QI Project Application Form

Project Leaders are responsible for completing this application form. This application takes approximately 15-30 minutes to complete if you have the information on hand. Click here to download the application questions to work offline. Applications for completed projects must be submitted by December 1 to allow time for processing in time for the December 21 MOC cycle deadline. Note that incomplete of insufficient information on applications will delay submission to the MOC Oversight Task Force.

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* 1. Please provide the following demographic information for the Project Leader. Physician's date of birth (month and day) as well as first and last name must match ABP records exactly to receive points. Every ABP Board certified physician has a unique, ABP ID number. Physicians who do not know their ABP ID can look it up on the ABP website: https://www.abp.org/content/verification-certification.

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* 2. MOC project participation at ETCH requires completion of the Institute for Healthcare Improvement (IHI) Open School Online Course: QI 102: How to Improve with the Model for Improvement.
Click here to access this FREE online course.

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* 3. Upload you IHI QI 102 certificate of completion.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
Choose File

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* 4. Project Title (a brief title for your project) e.g., Better Otitis Management at 123 Pediatrics

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* 5. Status of the quality improvement effort at the time of submission.

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* 6. Start date of the quality improvement effort (or anticipated)

Date

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* 7. End date of the quality improvement effort (or anticipated)

Date

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* 8. Will this be a(n):

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* 9. If it is a group project, will it be:

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* 10. If this project accepts additional participants, please indicate an enrollment cut-off date.

Date
Quality Improvement Project Description

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* 11. What problem (gap in quality) did the project address?
e.g. Influenza vaccination rates in our practice were consistently lower than the national standard, resulting in an increased frequency of flu among our pediatric patients.

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* 12. Which core competencies does the project address (select all that apply)?
More information about the core competencies is available on the ABP website: https://www.abp.org/content/acgme-core-competencies

Aim Statement
What did the project aim to accomplish?
An aim statement should state a clear, quantified goal set within a specific time frame. Each aim should address:
1. What did you try to change?
2. What was your improvement goal?
3. What was the time frame for this to be accomplished?

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* 13. Label each aim with a numbered bullet.
e.g.
1. Decrease ED LOS through increased utilization of RT driven asthma protocol 20% by October 2018.
2. Decrease 30 day return visit rate for acute exacerbation 20% by October 2018.

Measures
List the measures used to evaluate progress.
Measures are directly related to the aim statement, showing whether a project's changes are resulting in improvement. Each measure should include:
1. Measure Name
2. Measure Type
3. Measure Calculation
4. Data Source
5. Measure Goal
6. Collection Frequency

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* 14. Label each measure with a numbered bullet.
e.g.
1. Managed on Protocol (Process Measure): Increase monthly percentage by 10% the number of patients over 4 with a DC diagnosis of asthma managed with the asthma protocol as per EHR.
2. 30 Day Re-encounter Rate (Outcome Measure): Decrease percentage of 30 day return visits by 10% for acute exacerbation as per EHR.

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* 15. How are results captured and displayed over time?
For more information on measurement tools refer to IHI Open School, QI 104: Interpreting Data: Run Charts, Control Charts, and Other Measurement Tools

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* 16. How will you use the data to drive improvement throughout this project?

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* 17. Is feedback given to the participating physicians at least monthly?

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* 18. Describe the interventions implemented or will be implemented that directly related to achieving the aim of this project with corresponding start dates for each.

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* 19. What are the specific requirements for meaningful physician participation in the quality improvement effort?
Physician Meaningful Participation is defined by the ABP as involving both an active role in the project, and participation over an appropriate period of time. The ABP approves QI projects in which pediatricians are active participants in implementing change.
Active Role: for MOC purposes, means the pediatrician must:
- Be intellectually engaged in planning and executing the project.
- Participate in implementing the project's interventions (the changes designed to improve care).
- Review data in keeping with the project's measurement plan.
- Collaborate actively by attending team meetings, whether in person or virtually.

MOC Oversight Task Force
- Jeanann Pardue, MD, Chief Quality Office, MOC Portfolio Manager
  865-541-8663, jpardue@etch.com
- Tammy Van Dyk, Director of Quality Management
  865-541-8623, tvandyk@etch.com
- Ameeta Lall, MD, Continuing Medical Education Committee Chairman
  alall@etch.com
- Kimberley Campbell, MOC Portfolio Administrator
  865-541-8539, kcampbell@etch.com 
- Karen Smith, Accreditation and  Performance Analyst, MOC Portfolio Administrator
  865-541-8571, kssmith@etch.com
Click DONE to submit your project application.
You will be contacted within 1 week by the MOC Oversight Task Force
with any follow up questions or information regarding next steps.
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