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OCR for page 97
Chapter 5
Health Professions Oversight
Processes: What They Do and
Do Not Do, and What They Could
Do
Part of the charge to this committee was to "assess the implications of the changing health
system for provider credentialing and licensing programs." The committee interpreted this charge to
include the array of mechanisms and rules meant to ensure that health professionals are properly
educated and competent to practice. Such mechanisms, grouped by the committee under the rubric
of oversight processes, include accreditation, licensure, and certification. Accreditation serves as a
leverage point for the inclusion of particular educational content in academic and continuing
education curricula. Licensure and certification can serve as a lever for ensuring that practicing
health professionals meet specific standards and continue to maintain competence in a given content
area. The spectrum of oversight processes can also include organizational accreditation, which
serves to accredit practice institutions and health plans, but has some impact on the continuing
competence of practicing professionals through the standards imposed.
This chapter reviews accreditation, licensure, and certification requirements related to the
education of health professionals in the five competencies outlined in Chapter 3 with respect to
medical, nursing, pharmacy, and physician assistant undergraduates and graduates. A review of all
of the allied health professions was beyond the scope of this report. Thus the committee chose to
review three allied health occupations that are large and well known, have diverse scopes of
authority, collectively include practitioners working in a variety of health care settings, and have an
ever-increasing role in caring for the chronically ill: clinical laboratory scientists (also known as
medical technologists), occupational therapists, and respiratory therapists. The committee discussed
issues related to oversight processes that facilitate or hinder professional development and education
in the five competencies and briefly examined the future role of organizational accreditation in
fostering the maintenance of competence.
It should be noted that throughout its deliberations, the committee faced a paucity of research in
97
OCR for page 98
HEALTH PROFESSIONS EDUCATION
this area. There is virtually no study
documenting the impact of accreditation,
licensure, or certification on clinician
performance or health outcomes.
Overview
The manner in which health professionals
are educated and maintain their competence is
subject to a myriad of oversight structures and
processes, some voluntary and some mandatory.
The committee chose to focus on the three
primary venues noted above that it believes
have the most leverage in determining the initial
competency and ongoing professional
development and maintenance of competency
for practicing clinicians: accreditation,
licensure, and certification.
Academic institutions provide learners with
opportunities to develop knowledge and skills
necessary for safe and effective practice.
Ideally, such institutions collaborate with
consumers and employers to determine what
knowledge and skills are needed for practice.
Accrediting organizations assess educational
programs to determine whether their content is
designed to produce competent graduates and
then offer accreditation to those programs
meeting their standards.
State 1/licensing bodies are called upon to
protect the public by setting minimum standards
of competency for health professionals. They
generally do so by establishing educational
requirements, assessing character and other
attributes, and testing through licensure exams.
Health professionals that meet the requirements
are granted the right to practice in a given state.
Licensing boards interact with health
professionals after initial licensure by requiring
periodic relicensure or imposing discipline on
poor performers. The majority of U.S. health
professionals are licensed; thus these boards
have a large impact on the ongoing
development of health professionals.
Health professional organizations frequently
administer or set up independent certifying
bodies, which grant a certification or credential
recognizing that individuals have successfully
demonstrated knowledge of or competency in a
particular specialty. Often the requirements for
certification go beyond the competency
requirements for licensing, which by statute are
set to ensure a minimum level of competence.
Though the process is usually voluntary, some
states mandate certification as part of the
licensure process for certain disciplines.
Often professionals work in institutions
subject to organizational accreditation. To
receive accreditation, such institutions are
required to demonstrate that the health
professionals they employ or contract with are
appropriately skilled. For example, managed
care organizations require certification of
network clinicians.
It is this patchwork of institutions, all
working independently, that defines the nature
and length of training for health professionals,
their ability to perform particular tasks or work
in certain jurisdictions, and the maintenance and
development of their skills and competencies.
Educational Accreditation
.
Educational accreditation, unlike individual
licensure and certification, provides evaluation
and judgments of institutions and programs
rasher thanindividuals. Accreditation
guidelines can influence many decisions
regarding an educational program, including the
number of hours of a particular subject area
offered and the types of learning experiences
students undertake. If effective, accreditation
(Institute of Medicine, 19954:
· Protects the public welfare by ensuring that
health professions graduates are
appropriately prepared to provide health care
services.
Ensures students that their educational
program meets basic standards and facilitates
the transfer of credit between different
programs.
· Guards public funds from use in support of
. ,~ .
interior programs.
