INNOVATIONS AND IMPROVEMENTS IN MAINTENANCE OF CERTIFICATION MARSHALL L LAND JR MD RJ MCKAY JR MD GREEN amp GOLD PROFESSOR OF PEDIATRICS UNIVERSITY OF VERMONT COLLEGE OF MEDICINE AMERICAN BOARD OF PEDIATRICS ADVISOR FOR DIPLOMATE OUTREACH AND STRATEGIC PLANNING ID: 935219
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TRUST ME, I’M A (CERTIFIED) DOCTOR INNOVATIONS AND IMPROVEMENTS IN MAINTENANCE OF CERTIFICATIONMARSHALL L. LAND, JR., MDR.J. MCKAY, JR., MD GREEN & GOLD PROFESSOR OF PEDIATRICSUNIVERSITY OF VERMONT COLLEGE OF MEDICINE AMERICAN BOARD OF PEDIATRICS, ADVISOR FOR DIPLOMATE OUTREACH AND STRATEGIC PLANNINGMay 3, 2019
Slide2DisclosuresI have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity.I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.
Slide3ObjectivesBrief history of “Why” MOCOverview of recent changes in MOCPart 2: Lifelong Learning and Self Assessment Part 3: Cognitive Expertise Part 4: Improvement In Practice
Fees
Listen for your ideas!
Slide4Why do I have to do MOC?
Slide5Began 1933Mission to the publicTo certify pediatricians based on standards of excellence that lead to high quality care. The ABP certification provides assurance to the public that a pediatrician fulfills the continuous evaluation requirements that encompass the six core competencies.The ABP Mission
Slide6The Evolution of Board Certification1934 Permanent certification
Slide71934
1988
2003
2010
2019
Re-test
every 7 years
4 part program,
test every 10 years
Permanent
c
ertification
Point system,
t
est every 10 years
MOCA-
Peds
The Evolution of Board Certification
Slide8Why these changes?
Slide9PEDIATRICS1000 MORE ARTICLES PER YEAR BEING SUBMITTED THAN 7 YEARS AGOExplosion of knowledge
Slide10Explosion of knowledge: weekly/daily
Slide11Recognition of Medical Errors Medical errors 100,000 deaths per year (now est. 400,000) Hospitalized children medical error rate 1.81–2.96/100 discharges 25% incidence of medication errorsIOM: “To Err is Human” & “Crossing the Quality Chasm”
Slide12Improvements and innovationsContinuing to try to make this process betterLESS BURDENSOMEMORE RELEVANTLESS TIME CONSUMINGMORE MEANINGFUL
Slide13Evolution of Board CertificationSingle test of knowledge Periodic test of knowledge More continuous measurement of knowledge acquisition and quality improvement
Slide14Evolution of Board CertificationMOC is about “staying current”, but it is also about attempting to improve the care we are giving, even if that care isat a high level
Slide15Professional Standing (Part 1)Lifelong Learning and Self Assessment (Part 2)Cognitive Expertise (Part 3)Improvement In Practice (Part 4)4 Part MOC
Slide16Part 2 Lifelong Learning and Self Assessment “I already keep up……Why can’t CME count for Part 2?”WHAT’S NEW?
Slide17Part 2 Changes ACCME Collaboration AAP Chapter meetings, NCE, Grand Rounds, etcAs of 12/11/18:Total number MOC Part 2 activities registered: 4,1532018 number of MOC points awarded: 123,944.25MOC points for CME!
Slide18Part 2 ChangesNew Self Assessments: Professionalism in Global HealthCare of a Transgender ChildImmigration Health CareUpdating Patient Safety A Journey of Improvement: The Basics of QIQuestion of the Week Enhancements
Slide19Question of the WeekPainless and FunHow good is the power of suggestion to manage a child with functional abdominal pain?
Slide20Question of the WeekPainless and FunTo use or not to use ibuprofen post tonsillectomy:That is the question
Slide21Question of the WeekPainless and FunWhat’s the best way to fight off a recurrent case of the “runs” after a bout of c. diff.?
Slide22Part 3 Cognitive expertise“That exam every 10 years is not a learning experience……I hate the Testing Center”WHAT’S NEW?
