Navigating the gray areas in Maintenance of Certification (MOC) compliance can create confusion and inefficiency, but understanding these nuances is essential to maintaining accreditation and offering high-quality continuing medical education (CME). Immersed in the world of MOC, we — Sabrena Lary and Katie O’Connell — bring our unique journeys through the complexities of MOC processes and requirements. Katie’s longstanding experience in MOC workflow development complements Sabrena’s newcomer perspective, driven by a desire to understand the subtle details that influence compliance.
Together, we've realized how frequently MOC requirements fall into "gray areas," where interpretation and organizational standards can vary. We've written this article to share our insights, hoping to clarify some of these challenges by sharing real cases where compliance was unclear. Here’s how it all started!
"Hey, Katie! Do you find the requirements confusing? There seems to be a lot of gray areas left open to interpretation." Sabrena asked one afternoon.
Katie chuckled, "Yes, even after all these years, I still run into certain instances that require a deeper dive into the ACCME MOC Guide."
"Exactly." Sabrena agreed, "I find that I am constantly looking through the guide to ensure requirements are met, and I struggle with defining those gray areas.”
"You’re not alone, that's why sharing our experiences is so important," Katie said. "If we can help others, we should do it! We should see what challenges others are having.”
What started as a simple survey has led us here, to this article. But don't be fooled — this article is just the opening chapter of an exciting new adventure.
Here are two cases that highlight the gray areas we've encountered, along with data from a survey we conducted to see how we could best support other CME professionals navigating these same issues.
Case: Health Equity and Board-specific Requirements
Katie's team wanted to offer MOC credits for a health equity-focused activity related to cancer. While this topic was relevant to multiple medical boards, it created a gray area for the American Board of Orthopedic Surgery (ABOS).
Unlike other boards that allowed non-specialty-specific MOC activities, ABOS required that activities be directly related to orthopedic subspecialties to qualify for MOC credit. Health equity in cancer care, despite its importance and relevance to orthopedic patients, didn’t meet ABOS's strict criteria for orthopedic-specific content.
It was initially believed the activity would qualify across all boards, but after consulting with the Accreditation Council for Continuing Medical Education (ACCME) and reviewing the ABOS Special Activity Requirements in the MOC Guide, she realized it wouldn’t meet orthopedic MOC criteria. With this new insight, she explained the specific requirements to her team and activity planners, encouraging everyone to closely examine each board’s Special Activity Requirements in the MOC Guide before offering MOC credits.
This experience underscores the importance of understanding board-specific guidelines and the complexities that emerge when MOC requirements intersect with broader healthcare topics like health equity.
Case: Failed Audit Due to Insufficient Post-test Feedback
In a past audit by the ACCME for the American Board of Internal Medicine (ABIM) MOC credit, Sabrena’s team was flagged for missing critical feedback components in a post-test for an enduring material activity. The activity, which involved a recorded video with a post-test, provided immediate correct/incorrect responses to learners but lacked an explanation or rationale for why each answer was correct.
ABIM’s “Medical Knowledge” MOC credit falls under the American Board of Medical Specialties (ABMS) Part II — Accredited CME with Evaluation and Feedback category. For ABIM and similar boards, providing feedback with a rationale and references for each test question is required to meet their MOC evaluation standards.
At the time the activity was conducted, Sabrena was relatively new to the role and was unaware of the specific guidelines for Accredited CME with Evaluation and Feedback, particularly for post-tests. Simply marking answers as correct or incorrect is not enough — detailed rationales with references are essential to meet board standards. This audit finding prompted Sabrena to ensure that all future evaluations meet the required standards by reviewing Appendix A of the MOC Guide: Evaluation and Feedback Resources more closely.
This experience underscores how small details can have significant compliance implications and highlights the importance of thoroughly reviewing MOC requirements, especially when designing Accredited CME with Evaluation and Feedback.
The Survey
Our goal was to uncover and clarify “gray areas” in MOC practices — those situations where guidelines are open to varied interpretations and lack clear application, creating potential pitfalls. By gathering feedback from our CME colleagues, we aimed to highlight these ambiguous areas to help others avoid similar challenges and enhance understanding across the field.
After analyzing 27 unique responses from a total of 30 collected, we are excited to share these insights with the community, with ChatGPT as a thought partner. Our survey included both qualitative and quantitative questions; quantitative responses offered an overview of current provider offerings, while qualitative feedback shed light on the nuanced challenges providers face.
This summary reflects the findings of the “MOC Evaluation Gray Areas — Survey,” conducted in March 2024 with members of the Alliance Hospitals and Health Systems Section, Northeast CME Group, Society for Academic CME (SACME) and cloudCME user groups.
Current Providers Offerings:
- By board: American Board of Internal Medicine (ABIM) - 22, American Board of Surgery (ABS) - 24, American Board of Pediatrics (ABP) - 18, American Board of Pathology (ABPath) - 10, American Board of Anesthesiology (ABA) - 11, American Board of Otolaryngology – Head and Neck Surgery (ABOHNS) - 9, American Board of Thoracic Surgery (ABTS) - 4, American Board of Orthopaedic Surgery (ABOS) - 4.
