CommentaryMaintenance of Certification: Realities for the Practitioner

Author Disclosure

Dr Bose has disclosed no financial

relationships relevant to this

commentary. This commentary does

not contain a discussion of an

unapproved/investigative use of a

commercial product/device.

AbstractDuring the 2011 Workshop on PerinatalPractice Strategies sponsored by theAmerican Academy of Pediatrics Sec-tion on Perinatal Pediatrics, I reviewedthe essentials of the American Board ofPediatrics (ABP) program for Mainte-nance of Certification (MoC). This arti-cle is a synopsis of that presentation.Although the principles of MoC areapplicable across pediatric subspecial-ties (and many apply to General Pedi-atrics as well as the subspecialties), mycomments in this article are directedprimarily to clinicians interested in theMoC program as it applies to certificateholders in Neonatal-Perinatal Medicine(NPM).

IntroductionThe process of awarding certificates inGeneral Pediatrics and pediatric sub-specialties is under the governance oftwo organizations: the AccreditationCouncil for Graduate Medical Educa-tion (ACGME) and the ABP. The ACGMEdevelops accreditation requirements fortraining programs in 26 medical spe-cialties and evaluates the programsthrough on-site visits and data collec-tion. The ABP sets the standards that aresident or fellow must meet duringtraining to be admitted to the initial

certification examinations for GeneralPediatrics and 20 pediatric subspecial-ties. The ABP works closely with theACGME to ensure that requirements foraccreditation of training programs andstandards for certification are aligned.The ABP also creates and implementsthe process of MoC to ensure ongoingmastery of the competencies measuredduring training.

From the inception of the process ofboard certification until 1988, certifi-cation was obtained by passing a test ofcognitive knowledge, typically at theend of training, with such certificationremaining permanent. Beginning in1989, a diplomate (the term used todescribe a certificate holder) was re-quired to pass a similar test every 7years. The certificates became known astime-limited certificates. In 2002, thetransition from a system of time-limited certificates to a program ofMoC began. Unlike the episodic natureof time-limited certification and recer-tification, MoC is a continuous process,requiring ongoing participation in var-ious evaluative and self-assessment ac-tivities designed to enhance profes-sional development.

The evolution of the certificationprocess followed the adoption by theACGME and the American Board ofMedical Specialties (ABMS), the cer-tifying boards of medical specialties,of the idea of general competenciesfor physicians. Such competencies arebased on the concept that althoughmedical knowledge is essential, it isnot sufficient; competency in patientcare, communications, professionalism,practice-based learning and improve-ment, and system-based practice arealso necessary to deliver quality care.

This idea was the product of obser-vations identified in the Institute ofMedicine’s report “Crossing the QualityChasm,” (1) which described the gap inquality of health care between what isand what could be.

The ABP and the other 23 certifyingboards of the ABMS collaborated tocreate a program for maintaining boardcertification that included the follow-ing four-part structure:● Part 1. Professional Standing● Part 2. Lifelong Learning● Part 3. Cognitive Expertise● Part 4. Performance in PracticeBased on these four elements, the ABPdeveloped their strategy for MoC forpediatric generalists and subspecialists.

Part 1: Professional StandingDiplomates must hold a valid, unre-stricted license to practice in a UnitedStates state, territory, or Canadianprovince, and the license must be heldcontinuously.

Part 2: Lifelong LearningDiplomates must participate in activi-ties that assess and enhance knowl-edge in areas important to their prac-tice through ABP-approved activities.Although diplomates in NPM maycomplete any ABP-approved activityto satisfy the requirements for Part 2of MoC, diplomates in NPM currentlyhave two logical options for satisfyingthese requirements: participate in anonline assessment and learning tooldeveloped by the ABP for NPM diplo-mates or participate in the AmericanAcademy of Pediatrics (AAP) programNeoReviewsPlus.

