In this month’s column, I will explore how orthopaedists and their patients benefit from the case list requirement. I will also describe new tools being developed that will help orthopaedists make continuous process improvements in the future.


Published 11/1/2013
Shepard R. Hurwitz, MD

Improving “Performance in Practice” with MOC

Confidential reports and PIMs will provide useful data on self-reported measures

Orthopaedic surgeons understand the importance of continuously measuring, assessing, and improving the quality of care they provide to patients. One way to ensure that this ongoing performance improvement occurs is by satisfying the requirements of the American Board of Orthopaedic Surgery’s (ABOS) Maintenance of Certification (MOC) Part IV: “Performance in Practice.”

As part of Part IV, all orthopaedists who participate in MOC and are currently performing surgery must submit one of the following to the ABOS:

  • a 3-month list of surgical cases, with a minimum of 14 consecutive cases and a maximum of 75 consecutive cases (for the computer examination)
  • a case list from 6 consecutive months (for the oral examination)

Shepard R. Hurwitz, MD

Case list basics
The reason the ABOS requires orthopaedists to submit case lists is to ensure that orthopaedic surgeons gather and review information on recent procedures and reflect upon the outcomes. Quite simply, Part IV of MOC is designed to provide meaningful feedback to surgeons, with the goal of improving performance in practice. It is not to unduly sanction surgeons whose patients have complications or less-than-perfect outcomes.

As part of the process, orthopaedists are asked to gather information concerning compliance with Centers for Medicare & Medicaid Services guidelines for deep vein thrombosis prophylaxis and intravenous antibiotics, as well as information about the following:

  • unplanned returns to the operating room
  • hospital readmissions
  • surgical site infections
  • pulmonary emboli
  • strokes
  • myocardial infarctions
  • other problems or complications

Interestingly, case list data submitted to the ABOS has been used by researchers searching for anonymous data to conduct orthopaedic reviews of contemporary practice. For example, a recent study in The Journal of Bone & Joint Surgery documented the significant shift from the use of sliding hip screws to intramedullary nail fixation in the treatment of intertrochanteric hip fracture. The information gathered that was provided by the ABOS was used to document change, not to demonstrate improvement or the advantage of one technique over another.

Confidential reports,PIMs coming soon
Beginning in 2014, each ABOS diplomate will be able to log in to the ABOS website and access a secure, confidential report based on his or her own case list submissions. These reports will provide comparative data on self-reported measures, with the goal of helping orthopaedists improve the quality of care they provide. In turn, the reports may also help reduce healthcare costs.

In the future, the ABOS plans to integrate Practice Improvement Modules (PIMs) into the MOC process to give diplomates a new way of assessing their performance (see “Orthopaedic PIMs.”) PIMs will complement the case submission requirement, rather than replace it.

PIMs involve a cycle of steps, beginning with documentation of several cases with the same diagnosis. After treating the patients, the surgeon evaluates the results and makes changes based on his or her findings. PIMs can be part of a CME module, enabling surgeons to earn CME credit for completing the process.

Surgical specialties have adopted PIMs as part of MOC because the PIMs use case-reported material that is analyzed and returned to the surgeon, followed by an improvement plan or educational activity—for example, continuing medical education or a hands-on educational course—followed by another reporting of a different set of the same procedures. Several surgical specialty boards now have case-reporting requirements, including the American Board of Thoracic Surgery, which requires continuous reporting by its diplomates to maintain board certification.

By submitting cases for analysis or participation in the PIM process, the orthopaedic surgeon creates a “before-and-after” scenario in which the educational activity may lead to demonstrated improvement in some measure of patient care.

PIMs may also have benefit outside of the MOC process because they may be used to show a hospital or insurer that the orthopaedic surgeon is involved in a quality assessment program.

Shepard R. Hurwitz, MD, is executive director of the ABOS. He can be reached at

Orthopaedic PIMs
The first series of orthopaedic PIM/PI-CME modules is currently being developed. Two PIMs—one for treatment of carpal tunnel syndrome and another for hammer toe correction—are expected to be available in early 2014.