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 ActivityQI Activity TitleQI Activity Start Date MM slash DD slash YYYY If the QI Activity is "continuous" or "ongoing," the End date should be listed as an arbitrary future date Ex. 1/1/2099 Anticipated End Date MM slash DD slash YYYY Status of QI Activity at Time of Submission Beginning, assembling current state. Beginning, team formed. Analyzing baseline data. Completed Date when MOC credit determination is needed MM slash DD slash YYYY QI Leader Name QI Leader E-mail QI Leader Phone NumberRelationship 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 PhysiciansResidents/FellowsPhysician AssistantsNurses (APNP, NP, RN)Other Allied Health 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 Preventive care Procedural Skills Professionalism Provider Resilience Readmissions Resource stewardship/utilization/value and/or cost of care Satisfaction Sepsis Surgical site infections Teamwork/team-based care Transitions of care Other HiddenChoose two of the six Institute of Medicine quality dimensions the QI Effort addresses: Safety Effectiveness Timeliness Efficiency Equity Patient-Centeredness HiddenChoose 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 HiddenSelect 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 Quality Improvement Activity: American Board of Allergy and Immunology American Board of Anesthesiology American Board of Colon and Rectal Surgery 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 Neurological Surgery American Board of Nuclear Medicine American Board of Obstetrics and Gynecology American Board of Ophthalmology American Board of Orthopaedic Surgery American Board of Otolaryngology American Board of Pathology American Board of Pediatrics American Board of Physical Medicine and Rehabilitation American Board of Plastic Surgery American Board of Preventive Medicine 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 For subspecialty information please click hereSelect any specialties or subspecialties addressed through the American Board of Anesthesiology Critical Care Medicine Subspecialty Hospice and Palliative Medicine Subspecialty Neurocritical Care Subspecialty Pain Medicine Subspecialty Pediatric Anesthesiology Subspecialty American Board of Anesthesiology - Sleep Medicine Subspecialty Select any specialties or subspecialties addressed through the American Board of Dermatology Micrographic Dermatologic Surgery Subspecialty Dermatopathology Subspecialty Pediatric Dermatology Select any specialties or subspecialties addressed through the American Board of Emergency Medicine Anesthesiology Critical Care Medicine Subspecialty Emergency Medical Services Subspecialty Hospice and Palliative Medicine Subspecialty Internal Medicine-Critical Care Medicine Subspecialty Medical Toxicology Subspecialty Neurocritical Care Subspecialty Pain Medicine Subspecialty Pediatric Emergency Medicine Subspecialty Sports Medicine Subspecialty Undersea and Hyperbaric Medicine Subspecialty Select any specialties or subspecialties addressed through the American Board of Family Medicine Adolescent Medicine Subspecialty Geriatric Medicine Subspecialty Hospice and Palliative Medicine Subspecialty Pain Medicine Subspecialty Sleep Medicine Subspecialty Sports Medicine Subspecialty Select any specialties or subspecialties addressed through the American Board of Internal Medicine Adolescent Medicine Subspecialty Adult Congenital Heart Disease Subspecialty Advanced Heart Failure and Transplant Cardiology Subspecialty Cardiovascular Disease Subspecialty Clinical Cardiac Electrophysiology Subspecialty Critical Care Medicine Subspecialty Endocrinology, Diabetes and Metabolism Subspecialty Gastroenterology Subspecialty Geriatric Medicine Subspecialty Hematology Subspecialty Hospice and Palliative Medicine Subspecialty Infectious Disease Subspecialty Interventional Cardiology Subspecialty Medical Oncology Subspecialty Nephrology Subspecialty Pulmonary Disease Subspecialty Rheumatology Subspecialty Sleep Medicine Subspecialty Sports Medicine Subspecialty Transplant Hepatology Subspecialty Select any specialties or subspecialties addressed through the American Board of Medical Genetics and Genomics