Quality Payment Program (QPP) CME Improvement Activity Worksheet

    Date:
    Account Activity:
    Prepared by:
    CME/CE Provider:
    Questions Description Yes No
    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

    QPP CME Improvement Activity Credit Worksheet cont.

    Date:
    Activity Title:
    Prepared by:
    CME/CE Provider:
    Credits Description 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