Slide23Maintenance of Certification Assessment for PediatricsAssessment FOR Learning
Slide24MOCA-Peds OverviewContinuous assessment toolQuestions sent quarterly; flexibility in answering Delivered via web or mobile device at home or officeFocuses on assessment and learningFulfill the MOC Part 3 requirement/ also Part 2 points
Slide25Question OverviewApplication of fundamental knowledge of everyday pediatricsShort clinical vignettes, mimic real world situationsMultiple-choice, single-best answer5 minutes per question, may use resources (eg, books, internet)Instant feedback, clinical rationale, and references
Slide26Slide27Slide28Slide29Slide30General Phase-in Plan Enter MOCA-Peds at start of the 5-year MOC cycle during which next exam due Pilot 2017 and 2018 With changes guided by diplomate input – clinical practice guidelinesNow live 2019!Subspecialties will phase in over time (2019-2022)
Slide31Pediatric Subspecialties31
Slide32Pilot Participation2017: 5,081 of 6,814 (74.6%)2018: 6,025 of 7,562 (79.7%)
Subspecialists: 81.1% registered
Slide33Participant Experience: Using The PlatformSample Size: Quarter 1 = 4,181, Quarter 2 = 3,772; Quarter 3 = 3,761; Quarter 4 = 4,016 Any technical issues with the MOCA-Peds system?Quarter 1
Quarter 2
Quarter 3
Quarter 4
Yes
16.1%
10.8%
7.5%
8.6%
No
83.9%
89.2%
92.5%
91.4%
Total
100%
100%
100.0%
100%
Slide34Overall Acceptability: General PediatricsWhich Part 3 method do you expect to use to maintain your General Pediatric (GP) certification?FrequencyPercentMOCA-Peds GP (the new online format)
2,748
96.2%
The GP proctored exam
at
the testing
center
40
1.4%
I plan to stop maintaining my GP certification (for any reason)
68
2.4%
Total
2,856
100.0%
Slide35Overall Acceptability: SubspecialistsWhich Part 3 method do you expect to use to maintain your subspecialty certification(s)? FrequencyPercent
MOCA-Peds (the new online format), once available for my subspecialty
686
95.3%
My subspecialty proctored exam
at
the testing
center
15
2.1%
I plan to stop maintaining my subspecialty certification (for any reason)
19
2.6%
Total
720
100.0%
Slide36Overall SatisfactionAgreement about the MOCA-Peds modelStrongly disagreeDisagree
Neutral
Agree
Strongly agree
Both
SA/A
20
questions per quarter
will
be feasible for my schedule
3.1%
6.7%
7.2%
49.9%
33.0%
82.9%
A
feasible method for subspecialists to keep up-to-date with general pediatric knowledge
2.0%
2.9%
22.3%
48.1%
24.6%
72.7%
Slide37Overall Satisfaction Comments “THANK YOU for listening to pediatricians…”“The MOCA-Peds pilot is a great improvement over the secure exam! Thank you so much for creating this new form of evaluation for pediatricians…so much less stressful, I am learning a lot while I take the exam and find the exam useful for my daily pediatric practice.”
Agreement about
the MOCA-
Peds
model
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Both
SA/A
20
questions per quarter
will
be feasible for my schedule
3.1%
6.7%
7.2%
49.9%
33.0%
82.9%
A
feasible method for subspecialists to keep up-to-date with general pediatric knowledge
2.0%
2.9%
22.3%
48.1%
24.6%
72.7%
Slide38Overall SatisfactionAgreement about the MOCA-Peds model.Strongly disagreeDisagree
Neutral
Agree
Strongly agree
Both
SA/A
O
verall
satisfied
with
the
MOCA-Peds model
as a replacement for the previous Part 3
testing
2.1%
2.9%
6.8%
43.7%
44.5%
88.2%
L
ess
anxious about taking an exam using the online MOCA-Peds system
compared
to
a proctored exam at a secure testing center
0.9%
2.7%
7.0%
32.6%
56.9%
89.5%
Slide39Overall SatisfactionWhat one enhancement would you recommend that the ABP make to improve MOCA-Peds?“A continuous exam lasting for 4 out of 5 years is excessive”Agreement
about the MOCA-Peds model.
