The American Board of Pathology’s Maintenance of Certification Program Update Rebecca L. Johnson, MD

 Context.—The American Board of Pathology (ABP) began issuing time-limited certificates in 2006. New diplomates of the ABP are required to participate in the ABP’s Maintenance of Certification (MOC) program to maintain certification. Voluntary participation in the MOC program is also available to diplomates with non–timelimited certificates. Objective.—To update the pathology community on the requirements of the ABP’s MOC program and some current MOC policies and to demonstrate the value of MOC participation for both time-limited and non–time-limited certificate holders.

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he American Board of Pathology (ABP), along with the other 23 member boards of the American Board of Medical Specialties (ABMS), has developed a Maintenance of Certification (MOC) program that allows physicians to demonstrate their commitment to lifelong learning and competence.1,2 The mission of the ABP is presented in Figure 1. The MOC program is a comprehensive program of continuous professional development that meets public expectations for enhanced patient safety and improved clinical outcomes. The ABP, like the other ABMS boards, uses a 4-part process of assessment, based on ongoing measurement of the ABMS/Accreditation Council for Graduate Medical Education (ACGME) 6 core competencies. The 4 parts of the MOC process are:

Part I—Licensure and Professional Standing: Diplomates must hold a valid, unrestricted medical license. Part II—Lifelong Learning and Self-Assessment: Diplomates must meet the ABP’s educational and selfassessment requirements. Part III—Cognitive Expertise: Diplomates must pass a secure examination that assesses their fundamental pathology-specific skills and knowledge. Part IV—Evaluation of Performance in Practice: Diplomates must demonstrate that they can assess the quality of care they provided compared with peers and Accepted for publication August 30, 2013. From the American Board of Pathology, Tampa, Florida. The author has no relevant financial interest in the products or companies described in this article. Reprints: Rebecca L. Johnson, MD, American Board of Pathology, PO Box 25915, Tampa, FL 33622-5915 (e-mail: [email protected] org). 512 Arch Pathol Lab Med—Vol 138, April 2014

Data Sources.—This review uses ABP-archived minutes of the MOC Committee, the ABP MOC Booklet of Information, the ABP Pathway system reports, and the collective experiences of the ABP trustees and staff. Conclusions.—The ABP’s MOC program has active participation by almost 5000 diplomates of the ABP. The ABP, in conjunction with the American Board of Medical Specialties, continually strives to enhance the relevance and value of MOC to our diplomates and to the public. (Arch Pathol Lab Med. 2014;138:512–517; doi: 10.5858/ arpa.2013-0362-RA) national benchmarks and use best evidence and practices to improve care. The ABMS/ACGME 6 competencies that are assessed by the MOC process are listed in Table 1. As of January 1, 2006, all primary and subspecialty certificates issued by the ABP are time limited and expire on December 31, 10 years after they are issued. Maintenance of Certification is a continuous process that begins January 1, immediately after board certification. There are reporting deadlines at 2-year intervals during the 10-year cycle. Failure to meet these deadlines results in early expiration of certification. Figure 2 shows the MOC 10-year cycle reporting requirements summary. The ABP has one of the lowest costs for MOC of the 24 ABMS member boards. Diplomates pay $100 every 2 years when they submit an MOC reporting form. The current cost of the Part III examination is $500. The ABMS has compiled a reference library3 of peerreviewed articles that support certification and MOC activities and methodologies at www.abms.org/EvidenceLibrary. The informative document ‘‘ABMS MOC Myths & Facts’’ is also available in the reference library. MOC REQUIREMENTS Part I: Professional Standing Medical Licensure—Diplomates practicing in the United States or Canada must maintain a full and unrestricted license to practice medicine in at least one jurisdiction of the United States, its territories, or Canada. If a diplomate holds more than one license, all must be full and unrestricted. Diplomates practicing outside the United States or Canada must maintain a full and unrestricted license in the local jurisdiction in which they practice. The ABP’s MOC Program Update—Johnson

tialing, etc, as well as the requirements of the ABP. Links to all ABP-approved SAMs providers are available on the ABP Web site. Part III: Cognitive Expertise

Figure 1. The mission of the American Board of Pathology, as a member of the American Board of Medical Specialties, is to promote the health of the public and advance the practice and science of pathology by establishing voluntary certification standards and assessing the qualifications of those seeking to practice the specialty of pathology.

