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IRCDA – MOC Overview

IRCDA – MOC Overview. MOC Walkthrough. Background Review MOC Requirements by Institution Project Physician SCAMPs Process Meaningful Participation: How does a SCAMP meet requirements? Defining SCAMP Cycle Defining Quality Measure Requirements MOC Process - Deliverables.

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IRCDA – MOC Overview

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  1. IRCDA – MOC Overview

  2. MOC Walkthrough • Background • Review MOC Requirements by • Institution • Project • Physician • SCAMPs Process • Meaningful Participation: How does a SCAMP meet requirements? • Defining SCAMP Cycle • Defining Quality Measure Requirements • MOC Process - Deliverables

  3. SCAMPs MOC Background • Boston Children’s Hospital (BCH) is Sponsor of MOC portfolio • SCAMPs conducted by IRCDA members go through BCH application process for approval • ABP put in place new requirements for credit, and began auditing of Sponsor portfolios in 2013 • SCAMPs in BCH portfolio did not meet new criteria set forth by ABP • BCH and IRCDA have undergone a 4-month project to make SCAMPs fit the MOC QI mold

  4. MOC Portfolio Structure for NECCA

  5. MOC Sponsor Portfolio Criteria A QI activity must be formally structured by the sponsor organization to include: • Leadership, staff, and support for QI activities; • Clearly defined roles, responsibilities, and accountability for project leaders and participating physicians; • Effective mechanisms for ensuring that physicians who receive MOC Part IV credit have participated meaningfully; • An auditable record-keeping system to track physician participation in QI efforts; • Hold documentation of policies and procedures for management and administration of the project (including project design, processes, leadership, participant activities, and results) for 7 years • Dispute resolution process regarding physician participation; • HIPAA compliance.

  6. QI Project Criteria A QI activity seeking qualification for MOC Part IV credit must address the following: • Impact one or more of the IOM quality dimensions • Have a defined project aim statement • Use accepted QI improvement methods • Select an appropriate target population for achieving the project aim • Collect a minimum of two quality measures to be tracked over time • Systematic implementation of interventions seeking improvement and relevant to aim • Use of data improvement • Have meaningful physician participation • Produce an annual progress report • 10% of BCH’s portfolio is selected for submission to ABP

  7. Physician Meaningful Participation Criteria • -Expectation for ALL physicians seeking credit, including project leadership. • -Physician cannot receive credit for the same QI project twice in the same 5 year cycle. • Minimum 6 months participation in QI project • Completion of QI science education program • Provide direct or consultative care to patients as part of the QI project • Implement the project’s interventions • Collect, submit and review data in keeping with the project’s measurement plan • Collaborate actively by attending at least four project meetings • Personally reflect on the QI activity

  8. SCAMPs MOC Process - Deliverables • Pre-Application Questionnaire • Identification of Participating Physicians • “MOC Project Application” • SMART aim statement • Minimum two (2) quality measures “MOC Progress Report” Minimum four (4) project meetings Complete SDFs for SCAMP Routine data review “Physician Attestation” “SCAMPs Personal Reflection” QI Science Education Certificates of Completion $150 check to BCH Project Initiation Project in Progress “Cash-in” for Credit

  9. SCAMPs MOC Process - Deliverables • Pre-Application Questionnaire • Identification of Participating Physicians • “MOC Project Application” • SMART aim statement • Minimum two (2) quality measures “MOC Progress Report” Minimum four (4) project meetings Complete SDFs for SCAMP Routine data review “Physician Attestation” “SCAMPs Personal Reflection” QI Science Education Certificates of Completion $150 check to BCH ProjectInitiation Project in Progress “Cash-in” for Credit

  10. SCAMPs MOC Process - Deliverables • Pre-Application Questionnaire • Identification of Participating Physicians • “MOC Project Application” • SMART aim statement • Minimum two (2) quality measures Project Initiation Complete “SCAMP MOC Pre-Application Questionnaire.docx”

  11. SCAMPs MOC Process - Deliverables • Pre-Application Questionnaire • Identification of Participating Physicians • “MOC Project Application” • SMART aim statement • Minimum two (2) quality measures Project Initiation Complete “Participating Physicians Template.xlsx”

  12. SCAMPs MOC Process - Deliverables • Pre-Application Questionnaire • Identification of Participating Physicians • “MOC Project Application” • SMART aim statement • Minimum two (2) quality measures Project Initiation Complete “SCAMP MOC Application.doc”

  13. SCAMPs MOC Process - Deliverables • Pre-Application Questionnaire • Identification of Participating Physicians • “MOC Project Application” • SMART aim statement • Minimum two (2) quality measures Project Initiation • Ensure the project aim statement is SMART: • Specific: The aim is well-defined and clear, and has a better chance of being reached than a general aim. • Measurable: Objectives should have a benchmark and target, to help determine when objectives are achieved. • Achievable: The aim is something that can actually be reached. • Relevant: The aim is relevant to your program’s mission, vision, and goals, and is agreed upon by stakeholders. • Timely: The aim has a set time-frame to be met.

