Advancement in medicine is evolving from an approach relying on individual knowledge and skill, to a strategy emphasizing practice-based learning and improvement.1 A growing body of evidence supports this strategy, demonstrating that practice improvement activity improves patient care.2,3 As a result, the American Board of Medical Specialties—the governing body for all medical specialty boards including the American Board of Orthopedic Surgery (ABOS)—is requiring that all physicians participate in Maintenance of Certification (MOC), which includes practice-based learning and improvement, to remain certified in their medical specialty.4
MOC has 4 parts (Table 1). Practice-Based Self-Assessment is an essential component of Part IV of MOC. Practice Improvement Modules (PIMs) were initially conceived as a tool which could be used by orthopaedic surgeons to satisfy the Part IV MOC requirement for Practice-Based Self-Assessment. However, at this time, the ABOS will likely use PIMs to award orthopaedic surgeons Part II MOC credit as evidence of life-long learning.
The ABOS has tasked specialty societies, as content experts, to develop the PIMs. The Pediatric Orthopedic Society of North America (POSNA) has chosen to develop a PIM around supracondylar humerus fracture care for the following reasons:
- Supracondylar humerus fracture pinning is the most commonly performed procedure by ABOS Pediatric Orthopedic Diplomats.
- The AAOS has developed Clinical Practice Guidelines for supracondylar fracture treatment on which a PIM can be based.5
- Safety checklists for supracondylar fracture treatment have been developed, which are available to guide PIM creation (M. Goldberg, verbal and written personal communications, Supracondylar Safety Checklist at Seattle Children’s Hospital, 2012).
Combining information and questions from the AAOS Clinical Practice Guidelines and safety checklists, a 33-question data collection tool was developed: 6 questions record data pertaining to the preoperative assessment, 14 questions are related to treatment, and 13 questions collect information regarding follow-up (Appendix A, Supplemental Digital Content 1, http://links.lww.com/BPO/A40). Using a current electronic medical record, approximately 10 minutes is required to complete the data collection tool for 1 patient.
The proposed process for the Supracondylar Fracture PIM completion involves first purchasing the PIM from the Specialty Society. The PIM is then activated on the diplomat’s ABOS MOC Dashboard. The ABOS diplomat enters 10 consecutive cases into the ABOS Scribe Database to complete the Section 1 of the Supracondylar PIM. The ABOS diplomat will then be provided feedback from the ABOS in the form of a report, which shows the diplomat’s answers compared with data provided by all diplomats who have previously completed the PIM. By comparing one’s own answers to answers provided by the body of diplomats previously completing the PIM, the diplomat is able to identify areas for improvement. Diplomats are encouraged to read and participate in CME activities related to supracondylar fracture treatment to identify improvement opportunities. In Section 2 of the Supracondylar PIM, the ABOS diplomats return to the ABOS Web site and attests to a Personal Action Plan and steps, which the diplomat will incorporate into practice and treatment of supracondylar fractures (Appendix B, Supplemental Digital Content 2, http://links.lww.com/BPO/A41). The ABOS diplomat then completes Section 3 of the Supracondylar PIM by implementing the Personal Action Plan when caring for the next 10 consecutive supracondylar humerus fracture patients and completing the Supracondylar Fracture PIM data collection tool for these 10 subsequent cases. Like Section 1, the data are entered into the ABOS Scribe data base and the ABOS diplomat is provided a report that shows how treatment has changed between the initial Section 1 and subsequent Section 3. The anticipated outcome is that comparison of answers from Section 1 with answers from Section 3 will demonstrate that learning and practice improvement has taken place.
As was mentioned earlier, the initial purpose of PIMs was to provide Part IV MOC credit, but at this time, the ABOS is intending to offer Part II MOC credit for PIM completion as evidence of Life-Long Learning. The current plan is to award 5 Part II Self-Assessment credits after completion of the Supracondylar PIM Section 1 and 5 more credits after completion of Section 2. An additional 10 Part II Self-Assessment credits will be awarded after completion of the Supracondylar PIM Section 3, for a total of 20 Part II MOC credits. Benefits to ABOS diplomats beyond certification include the opportunity to review and evaluate one’s practice and to demonstrate involvement in a quality assessment process. In the future, participation in a quality improvement activity may be recognized by third-party payers, may be needed for hospital credentialing and may become a necessary component of state licensure. While the Supracondylar PIM is implemented and refined, POSNA has a second PIM built around hardware removal on deck and ready for development. POSNA will remain engaged with the ABOS in MOC and practice improvement activities.
1. Duffy FD. American Board of Medical Specialties Maintenance of Certification
Committee, Practice Improvement
Module Summit, June 17, 2011, Chicago, IL.
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(MOC) affect quality of patient care? J Am Board Fam Med.. 2014;27:19–25.
3. Hess BJ, Johnston MM, Iobst WF, et al.. Practice-based learning
can improve osteoporosis care. J Am Geriatr Soc.. 2013;61:1651–1660.
4. Iglehart JK, Baron RB. Ensuring physicians’ competence—is maintenance of certification
the answer? N Engl J Med.. 2012;367:2543–2549.
5. Mulpuri K, Hosalkar H, Howard A. AAOS clinical practice guideline: the treatment of pediatric supracondylar humerus fractures. J Am Acad Orthop Surg.. 2012;20:328–330.