The online ABP-sponsored activityprovides a list of sentinel and recently

commentary

NeoReviews Vol.12 No.10 October 2011 e553 by guest on June 8, 2018http://neoreviews.aappublications.org/Downloaded from

published articles in neonatal perinatalmedicine. Diplomates are given creditfor participation in this activity bypassing an online examination that in-cludes a series of multiple-choice ques-tions addressing the content of thesearticles. Articles are selected by theNPM Subboard, with a new list postedannually. There is no charge for partic-ipating in this activity. Alternatively,diplomates in NPM may participate inthe AAP-sponsored NeoReviewsPlus.

Part 3: Cognitive ExpertiseDiplomates in NPM must pass a secureexamination every 10 years. The exam-ination is offered semiannually at test-ing sites throughout the United Statesand at selected locations abroad. Theexamination is developed by the NPMSubboard and is not the same exami-nation administered for initial certifica-tion. The questions are intended to testknowledge expected of competentpracticing neonatologists. The passagerate is in excess of 90%.

Part 4: Performance inPracticeDiplomates must participate in ABP-approved projects designed to assessand improve the quality of their care.The underlying principle of Part 4 isfor practitioners to incorporate qual-ity improvement science into theirdaily practice, that is, to demonstratethat they can assess and improvetheir quality of care by incorporatingevidenced-based practices. Physiciangroups are encouraged to develop pat-terns of care based on current scientificknowledge. In addition, they are en-couraged to track clinical outcomescontemporaneously to discover and dis-seminate practices that achieve thebest outcomes.

One option for satisfying the Part 4requirement is participation in web-based improvement activities. Althoughdiplomates in NPM may participate inany ABP-approved activity, only two

web-based modules are well suited forapplications in neonatal medicine: thePerformance Improvement Modulesdeveloped by the ABP of Hand Hygieneand Breast Milk Use. Detailed informa-tion about these modules, includingan online demonstration video, is avail-able on the ABP web site. These mod-ules form a comprehensive platformthat includes education about qualityimprovement science as well as re-sources for performing improvementprojects in these two domains. Thecharge for participation in these mod-ules is included in the enrollment feefor MoC.

A second option is to participate inestablished quality improvement proj-ects sponsored by consortia of pro-vider groups. Examples include initia-tives developed by national collabora-tives (eg, the Vermont Oxford Network),state collaboratives (eg, the CaliforniaPerinatal Quality Care Collaborative),or corporate physician groups (eg, thePediatrix Medical Group). In addition,selected individual hospitals have beenapproved by the ABP to hold port-folios of projects for their clinicians(eg, Cincinnati Children’s Hospital).All projects must be approved in ad-vance as a qualifying activity. To ob-tain credit toward satisfying the re-quirements of Part 4, diplomates mustparticipate actively in an approvedproject, and their participation must bedocumented through an attestationprocess.

All Part 2 and 4 activities areawarded point values. Except for spe-cial requirements resulting from thecircumstances arising during the tran-sition from episodic recertification tothe MoC process, diplomates are re-quired to accumulate 100 points duringa 5-year cycle, with 40 points from Part2 activities, 40 points from Part 4activities, and 20 points from eitherPart 2 or 4 activities.

Special RequirementsDiplomates WhoseCertificates Expire in 2011 to2016

Diplomates who have time-limited cer-tificates scheduled to expire between2011 and 2016 can maintain their cer-tificates by completing one Part 2 andone Part 4 activity (regardless of theirpoint value) and enrolling in MoC byNovember 30 of the year of expirationof their certificates. Their new MoC5-year cycles will begin on the follow-ing January 1. Although the expirationdates of their certificates will be 7 yearsafter the date they last passed there-certification examination, they willnot have to pass the MoC examinationuntil 10 years after they last passed theexamination.

