Quality Improvement Tools & MOC Part IV Credit

For pediatricians seeking ABP MOC Part IV credit for maintenance of board certification, this project has undergone pre-approval through the ABP.  The deadline to receive credit is December 31, 2022.  There is no associated cost to individual physicians who apply for credit as part of a CASC neonatal antibiotic stewardship quality improvement project.

In order to receive this credit, each physician/site must follow the steps of a data-driven quality-improvement project with the following elements:

QI Project Requirements

  • The project sought to improve a known gap in quality, not acquire new knowledge.
  • The project had quantified goals within a specific time frame.
  • Measures were used to track the progress of the QI project.
  • At least three points of de-identified aggregate data were gathered over time.
  • The physician(s) applying participated in this QI project’s planning, execution, data review,
    implementation of changes, and team meetings.

Information to CASC

The physician(s) applying for credit must submit the following information to CASC upon completion of the project (info@cpcqc.org)

Aim Statement

  • A GAP you want to improve
  • HOW MUCH, and
  • By WHEN


  • Data elements tracked through this project
  • Goals for each measure
  • How often each measure was tracked


  • Graphic displaying AT LEAST three points of data over time (Pre, Post, Sustain OR Baseline, Improvement 1, Improvement 2)
  • Attestation that the physician seeking credit was intellectually engaged in planning and executing the project, helped to implement the project’s interventions (the changes designed to improve care), reviewed data in keeping with the project’s measurement plan and collaborated actively by attending team meetings.

Implementation Guidance

The toolkit section entitled Creating a neonatal antibiotic stewardship quality improvement team will be helpful in designing a project that meets the ABP requirements outlined above.

CPCQC implements quality improvement initiatives following the Institute for Healthcare Improvement’s (IHI) Model for Improvement. This model is built on three simple questions:

  1. What are we trying to accomplish?
  2. How will we know when a change is an improvement?
  3. What change can we make that will result in improvement?

Once they have answered these questions, improvement teams:

  1. Plan a change
  2. Implement (Do) the change on a small scale
  3. Study the outcome of the change
  4. Act on the results
    1. If the change was effective: spread beyond the small test
    2. If the change was not effective: revise the plan and repeat the cycle

This process is commonly referred to as a PDSA Cycle (Plan-Do-Study-Act Cycle), and helps QI teams break down seemingly insurmountable challenges into small, manageable, rapid tests of change.

This toolkit provides specific tests of change for your team to implement. For more detailed guidance on how to conduct quality improvement work, visit IHI’s How to Improve page.

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A steady rise in maternal mortality rates and disparities in infant mortality have increased the spotlight on the quality of care delivered by hospitals and their staff. Together, we can address these issues, improve outcomes and reduce preventable deaths in our state.

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