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
Both
SA/A
O
verall
satisfied
with
the MOCA
-Peds model
as a replacement for the previous Part 3
testing
2.1%
2.9%
6.8%
43.7%
44.5%
88.2%
L
ess
anxious about taking an exam using the online MOCA-Peds system
compared
to
a
proctored exam at a secure testing center
0.9%
2.7%
7.0%
32.6%
56.9%
89.5%
“Would eliminate the 5 minute limit per question or lengthen significantly”
______
New knowledge: articles and guidelines
Slide40Participant Experience: Time SpentFor the entire MOCA-Peds pilot in 2017 how much time spent answering questions (including time spent studying, looking at reference material, taking questions, and reviewing feedback)?Frequency
Percent
< 2 hours
144
5.0%
2 to < 5 hours
618
21.6%
5 to < 10 hours
756
26.5%
10 to < 20 hours
648
22.7%
20 to < 40 hours
450
15.8%
> 40 hours
240
8.4%
Total
2,856
100.0%
< 2 minutes/question
38
mins
for 20 questions
Slide41How often did you use external resources?Quarter 1Quarter 2
Quarter 3
Quarter 4
No Resource Use
19.2%
17.4%
15.8%
14.7%
With 1 to 5 questions
42.6%
41.3%
39.9%
39.2%
With 6 to 10 questions
22.2%
22.2%
25.0%
24.8%
With more than 10 questions
16.0%
19.0%
19.4%
21.4%
Total
100%
100%
100%
100%
Participant
Experience: Resource
Use
Most common resources:
UpToDate
: 57.1%
Government websites (
eg
,
CDC, NIH, NICHD): 33.7%
Search
engines (
eg
Google,
Yahoo): 58.6%
Professional sites (
eg
, AAP)
26.7%
Textbook:18.8%
PREP: 8.3%
Slide42How often did you use external resources?Quarter 1Quarter 2
Quarter 3
Quarter 4
No Resource Use
19.2%
17.4%
15.8%
14.7%
With 1 to 5 questions
42.6%
41.3%
39.9%
39.2%
With 6 to 10 questions
22.2%
22.2%
25.0%
24.8%
With more than 10 questions
16.0%
19.0%
19.4%
21.4%
Total
100%
100%
100%
100%
Participant
Experience: Resource
Use
Most common resources:
UpToDate
: 57.1%
Government websites (
eg
,
CDC, NIH, NICHD): 33.7%
Search
engines (
eg
Google,
Yahoo): 58.6%
Professional sites (
eg
, AAP)
26.7%
Textbook:18.8%
PREP: 8.3%
Slide43Did learning occur?Most significant practice changes you made as a result of participation in the 2017 pilot? Learn, refresh, or enhance medical knowledge based on using MOCA-Peds in the 2017 pilot?
Yes
97.6%
A
ble
to apply any of what you learned to your clinical practice?
Yes, I have already
1,727
62.0%
No, but I plan to moving forward
468
16.8%
No, because my practice area is not general pediatrics focused
451
16.2%
No, for another reason (please explain)
141
5.0%
Total
2,787
100.0%
“More diligent with antibiotic
mgx
in otitis media.
In
general am practicing more evidence based medical care with
confidence.”
“Started to pay more attention to features of autism.
”
“I identified a Kawasaki patient based on review; ..that is just one instance “
“Follow up on High BP”
“Became aware of my deficiency in
acute drug intoxication”
Slide44Slide45“I'm a neonatologist with a follow up clinic for babies discharged from the NICU. In many areas I realized that some of my practice in the clinic might have been dated. I now have far more frequent discussions with both my general and subspecialty peds colleagues regarding the outpatient care of my former patients seen in their clinics. CommentsHaving to go read up on the topics I got wrong in my answers was also enlightening. I became more facile in this process as the year went by and in fact found myself reading far more general pediatrics than I had anticipated at the beginning of the year. I truly believe that this should be the way of the future to ensure practitioners keep up to date.”