98
OCR for page 99
HEALTH PROFESSIONS OVERSIGHT PROCESSES
· Assists educational programs in achieving
and improving on minimum standards.
As the roles of the health care workforce
have become more specialized over recent
decades, a number of new professions have
emerged. As a result, many new educational
programs have been developed, most having
specialized accreditation agencies. Today there
are more than 50 health profession accreditation
programs (Gelmon et al., 1999~. The average
educational program is accredited every 3-10
years, with occasional random audits being
conducted between accreditation cycles in
response to specific problems needing
immediate attention.
Standards Related to the Five Competencies
Accrediting organizations vary in their
approach to the core competencies, ranging
from assessing such competencies in their
standards, to requiring related curricula and
education experiences, to encouraging
educational institutions to include the
competencies. Table 5-1 shows how the
standards of the various accrediting
organizations map to the five competencies set
forth in this report.
A number of accrediting bodies have
competencies defined in their accreditation
standards, representing competencies each
deems necessary for practice. These include the
accrediting organizations for graduate medicine.
pharmacy, and osteopathy; for respiratory
therapy; for occupational therapy; and one of
the two accrediting bodies for nursing, the
National League for Nursing Accrediting
Commission (NLNAC). These accrediting
bodies require that educational programs offer
curricula and educational experiences related to
their defined competencies. Within their
respective requirements, each addresses selected
elements of some or all of the five competencies
outlined in this report (see Table 5-1~.
Some accreditation organizations do not
have articulated competencies that their students
should possess upon graduation, but are
prescriptive regarding curricula and educational
experiences. The accreditation standards for
physician assistants, undergraduate medicine,
and clinical laboratory have articulated
curriculum requirements for those areas deemed
integral to the educational preparation of their
respective disciplines. These requirements also
address certain elements of some of the five
competencies (see Table 5-1~.
Finally, other accrediting bodies do not
have articulated competencies or stated
curriculum requirements in their standards.
These include the other accrediting body for
nursing the Commission on Collegiate
Nursing Education (CONE) and that for
undergraduate osteopathy. For example, CONE
encourages nursing education programs to
pursue teaching, learning, and assessment
practices in accordance with the unique mission
of the institution with the aim of supporting
flexibility and innovation among institutions
while providing guidance on essential
educational elements (American Association of
Colleges of Nursing, 19994. However, it does
require some evidence of interdisciplinary
curricula (Commission on Collegiate Nursing
Education, 1998~. Such accrediting bodies
require that educational programs offer
curricula and educational experiences related to
their individually defined competencies, which
may or may not overlap with the five
competencies outlined in this report.
~ The baccalaureate degree is being phased out of pharmacology education. By 2004, all pharmacology programs will offer
only the doctor of pharmacy degree.
coca
OCR for page 100
HEALTH PROFESSIONS EDUCATION
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100
OCR for page 101
HEALTH PROFESSIONS OVERSIGHT PROCESSES
Accreditation Issues and Debates
Educationa1/t Accreditation and Outcomes
At this time, the majority of accrediting
organizations are concerned with a descriptive
model of evaluating educational programs that
focuses on structure and process, such as the
number of hours of course content, for a
particular subject. A minority of bodies are
beginning to expand upon this descriptive
model and enlarge their scope to include a focus
on evaluating educational institutions based on
outcomes (Batalden et al., 2002, Leach, 20024.
Outcomes are evidence demonstrating the
degree to which the purposes and objectives of
an educational program are or are not being
attained, including achievement of appropriate
skills and competencies by students (Carraccio
et al., 20024. Examples of outcomes are
learning or development of knowledge, skills,
and attitudes by students; improved teaching by
faculty; and improved treatment outcomes.
The accrediting bodies surveyed for this
report have begun to address outcomes to some
extent in their position statements, but vary in
their progress toward implementing assessment
of educational outcomes. The committee
applauds the work of those focusing on
outcomes, such as the Accreditation Council for
Graduate Medical Education (ACGME) and the
American Council on Pharmaceutical Education
(ACPE) (see Boxes 5-1 and 5-2) and hopes that
other accrediting organizations will follow suit.
Many accrediting organizations continue to
evaluate programs against process and structure
standards, yet there is no research that correlates
such an approach with outcomes (Gelmon,
19974.
