Making MOC a Meaningful Process

ABNS Announces Its Maintenance of Certification Program
The American Board of Neurological Surgeons is committed to implementing its new Maintenance of Certification (MOC) Program. The MOC process has been developed under the auspices of the American Board of Medical Specialties (ABMS) in response to the public’s call for increased accountability in many sectors. Recent revelations, such as the Institute of Medicine’s report on medical errors, have given rise to expectations of greater physician accountability. The American public asked for-and as consumers justly deserve-assurance that physician specialists are held accountable to high standards of care.

The intent of MOC is to demonstrate to the public and our profession that diplomates of the ABNS maintain their knowledge and skills to provide quality care in neurosurgery throughout their professional practice careers. The new MOC Program will provide increased value to our diplomates and the public by promoting and sustaining the integrity, quality, and standards of training and practice of neurosurgery with an overriding emphasis on improvement of practice. Over the last three years, the ABNS has been working diligently to develop its MOC Program and soon will be ready to submit its proposal to the ABMS for approval.

Like the ABNS, the 23 other ABMS member boards must decide how to implement the process of MOC. The existing recertification programs of several boards have been reviewed as possible options available to the ABNS for incorporation into its MOC structure. The recertification programs of the other boards have varied widely: about half of the boards utilize secure written examinations while others have used self-assessment exams. A few boards have offered oral examinations as an alternative, but few physicians have chosen this option. Approximately half of the boards have required completion of continuing medical education (CME) requirements.

More Than Recertification
In 1999 the ABNS embarked on its own recertification program, awarding time-limited certificates that must be renewed every 10 years, conditional on passing a written examination of neurosurgical knowledge. In contrast, the MOC Program will be much more comprehensive through maintenance and assessments of basic competencies throughout a 10-year cycle. The ABMS has formulated and adopted six essential competencies for the practicing physician: 1) medical knowledge, 2) patient care, 3) interpersonal and communication skills, 4) professionalism, 5) practice-based learning and improvement, and 6) systems-based practice.

Unlike recertification, the MOC Program is an ongoing process in which a diplomate’s credentials, licensures, and professional standing are verified, and practice-related knowledge and performance are evaluated. The MOC Program will evaluate each physician on the six general competencies. All physician specialists will be required to develop these competencies during their medical education and residency training, to confirm them as part of initial certification, and to maintain them throughout their professional careers in practice.

The ABMS and the Accreditation Council for Graduate Medical Education have defined the six competencies as follows:

1. Medical Knowledge: To demonstrate knowledge of established and evolving medical, clinical, and social sciences and the application of that knowledge to patient care and education of others.
2. Patient Care: To provide compassionate patient care that is appropriate for the promotion of health, prevention of illness, and treatment of disease.
3. Interpersonal and Communication Skills: To demonstrate interpersonal and communication skills that enable the physician to establish and maintain professional relationships with patients, families, and other members of healthcare teams.
4. Professionalism: To demonstrate behavior that reflects commitment to continuooous professional development, ethical practice, understanding and sensitivity to diversity, and a responsible attitude toward patients, profession, and society.
5. Practice-Based Learning and Improvement: To use scientific evidence and methods to investigate, evaluate and improve patient-care practices.
6. Systems-Based Practice: To demonstrate both an understanding of the context and systems in which healthcare is provided and the ability to apply this knowledge to improve and optimize healthcare.

Diplomates will be required to demonstrate that they have met the competency standards established by the ABMS and adopted by the ABNS. In addition to a secure cognitive examination every 10 years after initial certification, diplomates will be required to maintain their certification by fulfilling each component of the MOC Program and to do so on a continuing basis.

Implementing MOC
The ABNS will plan and implement MOC as a fair and credible process; one that we expect will pass public and professional scrutiny, will properly consider the concerns and responsibilities of our diplomates, and will preserve the high standards of our specialty. A specific requirement for participation in the ABNS MOC Program will be forthcoming for those diplomates certified in the near future and also for those with time-limited certificates issued by the ABNS in 1999 and thereafter. The program will be offered on a voluntary basis to all diplomates of the ABNS certified before 1999. The ABNS will have responsibility to determine a diplomate’s admissibility for MOC and will set the specification requirements and standards of our MOC Program.

