Meaningful Participation Criteria

Meaningful participation refers to the active participation of physician participants in QI Efforts. The BMC Portfolio Program has established the following minimum standards, which should be used as a guide when planning your QI Effort. As a QI Leader/Project Lead, you will attest to your selections below near the conclusion of the QI Effort.

Please note: The Meaningful Participation Attestation form should be completed and submitted in the BMC Portfolio Application System, however, we recommend using this form to make sure your team is meeting the following minimum requirements. Should any disputes arise among participating physicians regarding their eligibility for credit, these are the standards they will be held to when resolving the dispute:

  1. Physicians perform at least one of the following roles:
    • Option 1: Participates in QI Effort by providing direct or consultative care to patients
    • Option 2: Facilitates/supervises residents during QI Effort
    • Option 3: Leader or core implementation team member of QI Effort

  2. Test, implement and assimilate the QI Effort’s intervention(s) into practice as appropriate for each role identified in standard 1 above:
    • Option 1: Each participating physician should engage in the QI Effort intervention in at least 50% of all available opportunities (Note: If 50% is not an appropriate standard for participation in your QI Effort intervention, please specify why and describe your alternative requirement)
    • Option 2: Resident supervisors/facilitators participate sufficiently to the QI Effort to meet your standards (Please define the standard. Example: Faculty supervising/observing resident I-PASS patient handoffs must make 6-12 observations in 1 year to be eligible for credit)
    • Option 3: Project Leader or core team member was involved in the design, implementation and evaluation of the QI Effort

  3. Collect, submit and/or review data at least three times.
  4. Reviewing key performance metrics for the project must happen at least quarterly. Monthly or weekly review is strongly encouraged. Data may be collected by participating physicians, IT reports, medical student, support staff or other methods.
    • Option 1: Weekly, monthly, or quarterly meetings
    • Option 2: Participating physicians performed self-review of 5-10 charts to assess personal performance at least quarterly
    • Option 3: Review QI Effort group data on CME data portal or other web-based interface where it is displayed at least 3 times (documented by an evaluation form provided by the web-based interface)
    • Option 4: If another method was used, you will be asked to describe it in the BMC Portfolio Application System

  5. Collaborate actively by attending at least four project meetings over the attestation period.
  6. Project meetings may be the same meetings during which you reviewed data. Meeting topics should include at least one of the following:
    • Review of group performance data
    • Discussion of ideas on new solutions to test and implement
    • QI education component (optional meeting topic)

  7. Complete QI Education Component.
  8. Once QI education requirement is satisfied for a participating physician, she or he does not have to repeat that education for each new project initiated in the department. Potential options that satisfy this requirement include:
    • Complete BMC QI Curriculum, available from: QI Curriculum at BMC
    • Require all participating physicians to complete the IHI’s QI 101-103 online modules. Note that modules 101-103 are accredited for AMA PRA Category 1 CreditTM and are eligible for MOC Part II credit from the primary care specialty boards if participants complete modules 101-106.
    • QI education in a Grand Rounds session. Note that if you can incorporate this into your department’s grand rounds schedule, it will be eligible for AMA PRA Category 1 CreditTM and risk management credit.
    • Participants attend at least 4 sessions of the BMC QI Training Program Curriculum led by James Moses (please contact Makeba Kent to be added to the listserv for upcoming sessions: Makeba Kent)
    • Department has already completed QI education from a previous project (please describe):

  9. Complete pre and post self-assessment of QI proficiency.
  10. If you submitted your project prospectively using the QI Effort: Proposal application, please try to have participants complete both the pre and post.

  11. You may specify additional requirements as appropriate to your QI Effort.


If you have any questions, please contact Emily Jansen by e-mail, or by calling the CME Office at 617-638-4605