- By activity type: Regularly Scheduled Series (25), Live Course (22), Enduring Material (11), Performance Improvement (8), Journal CME/CE (2), Other/Blended Learning (2) Committing Learning (1)
- By evaluation format: Case Discussion (17), Written Responses/Statements (21), Quiz (12), Simulation (5), Other (4), Audience Response System (2), Writing Test Items (1), Table-top Exercise (1).
How do you choose when to offer MOC?
Providers typically decide to offer MOC based on a few core factors. The most common approach is offering MOC when planners or course directors request it during the planning process. Regularly Scheduled Series (RSS) formats, like tumor boards and case reviews, are often favored due to their ease of evaluation mechanism and documentation. We always need to consider the resources available, including staff time and the complexity of the evaluation process. Finally, the target audience significantly influences the decision, especially for activities involving large groups of specialty physicians like surgeons or anesthesiologists, where MOC might be more impactful.
What complex scenarios do you encounter?
Respondents expressed frustration over the ambiguity in ACCME and board guidelines, especially concerning compliance and evaluation methods. Many organizations highlighted the need for explicit examples and more consistent communication from boards. The core challenge is the inconsistency in requirements across certifying boards, leading to confusion and added administrative workload. This is further complicated by the design of evaluation mechanisms, where organizations struggle to meet MOC standards, especially with limited guidance. Data management adds another layer of complexity, with issues like data mismatches and integration problems with systems like Program and Activity Reporting System (PARS) and learning management system (LMS) platforms consuming significant time. Additionally, evaluation and feedback continue to be problematic, as organizations move away from traditional methods like quizzes, creating uncertainty about what qualifies as sufficient feedback for MOC credit.
What resources do you use?
Respondents reported a wide range of resources, with ACCME's CME for Maintenance of Certification Program Guide as the most frequently used (14 mentions), followed by board-specific websites (ABP, ABS, ABIM) and program guides (5 mentions). The ABMS website, staff, and external collaborations like webinars also support MOC efforts. However, resources like the Certifying Board Crosswalk Tool, though less commonly mentioned, provide valuable assistance in aligning processes across different certifying bodies. We have linked some resources we have found invaluable below:
ACCME Maintenance of Certification Website: https://accme.org/data-reporting/maintenance-of-certification/
CME for MOC Program Guide: https://accme.org/resource/cme-for-moc-program-guide/
CME for MOC Crosswalk: https://accme.org/resource/cme-for-moc-crosswalk/
ABIM Medical Knowledge Assessment Recognition Program Activity Audit Structured Abstract: https://accme.org/resource/abim-medical-knowledge-assessment-recognition-program-activity-audit-structured/
ABP MOC Part 2 Audit Checklist: https://accme.org/resource/abp-moc-part-2-audit-checklist/
CME for MOC Activity Planning Worksheet: https://accme.org/resource/cme-for-moc-planning-guide/
Conclusion
Navigating the gray areas in maintaining compliance with MOC standards can feel overwhelming, but with the right resources and support, it becomes manageable — and even an opportunity for innovation. Collaborate with CME colleagues, tap into resources from ACCME and user groups, and lean on your network of CME professionals to understand what works in similar settings. Ultimately, it’s essential to create workflows that make sense for your institution, transforming those gray areas into clear, actionable processes that meet both board requirements and organizational goals. By doing so, you’re not only ensuring compliance but also setting a foundation of consistency and clarity that will serve your learners and your institution well into the future.
Here’s to turning those gray areas black and white, one process at a time!
With CME love,
Sabrena & Katie
Sabrena D. Lary, ATC, is an Athletic Trainer with 20 years of experience who transitioned to CE at Hartford HealthCare during the pandemic. Proficient in MOC, ACPE, JA-PARS, and On-Demand Learning, she is passionate about fostering inclusive, team-based education. Sabrena is a strong advocate for the growth and inclusion of athletic trainers, encouraging collaborative knowledge-sharing within multidisciplinary teams. She thrives on working collaboratively and is always seeking innovative solutions to enhance learning experiences. Outside of her professional work, Sabrena enjoys reading, rucking, and pursuing personal growth through continuous learning.
Katie O’Connell, CHCP, is a CME Professional at Memorial Sloan Kettering Cancer Center in New York City, residing in Jersey. Since 2016, she has been an active member of the CME community, demonstrating a strong commitment to professional development and engagement. Her dedication was recognized with the inaugural CPD Forty Under 40 Award in 2024. Katie recently earned her CHCP certification and serves as the co-leader of the Alliance Hospitals and Health Systems Member Section. Outside of her professional endeavors, she enjoys planning adventures with family and friends, volunteers with an animal rescue organization, and is a proud dog mom to a “foster fail” Bluey the Maltese.