MOC will dramatically change the way neurosurgeons are credentialed. MOC adds a new dimension of continually maintaining skills and keeping knowledge current. It means ongoing attention to requirements for maintaining one’s good standing within the profession.

Some details of the ABNS program remain to be developed. Like other specialties, the ABNS is free to turn away from the broad requirements of the ABMS for participation in MOC, although to do so would jeopardize its status as an ABMS-member board. Nevertheless, the ABNS is free to implement the principles of MOC in a manner that is most appropriate for neurosurgeons with the provision that they incorporate the basic ABMS structure. This MOC process must meet four requirements:

• Evidence of Professional Standing
• Evidence of Commitment to Lifelong Learning and Periodic Self-Assessment
• Evidence of Cognitive Expertise
• Evidence of Evaluation of Practice Performance

The ABNS has been and is continuing to formulate its requirements and standards within these four components.

Professional Standing With slight modification the ABNS has accepted the ABMS basic requirement for evidence of professional standing as:

• A full and unrestricted license to practice medicine in all jurisdictions in which the diplomate is licensed to practice (letters of concern or reprimand are not considered restrictions).

The ABNS additionally is considering requirements for hospital admitting privileges to practice neurosurgery, recommendations from peers or chief of staff of primary hospitals, and confirmation of these credentials every two years.

The ABNS has not finalized its requirements for the last three MOC components, but is considering the following alternatives:

Lifelong Learning and Self-Assessment For lifelong learning and self-assessment, a diplomate could be required to complete practice-related CME, which would be coordinated with ABNS neurosurgical society and association programs. Exercises and examinations produced by sponsoring societies could be used to satisfy portions of CME as well as self-assessment requirements. Completion of open-book examinations for knowledge assessment and education may contribute to ffuulfilling these requirements as well as preparation for the periodic secure examinations. Besides general neurosurgery topics, subspecialty modules such as vascular, spine, or pediatrics will likely be offered in such an examination.

Cognitive Expertise In assessment of cognitive expertise, diplomates will be required to pass a secure examination every 10 years. It is intended that this examination will be offered in a module format that matches the diplomate’s practice profile as evidenced by practice data or the neurosurgeon’s preference. As an example, each examination might consist of 200 questions, 50 of which pertain to basic knowledge common to all examinees, while the remaining 150 questions would be specific to the selected module(s). The exam content will be based on the pool of questions from the self-assessment examinations. We anticipate this computer-based exam will be offered at regional testing centers and open to diplomates starting three years before the 10-year anniversary of the last certification. Diplomates who fail the knowledge-based test may repeat the examination an unlimited number of times. Also, many states no longer recognize recertification in lieu of a state licensing examination unless the examination is performed in a secured setting. Consequently, the cognitive component of the MOC Program will take the place of possible onerous state examination.

Practice Performance ABNS evaluation of practice performance will undoubtedly evolve in the coming years. One proposed method would require the neurosurgeon to submit a surgical case log of select (key) cases specific to the physician’s type of practice. In a large database from participating neurosurgeons, certain measures related to these cases could be used to establish benchmarks, providing the individual neurosurgeon with valuable information regarding his or her individual performance and areas for improvement. Alternatively, diplomates could be required to submit practice data using an Internet program.

Whatever methodologies are used in meeting the four required components, the MOC Program must encompass within its cycle evaluation of the six general competencies.

In association with its diplomates and organized neurosurgery, the ABNS is working hard to develop a meaningful process of MOC that conforms to the ABMS guideline. The ABNS acknowledges that adopting the MOC Program and process will significantly change professional requirements and at the outset generate considerable frustration. The ABNS, however, is committed to making this new program accessible, affordable, and professionally enhancing for all of its diplomates, and thereby a more meaningful certification process.

Volker K.H. Sonntag, MD, is a director of the ABNS and chair of the MOC Committee. He is the program director of neurosurgery at Barrow Neurological Institute.