QI Effort Title

QI Effort Start Date

Anticipated End Date

Status of QI Effort at Time of Submission

Date when MOC credit determination is needed

QI Leader Name

QI Leader E-mail

QI Leader Phone Number

Relationship between Portfolio Sponsor and Participating Individuals

The individuals are employed or contracted by the Portfolio Sponsor.
The individuals are in the Sponsor's health system or network.
The individuals have other oversight arrangements with the Sponsor.

Provide the numbers, as available, of health care providers who are participating in this QI Effort (regardless of their intention to claim MOC Part IV through the Portfolio Program).

Practicing Physicians	Residents/Fellows	Physician Assistants	Nurses (APNP, NP, RN)	Other Allied Health

Indicate concerns explicitly addressed by this QI Effort

Reduction of Harm (patient safety)
Cost of Care
Patient Care Outcomes
Experience of Healthcare

Choose two of the six Institute of Medicine quality dimensions the QI Effort addresses:

Safety
Effectiveness
Timeliness
Efficiency
Equity
Patient-Centeredness

Choose two of the following six ACGME/ABMS competencies the QI Effort addresses. (Practice-based learning and improvement, and Systems-based practice are both assumed for every QI Effort submitted through the Portfolio Program.)

Practice-based Learning and Improvement
Patient Care and Procedural Skills
Systems-based Practice
Interpersonal/Communication Skills
Medical Knowledge
Professionalism

Select one or more relevant topics for this QI Effort:

Access to care
Asthma
Cancer
Cardiovascular
Medical Knowledge
Professionalism
Other

Select one or more medical specialties addressed as part of this QI Effort:

Will the QI Effort require funding?

Yes
No
Undetermined at this time

If funded, indicate the source of funding:

Grant
Internal
Industry (pharma or medical device manufacturer) funding

Select the methodology that most closely represents the methodology being used in the QI Effort

Describe the gap in quality that is causing this QI Effort to be undertaken. This can be done by comparing the current state of care within your department/organization or practice relative to this QI Effort with the state of care in other settings

Is the QI Effort related to a national, regional, or local initiative?

Yes
No

If 'yes,' what initiative?

Are the planned project interventions directly related to the physician's clinical practice or organizational/leadership role in improving care?

Yes
No

Will physician participants attempt or plan to translate or implement an improvement intervention into routine care (or disseminate or spread and sustain an existing improvement into practice)?

Yes
No

What is the specific aim of the QI Effort? 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 targeted patient population for this QI Effort?

Describe the projected measures of success that are being, were, or will be used by participants in the QI Effort. Include baseline measures and goal/target for each. If you have not identified measures at this time, indicate "Unknown at this time". HINT: If your data is presented solely in table format, if may not be sufficient and may require further data analysis.

Measure	Baseline Result	Target

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

Indicate the requirements for an individual to meaningfully participate in this QI Effort. CHECK ALL REQUIREMENTS THAT 24. APPLY TO THIS QI EFFORT

Involvement in the conceptualization, design, implementation and assessment/evaluation; or Provision of direct patient care as an individual or a member of the care delivery team; or Supervising resident or fellows through the entire initiative.
Review performance data not less than 3 times including at baseline, and prior to completion of activity for MOC purposes (Post PDSA1, Post PDSA2).
Apply tools/interventions to individual team practice.
Reflect on impact of the initiative on their practice or organizational role.
Attest to both meeting/working with others involved in the improvement activities; AND Personal completion of all meaningful participation requirements of this QI Effort.
Other requirements specific to the QI Effort.

Attach any relevant files regarding the QI Effort that you wish to share with the Portfolio Program Committee

Drop files here or

Please add any additional comments:

Name of person completing this application:

First Last Suffix

Date submitted:

Multi-Specialty Portfolio Program – Application for QI Effort Approval

Description of QI Effort