  14. SCAMPs MOC Process - Deliverables • Pre-Application Questionnaire • Identification of Participating Physicians • “MOC Project Application” • SMART aim statement • Minimum two (2) quality measures Project Initiation Complete “Measures Table Template.xlsx”

  15. SCAMPs MOC Process - Deliverables • Pre-Application Questionnaire • Identification of Participating Physicians • “MOC Project Application” • SMART aim statement • Minimum two (2) quality measures “MOC Progress Report” Minimum four (4) project meetings Complete SDFs for SCAMP Routine data review “Physician Attestation” “SCAMPs Personal Reflection” QI Science Education Certificates of Completion $150 check to BCH Project Initiation Project in Progress “Cash-in” for Credit

  16. SCAMPs MOC Process - Deliverables “MOC Progress Report” Minimum four (4) project meetings Complete SDFs for SCAMP Routine data review Project in Progress Complete “MOC Progress Report.docx” annually in June

  17. SCAMPs MOC Process - Deliverables “MOC Progress Report” Minimum four (4) project meetings Complete SDFs for SCAMP Routine data review Project in Progress How is attendance captured? Meeting minutes must reflect physician attendance Project leader must attest to active participation in SCAMP decision making

  18. SCAMPs MOC Process - Deliverables “MOC Progress Report” Minimum four (4) project meetings Complete SDFs for SCAMP Routine data review Project in Progress Complete SDFs as part of patient care and SCAMP algorithm

  19. SCAMPs MOC Process - Deliverables “MOC Progress Report” Minimum four (4) project meetings Complete SDFs for SCAMP Routine data review Project in Progress Review selected quality measures as part of monthly report

  20. Physician Meaningful Participation

  21. SCAMPs MOC Process - Deliverables • Pre-Application Questionnaire • Identification of Participating Physicians • “MOC Project Application” • SMART aim statement • Minimum two (2) quality measures “MOC Progress Report” Minimum four (4) project meetings Complete SDFs for SCAMP Routine data review “Physician Attestation” “SCAMPs Personal Reflection” QI Science Education Certificates of Completion $150 check to BCH Project Initiation Project in Progress “Cash-in” for Credit

  22. SCAMPs MOC Process - Deliverables • “Physician Attestation” • “SCAMPs Personal Reflection” • QI Science Education Certificates of Completion • $150 check to BCH “Cash-in” for Credit Complete and sign “MOC Physician Attestation.docx”

  23. SCAMPs MOC Process - Deliverables • “Physician Attestation” • “SCAMPs Personal Reflection” • QI Science Education Certificates of Completion • $150 check to BCH “Cash-in” for Credit Complete “SCAMP MOC Personal Reflection.docx”

  24. SCAMPs MOC Process - Deliverables • “Physician Attestation” • “SCAMPs Personal Reflection” • QI Science Education Certificates of Completion • $150 check to BCH “Cash-in” for Credit Complete QI Science Education The Institute for Health Improvement (IHI) courses may be accessed through their website: http://app.ihi.org/lms/onlinelearning.aspx

  25. SCAMPs MOC Process - Deliverables • “Physician Attestation” • “SCAMPs Personal Reflection” • QI Science Education Certificates of Completion • $150 check to BCH “Cash-in” for Credit After obtaining all required signatures, please write a check for $150 payable to “Boston Children’s Hospital” Please direct your attestations to: Ashley Renaud, RN Manager, Training and Implementation Ashley.Renaud@ircda.org 617-355-4280 Include: (1) Signed attestation (2) Personal reflection form (3) QI Science Education Certificates of Completion (4) $150 check

  26. Next Steps for NECCA General: • Develop a structure for maintaining records of meeting minutes for SCAMP review meetings. • Reiterate importance of including the clinician’s name on all completed SDFs • Create a list of physicians who are considered to be on SCAMP development team and send to IRCDA For 2014 Credit: • Identify Local Leaders and Local Physicians, by site location, planning to use MOC for 2014 credit • All requests for 2014 MOC credit must be submitted by December 1st • BCH will sign off on all reasonable requests for 2014 credit for those who have not already received credit for the project Starting in 2015: • New rules apply: • All requests for credit must be accompanied by supporting documentation • All participation criteria must be met for credit • Physicians must have participated in 2 SCAMP iteration cycles for credit

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