Is MOC Just a Game?
"There's no MOC Part 4 activity that relates to my area of practice. Is MOC just a game or a make-work activity?"
So began one of the many e-mails I have received over the past few months. One of the wonderful things about assuming a new position at any organization and especially the American Board of Pediatrics (ABP) is the warm welcome offered by so many individuals. An equally important component is the opportunity to listen to frank observations about what an organization is doing right and where it can improve. It's no secret that Maintenance of Certification (MOC) - consisting of demonstration of professional standing (Part 1), life-long learning (Part 2), and periodic secure examinations (Part 3), and quality improvement (Part 4) - has been a source of intense discussion for all specialty boards. Therefore, I was not surprised that MOC has dominated some of the commentary in my e-mails.
So, is MOC a game or just a make-work activity? Because my e-mail correspondent was referring specifically to the quality improvement (QI) part of MOC, my comments below focus mainly on Part 4 of MOC.
The Evolution of Standards in a Profession
The exploration of my correspondent's question begins with an appreciation of the mission of a specialty board and the momentous changes in the external environment-particularly in the last 20 years. In exchange for being granted the privilege of practicing in a profession, members of the profession voluntarily set high standards and develop mechanisms to identify those members of the profession who meet the standards.
The late 19th and early part of the 20th centuries witnessed the development of the truly scientific basis for the practice of medicine. A major enhancement in professional standards followed, including the four-year postgraduate medical school (Flexner report), the adoption of residency training programs, and the creation of specialty boards. Throughout much of the 20th century, specialty boards such as the ABP have sought to satisfy their responsibility to the public by certifying that the pediatrician has completed an accredited training program and mastered a body of knowledge, as evidenced by passing a single certifying examination upon graduation from residency training. Until recently, however, there have been only modest efforts to assess the quality of actual practice.
Knowledge Explosion and Quality Gaps as External Drivers in the 21st Century
Figure 1 illustrates the difficulty with the above approach for the 21st century. MOC is an evolution of the recertification effort that started in the 1990s, which in turn developed out of the recognition that the exponential growth in biomedical knowledge meant that pediatricians could not be expected to practice throughout a 30- to 40-year career without demonstrating that they had updated the knowledge base they acquired in pediatric residency. What may have been a defensible position when the ABP was founded in 1933 was not likely to provide adequate assurances to the public considering that scientific knowledge about children's health had entered an exponential growth phase, which began with President Kennedy's establishment of the National Institute of Child Health and Human Development (NICHD) of the National Institutes of Health.
In addition to the sheer volume of information, data beginning in the 1960s began to reveal the risk of erosion of physician performance after residency training.1
The tipping point for a complete change in certification standards occurred when the Institute of Medicine (IOM) released its two seminal reports, To Err is Human2 and Crossing the Quality Chasm.3 The press, the public, and the federal government received these bombshell studies, which reported nearly 100,000 deaths in the United States annually because of lapses in patient safety and quality. Thereafter, the medical profession and the American public made systematic QI efforts a priority. In the wake of these reports, all 24 specialty boards agreed to make patient safety and QI requirements of MOC. The ABP assumed a leadership role among specialty boards in promoting systematic improvement in the quality of every pediatrician's practice as a central ingredient in the designation "Diplomate of the American Board of Pediatrics."
Once the ABP made the decision to develop a QI program, the question then became how to design a program that would be relevant to more than 65,000 practicing diplomates in general pediatrics and numerous subspecialties in settings ranging from solo practices to large academic medical centers. An additional challenge proved to be the fact that most practicing pediatricians had no formal training in the methods of QI.
Pediatricians own Part 4 of MOC; the ABP just awards the points...
The current Part 4 MOC program has been designed to address these challenges. It includes on-line practice improvement modules (PIMs) in which all participants can learn and apply the basics of a QI program to their practices. Still, some critics have called ABP's hand-hygiene PIM "just a game." If that's so, then it's a deadly game with more than 2 million nosocomial infections and 90,000 nosocomial infection-related deaths in the US annually. Frankly, there is abundant evidence that specific, directed QI interventions are needed to sustain compliance with hand-hygiene standards and reduce nosocomial infection rates.4 More than 10,000 pediatricians have completed the ABP hand-hygiene PIM with documented improvement in adherence to the recommended guidelines.
