During the 2011 Workshop on Perinatal Practice Strategies sponsored by the American Academy of Pediatrics Section on Perinatal Pediatrics, I reviewed the essentials of the American Board of Pediatrics (ABP) program for Maintenance of Certification (MoC). This article is a synopsis of that presentation. Although the principles of MoC are applicable across pediatric subspecialties (and many apply to General Pediatrics as well as the subspecialties), my comments in this article are directed primarily to clinicians interested in the MoC program as it applies to certificate holders in Neonatal-Perinatal Medicine (NPM).
The process of awarding certificates in General Pediatrics and pediatric subspecialties is under the governance of two organizations: the Accreditation Council for Graduate Medical Education (ACGME) and the ABP. The ACGME develops accreditation requirements for training programs in 26 medical specialties and evaluates the programs through on-site visits and data collection. The ABP sets the standards that a resident or fellow must meet during training to be admitted to the initial certification examinations for General Pediatrics and 20 pediatric subspecialties. The ABP works closely with the ACGME to ensure that requirements for accreditation of training programs and standards for certification are aligned. The ABP also creates and implements the process of MoC to ensure ongoing mastery of the competencies measured during training.
From the inception of the process of board certification until 1988, certification was obtained by passing a test of cognitive knowledge, typically at the end of training, with such certification remaining permanent. Beginning in 1989, a diplomate (the term used to describe a certificate holder) was required to pass a similar test every 7 years. The certificates became known as time-limited certificates. In 2002, the transition from a system of time-limited certificates to a program of MoC began. Unlike the episodic nature of time-limited certification and recertification, MoC is a continuous process, requiring ongoing participation in various evaluative and self-assessment activities designed to enhance professional development.
The evolution of the certification process followed the adoption by the ACGME and the American Board of Medical Specialties (ABMS), the certifying boards of medical specialties, of the idea of general competencies for physicians. Such competencies are based on the concept that although medical knowledge is essential, it is not sufficient; competency in patient care, communications, professionalism, practice-based learning and improvement, and system-based practice are also necessary to deliver quality care. This idea was the product of observations identified in the Institute of Medicine's report “Crossing the Quality Chasm,” (1) which described the gap in quality of health care between what is and what could be.
The ABP and the other 23 certifying boards of the ABMS collaborated to create a program for maintaining board certification that included the following four-part structure:
Part 1. Professional Standing
Part 2. Lifelong Learning
Part 3. Cognitive Expertise
Part 4. Performance in Practice
Based on these four elements, the ABP developed their strategy for MoC for pediatric generalists and subspecialists.
Part 1: Professional Standing
Diplomates must hold a valid, unrestricted license to practice in a United States state, territory, or Canadian province, and the license must be held continuously.
Part 2: Lifelong Learning
Diplomates must participate in activities that assess and enhance knowledge in areas important to their practice through ABP-approved activities. Although diplomates in NPM may complete any ABP-approved activity to satisfy the requirements for Part 2 of MoC, diplomates in NPM currently have two logical options for satisfying these requirements: participate in an online assessment and learning tool developed by the ABP for NPM diplomates or participate in the American Academy of Pediatrics (AAP) program NeoReviewsPlus.
The online ABP-sponsored activity provides a list of sentinel and recently published articles in neonatal perinatal medicine. Diplomates are given credit for participation in this activity by passing an online examination that includes a series of multiple-choice questions addressing the content of these articles. Articles are selected by the NPM Subboard, with a new list posted annually. There is no charge for participating in this activity. Alternatively, diplomates in NPM may participate in the AAP-sponsored NeoReviewsPlus.
Part 3: Cognitive Expertise
Diplomates in NPM must pass a secure examination every 10 years. The examination is offered semiannually at testing sites throughout the United States and at selected locations abroad. The examination is developed by the NPM Subboard and is not the same examination administered for initial certification. The questions are intended to test knowledge expected of competent practicing neonatologists. The passage rate is in excess of 90%.
Part 4: Performance in Practice
Diplomates must participate in ABP-approved projects designed to assess and improve the quality of their care. The underlying principle of Part 4 is for practitioners to incorporate quality improvement science into their daily practice, that is, to demonstrate that they can assess and improve their quality of care by incorporating evidenced-based practices. Physician groups are encouraged to develop patterns of care based on current scientific knowledge. In addition, they are encouraged to track clinical outcomes contemporaneously to discover and disseminate practices that achieve the best outcomes.