101
OCR for page 102
HEALTH PROFESSIONS EDUCATION
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102
OCR for page 103
HEALTH PROFESSIONS OVERSIGHT PROCESSES
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The committee recognizes that outcomes-
based accreditation is a large challenge and that
there are debates about the most effective ways
to assess such an approach, how it will be paid
for, and how it will be incorporated into
accreditation site visits. Regardless, the
committee believes that accrediting
organizations must surmount these obstacles
and begin to move away from the evaluation of
programs against process and structure
standards, as there is no research that correlates
such an approach with improved learning or
health outcomes (Gelmon, 1997~. The
"minimal threshold model," in which the
accreditation evaluation serves to identify
whether a program has the potential to educate
students, is not robust enough to guarantee that
students will be competent upon graduation
(Accreditation Council for Graduate Medical
Education, 2001~.
Faci11titation of Interbliscip11tinary Teams
Though accreditation processes vary
regarding requirements for the five
competencies in the educational experiences of
health professionals, accreditation as it is
structured today poses a particular barrier to
working in interdisciplinary teams at the
educational level. A great deal of collaboration
and coordination among the various accreditors
will be needed to realize the promise of
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HEALTH PROFESSIONS EDUCATION
interdisciplinary education. Standards,
measures, and incentives for faculty are just
some of the matters that need to be aligned by
accrediting bodies.
Review bodies have argued that various
professions and organizations could benefit
greatly from collaboration in developing,
testing, and evaluating common core
competencies that utilize the same language so
that professionals can better communicate and
collaborate, with the ultimate goal of improving
the quality of care (Health Resources and
Services Administration, 19994. Such bodies
have argued that many skills are currently
taught discipline-by-discipline, whereas these
skills often are, or should be, generic to all
disciplines. Identifying these skills and
collaborating across professions would increase
the efficiency with which education is
delivered. The Pew Commission for Allied
Health expanded this notion by advocating a
core curriculum or set of interdisciplinary
courses, clinical training, and other educational
experiences designed to provide students at each
level with common knowledge, skills, and
values necessary to perform effectively in the
evolving health care workplace (Finocchio et
al., 1995; Gelmon, 1997~.
Development of a core curriculum or
competencies has obvious application to all the
health professions. However, it requires
extensive collaboration across the existing
accrediting organizations and involves working
with faculty, professional associations, students,
and practicing professionals to determine the
content of such curriculum and appropriate
standards as benchmarks for educational
practice (Gelmon, 1997~. Such is not the
current reality in the accrediting of health
professions schools, though it has been
accomplished successfully in health services
administration (Gelmon et al., 1990) and public
health (Council on Education for Public Health,
1994; Evans and Keck, 19984.
Licensure
The general public does not have adequate
information to judge provider qualifications or
competence; thus professional licensure laws
are enacted to assure the public that
practitioners have met the qualifications and
minimum competencies required for practice
(Safriet, 1994~. State governments, through
state health professional licensing boards,
provide health professionals with the legal
authority to practice through licensure. Because
licensure is implemented at the state level, there
is a great deal of variation in who is licensed
and what standards for licensure and practice
are applied. State licensure is intended to
permit regulations to be tailored to meet local
needs, resources, and public expectations, and
many boards have public members to ensure
that this tailoringis done. Licensing boards
evaluate when a health professional's conduct
or ability to practice warrants modification,
suspension, or revocation of the license. To be
licensed, licensees must pass an examination
sometimes national, sometimes administered by
the state, or both that serves to demonstrate
that they have acquired basic knowledge for
competent practice.
A key licensing issue that affects the health
care workforce and the way it is prepared and
used is scope-of-practice acts, implemented at
the state level. These acts set forth the
parameters of practice activities for the licensee,
including what duties can be performed, in what
settings the licensee can practice, and what (if
any) oversight is required. These acts vary
tremendously by state, sometimes by location
within a state (i.e., rural or urban), and by the
types of medical conditions professionals are
allowed to treat. All health professions, largely
with the exception of medicine, have scopes of
practice that limit what they can do to some
extent (Jost, 1997; Safriet, 19944. In the case of
nurse practitioners, for example, 43 states and
the District of Columbia authorize practice
through a state board of nursing, and of these,
about half have statutory requirements for
physician collaboration or supervision and
considerable variation in prescriptive authority
(Pearson, 2000; Phillips et al., 2002; Safiiet,
20024.
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HEALTH PROFESSIONS OVERSIGHT PROCESSES
Licensure Exams and the Five Competencies
The committee reviewed national licensure
examinations for content related to the five
competencies. In doing so, the committee kept
in mind that schools use the passing rate for
such national exams as an educational outcome
indicator. Thus the influence of the exam on
curricular decisions for educational institutions
cannot be underestimated.
