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Date Updated: November 9, 2011

Health System Reform Policies Appendix

Current System Characteristics

Assuring the quality of the healthcare workforce begins in professional school, continues through postgraduate training (residency), and should extend through the lifetime of practice. Assessment of competence (what a clinician is able to do) dominates assessment in formal professional education and throughout the lifelong learning and continuous quality improvement expected of individual practitioners. While such assessment may provide insight into actual performance (what the clinician does habitually when not observed), direct measures of performance are few. Furthermore, the extent of competence testing in practice is variable and often absent among practitioners.

Measures of performance are presently relatively undeveloped and often resisted by physicians. A further complicating factor is the multitude of interrelated but independently governed professional organizations with responsibility for assuring the proficiency of individual practitioners. While each of these organizations generally includes key stakeholders, there is no overarching group with a mandate to define healthcare professional competencies and appropriate standards. Participants in the Physician Accountability for Physician Competence summits have recently drafted a detailed description of essential competencies for medical doctors (A Guide to Good Medical Practice – USA14 ) based on the six general competencies articulated by ACGME and ABMS, but have been unable to reach consensus on whether the defined competencies should be used solely as aspirational goals or considered standards.

Several elements of current systems to assure proficiency merit additional discussion.

Medical Licensure

The license to practice medicine and most other healthcare professions in the United States is not granted at the time of graduation. Licensure requires documentation of competence beyond graduation alone. The licensing authority of each state is empowered by the legislature to issue licenses, regulate practice within the guidelines of the state's practice act, and discipline clinicians who violate the act. Licensing authorities predominantly rely on measures of competence. In medicine these are reflected by medical school and residency credentials and successful completion of all three steps of the USMLE or the Comprehensive Osteopathic Medical Licensing Exam (COMLEX-USA). However, the individual licensing authorities established to oversee individual health professionals rarely coordinate their work across jurisdictions or across professions, despite the fact that there are increasing areas of overlap in the domains of practice of licensees of different health professions.

Professional licenses must be periodically renewed, usually every few years. However, state licensing boards have limited ability to assess the competence or performance of applicants throughout a lifetime of practice. Requirements for continuing education have been adopted by many boards but are inconsistently enforced, and the impact of traditional continuing education on patient outcomes is limited. Assessments of the knowledge and clinical skills requisite for undifferentiated practice, such as the Special Purpose Examination (SPEX15), have been developed for physicians reactivating a license after a period of inactivity or involved in disciplinary proceedings, but they have not been widely adopted.

State licensing authorities are under increasing pressure from the public to assume more accountability for healthcare professional performance across a lifetime of practice. There is general agreement that competence and performance in practice should be periodically reassessed as part of a system to encourage continuous improvement while assuring minimum competence, although views differ on specific objectives, reassessment intervals, assessment methods, and how reassessment should be linked to licensure, certification, and employment (credentialing and clinical privileging).

The Federation of State Medical Boards (FSMB), a membership organization of state medical licensing authorities, recognizes that "state medical boards have a responsibility to the public to ensure the ongoing proficiency of physicians seeking relicensure." In 2008, the FSMB adopted five principles to guide future maintenance of licensure (MOL) policy development.16 They include: support physicians' commitment to lifelong learning and facilitate practice improvement; be administratively feasible; not be overly burdensome to the profession; offer a choice of options for meeting requirements; and balance public transparency with physician privacy protections. In addition, the FSMB reemphasized that, in its opinion, the "authority for establishing MOL requirements should remain within the purview of state medical boards."

In 2010, the House of Delegates of the FSMB adopted a framework for maintenance of licensure17. The framework includes the following elements:

"As a condition of license renewal, physicians should provide evidence of participating in a program of professional development and lifelong learning that is based on the general competencies model:

  • medical knowledge
  • patient care
  • interpersonal and communication skills
  • practice-based learning
  • professionalism
  • systems-based practice"

"The following requirements reflect the three major components of what is known about effective lifelong learning in medicine:

  1. Reflective Self-Assessment (What improvements can I make?)
    Physicians must participate in an ongoing process of reflective self-evaluation, self-assessment and practice assessment, with subsequent successful completion of appropriate educational or improvement activities.
  2. Assessment of Knowledge and Skills (What do I need to know and be able to do?)
    Physicians must demonstrate the knowledge, skills and abilities necessary to provide safe, effective patient care within the framework of the six general competencies as they apply to their individual practice.
  3. Performance in Practice (How am I doing?)
    Physicians must demonstrate accountability for performance in their practice using a variety of methods that incorporate reference data to assess their performance in practice and guide improvement."

Work is ongoing to translate these principles into an operational plan acceptable to licensing authorities.

Significant strains affecting the state-based medical licensing system arise from demographic and practice trends. Notable examples include physician mobility that requires multiple licenses; technological innovations that allow a physician in one jurisdiction to practice in another; and focused training and practice that result in highly specialized practitioners, in the face of a license that grants the right to undifferentiated medical practice. The need for validated practice-based assessment tools and universal minimum medical licensing standards in the United States is increasingly evident.

