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Project requirements

Project leader expectations: 

  • Ensure physician adherence to the participation criteria (see below)
  • Monitor meeting attendance and participation, with notes which may be audited
  • Lead design of intervention(s)
  • Oversee data collection and analysis
  • Evaluate impact of intervention(s) to achieve aims
  • Assess QI knowledge of participants and teach QI methods when indicated
  • Review and approve physician attestation forms for all group participants
  • Although not required, we strongly encourage formal QI training (see Where to Get Training in Quality Improvement)
  • Although not required, early consultation with the QIIRC to determine appropriateness of the proposed project is strongly recommended

The project must:

  • Actively engage physicians in problems they can influence in their own practice
  • Use standard QI methods
  • Impact one or more Institute of Medicine quality dimensions: safety, effectiveness, patient-centeredness, timeliness, efficiency and/or equity
  • Have a specific, measurable, relevant and time-appropriate (SMART) aim statement
  • Include appropriate intervention(s), linked to project aims, to be tested for improvement. Improvement changes must include a process change in addition to any educational interventions. Education-only interventions will not meet approval criteria.
  • Collect and monitor data to assess the impact of the intervention. Data should be:
    • Only one measure is required, but we strongly recommend the use of relevant outcome, process and balancing measures to effectively assess impact of interventions and potential unintended consequences.
    • Sufficient sample size to support effective assessment of the impact of the intervention.
    • Evidence that data are of sufficient quality to provide accurate guidance to the project team.
    • Ongoing in collection and reporting in order to assess the impact of the interventions.
    • Processed with regular feedback reports to allow for rapid improvement cycles
  • Be of sufficient duration (generally 6 months) to allow for physician participation in at least one full “PDSA cycle” (cycle of assessment, intervention and re-measurement).
  • Use appropriate charting or reporting tools to document performance over time (e.g., annotated run charts, control charts, etc). Visual representation of at least 3 data points (eg baseline, post intervention 1, post intervention 2) are required.
  • Comply with HIPAA and other regulatory/corporate integrity standards
  • Must be completed within 12 months and submitted by October in order to receive credit for the year