All the exams in nursing, pharmacy, and
medicine have some content on providing
patient-centered care. In allopathic medicine,
the licensing exam contains content related to
gender, ethnic, and behavioral considerations
affecting disease treatment and prevention;
psychological and social factors influencing
patient behavior; patient interviewing and
consultation; and interaction with the family.
The osteopathic licensing exam and the
physician assistant exam cover health
promotion and health prevention content. The
computerized licensure exam for registered
nurses includes content on psychosocial
integrity, communication with the patient,
knowledge of and sensitivity to the beliefs and
values of the patient, the impact of diversity on
the health care experience, and promotion of
self-management. The pharmacy licensure
exam has content on providing information to
patients, including information regarding
nutrition, lifestyle, and other nondrug measures
that are effective in promoting health.
Some but not all of the licensing exams
cover the other competencies. The exams for
allopathic medicine and pharmacy cover content
related to evidence-based practice, such as
interpreting results based on experimental or
biometric data, recognizing design features of
clinical studies, understanding issues regarding
the validity of research protocols, knowing the
sensitivity and specificity of selected tests, and
recognizing potential bias in clinical studies.
The exams for allopathic medicine and
registered nurses include content on quality
improvement, such as assessment, analysis,
planning, implementation and evaluation, error
prevention, and safety maintenance. Only the
registered nursing exam has content on
interdisciplinary teams. None of the exams has
content related to informatics.
In the three allied health disciplines
examined, clinical laboratory technologists/
scientists are not uniformly required to be
licensed by all states, and thus each state
administers its own licensure exams. In
occupational therapy, some but not all states
require passing the national certification
examination administered by the National
Board for Certification in Occupational
Therapy. That exam has content related to
patient-centered skills, especially eliciting
patients' values and concerns, making shared
decisions, and conducting health promotion, as
well as evidence-based practice skills, such as
collecting and assessing data from research
studies. The exam also covers content related to
assessment of service delivery and the
collection of satisfaction data related to quality
improvement. There is no mention of
informatics or interdisciplinary teams. For
respiratory therapists, some but not all states
require the National Board for Respiratory
Care's Entry Level or Advanced Practitioner
Respiratory Care examination, which is
technical in nature and does not include content
related to any of the five competencies.
Table 5-2 shows how the licensing exams in
each of the health professions examined by the
committee map to the five competencies.
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HEALTH PROFESSIONS EDUCATION
Table 5-2 Licensure Examinations and Content Related to the Five Competencies
Patient- Inter- Evidence-
Quality Centered disciplinary Based
Examination Improvement Care Informatics Teams Practice
Medicine
JSMLE (United States Medical X X X
Licensing Exam, 2002a)
OMLEX (National Board of X
Osteopathic Medical Examiners,
2002)
PANCE (National Commission on X
Certification of Physician
Assistants, 2002)
Pharmacy
NAPLEX (NationalAssociationof X X
Boards of Pharmacy, 2002)
Nursing
NCLEX-RN(National Councilof X X X
State Boards of Nursing, 2000)
'allied Health
NCBOT (NationalBoard for X X X
Certification in Occupational
Therapy, 2002a)
NBRC (National Board for
Respiratory Care, 2001)
Requirements for Maintenance of Licensure
Requirements for maintaining one's clinical
license differ from state to state within a given
profession, as well among the health
professions. In general, one maintains his or her
license by paying a fee at the time of license
renewal. For certain professions, some states
require licensees to take specified hours of
continuing education as a condition of
relicensure. A recent survey of 323 licensing
boards representing a variety of health
disciplines revealed that 83 percent required
licensees to demonstrate that they had done
something to keep their knowledge and skills
updated as a condition of license renewal; 94
percent of these boards required licensees to
accumulate a specific number of continuing
education credits as the only method for doing
so (Swankin,2002~.
Regarding the professions reviewed in this
paper, the range is great. In pharmacy and
occupational therapy, nearly all state boards
require that registered professionals complete a
certain number of continuing education units
before they can renew their licenses (Council on
Credentialing in Pharmacy, 2000; Fisher, 2000;
National Board for Certification in
Occupational Therapy, 2002b). For physician
assistants, maintenance of certification from the
National Commission on Certification of
Physician Assistants is required by 22 state
boards as assurance of continued competence
(National Commission on Certification of
Physician Assistants, 2002), while the other
states vary in this regard. In nursing, the
majority of boards require only a fee or a certain
number of practice hours for maintenance of
licensure, with a minority of boards requiring
continuing education (Yoder-Wise, 2002~.
