Moore’s Level 4, Competence


The fourth level in one established outcomes framework, Moore’s Level 4 emphasizes the need to measure the change in competence that are associated with an educational intervention. Competence is defined as SHOWING (within an educational setting) how to do what the CME activity intended a Learner to be able to do. This is different than DOING…



A comparison of clinical problem-oriented question responses that demonstrates clinical behavior competency; from a Pre-test to at least one Post-test. To measure competence, clinical problem -oriented questions should require the learner to meet each of the following three criteria: 1) interpret and synthesize data framed in a clinical scenario, 2) apply his or her knowledge to this situation, and 3) make some type of judgment. Unlike knowledge-based MCQs, case vignettes may have an evidence-based best (not single correct) answer.

Secondary method: Intent to Change or Commitment to Change methodology or Self-efficacy statements.



Moore et al. JCEHP, 29(1):1–15, 2009.

National Board of Medical Examiners Constructing Written Test Questions for the Basic and Clinical Sciences, 2018.

Peterson ED, et al. Using perceived self-efficacy to measure outcomes: evaluation of a two-day course. CE Meas. 1:59-64. 2007.

Peterson ED. Measures of perceived self-efficacy as a method of evaluating educational outcomes: an introduction. CE Meas. 1:35-9. 2006

Overton GK, MacVicar R. Requesting a commitment to change: conditions that produce behavioral or attitudinal commitment. JCEHP, 28:60-66. 2008.

White MI, Grzybowski S, Broudo M. Commitment to change instrument enhances program planning, implementation, and evaluation. JCEHP, 24:153-162. 2004

Peabody JW, et al. JAMA, 283(13):1715-22. 2000.



A 65 years old taxi driver was admitted for 1-day onset of acute left lower limb pain and swelling. On clinical exam, there was generalized purplish discoloration and swelling of his entire left lower limb. Proximal as well as distal arterial pulses were present and strong in the lower limb. Neuromotor functions were intact.

What other treatment(s) should you consider?

  1. Antibiotics
  2. Thrombolysis
  3. Endovascular thrombectomy
  4. Surgical thrombectomy


Additional Contextual Information:

  • Measures of Competence should be aligned with a predefined learning objective.
  • Since Level 4 is defined by the change in Competence, data should be collected before and after the educational intervention. If statistical approaches are being applied, one should understand the limitations of such approaches.
  • Note: there are well-established best practices for the construction and deliver of assessment questions, for this reason it is the suggestion of the OSP Steering Team that questions should be developed in accordance with National Board of Medical Examiner guidelines.
  • It is recognized that the while the secondary methods of commitment-to-change and self-efficacy are considered by Moore’s framework to be Competence measures, the accuracy of these data are broadly questioned within the profession. As such, it is the recommendation to refer to commitment-to-change and self-efficacy as “Surrogate Competence” measurements.