NPM Fellows CompletingTraining in 2011

Fellows who successfully completeall training requirements in 2011 areeligible to sit for the certificationexamination in 2012. After passingthe examination, they will be issueda time-limited certificate. They mustmaintain certification by accumulating100 points in Part 2 and 4 activities (asoutlined previously) during each subse-quent 5-year period and passing anexamination every 10 years.

Diplomates HoldingPermanent Certificates

Before 1989, diplomates were awardedpermanent certificates in NPM. Theseindividuals will always be considereddiplomates (ie, certificate holders) bythe ABP as long as they maintain activemedical licenses, regardless of whetherthey participate in MoC. However, per-manent certificate holders who wish toparticipate in the MoC program may doso at any time by passing the examina-tion, acquiring 100 points in Part 2 and4 activities, and enrolling in MoC.

commentary

e554 NeoReviews Vol.12 No.10 October 2011

by guest on June 8, 2018http://neoreviews.aappublications.org/Downloaded from

Maintaining a Certificate inGeneral PediatricsMaintenance of a certificate in GeneralPediatrics is not a requirement formaintenance of a certificate in NPM.However, for those who choose tomaintain both certificates, the only re-quirement, in addition to the MoC re-quirements for NPM, is to pass theexamination in General Pediatrics every10 years. The Part 2 and 4 activitiesused to satisfy the requirements forMoC in NPM count toward the require-ments for MoC in General Pediatrics;additional activities need not be com-pleted.

Understanding MoCRequirements and IdentifyingPart 2 and 4 ActivitiesThe only authoritative resource for un-derstanding individual requirements forMoC is the ABP web site. Within thisweb site, each diplomate has an indi-vidual portfolio that can be accessedthrough the ABP home page (https://www.abp.org; Fig. 1). The individualportfolio is a private, password-protected area of the web site. Theinitial screen after logging in directsthe diplomate to one of four categories(Fig. 2). Choosing the “Maintenance ofCertification” option directs the diplo-

mate to all of the essential informationregarding his or her certificate, includ-ing dates for completion of requiredactivities and resources for completingParts 2 and 4 (Fig. 3). All certificateholders should review their portfoliosthoroughly.

Development of NewResources forParts 2 and 4The ABP has developed guidelines forexternal organizations that plan to cre-ate self-assessment activities to satisfythe MoC Part 2 requirements. These areavailable on the ABP web site. Diplo-

Figure 1. Image of the home page of the American Board of Pediatrics web site. The arrow indicates the location for access to adiplomate’s individual portfolio.

commentary

NeoReviews Vol.12 No.10 October 2011 e555 by guest on June 8, 2018http://neoreviews.aappublications.org/Downloaded from

mates in NPM may have additionaloptions in the future, developed byexternal organizations, for satisfyingthe requirements for Part 2 of MoC.Possible examples include the ongo-ing programs sponsored by the AAP:NeoReviews or NeoPREP.

The ABP also welcomes new appli-cations from external organizations forapproval of Part 4 activities. These ac-tivities must be established, structured,sustainable quality improvement proj-ects that have previously demonstratedimprovements in care and are based onaccepted quality improvement scienceand methodology. Details of these re-quirements and the application proce-dure are available on the ABP web site.

The sponsoring organization is respon-sible for the cost of the application fee(currently $500), the development andadministration of the activity, and allrequired reporting to the ABP.

The ABP recently piloted a programin which organizations maintain a port-folio of projects. The organization as-sumes the responsibility for evaluatingeach project in their portfolio using thestandards established by the ABP. Theevaluation and review of projects isconducted by a standing committee ofquality improvement experts within thesponsor organization. Although ap-proved portfolios are currently heldonly by individual hospitals, the ABPhas expressed an interest in expanding

this aspect of MoC to other sponsororganizations, such as AAP sections andprovider groups. Inquiries about thisoption should be directed to Dr PaulMiles at the ABP.