Licensure Issues and Debates
A review of state licensing laws and related
practice acts that define what services health
professionals can be licensed to provide was
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HEALTH PROFESSIONS OVERSIGHT PROCESSES
beyond the scope ofthis report. The committee
believes, however, that geographic licensure
and scope-of-practice acts may have an effect
on the integration of the core competencies-
particularly informatics and interdisciplinary
teams into practice and education, and
therefore deserve particular attention and further
study.
The broad variation among the states in who
is licensed and what standards for licensure and
practice are applied is one of the trademarks of
the licensure system, aimed at ensuring that
licensure is tailored to meet local needs,
resources, and patient expectations. This
approach works well when the health facility,
the health professional, and the patient are in the
same geographic location. However, the current
approach to licensure is increasingly being
questioned given the growth of electronic health
care and the formation of large, multistate
provider groups or teams that cut across
geographic boundaries (Finocchio et al., 19984.
When professionals are not practicing in the
same state, licensure currently acts as a barrier
for many clinical applications of electronic
health care that can serve the public's needs.
Examples are centralized consultation services
to support primary care; the provision of online,
continuous, 24-hour monitoring and clinical
management of patients in intensive care units
for hospitals; and specialty consultations for
rural hospitals that do not have such specialists
in their communities (Daly, 2000; Hutcherson,
2001; Rosenfeld et al., 2000~.
Additionally, the separate scopes of
practice, governance structures, and standards
maintained by licensing bodies for different
types of health professionals even though
these professionals may perform a subset of
overlapping functions as well as the
complexity of rules across disciplines and
settings, may make it a challenge to form
multidisciplinary teams and provide optimum
care for patients when they need it (Finocchio et
al., 1998; Institute of Medicine, 1996, 2001;
Jost, 1997; Sage and Aiken, 1997~. Efforts to
change scope-of-practice acts are often the
focus of turf battles among the professions
fought out in state legislatures; the result is
distrust and hostility among professions that are
supposed to be collaborating to provide
coordinated care (Sage and Aiken, 19974.
Boundaries defined by scope-of-practice
acts are sometimes blurred. Studies of diverse
physician assistants, nurses, and allied health
professionals indicate that they can perform
some of the clinical tasks of physicians and
provide equivalent quality of care (Kinnersley,
2000; Mundinger et al., 2000; Phillips et al.,
2002; yenning, 20004. One panelist at the
summit, Charles InIander of the People's
Medical Society, noted: "We still have laws
that are so archaic that they protect no one
except certain professional bases. That's
archaic in this era of technology and better
training. It's time for a new look at regulating,
and if we do that, we will then be able to focus
back on where professional education has to go
(Inlander, 20024."
The committee believes that in today's
environment with care delivery that crosses
state lines supported by information technology,
more emphasis on interdisciplinary teams, and
workforce shortages licensure and scope-of-
practice acts need to be reexamined to ensure
that they are flexible enough to allow health
professionals to practice to the fullest extent of
their technical training and ability. Specifically,
health professionals should not be denied the
opportunity to realize the promise of optimum
patient care offered by utilizing informatics and
working in teams.
One example of licensure-supported
collaboration for quality care is the increasing
number of collaborative practice agreements
between physicians and pharmacists (Ferro et
al., 19984. Voluntary collaborative practice
agreements are characterized by an
interdisciplinary approach toward patient care
among health care practitioners, allowing
pharmacists to extend the provision of
pharmaceutical care to the management of
various therapies for patients. Depending on the
agreement and state regulations or practice acts,
pharmacists are able to approve refills,
administer drugs and vaccines, and initiate or
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HEALTH PROFESSIONS EDUCATION
assess, prove, track, and improve the
competence of all their employees. JCAHO
competency standards include the provision of
ongoing in-service and other education and
training to maintain and improve staff
competence, regular collection of data on
competence patterns and trends, and
identification of and response to staff learning
needs (Joint Commission on Accreditation of
Healthcare Organizations, 2000~. The National
Committee for Quality Assurance (NCQA)
(2002), which accredits managed care
organizations, requires accredited organizations
to credential the professionals whom they
employ or who practice under their auspices.
Such organizations also have standards
related to how care is delivered and performed,
with direct implications for clinicians' ongoing
professional development. This is particularly
the case with regard to quality improvement and
patient safety standards. NCQA's accreditation
standards specifically mandate quality
improvement activities in which practitioners
and health plans are required to participate.