Participation in a quality improvement network represents a more rigorous approach to QI that is recognized through Part 4 of MOC. In this pathway, pediatricians join a team or network that develops specific goals, interventions, and registries to improve the health of a population of kids. During a recent visit to the American Academy of Pediatrics (AAP) offices in Chicago, for example, I stumbled upon just such a group of primary care pediatricians from around the country. They had come together to establish a QI Network on Genetics in Primary Care (Figure 2). These pediatricians receive MOC Part 4 credit, but that is not their primary motivation for taking time from their practices to set up this network. They, like thousands of others, have decided to assume ownership of improving care for their patients in a systematic way.
A number of other networks have also been established. The outcomes in central-line associated blood stream infections, inflammatory bowel disease remission, cystic fibrosis pulmonary and nutritional status, and asthma hospital admissions, for example, attest to the power of a network of pediatricians focused on improving care.5,6,7 To date, the ABP has approved more than 300 QI efforts from more than 125 organizations-often with dramatic results and all because the pediatricians involved have collectively decided to assume ownership of a children's health care problem and make it better. It is true that they are diplomates meeting the requirements of certification, and as such they receive "points" from the ABP for their involvement in QI; however, MOC is an afterthought in these networks and projects. It is the expression of their commitment to improve the health of children ("ownership") that drives the involvement of these diplomates in QI.
So when some pediatricians argue there are no MOC Part 4 activities that fit their practices, my reply is that ABP is working as fast as it can to promote the development of more QI activities for children, but don't wait for us. Do what the pediatricians in the more than 125 organizations approved for MOC QI activities (and our colleagues in Figure 2) have done. Go out and take ownership of a quality or safety problem that does relate to your practice; and then be sure and tell us about it. We will help you with the methodologies and proudly offer you MOC Part 4 credit. If you are part of an organization that wishes to tackle a quality improvement project in pediatrics, you can go to https://www.mocactivitymanager.org/public/abp/ for more information.
The ABP's Commitment
Even though my e-mail correspondent did not ask what the ABP does about its own internal QI, it is important to note that we are engaged in similar initiatives. Like any other organization, the ABP finds that gaps in performance develop without constant attention. We believe in applying QI methodology for ourselves first. We have a great staff hard at work trying to help you improve the health care of children by upgrading our technological infrastructure, improving access through our Web site, and simplifying the communications process needed to set up a QI network or check on your MOC status. At the policy level, we are also advocating for streamlining the pediatrician's demonstration of competency such that MOC credits can, for example, count toward maintenance of licensure (MOL), Medicaid incentive payments, and Joint Commission "Ongoing Professional Practice Evaluation (OPPE)."
Just as pediatricians had to adapt to changing circumstances at the beginning of the last century so that parents would be assured their children were receiving the best possible care, so too must we adapt in this century. Fortunately, I can say with confidence that diplomates of the ABP are leading the change for better care for children. This is what I think. Please let me know what you think by leaving a comment below.
David G. Nichols, MD, MBA
President and CEO References:
- Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142:260-273.
- Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
- National Research Council. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
- White CM, Statile AM, Conway PH, et al. Utilizing improvement science methods to improve physician compliance with proper hand hygiene. Pediatrics. 2012;129:e1042-e1050. doi:10.1542/peds.2011-1864.
- Crandall WV, Boyle BM, Colletti RB, et al. Development of process and outcome measures for improvement: lessons learned in a quality improvement collaborative for pediatric inflammatory bowel disease. Inflamm Bowel Dis. 2011;17:2184-2191. doi:10.1002/ibd.21702.
- Meyer H. Targeted care improvements show promising results for treating children with asthma. Health Aff (Millwood). 2011;30:404-407. doi: 10.1377/hlthaff.2011.0045.
- Miller MR, Niedner MF, Huskins WC, et al. Reducing PICU central line-associated bloodstream infections: 3-year results. Pediatrics. 2011;128:e1077-e1083. doi:10.1542/peds.2010-3675.