Public Reporting of Status ofCertificate HoldersBecause the ABP has a primary respon-sibility to the public, an importantfunction of the ABP web site is toprovide information about the status ofdiplomates. This is reported in a publicarea of the web site: “Verification ofCertification” (Fig. 4). An individual’sstatus is reported in three ways: 1) Cer-tificates held, 2) Year of most recentcertification and expiration date (“No

Figure 2. Image of the portfolio home page from which a diplomate may access all current and past information related to his orher certificate.

commentary

e556 NeoReviews Vol.12 No.10 October 2011

by guest on June 8, 2018http://neoreviews.aappublications.org/Downloaded from

Expiration” is listed for permanent cer-tificate holders), and 3) Indication ofwhether the diplomate is meeting therequirements for MoC. Further infor-mation about the implications of theentry is available for each entry. Forexample, if a diplomate has permanentcertificates in General Pediatrics andNPM but has chosen not to participatein MoC, the following informationwould be provided about this status:

“Maintenance of Certification (MoC)is a new process by all 24 ABMS boardsthat continuously assesses the six corephysician competencies adopted by theABMS and the ACGME throughout aphysician’s career. The six competen-

cies that have been identified as impor-tant to deliver quality care are commu-nication skills, professionalism, medicalknowledge, patient care, practice-based learning and improvement,which includes the ability to measureand improve quality of care andsystem-based practice.”

Why Participate in MoC?A powerful motive for participation inMoC, particularly Part 4 activities, isthat doing so will improve the qualityof care for children. Ample evidenceshows that properly executed qualityimprovement projects can improve pro-

cesses of medical care, including thosethat are essential to neonatal intensivecare. Evidence also indicates that suchprojects can change selected importantoutcomes of care. The most compellingevidence is the reported reduction incatheter-associated bloodstream infec-tions. (2)(3)(4) In addition, a reductionin retinopathy of prematurity hasbeen reported. (5) However, a majorcriticism of these reports is their reli-ance on historical controls or changesin the incidence of an outcome beforeand after institution of a bundle ofinterventions to determine success.This, of course, is an inherent featureof quality improvement methodology,

Figure 3. Image of the Maintenance of Certification main screen from which diplomates can access information pertinent to theirMoC requirements and resources.

commentary

NeoReviews Vol.12 No.10 October 2011 e557 by guest on June 8, 2018http://neoreviews.aappublications.org/Downloaded from

but such design lacks the rigor of therandomized, controlled trial designused in traditional clinical research.Further, evidence in support of thesuccessful application of quality im-provement methodologies to changeother important neonatal outcomes islacking, and some disappointing fail-ures have been reported. (6) In thefuture, additional successes should in-crease the enthusiasm of neonatolo-gists for participation in such projects.

Another motivation for participationin MoC is that some hospitals requireMoC as a requisite for credentialing.Although only a few hospitals currentlyrequire MoC, there is little doubt that

others will institute this requirement inthe future.

Finally, certification by one of thespecialty boards (eg, the ABP) is in-creasingly used as a marker of expertiseby state medical licensing boards. TheFederation of State Medical Boards, agroup that oversees most state licens-ing boards, has approved the concept of“maintenance of licensure” for all li-censed physicians in the United States.State boards ultimately may offer twooptions for maintenance of licensure:periodic successful completion of thestate general licensing examination ormeeting the requirements of MoC of amember board of the ABMS. Although

significant obstacles must be overcomebefore this concept becomes law inmost states, it is being piloted in atleast four states, and some see thischange as inevitable.

ConclusionsThe transition from permanent certifi-cation by the ABP to periodic recertifi-cation to a program of MoC is nearlycomplete. Diplomates who have time-limited certificates in NPM are nowrequired to complete four parts of theMoC program to continue to hold theircertificates beyond the expiration date.All diplomates must participate in theprogram to be listed on the ABP web

Figure 4. Image of the Verification of Certification screen from which the public can access information describing the status ofthe certificate of any diplomate.

commentary

e558 NeoReviews Vol.12 No.10 October 2011

by guest on June 8, 2018http://neoreviews.aappublications.org/Downloaded from

site as meeting the requirements ofMoC, and MoC may, in the future, berequired for hospital credentialing andstate licensure.