Such activities must address data collection
measurement, and analysis to assess
performance on three nonpreventive acute or
chronic care clinical issues, including one
behavioral health issue. Practitioners are also
required to participate in the selection and
adoption of evidence-based clinical guidelines
(National Committee for Quality Assurance
2002~. Patient safety is addressed as well
through a standard that requires plans to
develop systems to monitor for drug
interactions, Food and Drug Administration
alerts, and drug recalls, and to alert pharmacists,
patients, and providers to potentially serious
problems (National Committee on Quality
Assurance, 20024. Similarly, JCAHO requires
hospitals to initiate specific efforts to prevent
medical errors and to tell patients when they
have been harmed during their treatment (Joint
Commission on Accreditation of Healthcare
Organizations, 20014.
I,
Such standards have the potential to serve
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HEALTH PROFESSIONS OVERSIGHT PROCESSES
as a lever for maintenance of competence,
though questions remain about their
implementation. For example, the JCAHO
standards do not dictate how the accredited
organization must assess and validate the
ongoing competence of its employees. It is up
to the individual organizations to determine how
their competency programs will be structured.
JCAHO surveyors also do not define
competence beyond job skills, knowledge, and
tasks. Thus, conducting skilled interpersonal
communication, acknowledging patient values
and promoting shared decision making, being a
lifelong learner, applying critical thinking,
being an effective team member, and managing
information are just some of the many important
skills overlooked by such an approach (Decker,
1999; Decker et al., 19974.
Demonstration and Maintenance of
Competence
Increasingly, oversight organizations are
being challenged to provide assurance to the
public that health professionals meet minimum
levels of competence throughout their careers,
not only at the time of entry and initial licensure
and certification. In medicine, surveys have
shown that an estimated 20 to 50 percent of
primary care practitioners are not aware of or
not using new evidence related to common
current practices. Yet health professionals face
increasing pressures to keep up to date with the
ever-expanding knowledge base and new
technological innovations, and ongoing
knowledge and skill development are necessary
to ensure the continued relevance of their
clinical care to the changing health care
environment.
Currently, there is no mechanism for
ensuring that practitioners remain up to date
with current best practices. Responsibility for
assessing competence is dispersed among
multiple authorities. For example, a licensing
board may question competence only if it
receives a complaint, but most boards do not
routinely assess competency after initial
licensure. Professional societies and
organizations may require examination for
certification and are now beginning to assess
competence in addition to knowledge, but such
practices are at an early stage and inconsistent
among the professions. Some institutional
accreditors require competence to be measured
for all individual practitioners, but such
requirements remain highly task-specific and
subject to great variability in terms of
implementation in hospitals, health plans, and
other health care organizations.
Though the public and professionals
themselves might agree that continued
competence is desirable, there is much
disagreement and debate as to what constitutes
evidence of competence, who should ensure it,
and how often it should be demonstrated
(Grossman, 19984. Historically, licensure has
been concerned with minimum competency,
whereas certification has been reserved for
those meeting higher standards. This distinction
is less clear-cut today; for some professions,
such as nurse anesthetist, nurse practitioner, and
physician assistant, certification adheres to the
basic entry standards traditionally required by
licensure. Determining where to place the
emphasis in reform is further complicated by a
lack of research on the effect of certification
and licensure on a provider's performance over
time (Bashook et al., 2000; Davis et al., 20014.
Evidence of Competence
Though they remain the dominant method
used by oversight organizations to assess a
health professional's continued competence,
traditional, didactic methods of continuing
education, such as formal conferences, lectures,
and dissemination of educational materials,
have been shown to have little effect by
themselves on changing clinician behaviors or
health outcomes (Cantillon and Jones, 1999;
Davis et al., 1999; Davis et al., 19954. Weekend
or day courses at hotels or resorts or sessions at
professional conferences are viewed more as
mini-vacations than as structured learning
activities. Indeed, there is widespread and
growing consensus that continuing education
OCR for page 112
HEALTH PROFESSIONS EDUCATION
courses, unless they are based on a needs
assessment and require participants to take a test
at the end of the course or otherwise
demonstrate mastery of the course content, are
not a viable means of ensuring that practitioners
remain competent over the course of years of
practice. To change professional performance
and practice, health professionals need to select
a portfolio of continuing education activities
based on reflection upon the gap between what
they know now and what they need to know, not
what is just merely convenient or interesting to
take. An example of such an approach is
presented in Box 5-5.
