We will be performing site maintenance on AAOS.org on February 8th from 7:00 PM – 9:00 PM CST which may cause sitewide downtime. We apologize for the inconvenience.


Published 10/1/2010
James R. Kasser, MD

MOC: Improving quality and safety

Maintenance of Certification (MOC) is a process that assures the public of physician expertise and ongoing competence in medical specialties by establishing standards for physician education, testing, and performance. The MOC Program, established by the American Board of Medical Specialties (ABMS) seeks to amplify the benefits of recertification in promoting physician performance improvement and educational update.

The American Board of Orthopaedic Surgery (ABOS) deployed the program 3 years ahead of schedule to ensure mandatory compliance and a productive program.

The 4 required components of MOC are as follows:

  • Evidence of professional standing
  • Evidence of lifelong learning and self-assessment
  • Evidence of cognitive expertise
  • Evidence of performance in practice

MOC and licensure
The first of these, maintenance of licensure, is easily understood as a requirement for physician competence. Maintenance of state licensure is required for board certification in all specialties, including orthopaedic surgery.

State medical licensure is granted upon completion of medical school or residency and is required to practice in all states. A physician may lose his or her license due to poor performance, criminal activity, or unethical behavior, at the discretion of the state board. Whether board certification and participation in an MOC program is or should be a requirement for state licensure is being discussed (See “Physician maintenance of licensure”).

If states require ongoing practice assessment to maintain licensure, certainly specialty-specific performance data (MOC) is preferable to repeated testing of general medical knowledge for specialists such as orthopaedic surgeons. I fully support the concept that specialty MOC should be sufficient for maintenance of state licensure, if ongoing testing becomes a state requirement. The ABOS also considers unrestricted credentialing at hospitals and surgical outpatient centers in the peer-review process for MOC.

Lifelong learning and self-assessment are clearly a requirement for practice, given the growing body of medical knowledge. Courses, reading, conferences, and the multiple venues for acquisition of Continuing Medical Education (CME) credits provide an opportunity for updating medical knowledge. The addition of a “scored and recorded” self-assessment examination to this process reinforces the feedback loop that is important in education.

The ABOS divided each 10-year MOC cycle into two 3-year periods during which diplomates are required to acquire 120 CME credit hours, including 20 hours of scored and recorded self-assessment examinations. The AAOS, specialty societies, and others have developed educational products and self-assessment exams that satisfy these requirements. The ABOS does not supply or specify the specific educational material required in this process.

Knowledge base
MOC also requires documentation of the cognitive expertise or specific knowledge required to practice orthopaedics. Recertification examinations, either oral or written, are offered in years 8, 9, and 10 of the MOC cycle. Approximately 85 percent of orthopaedic diplomates elect to take the written recertification examination.

Recertification examinations may be general or specialty-specific (sports, hand, adult reconstructive surgery, and spine). Written examinations in smaller specialty areas have not been developed due to the lack of testing validity in small sample sizes.

The written examination passing score is based on a standard setting exercise in which practicing orthopaedic surgeons determine what level of information is required to practice safe, effective orthopaedic surgery; that is, the passing score is set by what practicing orthopaedic surgeons believe a competent orthopaedic surgeon should know.

An alternative to the written examination—the oral recertification pathway—looks specifically at performance in one’s own practice, because the examination is based on a submitted case list. Examiners are drawn from both the private and academic practice worlds. Approximately 15 percent of orthopaedists choose this testing method, which provides an ideal way to evaluate applied knowledge in orthopaedic surgery.

Practice performance
The final part of the MOC process is assessment of performance in practice. A peer review document providing a nearly 360-degree evaluation of orthopaedic surgeons is sent to colleagues, hospital leadership, and staff when the diplomate applies for the recertification examination. The submitted documents are then reviewed by the credentials committee of the ABOS. This ensures professionalism and competence in orthopaedic surgeons sitting for the recertification examination.

A case list is also required for the recertification examination process. Documentation of time-out, deep venous thrombosis prophylaxis (as indicated), perioperative antibiotics (as indicated), and sign your site are required. The diplomates’ review of these process measures, as well as their case list, provides an opportunity for orthopaedic surgeons to assess performance in practice. The ABOS Research Committee has reviewed “never events” such as wrong-site surgery and shown the effect on practice improvement of the process measures as listed above.

We are presently looking into practice improvement modules (PIMs) so that orthopaedic surgeons can study specific case types common in their practices and compare techniques, management options, and outcomes to national norms. PIMs are currently being developed in hand surgery; an effort is being made to develop more through medical specialty societies.

In addition to developing PIMs, many organizations—both professional and medical—are requiring the use of clinical databases to analyze performance and practice to improve care and outcome. It is the mission of the ABOS to improve care through such self-reflective instruments as databases, PIMs, or case lists, and we will continue this process.

Public validation
The MOC effort assures the public that the orthopaedic surgery workforce has an updated knowledge base and conducts periodic review of practice performance. The 6 competencies required for quality care (compassionate patient care, current medical knowledge, practice-based learning and improvement, interpersonal communication skills, professionalism, and systems-based practices) are reflected in the 4 elements of the MOC process.

The oral or written examination process ensures that medical knowledge and quality of care are up-to-date. The ABOS evaluation questionnaire documents professionalism, interpersonal relationships, and communication in practicing orthopaedic surgeons when they recertify. The case list or practice improvement module provides an opportunity for practicing orthopaedic surgeons to compare their performance in practice to peers and national norms. The ABOS encourages the participation of its diplomates in societal and medical system databases to improve quality of care and outcome. These represent examples of practice-based learning as well as systems-based practice.

Guided lifelong learning
Through the MOC process, created by orthopaedists with wide input from surgeons outside the ABOS, orthopaedic surgeons can demonstrate to the public their dedication toward knowledge update and performance improvement. Importantly, MOC provides an incentive for ongoing structured learning and self-evaluation based on one’s own practice and interests.

MOC clearly documents competence in the 6 competencies identified by the Accreditation Council for General Medical Education and a coming Joint Commission and hospital credentialing requirement. It thus helps enhance both clinical knowledge and skills and provides evidence of performance that may well be required for state licensure and hospital credentialing in the near future.

James R. Kasser, MD, is president of the ABOS.He can be reached at james.kasser@childrens.harvard.edu