Supporting Quality Efforts with Maintenance of Certification

October 20, 2014   |  Tags: Blog   |  Tags: QI , Maintenance of Certification
RJ Gillespie, MD, MHPE, OPIP

The Oregon Pediatric Improvement Partnership (OPIP) is committed to working directly with practices in their quality improvement efforts, both through partnership with the Patient-Centered Primary Care Institute and other projects. One of the key factors in meaningful practice participation in quality improvement efforts is aligning intrinsic and extrinsic motivators for the providers involved.

All physicians must complete quality improvement activities to satisfy Part IV Maintenance of Certification (MOC) requirements to maintain board certification; this makes MOC credit a major motivator for providers to participate in quality improvement activities. Projects that lack this credit may compete for providers’ time and effort, making recruitment for non-MOC projects challenging.

The process of MOC includes four distinct parts:

  • Part I: maintaining an unrestricted license
  • Part II: self-directed learning
  • Part III: a standardized examination
  • Part IV: participation in quality improvement projects

Pediatricians must obtain 100 points between Parts II and IV, with a minimum of 40 points in each, and 20 additional elective points. Practically, this means that in every five year cycle pediatricians must participate in at least two eligible quality improvement activities. In the face of multiple health reform priorities, providers often have trouble organizing practice-based efforts that hit on these myriad requirements.

Since January, the American Board of Pediatrics (ABP) recognizes OPIP as a Portfolio Sponsor, meaning that OPIP has the ability to determine which of our projects qualify for MOC credit for participating pediatricians.


"We did quality improvement prior to working with OPIP, but the experience helped us to refine our procedures do it more efficiently."

                              - PCPCI Project Participating Provider


General requirements for participating providers include:

  • Development of aim statements
  • Selection of acceptable measures (done in conjunction with OPIP staff)
  • Implementation of practice changes to achieve the measures
  • Regular collection and review of project level data
  • Participation in project meetings

A minimum of three data collection points are required; continuous participation in a project must last at least nine to twelve months. While OPIP currently can offer MOC credit only to Pediatricians, we are exploring options for extending this benefit to Family Medicine providers as well.

Once a provider has met the requirements, they must submit an attestation form to OPIP to document their participation in the project. In our first round of PCPCI learning collaboratives with practices, OPIP was able to grant MOC credit to providers from three of the five practices implementing improvements while achieving the PCPCH standards.These providers were rewarded for their efforts in advancing the principles of medical home, which included numerous individual practice projects (see below).

Providers have been grateful for the additional benefit of MOC credit. When describing the PCPCI project, one participating provider described the QI project process:

"We walked in overwhelmed…this helped us to organize how we were going to approach the changes we had to make. We are a very busy clinic – taking time out is hard for us. Meaningful Use, CCOs, Medical home standards…were all very overwhelming to us."

The addition of the QI process embedded in MOC credit helped project participants to approach clinical improvement in a way that was logical and digestible for providers.


For more information about the ABP MOC process, visit


PCPCI Practice Spotlight- Sites Where Providers Received MOC Credit from OPIP


Bay Clinic Pediatrics, Coos Bay Oregon
Bay Clinic implemented an in-office administration of the CAHPS CG PCMH survey, including patient engagement materials to explain the need of the survey. Providers (as part of the practice QI team) designed quality improvement projects based on the results of this survey administration.  Components of this project are now being enhanced for a PCPCI learning collaborative on patient experience of care.

Treasure Valley Pediatric Clinic, Ontario Oregon
Treasure Valley Pediatric Clinic focused on improving care and care coordination for ADHD patients by seeking to improve visit rates for those with a diagnosis and prescription, and also to improve the number that had a completed parent questionnaire. After exceeding their goal in the first action period, Treasure Valley moved to implement and spread team based care.

Sanford Children's Clinic, Klamath Falls Oregon
Sanford Children’s Clinic focused initially on implementing the two Bright Futures recommended sensory screenings (hearing and vision) at the four and five year visits. In order to accomplish this, they made improvements to their quality improvement processes, and have since established an official QI Committee that includes all interested staff from the practice. As part of the effort to improve recommended screenings, they utilized public displays of run chart data, and held competitions among the nursing staff to encourage progress toward the goal.  



RJ Gillespie, MD, MHPE, is the Medical Director at OPIP. He can be reached via email at