Description of Practice—Diplomates must provide the ABP with information regarding medical staff membership and scope of health care organization privileges. If the diplomate’s practice is such that this information is not applicable, then the diplomate must provide a description of his or her practice. Part II: Lifelong Learning and Self-Assessment Each diplomate must obtain a minimum of 70 American Medical Association (AMA) category 1 continuing medical education (CME) credits for each 2-year period of the MOC cycle. At least 20 of the 70 AMA category 1 CME credits must be obtained from completion of self-assessment modules (SAMs). The difference between CME and SAMs is that SAMs require that the participant pass a selfassessment examination and receive feedback at the conclusion of the learning activity. Eighty percent of required CME must be directly related to a diplomate’s practice. The remainder may be in areas of general relevance to pathology, such as administration or ethics. The term SAM was developed by the ABP and is not recognized as a unique type of CME by the Accreditation Council for Continuing Medical Education. Because all SAMs must be AMA category 1 CME, a diplomate may use SAMs to satisfy CME requirements for licensure, creden-

Table 1. The American Board of Medical Specialties/ Accreditation Council for Graduate Medical Education Competencies Patient care and procedural skills Medical knowledge Practice-based learning and improvement Interpersonal and communication skills Professionalism Systems-based practice Arch Pathol Lab Med—Vol 138, April 2014

The MOC examination is mandatory for all participants in MOC. It will be given twice each year, beginning in 2014, and may be taken as soon as the seventh year after certification, but must be taken no later than 10 years after certification, with no longer than a 12-year interval between examinations. Satisfactory completion of the examination in the seventh, eighth, or ninth year of the cycle does not change the endpoint of the cycle, which is December 31, 10 years after the date of certification. The examination is a proctored, closed-book assessment based on practical need-to-know knowledge and day-today skills that a competent practitioner would be expected to possess without access to reference materials. It will include basic knowledge and skills in addition to validated, new knowledge in the field. The ABP recognizes the breadth and variation of pathology practice; therefore, the primary examinations (anatomic pathology [AP]/clinical pathology [CP], AP, and CP) are modular and diplomates will be able to select modules at the time of the examination tailored to their practice of pathology. The examination is composed of modules that add up to a total of 150 multiple-choice questions in the single best answer format. All diplomates will be required to take a 50-question module in their primary area of certification (AP/CP, AP only, or CP only). The diplomate may then choose any 4 additional 25question modules. An AP/CP certified diplomate may take all AP 25-question modules, all CP 25-question modules, all common modules, or a combination of these. The common modules are those that may be selected by any diplomate and currently include laboratory management/informatics, flow cytometry, general hematopathology I (lymph nodes, spleen, and tissues) and general hematopathology II (bone marrow and blood). Anatomic pathology–only certified diplomates may select from the AP modules and/or the common modules. Likewise, CP-only–certified diplomates may select from the CP modules and/or common modules. The subspecialty MOC examinations in hematology, molecular genetic pathology, neuropathology, and pediatric pathology will also be modular. All other subspecialty MOC examinations will be a single 150-question examination. For both primary and subspecialty exams, the selected modules are blended and graded together as a single 150question examination; therefore, each individual module does not have to be passed separately. A current list of MOC modules is available in an MOC PowerPoint presentation on the ABP Web site4 at www.abpath.org. A diplomate will be able to complete primary and subspecialty examinations in the same day or examination session, if necessary, and the cost to take both primary and subspecialty exams on the same day or examination session is $500. An examination session is defined as the days that the MOC examination is offered in the spring or fall. Initially, the examination will be given at the ABP Examination Center in Tampa, Florida. In the future, when commercial test centers can assure image quality comparable with that offered in our examination center, the ABP anticipates the use of regional testing centers. The ABP’s MOC Program Update—Johnson 513

Figure 2. A summary of the Maintenance of Certification (MOC) 10-year cycle requirements for each part of MOC. There are 5 reporting periods with submissions of MOC data by diplomates every 2 years. Abbreviations: MED LIC, medical license; MED PRIV, medical privileges; CME, American Medical Association category 1 continuing medical education credits; SAMs, self-assessment modules; QA, quality assurance; PI, performance improvement; LAB ACCRED, laboratory accreditation; PEER EVALS, peer evaluations.