Slide46“I have really enjoyed this, something I would never have thought I would say about the certification exam. I am both learning and meeting my requirement for certification, which is reflective of real practice!”“It is AMAZING. I love it. Honestly, I am learning a lot by doing it, and it’s very easy to make time to learn from it. This is a far better learning tool than a proctored exam.”“It is a great way for a subspecialist to keep up to date on general pediatrics. I would do it again. I think I will retain the general pediatrics information and actually be able to improve the clinical care I provide my subspecialty patients better…”
Slide47MOCA-Peds 2019CORE KNOWLEDGE45 learning objectives1 question per learning objective45 total questionsNEW KNOWLEDGEUp to 4 articles/guidelinesUp to 2 questions per articleQuestions appear after Q2 begins47
Up to 4 “time-sensitive” questions
Quickly developed and delivered questions based on current events
15 repeat questions
Based on confidence/relevance ratings and questions missed
Total Number of Questions
Annually
60
-
72
Quarterly
15
-
18
+
Slide48Learning objectives 2019Diagnose and manage a neonate with an abnormal head size or shape.Diagnose and manage neonatal abstinence syndrome.Evaluate a child with hemoptysis.Evaluate a hypotonic infant.Evaluate a patient with leukocoria.Evaluate an adolescent with a testicular mass.Evaluate and manage a child at risk for type 2 diabetes.Evaluate and manage a child with gross hematuria.Evaluate and manage a prepubertal girl with vaginal discharge.Evaluate and manage back pain in children.Evaluate and manage neonatal jaundice.Evaluate suicide risk in an adolescent.
Slide49Learning objectives 2019Diagnose and manage a neonate with an abnormal head size or shape.Diagnose and manage neonatal abstinence syndrome.Evaluate a child with hemoptysis.Evaluate a hypotonic infant.Evaluate a patient with leukocoria.Evaluate an adolescent with a testicular mass.Evaluate and manage a child at risk for type 2 diabetes.Evaluate and manage a child with gross hematuria.Evaluate and manage a prepubertal girl with vaginal discharge.Evaluate and manage back pain in children.Evaluate and manage neonatal jaundice.Evaluate suicide risk in an adolescent.
Slide50Learning objectives 2019Diagnose and manage a neonate with an abnormal head size or shape.Diagnose and manage neonatal abstinence syndrome.Evaluate a child with hemoptysis.Evaluate a hypotonic infant.Evaluate a patient with leukocoria.Evaluate an adolescent with a testicular mass.Evaluate and manage a child at risk for type 2 diabetes.Evaluate and manage a child with gross hematuria.Evaluate and manage a prepubertal girl with vaginal discharge.Evaluate and manage back pain in children.Evaluate and manage neonatal jaundice.Evaluate suicide risk in an adolescent.
Slide51Learning objectives 2019Diagnose and manage a neonate with an abnormal head size or shape.Diagnose and manage neonatal abstinence syndrome.Evaluate a child with hemoptysis.Evaluate a hypotonic infant.Evaluate a patient with leukocoria.Evaluate an adolescent with a testicular mass.Evaluate and manage a child at risk for type 2 diabetes.Evaluate and manage a child with gross hematuria.Evaluate and manage a prepubertal girl with vaginal discharge.Evaluate and manage back pain in children.Evaluate and manage neonatal jaundice.Evaluate suicide risk in an adolescent.
Slide52New knowledge 2019For General PediatricsCheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management. Pediatrics. 2018; 141 (3): e20174082.https://www.ncbi.nim.nih.gov/pubmed/29483201Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017; 140(3): e20171904.https://www.ncbi.nim.nih.gov/pubmed/28827377Greenhawt M, Turner PJ, Kelso JM. Administration of influenza vaccines to egg allergic recipients:A practice parameter update 2017. Ann Allergy Asthma Immunol. 2018; 120(1): 49-52.https://www.ncbi.nim.nih.gov/pubmed/29273128
Slide53New knowledge 2019For General PediatricsCheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management. Pediatrics. 2018; 141 (3): e20174082.https://www.ncbi.nim.nih.gov/pubmed/29483201Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017; 140(3): e20171904.https://www.ncbi.nim.nih.gov/pubmed/28827377Greenhawt M, Turner PJ, Kelso JM. Administration of influenza vaccines to egg allergic recipients:A practice parameter update 2017. Ann Allergy Asthma Immunol. 2018; 120(1): 49-52.https://www.ncbi.nim.nih.gov/pubmed/29273128