Clinical Biochemical Genetics Specialty Certificate Clinical Genetics and Genomics (MD) Specialty Certificate Laboratory Genetics and Genomics Specialty Certificate Medical Biochemical Genetics Subspecialty Molecular Genetic Pathology Subspecialty Critical Care Medicine Subspecialty Endocrinology, Diabetes and Metabolism Subspecialty Gastroenterology Subspecialty Select any specialties or subspecialties addressed through the American Board of Neurological Surgery Nuclear Medicine Specialty Certificate Neurocritical Care Subspecialty Select any specialties or subspecialties addressed through the American Board of Nuclear Medicine Nuclear Medicine Specialty Certificate Select any specialties or subspecialties addressed through the American Board of Obstetrics and Gynecology Obstetrics and Gynecology Specialty Certificate Complex Family Planning Subspecialty Critical Care Medicine Subspecialty Female Pelvic Medicine and Reconstructive Surgery Subspecialty Gynecologic Oncology Subspecialty Hospice and Palliative Medicine Subspecialty Maternal–Fetal Medicine Subspecialty Reproductive Endocrinology and Infertility Subspecialty Select any specialties or subspecialties addressed through the American Board of Ophthalmology Ophthalmology Specialty Certificate Select any specialties or subspecialties addressed through the American Board of Orthopaedic Surgery Orthopaedic Surgery Specialty Certificate Orthopaedic Sports Medicine Subspecialty Surgery of the Hand Subspecialty Select any specialties or subspecialties addressed through the American Board of Otolaryngology Surgery Otolaryngology – Head and Neck Surgery Specialty Certificate Neurotology Subspecialty Complex Pediatric Otolaryngology Subspecialty Plastic Surgery Within the Head and Neck Subspecialty Sleep Medicine Subspecialty Select any specialties or subspecialties addressed through the American Board of Pathology Pathology – Anatomic/Pathology - Clinical Specialty Certificate Pathology – Anatomic Specialty Certificate Pathology – Clinical Specialty Certificate Blood Banking/Transfusion Medicine Subspecialty Clinical Informatics Subspecialty Cytopathology Subspecialty Dermatopathology Subspecialty Hematopathology Subspecialty Neuropathology Subspecialty Pathology – Chemical Subspecialty Pathology – Forensic Subspecialty Pathology – Medical Microbiology Subspecialty Pathology – Molecular Genetic Subspecialty Pathology – Pediatric Subspecialty Select any specialties or subspecialties addressed through the American Board of Pediatrics Pediatrics Specialty Certificate Adolescent Medicine Subspecialty Child Abuse Pediatrics Subspecialty Developmental-Behavioral Pediatrics Subspecialty Hospice and Palliative Medicine Subspecialty Medical Toxicology Subspecialty Neonatal-Perinatal Medicine Subspecialty Pediatric Cardiology Subspecialty Pediatric Critical Care Medicine Subspecialty Pediatric Emergency Medicine Subspecialty Pediatric Endocrinology Subspecialty Pediatric Gastroenterology Subspecialty Pediatric Hematology-Oncology Subspecialty Pediatric Hospital Medicine Subspecialty Pediatric Infectious Diseases Subspecialty Pediatric Nephrology Subspecialty Pediatric Pulmonology Subspecialty Pediatric Rheumatology Subspecialty Pediatric Transplant Hepatology Subspecialty Sleep Medicine Subspecialty Sports Medicine Subspecialty Select any specialties or subspecialties addressed through the American Board of Physical Medicine and Rehabilitation Physical Medicine and Rehabilitation Specialty Certificate Brain Injury Medicine Subspecialty Hospice and Palliative Medicine Subspecialty Neuromuscular Medicine Subspecialty Pain Medicine Subspecialty Pediatric Rehabilitation Medicine Subspecialty Spinal Cord Injury Medicine Subspecialty Sports Medicine Subspecialty Select any specialties or subspecialties addressed through the American Board of Plastic Surgery Plastic Surgery Specialty Certificate Plastic Surgery Within the Head and Neck Subspecialty Surgery of the Hand Subspecialty Select any specialties or subspecialties addressed through the American Board of Preventive Medicine Aerospace Medicine Specialty Certificate Occupational Medicine Specialty Certificate Public Health and General Preventive Medicine Specialty