The cognitive examination uses the same proven psychometric principles as those of the primary and subspecialty certification examinations. The examinations will be criterion referenced. Part IV: Evaluation of Performance in Practice Laboratory Accreditation—The ABP regards accreditation as a very important part of systems-based practice. The accreditation status of the laboratory with which a diplomate is primarily associated must be reported to the ABP every 2 years. Laboratory Performance Improvement and Quality Assurance—Each laboratory with which a diplomate is associated must participate in interlaboratory performance improvement (PI) and quality assurance (QA) programs appropriate for the spectrum of anatomic and clinical laboratory procedures performed in that laboratory. The ABP Web site has a list of organizations approved for Part IV activities. Interlaboratory PI and QA programs are often a requirement for accreditation. In such cases, the proficiency testing program that is part of the accreditation process will meet the laboratory PI/QA requirement. Individual Pathologist PI and QA—A diplomate must participate in at least 1 PI and QA activity or program per 514 Arch Pathol Lab Med—Vol 138, April 2014

year appropriate for his or her principal professional activities. Some examples of activities that meet this requirement include the Clinical Laboratory Improvement Amendments of 1988 mandated annual cytology proficiency examination, participation as an inspector for a laboratory accreditation agency, participation in a departmental or institutional QA committee (eg, transfusion, infection control, patient safety), participation in an ABP-approved organization’s slide review program, participation in an ABP-approved sponsor’s SAMs activity designed to assess/ improve quality of practice, participation in an ABPapproved PI/QA activity sponsored by a local institution or department, participation in an ABP-approved organization-sponsored PI/QA activity, and participation as a program director for an ACGME-accredited residency or fellowship program. If the PI/QA activities provide CME credits, they can also be used to satisfy Part II CME/SAMs requirements. Peer Attestations—All diplomates are required to provide peer attestations as to their interpersonal and communication skills, professionalism, ethics, and effectiveness in systems-based practice. These references should include an ABP-certified pathologist; the chair of the hospital credentials committee (or designate), chief medical The ABP’s MOC Program Update—Johnson

officer, or chief of staff of the primary health care facility where the diplomate practices; a board-certified physician in another specialty; and a technologist or pathologist’s assistant. Patient Safety—All diplomates are required to complete a patient safety course at least once during each 10-year MOC cycle. The patient safety course must be approved by the ABMS. Currently the only ABMS-approved patient safety course designed specifically for pathologists is offered by the American Society for Clinical Pathology. This course can be used to meet both Part II and Part IV MOC requirements. MOC POLICIES See the MOC Booklet of Information at the ABP Web site,4 www.abpath.org, for complete information on the MOC program and ABP policies. Completion of an ACGME-accredited fellowship during one academic year of any 2-year MOC period will meet all Part II requirements and will also meet the Part IV laboratory and individual practice improvement and QA requirements for that period. If the fellowship is not accredited by the ACGME, the designated institutional official or program director must submit a letter to the ABP indicating that the fellowship is reviewed by the institutional GME committee and is held to the same standards as ACGME-accredited fellowships. Diplomates who are not current in reporting MOC CME/ SAMs activities will not be allowed to sit for the Part III cognitive examination or for any additional primary or subspecialty certification exams. The ABP recognizes that pathology practice is very diverse and that after a period of time, a diplomate who was initially certified in AP/CP may find his or her practice limited to only one of these areas. Therefore, a diplomate certified in AP/CP may choose to maintain certification in either AP or CP or both. Similarly, a diplomate who holds a subspecialty certificate and whose practice is confined entirely to that subspecialty may choose to maintain certification in the subspecialty only. The ABP strongly encourages diplomates to maintain all certificates, especially through at least one 10-year MOC cycle, because practice circumstances frequently change. It is much easier to maintain certification than to become recertified. Diplomates who hold multiple time-limited certificates can submit a single reporting form to maintain all certificates. Diplomates may use the same CME and SAMs (Part II) and Part IV activities to meet MOC requirements for all certificates. The MOC Part III examination is required for each certificate. The Royal College of Physicians and Surgeons of Canada have recognized the ABP’s MOC program as substantively equivalent to the MOC program in Canada. This means that Fellows of the Royal College who are living and practicing in the United States can use the ABP’s MOC program to maintain their membership and fellowship with the Royal College without having to participate in the Royal College’s MOC program. The Royal College of Physicians and Surgeons of Canada Continuing Professional Development Accredited Group Learning (section 1) credits in general pathology are accepted as equivalent to American Medical Association category 1 CME credits, and assessment (section 3) credits Arch Pathol Lab Med—Vol 138, April 2014