One option for satisfying the Part 4 requirement is participation in web-based improvement activities. Although diplomates in NPM may participate in any ABP-approved activity, only two web-based modules are well suited for applications in neonatal medicine: the Performance Improvement Modules developed by the ABP of Hand Hygiene and Breast Milk Use. Detailed information about these modules, including an online demonstration video, is available on the ABP web site. These modules form a comprehensive platform that includes education about quality improvement science as well as resources for performing improvement projects in these two domains. The charge for participation in these modules is included in the enrollment fee for MoC.
A second option is to participate in established quality improvement projects sponsored by consortia of provider groups. Examples include initiatives developed by national collaboratives (eg, the Vermont Oxford Network), state collaboratives (eg, the California Perinatal Quality Care Collaborative), or corporate physician groups (eg, the Pediatrix Medical Group). In addition, selected individual hospitals have been approved by the ABP to hold portfolios of projects for their clinicians (eg, Cincinnati Children's Hospital). All projects must be approved in advance as a qualifying activity. To obtain credit toward satisfying the requirements of Part 4, diplomates must participate actively in an approved project, and their participation must be documented through an attestation process.
All Part 2 and 4 activities are awarded point values. Except for special requirements resulting from the circumstances arising during the transition from episodic recertification to the MoC process, diplomates are required to accumulate 100 points during a 5-year cycle, with 40 points from Part 2 activities, 40 points from Part 4 activities, and 20 points from either Part 2 or 4 activities.
Diplomates Whose Certificates Expire in 2011 to 2016
Diplomates who have time-limited certificates scheduled to expire between 2011 and 2016 can maintain their certificates by completing one Part 2 and one Part 4 activity (regardless of their point value) and enrolling in MoC by November 30 of the year of expiration of their certificates. Their new MoC 5-year cycles will begin on the following January 1. Although the expiration dates of their certificates will be 7 years after the date they last passed the re-certification examination, they will not have to pass the MoC examination until 10 years after they last passed the examination.
NPM Fellows Completing Training in 2011
Fellows who successfully complete all training requirements in 2011 are eligible to sit for the certification examination in 2012. After passing the examination, they will be issued a time-limited certificate. They must maintain certification by accumulating 100 points in Part 2 and 4 activities (as outlined previously) during each subsequent 5-year period and passing an examination every 10 years.
Diplomates Holding Permanent Certificates
Before 1989, diplomates were awarded permanent certificates in NPM. These individuals will always be considered diplomates (ie, certificate holders) by the ABP as long as they maintain active medical licenses, regardless of whether they participate in MoC. However, permanent certificate holders who wish to participate in the MoC program may do so at any time by passing the examination, acquiring 100 points in Part 2 and 4 activities, and enrolling in MoC.
Maintaining a Certificate in General Pediatrics
Maintenance of a certificate in General Pediatrics is not a requirement for maintenance of a certificate in NPM. However, for those who choose to maintain both certificates, the only requirement, in addition to the MoC requirements for NPM, is to pass the examination in General Pediatrics every 10 years. The Part 2 and 4 activities used to satisfy the requirements for MoC in NPM count toward the requirements for MoC in General Pediatrics; additional activities need not be completed.
Understanding MoC Requirements and Identifying Part 2 and 4 Activities
The only authoritative resource for understanding individual requirements for MoC is the ABP web site. Within this web site, each diplomate has an individual portfolio that can be accessed through the ABP home page (https://www.abp.org; Fig. 1). The individual portfolio is a private, password-protected area of the web site. The initial screen after logging in directs the diplomate to one of four categories (Fig. 2). Choosing the “Maintenance of Certification” option directs the diplomate to all of the essential information regarding his or her certificate, including dates for completion of required activities and resources for completing Parts 2 and 4 (Fig. 3). All certificate holders should review their portfolios thoroughly.
Development of New Resources for Parts 2 and 4
The ABP has developed guidelines for external organizations that plan to create self-assessment activities to satisfy the MoC Part 2 requirements. These are available on the ABP web site. Diplomates in NPM may have additional options in the future, developed by external organizations, for satisfying the requirements for Part 2 of MoC. Possible examples include the ongoing programs sponsored by the AAP: NeoReviews or NeoPREP.
