August 2003 Bulletin

Maintenance of certification update: A report from ABMS

In response to concerns expressed by the membership, the AAOS and the American Board of Orthopaedic Surgery (ABOS) have been discussing the issue of recertification, including but not limited to concerns such as the need for a cognitive exam, the costs in time and money and the effectiveness of the current recertification process in discerning the quality of physician performance.

At the same time, the American Board of Medical Specialties (ABMS) and its member Boards began an evaluation of the recertification process, which in turn led to development of a new concept—namely, Maintenance of Certification (MOC).

The ABOS, in close cooperation with your Academy, developed three of the four basic components as part of its MOC Program, and submitted this plan to ABMS for its approval. What remains will most likely prove to be the most difficult— that of evidence of evaluation of performance in practice.

At its meeting in June 2003, the AAOS Board of Directors established a new standing Maintenance of Competence Committee, to be chaired by David G. Lewallen, MD. This committee will continue to interface with the ABOS to determine the role of the Academy in this process, including developing methods of educating members on professionalism, ethics, communication and patient safety and developing a curriculum for the cognitive exam.

The intent in publishing this article is to provide a continual update of this process as it progresses. In this particular article, Dr. Miller discusses the issue as visualized by ABMS.

— William W. Tipton, Jr., MD, AAOS Director of Medical Affairs

By Stephen H. Miller, MD, MPH

The Board movement originally arose out of the concern for physician quality. Every American Board of Medical Specialties Board of Directors, either explicitly or implicitly, addresses this concern by setting standards for training and cognitive knowledge for its specialty. Despite this process, quality in American health care, including physician quality, has once again become an issue. In the past three years, the Institute of Medicine published two major reports critical of the quality of American health care, "Too Err is Human" and "Crossing the Quality Chasm."

In response to these recent concerns, the ABMS Task Force on Maintenance of Competence was formed. The emerging program represents a major advance over recertification because it is a comprehensive program that focuses on assessing physicians on more than just their performance on a written examination.

It is hoped that assessment of physician practice performance will add value to the physician by: simplifying the work necessary to care for patients; improving the efficiency of practice; improving patient, staff and physician satisfaction; and reducing duplicate assessment efforts by serving as the benchmark standard to fulfill the requirements of multiple assessment processes. Effective MOC programs may also reduce medical licensure hassles and malpractice premiums.

The MOC program, approved by the ABMS on March 16, 2000, has four basic components: 1) evidence of professional standing; 2) evidence of a commitment to lifelong learning and involvement in a periodic self-assessment process; 3) evidence of cognitive expertise; 4) evidence of evaluation of performance in practice.

Several organizations, such as Joint Commission on Accreditation for Healthcare Organizations, National Committee for Quality Assurance, Agency for Healthcare Research and Quality, National Quality Forum and Centers for Medicare and Medicaid Services, are proposing programs to measure quality of care, including physician performance. The member Boards have a unique but narrow window of opportunity to assume a leadership role in current efforts to address the quality gap through the emerging MOC program, which includes assessment of physician practice performance. The standard for the assessment of physician practice performance will be based on participation in a valid process where physicians are asked to demonstrate that they can assess their own quality of care as a baseline compared to peers and national benchmarks and then apply the best evidence or consensus recommendations to improve care.

For practice assessment, the ABMS Member Boards plan to use a quality improvement approach rather than a regulatory or inspection approach that only identifies poor performers who fail to meet a minimal standard. Engagement in the process of critical self-assessment is essential for self-improvement. Except for a few instances of physicians performing large numbers of procedures, most health outcomes researchers feel it is currently not possible to accurately discriminate individual physician performance.

An approach that meets the requirements for Part IV of Maintenance of Certification assessing and improving care offers the greatest opportunity for the Boards to play a leadership role in addressing healthcare quality issues, and directly benefits both patients and diplomates.

Stephen H. Miller, MD, MPH, is executive vice president of the American Board of Medical Specialties.

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