are accepted as equivalent to SAM credits for purposes of the ABP MOC Part II program requirements. VOLUNTARY PARTICIPATION IN MOC; LIFETIME-CERTIFIED DIPLOMATES Voluntary MOC participation is available to diplomates with non–time-limited certificates, and the ABP strongly encourages such participation. These diplomates will have the same MOC requirements and cycle of reporting as diplomates who are required to participate in MOC, with 2 exceptions: (1) participation is not mandatory, and a decision to drop participation or failure to meet MOC requirements will not jeopardize the original non–timelimited certificate; and (2) there is a $100 fee to enroll in the MOC program. Diplomates with non–time-limited certificates are encouraged to participate in MOC to qualify for the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS)–MOC bonus described below. There are some physicians who are required by their state licensing boards to pass a secure examination at least once every 10 years as a condition of licensure. The ABP MOC examination meets these state requirements. The ABP’s voluntary recertification program, including a secure examination, ended as of July 2013 and is no longer available to meet licensure requirements. The ABP does not anticipate changing its policy with regard to diplomates with non–time-limited certificates; that is, the ABP does not and will not require these diplomates to participate in MOC. Discussions in various forums indicate that there are increasing pressures from hospital credentialing committees, third-party payers, and potentially government agencies for these diplomates to participate in MOC. COORDINATING MOC WITH OTHER ORGANIZATIONS The ABP and the ABMS continually strive to enhance the relevance and value of MOC to our board-certified physicians and align MOC with external physician assessment and quality reporting initiatives. Some current activities that support these goals are highlighted here. Maintenance of Licensure The Federation of State Medical Boards, which represents the state medical boards, has adopted a plan for maintenance of licensure (MOL).5 The MOL plan provides a framework for medical licensing that emphasizes the importance of continuous professional development, including CME, and a physician’s commitment to lifelong learning and improved health care. The ABMS has worked closely with the Federation of State Medical Boards to gain recognition of its MOC programs. Although the Federation of State Medical Boards has stated that MOC will not be required as part of future MOL systems, physicians who are participating in MOC will be recognized as being in ‘‘substantial compliance’’ with the MOL components. The advantage of MOC participation in meeting MOL requirements is that the MOC program is specialty specific and more relevant to a pathologist’s practice than a generic MOL program is likely to be. More information on MOL can be found at www.fsmb.org/mol.html.5 The ABP’s MOC Program Update—Johnson 515

Table 2.

American Board of Pathology Maintenance of Certification (MOC) Statistics

Time-Limited Certificate Statistics

2006

2007

2008

2009

2010

2011

2012

Total YTDa

Total certificates enrolled in MOC, No. Total diplomates enrolled in MOC, No. Total diplomates not participating, No. MOC nonparticipation rate, % Total diplomates MOC compliant, No. Total compliance rate, %

894 874 55 6.3 819 93.7

975 716 38 5.3 678 94.7

973 674 58 8.6 616 91.4

1148 722 48 6.6 674 93.4

1037 649 34 5.2 615 94.8

1111 637 0 0.0 637 100.0

1135 675 0 0.0 675 100.0

7273 4947 233 4.6 4714 95.4

Abbreviation: YTD, year to date. As of June 13, 2013.