The ABP also welcomes new applications from external organizations for approval of Part 4 activities. These activities must be established, structured, sustainable quality improvement projects that have previously demonstrated improvements in care and are based on accepted quality improvement science and methodology. Details of these requirements and the application procedure are available on the ABP web site. The sponsoring organization is responsible for the cost of the application fee (currently $500), the development and administration of the activity, and all required reporting to the ABP.
The ABP recently piloted a program in which organizations maintain a portfolio of projects. The organization assumes the responsibility for evaluating each project in their portfolio using the standards established by the ABP. The evaluation and review of projects is conducted by a standing committee of quality improvement experts within the sponsor organization. Although approved portfolios are currently held only by individual hospitals, the ABP has expressed an interest in expanding this aspect of MoC to other sponsor organizations, such as AAP sections and provider groups. Inquiries about this option should be directed to Dr Paul Miles at the ABP.
Public Reporting of Status of Certificate Holders
Because the ABP has a primary responsibility to the public, an important function of the ABP web site is to provide information about the status of diplomates. This is reported in a public area of the web site: “Verification of Certification” (Fig. 4). An individual's status is reported in three ways: 1) Certificates held, 2) Year of most recent certification and expiration date (“No Expiration” is listed for permanent certificate holders), and 3) Indication of whether the diplomate is meeting the requirements for MoC. Further information about the implications of the entry is available for each entry. For example, if a diplomate has permanent certificates in General Pediatrics and NPM but has chosen not to participate in MoC, the following information would be provided about this status:
“Maintenance of Certification (MoC) is a new process by all 24 ABMS boards that continuously assesses the six core physician competencies adopted by the ABMS and the ACGME throughout a physician's career. The six competencies that have been identified as important to deliver quality care are communication skills, professionalism, medical knowledge, patient care, practice-based learning and improvement, which includes the ability to measure and improve quality of care and system-based practice.”
Why Participate in MoC?
A powerful motive for participation in MoC, particularly Part 4 activities, is that doing so will improve the quality of care for children. Ample evidence shows that properly executed quality improvement projects can improve processes of medical care, including those that are essential to neonatal intensive care. Evidence also indicates that such projects can change selected important outcomes of care. The most compelling evidence is the reported reduction in catheter-associated bloodstream infections. (2)(3)(4) In addition, a reduction in retinopathy of prematurity has been reported. (5) However, a major criticism of these reports is their reliance on historical controls or changes in the incidence of an outcome before and after institution of a bundle of interventions to determine success. This, of course, is an inherent feature of quality improvement methodology, but such design lacks the rigor of the randomized, controlled trial design used in traditional clinical research. Further, evidence in support of the successful application of quality improvement methodologies to change other important neonatal outcomes is lacking, and some disappointing failures have been reported. (6) In the future, additional successes should increase the enthusiasm of neonatologists for participation in such projects.
Another motivation for participation in MoC is that some hospitals require MoC as a requisite for credentialing. Although only a few hospitals currently require MoC, there is little doubt that others will institute this requirement in the future.
Finally, certification by one of the specialty boards (eg, the ABP) is increasingly used as a marker of expertise by state medical licensing boards. The Federation of State Medical Boards, a group that oversees most state licensing boards, has approved the concept of “maintenance of licensure” for all licensed physicians in the United States. State boards ultimately may offer two options for maintenance of licensure: periodic successful completion of the state general licensing examination or meeting the requirements of MoC of a member board of the ABMS. Although significant obstacles must be overcome before this concept becomes law in most states, it is being piloted in at least four states, and some see this change as inevitable.
The transition from permanent certification by the ABP to periodic recertification to a program of MoC is nearly complete. Diplomates who have time-limited certificates in NPM are now required to complete four parts of the MoC program to continue to hold their certificates beyond the expiration date. All diplomates must participate in the program to be listed on the ABP web site as meeting the requirements of MoC, and MoC may, in the future, be required for hospital credentialing and state licensure.
Certain requirements for MoC demand a substantial commitment of time and effort, particularly Part 4 activities. For that reason, some diplomates may choose not to participate. For those who choose to participate, a thorough understanding of the requirements is critical. Participants should not rely on family, friends, and colleagues as sources of information regarding these requirements. Clinicians should search the ABP web site, specifically their individual portfolios, to learn more about MoC. Questions should be directed to the ABP either electronically () or by phone (919-929-0461).
Dr Bose has disclosed no financial relationships relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
- Copyright © 2011 by the American Academy of Pediatrics
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