Maintenance of Certification-A Prescription for Improved Child Health.

When parents seek care for their children, they typically turn togeneral pediatricians andpediatric subspecialists for this care, recognizing that pediatricians have receivedspecializedtrainingtailoredtochildrenandadolescents. Parents generally trust pediatricians inherently and expect that these physicianswill provide outstanding, state-of-the-art care on every encounter, keepingpacewith theconstantlyevolvingpracticeofpediatrics. To demonstrate to parents, hospitals, credentialing bodies, and payors evidence of the necessary background and expertise to provide state-of-the-art care,mostpediatriciansobtainboardcertification, avoluntaryprocess thatgoesaboveandbeyondstate licensing requirements for practicingmedicine and indicates an additional level of accomplishment and expertise. Hospitals increasingly require board certification for medical staff privileges, and credentialing bodies and payors often require board certification for participation in provider networks and for reimbursement. The process of board certification for general pediatricians andmost pediatric subspecialists is administeredby theAmericanBoardofPediatrics (ABP) and requires completionof training in an accreditedprogram, verification by the training programdirector of competence in 6 core competencies (patient care, medical knowledge, practice-based learning and improvement, professionalism, interpersonal and communication skills, and systems-based practice), and satisfactory performance on the ABP certifying examination in general pediatrics or the relevant pediatric subspecialty. For individuals who obtained initial certification in 1988 or afterward to remain certified, the ABP requires participation in Maintenance of Certification (MOC), aprogramthat currently focuseson3of thecore competencies, specifically professionalism, medical knowledge, and practice-based learning and improvement.Maintenance of certification is intended to demonstrate for thepublic thosepediatricianswhomeet the highest standards of professionalism (part 1), lifelong learning and self-assessment (part 2), ongoing knowledge assessment (part 3), and improving professional practice (part 4). The process of MOC has received considerable attention in recent years,1 raising questions amongmembersof thepediatric community (andothermedical specialties)about theobjectives, format, timecommitment, and impact relative to the cost to the diplomate. In response to feedback from pediatricians, the ABP has implementedmajor changes in theMOC program over thepast fewyears, allowingMOCtocontinue toevolve. In particular, the ABPhas attempted to clarify the goals ofMOC, expand the rangeof options to satisfyMOC requirements, create optionsmore applicable to a practitioner’s daily practice and achievable during a routine day, simplify and shorten theprocess for gaining credit, and, most importantly, demonstrate improvement in pediatric care. In an effort to address concerns that options for ongoing learning and self-assessment exclude many continuing medical education offerings and are too limited, the ABP is partnering with the Accreditation Council of ContinuingMedical Education to ensure that continuingmedical educationactivities associatedwith assessment result in automatic credit for part 2. In response to feedback that the closed-book MOC examination assessing knowledge once every 10 years does not reflect practice and is not conducive to sustained knowledge, the ABP has initiated a pilot called MOCAPeds (Maintenance of Certification Assessment– Pediatrics), patterned after an approach that was recently implemented in anesthesiology for part 3 credit. In thispilot, diplomateswill receive20 independentonlinequestionsperquarter andwill have5minutes toanswereachquestion,accessing referencematerial as time allows. The questions are associated with learning objectives, feedback, and references, aiming to stimulate learning and assess knowledge simultaneously and resulting in both part 2 and part 3 credit. To determine whether thenew format achieves thedesiredgoals and is as reliable as the secure examination, the ABPwill be studying this format during the pilot period. Of the 4 parts ofMOC, perhapsmost controversial is part 4, improving professional practice. As a consequence of recent changes, options for improving professional practice are nowplentiful and aremuchmore advanced thansomeof theearlyperformance improvementmodules, someofwhichgeneratedsignificantcynicism. Examples of current options includeparticipating in anyof a long list of national quality improvement (QI) collaborativenetworks,participating inprojects thatare developed andmanaged locally by an institution (institutional portfolios), gaining recognition for being certified as a “patient-centeredmedical home”or a “patientcenteredspecialtypractice,” completingQIprojects that are initiated in the practice workplace, and even facilitating improvements in residency and fellowship trainingprograms.All of theseoptions supplement the longstanding performance improvement modules and the many newer performance improvement modules. The impact that MOC has had on child health outcomes has been substantial, with potential for even greater impact in the future. Among the many QI projects thatpediatriciansarecurrentlypursuing, somewere stimulated directly by the ABP MOC program and otherswere influenced indirectly by theABPyetqualify for MOCcredit. As examples, the ImproveCareNowcollabVIEWPOINT