a

MOC:PQRS Program The ABP, in coordination with the ABMS, has received federal approval to qualify our diplomates to receive the CMS incentive payments for participation in MOC:PQRS in 2013 and 2014. The PQRS program, formerly known as PQRI, is a voluntary reporting program that provides an incentive payment to eligible physicians who satisfactorily report data on specified quality measures. Pathology currently has 5 CMS-approved quality measures. Physicians can choose to fulfill the PQRS reporting requirement through Medicare Part B claims (most commonly used by pathologists), a qualified electronic health record, or a qualified registry. For 2013 and 2014, the PQRS incentive payment is 0.5% of a physician’s total Medicare Part B–allowed charges. Physicians who do not participate in PQRS in 2013 will incur a 1.5% penalty on the Medicare payments in 2015. Beginning in 2013, if 2 members of a group (physicians with the same tax identification number) are reporting quality measures using a registry, the entire group can receive the incentive payment based on their total Medicare Part B claims. See the College of American Pathologists PQRS Resource Center at www.cap.org for more information. The MOC:PQRS program offers eligible physicians who have satisfactorily submitted data under PQRS the opportunity to earn an additional incentive payment of 0.5% for participating in the ABP’s CMS-qualified MOC program ‘‘more frequently’’ than is required to maintain board certification. A diplomate with a time-limited certificate must complete only 1 of the following ‘‘more frequently’’ requirements to qualify for the additional incentive payment: MOC Part II—Complete more than 35 CME credits per year. MOC Part III—Take and pass the secure examination in years 7, 8, or 9 of the MOC cycle. MOC Part IV—Complete more than 1 PI/QA activity per year. For diplomates with lifetime certificates, voluntary enrollment in MOC will meet the ‘‘more frequently’’ CMS reporting requirement, without any additional reporting requirements to the ABP in 2013 or 2014. Participation in MOC by these diplomates is voluntary and a decision to drop participation or failure to meet MOC reporting requirements in 2015 will not jeopardize the original non– time-limited certificate. Enrollment in the ABP’s MOC:PQRS is available at the MOC Matters portal6 on the ABMS Web site, https:// 516 Arch Pathol Lab Med—Vol 138, April 2014

mocmatters.abms.org/default.aspx. Diplomates will have to purchase and complete the MOC:PQRS attestation module for $30. This registry is also available for quality reporting, including a module that will satisfy the group reporting requirements noted above. The Joint Commission The Joint Commission standards now require physician credentialing to include ongoing professional practice evaluation. The ongoing professional practice evaluation initiative requires that physician privileging should be based on specific performance data and outcomes related to practice. There is ongoing discussion between the Joint Commission and the ABMS about the use of MOC Part IV programs to meet ongoing professional practice evaluation standards. ACGME Milestones The ABP participated in the development of the Pathology Milestones as part of the ACGME Next Accreditation System. The goal of the Milestones Project is to establish clear milestones that residents must attain during training and provide structured feedback as they proceed toward becoming independent practitioners. The ABP will consider how the level 5 milestones can inform and relate to the MOC process. The proposed ACGME pathology program requirements include a statement that the program directors should participate in the ABP’s MOC Program. MOC STATISTICS Table 2 summarizes the most current MOC program statistics for time-limited certificate diplomates. Note that some diplomates have more than 1 certificate, so the number of certificates is greater than the number of diplomates. The ABP has seen continuous improvement in on-time reporting by diplomates. With the increase in diplomates with time-limited certificates, the understanding and compliance with program requirements has improved. This has been further enhanced by an appreciation by our diplomates that physicians in all ABMS specialties must participate in their board’s MOC programs as well. Health care organizations’ bylaws and credentialing committees are increasingly requiring board certification and ongoing MOC for privileges. SUMMARY The ABP’s MOC program began in 2006, with almost 5000 current participants. The MOC program has 4 parts that assess the ABMS/ACGME 6 core competencies. The The ABP’s MOC Program Update—Johnson

value and relevance of MOC has been enhanced by coordinating with external physician quality and assessment initiatives, such as the MOC:PQRS incentive payments. Non–time-limited certificate holders are encouraged to voluntarily participate in the MOC program. The author would like to thank Patrick Lantz, MD, president of the ABP, and Sharon Weiss, MD, vice president of the ABP and chair of the Maintenance of Certification Committee, for their review of this manuscript.

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References 1. McKenna RW, Davey DD, Johnson RL, et al. Maintenance of certification for pathologists: what we know so far. Am J Clin Pathol. 2005;124(suppl 1); S5–S7. 2. Bennett BD. Certification from the American Board of Pathology: getting it and keeping it. Hum Pathol. 2006;37(8):978–981. 3. American Board of Medical Specialties evidence library. http://www.abms. org/EvidenceLibrary. Accessed August 26, 2013. 4. American Board of Pathology. American Board of Pathology home page. http://www.abpath.org. Accessed August 23, 2013. 5. Federation of State Medical Boards. Maintenance of licensure information center. http://www.fsmb.org/mol.html. Accessed August 26, 2013. 6. American Board of Medical Specialties. MOC Matters portal. https:// mocmatters.abms.org/default.aspx. Accessed August 26, 2013.

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The American Board of Pathology's Maintenance of Certification program update.

The American Board of Pathology (ABP) began issuing time-limited certificates in 2006. New diplomates of the ABP are required to participate in the AB...
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