The commission members of the Continuing Board Certification: Vision for the Future Initiative released their draft recommendations for the future of maintenance of certification (MOC) on December 11, 2018. The commission, initiated by the American Board of Medical Specialties (ABMS), is responsible for “assessing the status of continuing board certification and making recommendations to help enable the current process to become a system that demonstrates the profession’s commitment to professional self-regulation, offers a consistent and clear understanding of what continuing certification means, and establishes a meaningful, relevant and valuable program that meets the highest standard of quality patient care.”
Several of the boards are already piloting new, more-frequent, less-stressful assessment types, so ABMS is essentially catching up to its more innovative boards—and trying to standardize MOC across all the boards. This independent commission is the source of these recommendations.
The draft is open for public comment until January 15, 2019. The commission will review the comments and incorporate them into the final document.
The Commission’s Recommendations to ABMS
Here are the commission’s 15 recommendations, which they divided into three categories: (a) continuing certification programs, (b) stakeholders, and (c) evaluation of efficacy.
A. Expectations for Continuing Certification Programs
Importantly, the commission recommends that the term “Maintenance of Certification” be “abandoned.” In its place, it suggests ABMS use the term “continuing certification” and then uses it throughout its list of recommendations.
Recommendation 1. “Continuing certification should constitute an integrated program with standards for professionalism, assessment, lifelong learning and practice improvement.”
The commission states that the four parts of the current MOC framework are siloed and don’t equally require meaningful diplomate engagement in relevant activities.
Recommendation 2. “Continuing certification should incorporate assessments that support diplomate learning and retention, identify knowledge and skill gaps, and help diplomates learn advances in the field.”
ABMS Boards …
- Should use longitudinal assessment methods
- Should use multi-source data to assess knowledge
- Are encouraged to focus on the diplomates’ practice area
- Are encouraged to develop and test innovative assessments
- Must provide timely, relevant feedback as part of assessments
- Should not withdraw certification status solely due to substandard performance on a single, infrequent, point-in-time assessment (e.g., an exam every 7 to 10 years)
One consideration in deciding on these recommendations included wanting to base assessments in “adult-learning principles (e.g., frequent, spaced learning; repeated assessment; gap analysis with focused education).”
Another consideration was that physicians reported frequently accessing information on the internet during patient care, and so “assessments that rely exclusively on knowledge recall are not aligned with how diplomates practice.”
The commission calls out an example of a successful longitudinal program, the American Board of Anesthesiology MOCA Minute program,
…which allows diplomates to participate in ongoing knowledge assessment using computer-based platforms. Due to the success of this program that includes high ratings from diplomates in terms of value, more than half of the ABMS Boards were implementing, or planning to implement, pilot programs involving longitudinal assessment.
Recommendation 3. “Professionalism is an important competency for which specialty-developed performance standards for certification must be implemented.”
The commission states that its reason for hoping to define a more standard approach is that the ABMS member boards “inconsistently define professionalism and professional standing.”
Recommendation 4. “Standards for learning and practice improvement must expect diplomate participation and meaningful engagement in both lifelong learning and practice improvement. ABMS boards should seek to integrate readily available information from a diplomate’s actual clinical practice into any assessment of practice improvement.”
Recommendation 5. “ABMS Boards have the responsibility and obligation to change a diplomate’s certification status when certification standards are not met.”
The Commission also encourages the ABMS Boards to consider creating certification statuses other than certified or not. For example, diplomates may require remediation for failing to meet a particular set of continuing certification requirements.
Recommendation 6. “ABMS Boards must have clearly defined remediation pathways to enable diplomates to meet assessment, learning and practice improvement standards in advance of any loss of certification.”
B. Stakeholders in Continuing Certification
ABMS’s relationships with its member boards, specialty societies, state medical associations, hospitals, payers, and other stakeholders vary, and the following recommendations appear to standardize and facilitate coordination in support of continuing certification — boards should work with other organizations to help with the creation of the material, to provide input, and so on.
