The physician or PA seeking credit must meet one of the following criteria:

• Provide direct or consulting care to patients
• Oversee clinical care delivery
• Have an organizational leadership role in quality improvement or patient safety
• Serve as a quality improvement coach, trainer, or student/resident QI advisor

All individuals participating in a project must:

1. Identify and/or acknowledge a gap(s) in outcomes or in care delivery. 
2. Identify and/or review data related to the gap(s).
3. Identify and/or acknowledge appropriate intervention(s) designed to improve the gap(s), OR participate in the planning and selection of intervention(s) designed to improve the gap(s).
4. Implement intervention(s) for a timeframe appropriate to addressing the gap(s), OR monitor and manage implementation of intervention(s) designed to improve the gap(s).
5. Review post-intervention data related to the gap(s).
6. Reflect on outcomes to determine whether the intervention(s) resulted in improvement. If no improvement occurs after an intervention, the physician or PA must reflect on why no improvement occurred. 
7. Upon reflection of the outcomes, the physician or PA will attest to meeting the above criteria.