Specialty Certification

With the proliferation of specialization, voluntary certification by one of the 24 member boards of the American Board of Medical Specialties (ABMS) or the American Osteopathic Association’s Bureau of Osteopathic Specialties has become an important professional qualification for physicians. Between 1995 and 2004, member boards issued nearly 250,000 general certificates in 37 different specialties and nearly 80,000 subspecialty certificates in 92 different subspecialties. However, despite the availability of certification, it has been estimated that 25% to 35% of practicing physicians have chosen not to apply for or maintain certification. Dozens of boards that are not members of ABMS also offer specialty credentials; while there is some consistency in the requirements and rigor for certification from ABMS member boards, such consistency is not present among the many other groups offering certification. Similar specialty certifications are offered for other health professionals as well, including, for example, physicians’ assistants and advanced practice nurses.

ABMS board lifetime certification will soon be a thing of the past. Time-limited certificates have now been adopted by all ABMS-member boards; all new diplomates are automatically enrolled in their board’s maintenance of certification (MOC) program. In addition, information regarding participation of diplomates in a lifelong learning and assessment process will be made available to the public.

ABMS maintenance of certification involves five basic components: professional standing, as evidenced by an unrestricted license to practice medicine; continued learning, as evidenced by the completion of practice-relevant continuing education or self-evaluation modules; cognitive expertise, as evidenced by successful completion of a standardized examination; performance in practice, as illustrated by the medical care provided to patients with common or significant health problems; and behavior, including patient communication and professionalism.

Various ABMS member boards have instituted different approaches to fulfilling these general requirements. However, irrespective of approach, the weakest link in this ambitious program is the development of robust methodologies for assessing practice performance. Despite these challenges, many policymakers see MOC as an important step in documenting and enhancing physician proficiency given that state medical licensing boards set standards for licensure and relicensure at the most minimal level of physician proficiency. Indeed, it is likely that maintaining board certification will fulfill future MOL requirements (as is recommended in the FSMB framework).

Systems comparable to those described above are less developed, but no less needed, for other health professions. Further, as clinicians from different educational backgrounds assume increasing responsibility for patient care, the plethora of licensing and certifying authorities makes it likely that the public will have no uniform assurance of competence or performance unless the healthcare system incorporates a consistent, uniform approach to licensure and certification.

Credentialing

Credentialing is the process of formal recognition of current clinical competence utilized by hospitals, health plans, and employers. Credentialing includes verification of character, education and training, professional licenses and specialty certifications; review of adverse clinical occurrences, including malpractice determinations; and evaluation and monitoring of professional behavior, clinical judgment and technical proficiency relative to established norms. Credentialing defines a clinician's scope of practice and the clinical services he or she may provide (“clinical privileges”) within the confines of the credentialing organization and attempts to ensure that clinicians provide services solely within the scope of the privileges granted.

Credentialing must be the product of qualified and objective professionally controlled peer review, must be directly related to the quality of patient care, and must utilize criteria established through common professional, legal, and administrative practices. In the United States, standards promulgated by professional societies and the Joint Commission (which accredits hospitals and healthcare organizations) and other credentialing bodies form the basis of the credentialing and privileging processes.

As with MOL and MOC, health professions outside of medicine have made little progress in requiring evidence about performance as a condition of retaining permission to practice within individual institutions. Further, physicians practicing outside institutional settings may not be subject to these credentialing systems.

Continuing Education

Continuing education (CE) is the vehicle by which clinicians strive to match learning with the ever-evolving expectations of quality across a lifetime of practice. Delivered by a wide array of providers (from expert to uninformed) and often supported by sources external to the profession (predominantly pharmaceutical and medical device manufacturers), it is the longest component of the professional education continuum. Recently, professional organizations have worked to move beyond a predominantly lecture-based delivery system. The Accreditation Council for Continuing Medical Education (ACCME) and others have sought to move beyond a funding system dominated by significant actual and potential conflicts of interest, and leaders in the continuing education environment now emphasize the need for education linked to documented practice needs18.

The CE community faces a series of imposing challenges: to value, exemplify and promote lifelong learning; to employ validated, outcomes-based learning methods; to develop funding sources that do not foster potential and actual conflicts of interest; to interconnect healthcare education and delivery within the workplace; and to emphasize those competencies (e.g., team-based collaborative practice) critical to effective practice in a rapidly evolving healthcare system. While progress is evident on many of these fronts, we continue to be challenged to deliver demonstrably effective educational programs tailored to the needs of individual clinicians (or even groups of clinicians with similar scopes of practice).

 

14 See http://www.gmpusa.org.

15 The SPEX exam is an objective and standardized cognitive examination of current knowledge requisite for the general undifferentiated practice of medicine. It is cosponsored by the NBME and FSMB.

16 See http://www.fsmb.org/pdf/Special_Committee_MOL_Draft_Report_February2008.pdf.

17 See text of the report and policy actions at http://fsmb.org/pdf/mol-board-report-1003.pdf. For further information, see FSMB Website at http://library.fsmb.org/mol.html.

18 These challenges were most recently addressed in a state-of-the-art conference, sponsored by the Josiah Macy Foundation in 2007, which set the stage for reform by emphasizing the importance of: instilling lifelong learning skills in medical school and residency and thereafter maintaining and enhancing these skills; developing and deploying meaningful models of interprofessional education; increasing the awareness of workplace learning while simultaneously decreasing the focus on didactic methods as the primary format for CME; and heightening attentiveness to the importance of CME as a tool to improve competency and performance. A follow-up conference held in 2009 to define the essential steps in reforming CME has yet to report.

 

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