By: The Alliance Research Committee: Wendy Turell (Chair), Andrew Bowser, Greselda Butler, Elizabeth Franklin, Alexandra Howson, Jan Perez, Pesha Rubinstein, Greg Salinas
Overview and Methods
The Research Committee of the Alliance for Continuing Education in the Health Professions (”Alliance”) conducted an environmental scan between December 2016 and January 2017 to ascertain practices and member-organization direction in five domains of interest. In In total, 178 educational providers (“providers”) and 31 educational supporters (“supporters”) provided full survey responses.
Results of the environmental scan are reported for Almanac readers in two articles. This article — the second of a 2-part series — presents results regarding maintenance of certifications (MOC) and patient inclusion. Please see part one for a more detailed methodology, as well as results pertaining to quality improvement, adult learning principles/educational methods and outcomes measurement.
Maintenance of Certifications (MOC)
Respondents in both groups expressed similar levels of familiarity with Maintenance of Certification (MOC), although the majority of supporters (80%) did not consider MOC-II credit an assessment criterion by which they evaluated grant requests. Slightly more than half of providers (53%) plan activities that offer physicians MOC-II credit (on average, 65 hours from a range from 1–500 credits per year). The percentage of respondents within each community of practice who reported offering MOC-II activities was computed (Figure 1).
Figure 1: MOC-II Trends by Community of Practice
The main benefit by far that these providers experience from including MOC-II activities in their educational programs is that their physician learners appreciate the ability to meet their boards’ MOC requirements (96%). Other benefits were not as noteworthy (e.g. the knowledge self-assessment opportunities that MOC-II activities offer physician learners or MOC revenue to providers).
Providers who offer MOC-II activities report challenges in planning and implementing these activities. A majority (65%) found that managing the MOC-II process is labor intensive for staff; 47% stated that it is burdensome to train faculty and medical writers to create meaningful assessment questions; 28% found it is a burden to respond to physician resistance to MOC-II requirements, and 16% say that their learners report that MOC-II is too time-consuming or expensive.
Of the 47% providers who stated they did not provide MOC-II activities, slightly less than half (42%) say they will make changes to their programs to offer MOC-II activities. Almost all of the 58% of providers who say they will not be changing their programs to offer MOC-II activities cite workforce burden as the main reason for not making this change. Other reasons these providers gave for not changing their programs were lack of expertise (60%), faculty resistance (27%), and inadequate tools (25%). Additional comments were that these providers did not educate within the U.S., do not typically educate physicians and do not find MOC applicable to their organization.
Only providers were surveyed about MOC-IV activities, which involve physicians’ ongoing assessment and improvement in the quality of care they provide in their individual practices and/or in larger practice settings. Although a variety of formats are applicable to MOC-IV activities, most providers were familiar with the Performance Improvement format. Only 62% of provider respondents provide MOC-IV opportunities for their learners. Fifty percent of academic medical centers and 50% of hospital providers responding to the survey offer MOC-IV opportunities to physician learners. That is in contrast to the 38% of medical specialty society and 24% of MEC survey respondents offering MOC-IV opportunities to their learners.
Almost all respondents offering MOC-IV activities (90%) reported that the main benefit for their organizations of including these performance improvement opportunities in their educational programs is that physician learners appreciate the ability to meet their boards’ MOC requirements, and 48% agreed that another benefit in offering MOC-IV activities is that physician learners enjoy opportunities for knowledge self-assessment. Only 20% of providers offering MOC-IV reported that these activities are a revenue resource they did not have before MOC requirements were issued.
A majority (67%) of providers that offer MOC-IV find that managing the process is labor intensive for staff, and that there is considerable physician resistance to MOC-IV (61%). One third (34%) said that their learners deem MOC-IV too time-consuming and/or too expensive. A majority of providers responding to the survey (62%) say they have no plans to change their programs to offer Part IV in the future; the following reasons were reported: 1) they do not have staff/resources to establish a MOC-IV program (52%); 2) there is insufficient expertise to establish the MOC-IV program (35%); and, 3) some medical boards manage their own MOC-IV programs (18%).