The Council of Medical Specialty Societies
(CMSS) recently convened a task force to
review the continuing education field as it
presently stands and propose recommendations
for reform. Though the task force was
addressing the continuing education of medical
specialists, its recommendations could be
applied to any discipline. The task force
recommended that continuing education
providers define a core curriculum of content;
address competencies; emphasize quality
improvement using an evidence-based
approach; offer constituents a variety of
educational formats; and apply methods to
demonstrate the linkage between continuing
education and changes in knowledge, skills,
clinician practice behaviors, and patient
outcomes (Council of Medical Specialty
Societies, 2002~.
Research also suggests that lecture-based
courses need to be reinforced with interactive
techniques, such as case discussion, role play,
and hands-on practice sessions, offering a
chance to apply the new knowledge or skills in
practice, and then reinforce these activities with
further educational sessions (Davis et al., 1999;
O'Brien et al., 20014. Research suggests further
that continuing education needs to emphasize a
variety of interventions, particularly reminder
systems, academic detailing, and patient-
mediated methods, and to use a mix of
approaches, including Web-based technologies
(Cantillon and Jones, 1999; O'Brien et al., 2001;
Smith, 2000~. William Stead, Vanderbilt
University, suggested at the summit in his
address:
We have begun to experiment with
some forms of continuing
education that may be more
effective....You can watch thealth
providers'] pattern of intervention
with the system, and you can
identify areas in which they have
need for information, and then
deliver this in a tailored educational
intervention. Another thing you
can really begin to do is take those
same tools and use them in a case-
based learning experience, where
you present people with a
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HEALTH PROFESSIONS OVERSIGHT PROCESSES
simulated problem and let them use
the information tools to work
through it. I think the biggest thing
we've got to do with continuing
education is to make it model
problem solving, instead of being a
separate event that's taken out of
the work process. (Stead, 2002)
The committee perceives a larger issue with
continuing education the lack of relevance of
the content of existing courses to providing care
that meets the health care needs of the
population. There is no formalized process that
ensures coverage of the five competencies
outlined in Chapter 3. Some licensing boards
require that health professionals choose specific
courses for maintenance of their license, but
more often than not, the choice is wide open,
and health care practitioners can select a course
that is merely interesting or even just
convenient.
Measurement of Competence
Computerized or written multiple-choice
examinations are the main method by which
professionals are initially licensed or certified.
Questions remain about the validity of this
approach (Epstein and Hundert, 20024. Some
licensure and certification exams do not
encompass the range of complexity and degree
of uncertainty encountered in practice, or the
psychosocial behaviors needed for practice. In
medicine, both the licensing and certification
exams are being revised to include more
psychometric measures. By mid-2004, the
United States Medical Licensing Exam is
scheduled to include a new provision requiring
graduates to demonstrate that they can gather
information from patients, perform a physical
examination, and communicate their findings to
patients and colleagues. This exam is currently
required only for international medical
graduates. To "pass" the examination, a
candidate must demonstrate both satisfactory
clinical skills and satisfactory communication
skills, including providing feedback and
counseling to the patient (United States Medical
Licensing Exam, 2002b).
A variety of other mechanisms peer
review, professional portfolio, objective
structured clinical examination, patient survey,
record review, and patient simulation also are
being explored by certification bodies, and to
some extent by licensing boards, as means of
assessment. These have been shown to be valid
measures of professional performance, and the
consensus is that a combination of such
approaches is the best strategy (Epstein and
Hundert, 2002; Murray et al., 2000~. Box 5-6
presents one example of such an integrated
approach to professional development.
Conclusion
Ultimately, accreditation, certification, and
licensure are collectively but one leverage point
for ensuring that health professionals maintain
up-to-date skills and competencies. Educational
institutions have an essential part to play in
instilling a sense of the importance of being a
lifelong learner, and employers also have a
major role in shaping the ongoing professional
development of health professionals. However,
the oversight system remains a critical lever,
and there is room for improvement in the
system with regard to ongoing competency
development.
Lifelong learning can be thought of in six
stages, each impacted by the oversight system.