Slide54New knowledge 2019For General PediatricsCheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management. Pediatrics. 2018; 141 (3): e20174082.https://www.ncbi.nim.nih.gov/pubmed/29483201Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017; 140(3): e20171904.https://www.ncbi.nim.nih.gov/pubmed/28827377Greenhawt M, Turner PJ, Kelso JM. Administration of influenza vaccines to egg allergic recipients:A practice parameter update 2017. Ann Allergy Asthma Immunol. 2018; 120(1): 49-52.https://www.ncbi.nim.nih.gov/pubmed/29273128
Slide55New knowledge 2019For General PediatricsCheung AH, Zuckerbrot RA, Jensen PS, et al. Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management. Pediatrics. 2018; 141 (3): e20174082.https://www.ncbi.nim.nih.gov/pubmed/29483201Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017; 140(3): e20171904.https://www.ncbi.nim.nih.gov/pubmed/28827377Greenhawt M, Turner PJ, Kelso JM. Administration of influenza vaccines to egg allergic recipients:A practice parameter update 2017. Ann Allergy Asthma Immunol. 2018; 120(1): 49-52.https://www.ncbi.nim.nih.gov/pubmed/29273128
Slide56ScoringLife happens………Drop lowest 4 quarters of performance at end of year 4
Slide57Five-Year MOC CycleYear 1Year 2Year 3Year 4≤ 72 questions≤ 72 questions≤ 72 questions
≤ 72 questions
Year 5
Take the proctored exam
What if I did
not
pass at the end of Year 4, or if I chose not to participate in MOCA-Peds?
Slide58Five-Year MOC CycleYear 1Year 2Year 3Year 4≤ 72 questions≤ 72 questions≤ 72 questions≤ 72 questions
Because of the 4 lowest quarters rule, those performing well enough may be able to stop at end of Year 3*
*Diplomates may choose to continue participating for MOC Part 2 credit
What if I am meeting the passing standard at the end of Year 4?
Year 5
Options:
Take a break until the next 5-year MOC cycle
Continue learning and receive MOC Part 2 credit
Slide59Passing RateBased on 2017 pilot, passing rate will be over 95%
Slide60Part 3 OptionsMOCA-PedsDefault with enrollmentNo additional feesEarn Part 2 pointsProctored ExamEvery 5-years at proctored siteAdditional fee to cover cost of seat fee and processingNo Part 2 credit
Slide61Ongoing ImprovementContinue to obtain feedback from participants about MOCA-PedsWhat works? What does not?What new issues/concerns are identified by diplomates?Annual surveys, focus groups, user groups, interviews Evaluate subspecialty-specific issues as each is implementedInformation to the ABP to support continuous improvement of MOCA-Peds
Slide62Slide63Slide64Slide65Part 4 Improvement in practice“There’s no evidence this stuff improves care…It’s a waste of time”WHAT’S NEW?
Slide66The ABP is making every attempt to encourage people to engage in quality improvement activities which will give credit for work already being done in their officesImprovement in practiceHow am I doing?What might I do even better?How might I do that?Check it out.
Slide67PCMH, small or large group QI projects, institutional QI leadershipPortfolios Streamlined application processExpanded Part 4 Pathways Significant increase in those getting credit for QI projects initiated by: Individual, team, network, or institution (not online modules)
New: Multi-activity PIMs
Slide68“ensure…every child gets the right care every time.” “QI shown to be an effective tool…tobridge gaps in care.”
Slide69AAP Making MOC BetterAAP has portfolio sponsorship statusAllows Academy to evaluate QI activities and approve projects internally for MOC Part 4 credit Collaborative learningMultiple practices/sites work together (e.g., CQN, VIPN) ***AAP Chapter meetings***
Slide70AAP Making MOC BetterPediaLink QIWeb-based tool for small groupsProjects proposed/led by volunteer pediatriciansEducation in QI for pediatric practices (EQIPP)Online courses for self-directed learningPoster/platform presentations at NCESupport sessions on MOC at NCEUnderstanding MOC: Requirements/Resources Pedialink QI
Slide71FEES$1304 is way too much to pay…What if I stop doing this in 2 years?WHAT’S NEW?
Slide72FEESAnnual payment option $1304 for 5 year cycle $275 annual fee
Slide73We know you’re already doing great work as pediatricians. However, as a profession, we can show that you are staying current and making an effort to improve your (great) practice. Maintaining our certification in a meaningful and relevant way - includingour collaborative efforts to improve that process - can show that commitment to improving the health care of children.Summary
Slide74What are YOUR creative ideas?