Another New Responsibility: Maintenance of Certification

he American Board of Anesthesiology (ABA) continues to grapple with both the requirements for and implementation of maintenance of certification.

The goal of maintenance of certification is laudable and important — our patients need to know that we are competent, not just on the day we pass our orals but throughout our careers.

The American Board of Medical Specialties has decided that all 24 of its member boards must develop maintenance of certification programs that contain four elements:

Part I: Professional Standing: A valid, unrestricted medical license and no medical licenses that are restricted.

Part II: Lifelong Learning and Self-Assessment (LLSA): The LLSA requirement for maintenance of certification in anesthesiology (MOCA®) is 350 credits for continuing medical education (CME) activities over the 10-year MOCA cycle with at most 70 LLSA credits for all CME activities completed in a calendar year.

Part III: Cognitive Expertise: A secure computer-based examination.

Part IV: Practice Performance Assessment: ABA diplomates should be continually engaged in a self-directed program of practice assessment and performance improvement, including attestation by an individual’s department chair, practice group president or other qualified individual of the practitioner’s involvement in practice performance assessment and quality improvement activities.

These first three parts are straightforward. They are easy to design and implement even if none of us likes taking another examination.

Practice performance assessment (PPAI) is the tough one for all specialties, especially for anesthesiology. Like it or not, we are very different from much of medicine. As an example, the primary care specialties are putting a lot of time and money into tools that assess the patient’s opinion of the physician’s communication skills. While relating to patients is important in anesthesiology as well, its significance shrinks when compared to the skills involved in a six-hour anesthetic for a leaking thoracic aortic aneurysm.

PPAI remains the most challenging component of MOCA.

ABA believes that there are other productive and effective routes to practice improvement and hopes that the use of simulators and Web-based patient safety exercises can be incorporated in practice performance improvement in the future.

What is the relevance of MOCA right now? It is especially relevant for those with time-limited certificates. Diplomates with time-limited certificates will lose their certification if MOCA is not completed in a timely fashion.

For those of us old enough to have a non-time-limited certificate, it is likely that maintenance of certification will become progressively more valuable as medicine changes. Physicians are being challenged by a new world demanding greater accountability and transparency. Maintenance of certification may be the answer to that challenge. What are some examples?

The Federation of State Medical Boards has an official policy statement that state medical boards are responsible to the public for ensuring the ongoing competence of physicians as a condition of relicensure and is actively studying this issue.

The Joint Commission has moved to “make credentialing and privileging a more objective and evidence-based process, to facilitate continuous monitoring of performance, to help identify substandard performance and to provide a basis for intervening when safety and quality of care issues are identified.”

Insurance companies and the Centers for Medicare & Medicaid Services (CMS) want to “reward” high performing and “debit” poorly performing physicians based on objective standards of care.

What if successful involvement in MOCA could allow an anesthesiologist to fulfill the demonstration of quality that these diverse organizations require? What if maintenance of certification became an integral part of licensure and credentialing and payment? Rather than making our lives more difficult, it may offer the promise of decreasing the hassles and ensuring the best in patient care at the same time. It has even been suggested that the information could flow the other way as well. As an example, if CMS requires submission of data on quality (pay for performance), could the boards accept a report on this quality from CMS as meeting practice assessment?

This might be “pie in the sky” and never come to pass. Organized medicine, however, is facing an opportunity to control its destiny. Medicine can define quality and how it is measured and reported. An optimistic view is that maintenance of certification can be structured to help physicians improve the quality of their practice and will fulfill a number of roles with minimum hassle. Medicine, though, could well see others snatch this opportunity from us. A substantially more pessimistic view is that others will take from us the definition and measurement of quality and we will lose even more control of our practices.

Our definition and measurement of quality care in anesthesiology is an important issue, and ABA is spending significant time and resources to optimally position the specialty for the future.

Orin F. Guidry, M.D., is a staff anesthesiologist at the Ochsner Clinic Foundation, New Orleans, Louisiana. He is ASA Immediate Past President.