Activity Addresses a Quality or Safety Gap(list as many as applicable)

Yes

No

Is the Gap(s) above supported by a Needs Assessment or problem analysis or must support the completion of such a needs assessment as part of the activity

Yes

No

Activity has specific, measurable aim(s) for improvement (list as many as possible)

Yes

No

Activity includes interventions intended to result in improvement (specify how)

Yes

No

Activity include data collection and analysis of performance data to assess the impact of the interventions

Yes

No

CME/CE Provider defined meaningful clinician participation in their activity (explain how)

Yes

No

CME/CE Provider described the mechanism for identifying clinicians who meet the requirements (define how)

Yes

No

CME/CE Provider provided participant completion information (describe how)

Yes

No

Meet the QPP Criteria

(Yes or No) Answer

Yes

No

Type of CME/CE Credit (ACCME, AAFP, AOA, AANP, AAPA, etc.)

Yes

No

Does this program address QPP Quality Measures?

https://qpp.cms.gov/mips/quality-measures

Yes

No

Do participants in this program utilize Electronic Medical Records or Clinical Data Registry Reporting?

https://qpp.cms.gov/mips/advancing-care-information

Yes

No

Does participation in this program potentially qualify for other improvement activities?

https://qpp.cms.gov/mips/improvement-activities

Yes

No

Does participation in the program qualify for MOC Part II Credit (include the board name in description)

http://www.abms.org/member-boards/specialty-subspecialty-certificates/

Yes

No

Does participation in this activity meet the criteria for MOC Part IV (include board name in description)

http://www.abms.org/member-boards/specialty-subspecialty-certificates/

Yes

No