Recommendation 7. “ABMS Boards should collaborate with professional and CME/CPD organizations to create a continuing certification system that serves the public while supporting diplomates in their commitments to be better physicians.”
ABMS Boards should…
- Share data with stakeholders
- Work with CME providers on a uniform way to report credits, minimize costs, and enable meaningful engagement (e.g., gaps in knowledge)
- Hold meetings with specialty organizations to receive feedback
- Communicate with state medical societies and boards to receive feedback
Recommendation 8. “The certificate has value, meaning and purpose in the health care environment.” Hospitals, payers, and other organizations can independently decide what factors they use in making credentialing and privileging decisions and need not use continuing certification as the only criterion for these decisions.
NEJM Group Senior Consulting Education Editor Dr. Ole-Petter Hamnvik is a member of the ABMS commission and states:
Choosing to participate in continuing board certification is a public statement from physicians that they are dedicated to maintaining their medical knowledge as the knowledge base evolves, and to striving toward optimal patient care in all respects. It is therefore understandable that other entities — such as hospital credentialing committees and insurers — may end up using board certification in making their decisions. In a free marketplace, the boards cannot limit other entities’ use of the board certification status for this purpose, but the commission recommends that the board certification status should only be one of many data points that are considered by other entities in their evaluation of a physician — simply choosing not to participate in a continuing certification program should probably not be the sole reason for an adverse action against a diplomate.
C. Research and Evaluation of Continuing Certification
The commission recognizes that the member boards have differing methods for evaluating the effectiveness of their own programs, including “understanding what assessment methods work best and why.”
Recommendation 9. “ABMS and the ABMS Boards should collaborate with other organizations to facilitate and encourage independent research that determines:
- Whether and to what degree continuing certification contributes to diplomates providing a safe, high quality, patient-centered care; and
- Which forms of assessment and professional development activities are most effective in helping diplomates maintain and enhance their clinical skills and remain current in their specialties.”
Recommendation 10. “ABMS Boards must collectively engage in a regular continuous quality improvement process and improve the effectiveness and efficiency of continuing certification programs.”
Recommendation 11. “ABMS Boards must comply with all ABMS certification and organizational standards. ABMS Boards must include diverse diplomate representation for leadership positions and governance membership and require that a supermajority (more than 67%) of voting Board members be clinically active. ABMS Boards should also include at least one public member.”
Recommendation 12. “Continuing certification should be structured to expect diplomate participation on an annual basis.”
Recommendation 13. “ABMS Boards must regularly communicate with their diplomates about the standards for the specialty and to foster feedback about the program.”
Recommendation 14. “ABMS Boards should have consistent certification processes for the following elements:
- A uniform cycle length before a decision about certification status is determined;
- Grace periods (either before or after the certification date);
- Remediation pathways;
- Re-entry pathways to regain certification;
- Single set of definitions for how certification status is portrayed and communicated to users of the credential including the public (e.g. certified, participating in continuing certification, probation, revocation, not certified, etc.); and
- Appeals processes.”
Recommendation 15. “ABMS Boards should facilitate reciprocal longitudinal pathways that enable multi-specialty diplomates to remain current in multiple disciplines across ABMS Boards without duplication of effort or excessive requirements.”
Next Steps for the ABMS and Its Member Boards
The commission concedes that there are “inconsistencies that caused confusion and frustration among diplomates.” Some boards have moved to longitudinal assessment programs while some have maintained high-stakes exams. Some are proctoring assessments while some are allowing access to specific online resources. “These types of inconsistencies in content and requirements have led to perceptions of inequity among diplomates.”
While the commission’s recommendations’ goals are to address these concerns, some elements may require further clarification.
Dr. Hamnvik states:
The medical profession is allowed to self-regulate through the process of board certification. The public and policy makers expect board certification to have real meaning as a marker of a physician’s competence, even years after the initial certification. These recommendations lay the groundwork for continued self-regulation by recommending a fair, transparent, and meaningful continuing certification process.
Again, these draft recommendations are open for public comment until January 15, 2019, and the commission plans to review the comments and incorporate them into the final document.