Upon entering academic education, health
professionals are considered to be at the novice
stage. As they progress through educational
programs and complete their professional
education, which is based on explicit,
measurable outcome measures set forth in
accreditation standards, they are considered to
be at the advanced beginner stage. After
completing their academic experiences and
residency and internship as relevant, they obtain
licensure and/or certification based on defined
measures and are at the competent stage of the
learning process. As they progress through their
careers, they enter the proficient stage through
repeated experiences and ongoing maintenance
of competence by means of assessment and
feedback provided by peers, licensing boards,
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HEALTH PROFESSIONS EDUCATION
employers, and certification bodies. In the
expert stage, midcareer professionals have
learned to recognize patterns of discrete clues
and to work quickly with better intuition
(Batalden et al., 20024. Ultimately, health
professionals who remain lifelong learners,
continuously updating their skills and
knowledge, accumulating more and more
practice hours in their field, and supported by an
oversight system that provides regular feedback
on their performance, arrive at the master stage
of the learning process.
In the majority of the professions, however,
there is no formal oversight group to ensure a
smooth, organized progression of education
through these stages. Educational programs and
accreditation, certification, and licensure bodies
all work separately and sometimes at odds, and
are at times reviewing the same elements
(Enarson and Burg, 1992; LuUmerer, 1999~.
For example, in nursing, schools are approved
twice: the majority of states require that a
postsecondary educational program have state
licensing board approval if it is to apply for
accreditation by one of the two nursing
accreditation bodies NLNAC or CONE. In
medicine, for example, the following
organizations all influence the content of
medical education: the Liaison Committee on
Medical Education, the Association of
American Medical Colleges, the Accreditation
Council for Graduate Medical Education, 27
residency review committees, ABMS and its 24
certifying boards, the Bureau of Health
Professions at the Department of Health and
Human Services, the American Medical
Association, the American Osteopathic
Association and its 18 certifying boards, the
American Association of Colleges of
Osteopathic Medicine, and various professional
societies involved in continuing medical
education (Institute of Medicine, 20014.
Because so many health professionals must
graduate from an accredited program in order to
sit for licensure exams and obtain specialty
certification, greater linkage among
accreditation, certification, and licensure is
imperative. It means very little if accreditation
standards impose on educational programs
requirements that are not reinforced in the
licensing exam. All processes must be linked so
they are focused on the same outcome the
competence of the professional to deliver
quality health care. Accomplishing this linkage
requires partnerships among licensing and
accreditation boards, certification programs, and
educational institutions. Summit panelist Joey
Ridenour, National Council of State Boards of
Nursing, concurred: "I think one of the
strategies that would be most important for us as
~4
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HEALTH PROFESSIONS OVERSIGHT PROCESSES
regulators is to continue to work together
among disciplines to identify...competencies
that people need to develop over time, and
continue to discuss how these will be played
out...not only in traditional but in continuing
education (Ridenour, 2002~." Also, as noted
earlier, since professionals are increasingly
called upon to provide care that crosses state
lines and care in interdisciplinary teams,
geographic licensure and scope-of-practice acts
must be examined to determine whether
modification is necessary to promote this type
of care.
Though many agree that some form of
continued competence is important, health
professionals and experts struggle with how to
test competency and who should be involved in
competency assurance. A lack of resources and
political tensions among the various
organizations are major barriers to the assurance
ofcontinued competence. Moreover, the
complexity of the health care environment and
the vast differences in practice make testing for
competence difficult, as areas of expertise may
not fit well with standardized testing (Whittaker
et al., 20004.
In summary, the committee's assessment of
the oversight environment leads to the following
-
conclusions.
Accreditation
· There is little evidence to suggest
that accreditation status has a
significant influence on health
professionals' education as regards
delivering care that meets patients'
needs.
· Only a few accrediting bodies
require educational programs to
assess the competency of their
graduates.
Licensure
· Geographic licensure restrictions
and scope-of-practice acts mav
impede the ability of practicing
professionals to use some electronic
applications for health care and to
work in interdisciplinary teams.
These issues need further
· ~
exam~nahon.
.
.
.
.
Some licensing boards require
periodic demonstration of continued
competency, with continuing
education being the dominant
method for such demonstration.
The singular focus of continuing
education as a method to ensure
ongoing competence is problematic
considering the number of studies
indicating that this approach is not
effective.
Certification
The majority of certification
· · · - .
agencies require perlocllc
demonstration of competency, using
continuing education and other
methods for such demonstration.
Many certification agencies still rely
on continuing education to
demonstrate continued competence,
but are increasingly moving toward
other, more effective methods.
Organizational Accreditation
· Organizational accreditors have a
role in ensuring the ongoing
competency of practicing
professions. Standards that exist
focus mainly on quality
improvement and patient safety.
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