Certain requirements for MoC de-mand a substantial commitment of timeand effort, particularly Part 4 activities.For that reason, some diplomates maychoose not to participate. For thosewho choose to participate, a thoroughunderstanding of the requirements iscritical. Participants should not rely onfamily, friends, and colleagues assources of information regarding theserequirements. Clinicians should searchthe ABP web site, specifically theirindividual portfolios, to learn moreabout MoC. Questions should be di-

rected to the ABP either electronically(moc@abpeds.org) or by phone (919-929-0461).

Carl Bose, MDProfessor of PediatricsUniversity of North Carolina School of

MedicineChapel Hill, NC

References1. Institute of Medicine. Crossing the Qual-ity Chasm: A New Health System for the 21stCentury. Washington, DC: National Acad-emies Press; 20012. Kaplan HC, Lannon C, Walsh MC,Donovan EF. Ohio statewide quality-improvement collaborative to reduce late-onset sepsis in preterm infants. Pediatrics.2011;127;:427–435

3. Schulman J, Stricof R, Stevens TP, et al.Statewide NICU central-line-associatedbloodstream infection rates decline afterbundles and checklists. Pediatrics. 2011;127:436–4444. Wirtschafter DD, Powers RJ, Pettit JS, etal. Nosocomial infection reduction inVLBW infants with a statewide quality-improvement model. Pediatrics. 2011;127:419–4265. Chow LC, Wright KW, Sola A. Canchanges in clinical practice decrease the in-cidence of severe retinopathy of prematurityin very low birth weight infants? Pediatrics.2003;111:339–3456. Walsh M, Laptook A, Kazzi SN, et al.A cluster-randomized trial of benchmarkingand multimodal quality improvement to im-prove rates of survival free of bronchopul-monary dysplasia for infants with birthweights of less than 1250 grams. Pediatrics.2007;119:876–890

commentary

NeoReviews Vol.12 No.10 October 2011 e559 by guest on June 8, 2018http://neoreviews.aappublications.org/Downloaded from

DOI: 10.1542/neo.12-10-e5532011;12;e553NeoReviews 

Carl BoseMaintenance of Certification: Realities for the Practitioner

ServicesUpdated Information &

http://neoreviews.aappublications.org/content/12/10/e553including high resolution figures, can be found at:

Referenceshttp://neoreviews.aappublications.org/content/12/10/e553#BIBLThis article cites 5 articles, 5 of which you can access for free at:

Subspecialty Collections

curriculum_dev_subhttp://classic.neoreviews.aappublications.org/cgi/collection/teaching_Teaching/Curriculum Developmenteducation_subhttp://classic.neoreviews.aappublications.org/cgi/collection/medical_Medical Educationfollowing collection(s): This article, along with others on similar topics, appears in the

Permissions & Licensing

htmlhttp://classic.neoreviews.aappublications.org/site/misc/Permissions.xin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://classic.neoreviews.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

by guest on June 8, 2018http://neoreviews.aappublications.org/Downloaded from

DOI: 10.1542/neo.12-10-e5532011;12;e553NeoReviews 

Carl BoseMaintenance of Certification: Realities for the Practitioner

http://neoreviews.aappublications.org/content/12/10/e553located on the World Wide Web at:

The online version of this article, along with updated information and services, is

ISSN: 1526-9906. 60007. Copyright © 2011 by the American Academy of Pediatrics. All rights reserved. Online the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,it has been published continuously since . Neoreviews is owned, published, and trademarked by Neoreviews is the official journal of the American Academy of Pediatrics. A monthly publication,

by guest on June 8, 2018http://neoreviews.aappublications.org/Downloaded from