Maintenance of Certification Program in Quality Improvement : Project Application Checklist

Project Application Checklist

Project requirements

  • Impact one or more Institute of Medicine quality dimensions: safety, effectiveness, timeliness, equity, efficiency, or patient-centeredness
  • Follows a standard QI methodology (IHI Model for Improvement, lean principles, etc.)
  • Have a specific, measurable, relevant, and time-bound aim for improvement (outlined in a SMART aim statement)
  • Performance measures collected over the duration of the project. At least one balancing measure to monitor for unintended consequences of the change
  • Include at least 2 specific interventions/PDSA cycles that can be tested
  • Projects must have measures that can be plotted on a simple run chart or process control chart. Annotate interventions on your graphics to track progress overtime
  • Must include at least 6 months of documented physician involvement
  • Comply with HIPAA and other regulatory standards as applicable
  • Must provide data at least quarterly to the Internal Quality Review Committee.

Project Leader Requirements

  • Complete courses QI 101-103 in the IHI Open School or an equivalent QI training and send proof of completion (CME certificate) to the Internal Quality Committee manager
  • Complete and submit a QI project application form to the Internal Quality Review Committee.
  • Lead the project with the support of a QI/ Lean coach
  • Document attendance for team members who are coming to meetings
  • Collect data, annotate interventions, and create run chart/control chart to track progress
  • Provide quarterly data, a final report at project completion, and if selected by the ABP for annual review, an annual report to the Quality Review Committee
  • Attest for physician participants by signing their attestations and handle any disputes that arise in the attestation process.
  • Maintaining all project documentation for 7 years

Participant Requirements

  • Get formal approval to join an approved MOC project from leader
  • Attend at least 3 team meetings over the course of a minimum of 6 months
  • Complete courses QI 101-103 in the IHI Open School and send proof of completion (CME certificate) to
  • Participate in at least 2 tests of change with Plan-Do-study-act (PDSA) planning
  • Obtain and complete the Attestation form, which will be signed by the QI Project Leader at the end of project

Project Materials should be sent to Liz Bayes at