Certificate Addiction Medicine Subspecialty Clinical Informatics Subspecialty Medical Toxicology Subspecialty Undersea and Hyperbaric Medicine Subspecialty Select any specialties or subspecialties addressed through the American Board of Psychiatry and Neurology Psychiatry Specialty Certificate Neurology Specialty Certificate Neurology with Special Qualification in Child Neurology Medicine Specialty Certificate Addiction Psychiatry Subspecialty Brain Injury Medicine Subspecialty Child and Adolescent Psychiatry Subspecialty Clinical Neurophysiology Subspecialty Consultation-Liaison Psychiatry Subspecialty Epilepsy Subspecialty Forensic Psychiatry Subspecialty Geriatric Psychiatry Subspecialty Hospice and Palliative Medicine Subspecialty Neurocritical Care Subspecialty Neurodevelopmental Disabilities Subspecialty Neuromuscular Medicine Subspecialty Pain Medicine Subspecialty Sleep Medicine Subspecialty Vascular Neurology Subspecialty Select any specialties or subspecialties addressed through the American Board of Radiology Diagnostic Radiology Specialty Certificate Interventional Radiology and Diagnostic Radiology Specialty Certificate Radiation Oncology Specialty Certificate Hospice and Palliative Medicine Subspecialty Neuroradiology Subspecialty Nuclear Radiology Subspecialty Pain Medicine Subspecialty Pediatric Radiology Subspecialty Select any specialties or subspecialties addressed through the American Board of Surgery General Surgery Specialty Certificate Vascular Surgery Specialty Certificate Complex General Surgical Oncology Subspecialty Hospice and Palliative Medicine Subspecialty Pediatric Surgery Subspecialty Surgery of the Hand Subspecialty Surgical Critical Care Subspecialty Select any specialties or subspecialties addressed through the American Board of Thoracic Surgery Thoracic and Cardiac Surgery Specialty Certificate Congenital Cardiac Surgery Subspecialty Select any specialties or subspecialties addressed through the American Board of Urology Urology Specialty Certificate Female Pelvic Medicine and Reconstructive Surgery Subspecialty Pediatric Urology Subspecialty Will the QI Activity 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 A3 Continuous Quality Improvement (CQI) IHI Collaborative Model LEAN Model for Improvement (PDSA/PDCA) Six Sigma (DMAIC) Total Quality Management (TQM) Describe the gap in quality that is causing this QI Activity to be undertaken. This can be done by comparing the current state of care within your department/organization or practice relative to this QI Activity with the state of care in other settingsIs the QI Activity 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 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. 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 Activity?Describe the projected measures of success that are being, were, or will be used by participants in the QI Activity. 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, it may not be sufficient and may require further data analysis.Measure SourceBaseline ResultTargetBenchmark and source (as available) 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. 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 DescriptionHow will this impact individual practice?How will this impact patient care? 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 a QI/PS lead, coach, or a resident/student advisor, or other leadership role Individual participants in this QI Activity will complete the following. CHECK ALL REQUIREMENTS THAT APPLY TO THIS QI ACTIVITY 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 gaps(s). Reflect on outcomes to determine whether the intervention(s) resulted in improvement. If no improvement occurs after an intervention, diplomates must reflect on why no improvement occurred. Attest to meeting the above requirements and obtain attesting signature of the project leader or person in a position of authority Attach any relevant files regarding the QI Activity that you wish to share with the Portfolio Program Committee Drop files here or Select files Max. file size: 50 MB. Please add any additional comments:Name of person completing this application: First Last Suffix Date submitted: MM slash DD slash YYYY