ACCME’s new Criteria for Commendation (C24) encourage the inclusion of non-healthcare providers in the planning, teaching and delivery of certified CME activities.[i] To determine the level that respondents value, include or plan to include non-healthcare providers (non-HCP); specifically, patients and representatives from the public, we asked:
- Are providers including patients/public in their CME planning?
- Do supporters value patient/public inclusion?
- What are the barriers to patient/public inclusion?
Patients/Non-HCP Public as Planners
Supporters estimated that 28% of their supported HCP-directed activities included patients in planning. A majority (81%) saw value in including patients in the planning process. Approximately half of providers (46%) reported including patients/non-HCPs in some aspect of their CME/CE planning process and estimated that overall, 13% of their HCP-directed activities included patient/public planners. The percentage of respondents within each community of practice who use non-HCPs in the planning process computed (Figure 2).
Figure 2: Inclusion of Patients/Non HCPs in Educational Planning
A majority (76%) of providers are planning to include patients in the planning of future CME/CE activities. Barriers to patients/the public in planning include organizational culture (17%), lack of expertise (15%) and lack of human and financial resources (8%, 6%). Other barriers reported included challenges associated with the ethics and logistics of including or finding patients/the public to participate in the planning process, especially patients with serious and/or life-threatening illness and clinician resistance to the value of patient level knowledge as part of the CME planning process.
Patients/Non-HCP Public as Teachers and Authors
In some degree of frequency, 38% of providers (n=111) indicated they currently include patients or other members of the public as teachers or content authors for their certified activities. However, they estimated that only 13% of their certified activities overall include patients or the public in these roles. Looking towards the future, 47% of providers across communities of practice plan to include patients as teacher/authors of future HCP-directed certified activities (hospitals = 42%, MECs = 40%, specialty societies = 50%, Academic Medical Centers = 53%). In contrast, 53% reported they do not have plans to include patients and teachers or authors. Perceived barriers to using patients as teachers/authors in future HCP-directed certified activities included culture of resistance to/fear of change (17%), resistance from CME/CE committee (9%), lack of organizational recognition about the value of patient inclusion (22%), lack of expertise or time (12%, 7%), and insufficient staff (23%).
Supporters and the Value of Patient Inclusion
About half of supporters (48%) reported that the inclusion of non-HCPs as planners or teachers/authors is informally valued during the review process; 28% of supporters formally value patient inclusion; and 12% responded that it was not valued in the review process. A small group (12%) had alternate review criteria.
Examples of the comments were:
- “While it is not formally or informally valued by the company, we personally value patient involvement.”
- “Depends on the educational objectives and on the expected outcomes.”
Barriers to inclusion of patients/public in planning and delivery of CME/CE
When asked what specific barriers may exist in making the change to patient/public inclusion, answers were as follows:
- Organizational culture 17%
- Expertise 15%
- Financial resources 9%
- Human resources 8%
- Time resources 6%
Discussion and Conclusion
Although providers are developing MOC activities, there appears to be a need here for more information on MOC, particularly on MOC-IV, given the burden these activities impose on provider organizations. For example, more academic medical centers and hospital-based providers reported offering MOC-IV opportunities versus medical specialty societies and MEC responents. This could point to the challenge of offering MOC-IV projects in provider environments where there are more barriers to accessing patients or patient data.
Finally, patient inclusion is an encouraging trend, with roughly half of providers beginning to include patients as planners and/or content authors and teachers. Fewer supporters are currently including patients, although a majority see value in this trend. Resources pose a significant barrier to including patients as planners, while a culture of resistance currently limits the inclusion of patients as authors and teachers.
[i] Menu of New Criteria for Accreditation with Commendation ©2016 ACCME. http://www.accme.org/requirements/accreditation-requirements-cme-providers/proposal-new-criteria-accreditation-commendation. Accessed June 8, 2017