Public Trust Initiatives
Our mission is related to ensuring the public trust, physician accountability, and physician quality. This is pursued via two main processes: certification and maintenance of certification (MOC). Initial certification occurs in two parts: a written examination following completion of an approved residency program and two years later, a practice-based oral examination.
These formal and highly structured processes involve some of the most unique procedures and protocols in all of American medicine. First is the truly unique credentialing process which we do periodically for each candidate seeking board certification, either primary after residency training completion and/or for maintenance of certification, required every 10 years, since 1986. Credentialing is about quality care, through a rigorous process with measurable outcomes leading to the "best in practice" patient care.
ABOS credentialing is unique in all of organized medicine. The primary certification and MOC process involves a 360° evaluation of each candidate with 15 references from professionals who can evaluate the candidate. Following approval by the credentialing committee, there is a validated cognitive examination, testing candidates' orthopaedic knowledge across a board content range. The computer based certifying examination is one of the most rigorous in medicine and is scientifically evaluated by our partners in the National Board of Medical Examiners (NBME).
Our candidates have the only mandatory, practice based oral examination. The oral examination is psychometrically validated by our collaboration with the NBME and recognized experts in the field of high-stakes examination. Our practice-based oral examinations have been in place since 1993. The credentialing process plus passing both parts of the certifying examination are required for Board Certification and those candidates are now called diplomates. Diplomates who are maintaining certification currently have the choice of either a computer based examination or a practice based oral examination.
We were the first board to develop a web-based data collection system (SCRIBE©) for our candidates to enter a patient case list used as the basis for the practice based oral examination. Self-evaluation and personal improvement are keys to a successful and ongoing maintenance of quality. The case collection period allows candidates to review their own cases in an organized quality review process that allows for the best self-evaluation of one's clinical practice. This self-evaluation and reflection process is unique in all of organized medicine.
The submission of the case list has useful information for the ABOS database used for quality improvement and the creation of performance measures: demographic information, area of specialty or subspecialty concentration, fellowship training, hospital affiliation(s), and a great deal of specificity of each case submitted. Among the items collected are some of the most appropriate nationally recognized quality and safety measures. "Sign your site," first introduced by orthopaedic surgeons, has helped to decrease the incidence of "wrong site surgery" nationwide nearly ten-fold and has been adopted by other medical and surgical disciplines. Additional quality measures that are in place include deep venous thrombosis prophylaxis, to ensure protection for patients at high risk for blood clots that can be life threatening and pre-surgical time-outs that reduce the risk of operating room errors. Perioperative timing of prophylactic antibiotics is another important variable we monitor to help ensure a lower risk of infection to orthopaedic patients.
During the oral examination, recertified orthopaedic surgeons trained in the examination process question candidates about a subset of their submitted cases. Case are selected by current and former board members and those with extensive experience in the examination process.
Candidates present all medically related information related to the selected cases: medical records, informed consent, lab data, and images. The question and answer process is performed with each candidate being examined by six different examiners over three, 40-minute examination sesions. Categories evaluated for each candidate by each examiner include: indications, medical ethics, outcomes, complications, and medical record documentation.
In this process and all related processes, the board is fulfilling its mission to protect the public, always seeking better, evidence-based means to evaluate our candidates for certification while maintaining the highest standards of any medical profession. Additionally, because of our database system, Scribe, we have begun a flagging process of cases for review during the credentialing and examination processes. Recently, we flagged some high volume procedures, where more evidence based research is needed, e.g. -spinal fusion and shoulder arthroscopy. Without the ABOS database and our efforts from our research committee, the process of certification would not be evidence based or effective. The ABOS believes it is part of the learning health care system, being proactive and data driven in our certification processes.
Transparency is another important part of the ABOS mission. As part of our quality improvement effort for our diplomates and consistent with our transparency efforts we have begun an extensive quality initiative effort using our Scribe database. Such projects include but are not limited to: ACGME approved fellowships; newer treatments of femoral neck fractures; changes in treatment of wrist fractures; emergency department trauma responsibility; and spine surgery (cervical and lumbar) efficacy. All are conditions in which different procedures may accomplish the same outcome and the ABOS wants to take the leading role in the "comparative effectiveness" national initiative.
We have implemented a patient-focus group feedback initiative. This allows the ABOS to get direct patient feedback about the board certification process. This along with our public member provides direct ABOS public feedback to continually improve upon our mission and ensures accountability to the public. Our lay member participates in our discussions and decisions at the Board meetings.