Click for next page ( 98


The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

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 97
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 97
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 97
HEALTH PROFESSIONS EDUCATION cat o v .> I 5 ~3 5 5 o _I o 5 Cut En i. xx x x1x x 1 xlxl x e. , =c e >d x x x x x x x x x XX X X X X X Cat ~ ~ ~ 1 X X X X X X X X ';1$,; ~ ~ I !s {E 100

OCR for page 97
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 97
HEALTH PROFESSIONS EDUCATION ................................................................... ................................................................................................................................................................................ ... .. Court B--- :o--x~ lo- z~ Am-er-l-ca-n~ uo-u-n-cl-- ~ owns J 1armaceu -1-ca- -a--u-ca lOn Comae eon- e-q-u--l--~-m-e-n- S ................................... .. --u--rl-n-g~ :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::i::::::::::::::::::: :::::::::::::::::::::: ::::::::::::::::: :::::::::::::::::::: .p.~pae---p-n-a-rm-a.cy~ slu-a-e-n-~ lo p-mVl-a-.-.e~ m-o Ed p-al-l-e-n~-ce-n-le-rea~ o-u-lco-m-es o-rle-nlea~ p-n-a-rm-a-~ l .. . .. .. ... ... .... ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: .......................... ............................................................................................................. .................................................................................................................. .-.-.l--n~ r-~-~-a-rm-a-ceu--L-I-ca-~ ~-u-u--ca-~l-o-n~ a-uva-n-~-u~ m-a-o-~ re-~--o~-s~ s-u--p-po-~---Ll-n-a~ -----us vl-s-l-o-n~ a-n-u~ s-pe-cl-~--l-e~ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: .-.-""c""o-'''m.'''m.~ .2""""' 'i ... ::: :::::::::: :::::::::::::f ::::::::::::~::~:::::::::::::: :::::~::::::::::::::::::::::::::::::::::::::::::::~::::::::::f :::: ,.,.~.,.,.,e.,.,.n.,.,Ie-r~ Tori ~-n-e~ ~a-va-~-cem--e-nT~ oT~ ~-n-a-rm-ace-ull-cal~ ~-~-u-cat-Io-~ ~~--~-~ -on l-Is a-eve-l-o-p- ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: _ i i, i , . ..t.~.u.can. onal. u women a g lae for Dnarmac faculty anO aDminisimlors In assessing anO l T::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ev-- ~~ ~ ~ ~ l -- T ~ Sue- a e- IS O~ Sit I~ ~~ ~~ crack e reSnOnSIDIIIIIeS as Well as ............... ............................ ........ .... .......................... ............ - ....... ... ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: . j . j . . . --em-e~-l-n9~ rOI-e$~ tnat $ .... ............................................................................................................................. ...".."' 'd"""'i"' """" "..'t'i'' " t"""' ' '' '' '1'' t'i" '' ' All 1'1'' ' '' ' """~""'' 'h'' '' ' ' '-'-'',,'' -'-'-'' '' ' -'-'-' ' ' ' ~' -d~'t.'' '~' d-'' ' ' t' ~'' '' 'd'~ t' a ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ........................... . . 102

OCR for page 97
HEALTH PROFESSIONS OVERSIGHT PROCESSES ...................................................................................................................................................................... ............................................................................................................................ . . f ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: * ommunica ;e wr ; ~ 1ea 1 ca e pm essI S and pa lee ;s regard King a 1ona ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: - - ~ : r A: ran ~~ tA/~- . - r -- -or ~ --- Ace- l ~---nr~m-n Inn :~ : . :-:- :--:--:- :--:: : :I:-: :~ ~:1:-: :~ ~ -:----: -:- -:-t~ :~:I:-:~I::l::!:Y: Add:!::!::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: m I t nit I at ~ Elf :::::::::::::::::::::::::::::::::::::-::::::::::::::::::-:-::::::::::::::::::::::::::::::::-::::::::::::::::::::::::::::::::::::: ~ :f -~-r -~:-:-t-~::t~ ~:-:~-~-~:~.~:~-~:-~-J:~ ~:-r-~:~ r-t-~:-~:-:-~:-~.~ :~:~:-:~-:r r:?:~:~~:#r :::::~:~:~:~::::::~:~~:~~:::~r:-r:~~: ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ~ 'B' 'U ~' ' ' 't I' ' I'~ E '" "'V' ' ' 't~ ' ' '~'I' 'I'~'U'I' '~' ' ' =. I 'I' =. - ~I' V' ='- -' ' ' ~ ~ I '= - ' ' '" E ' E ~ ' ' '=~ - 'I' 'I'V'I' 'I' 'I 'I ~ E ' ' '"" L-I ~ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::: :::: :::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::: IOGE tll assess anO SOI ~ mOUlCa lOn relatBO p~OlOmS aE ~ pi IOG a . ................................. - - - - - -. - .::::::::::::::::::::::::::::::::I:I::I:A: t'm:^'nT:':':':~:'~:':':':r^:':':':r:n:~:':':':A ~nTll -i--l-l-n- E:':':':~^r:l'-:f-^'n'~:~:':':':~:':':':l:'m:A :'1:`':/1: E:E:':1:~:1:'1:7~: E:':':':~:n:~:r-:-~:' :':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':1'~'~' E:E:':I':'I'~:E:':E:L:':':' E - ':':':':L~':':':':L't':'t'W':':':' - ~'t':'t'il:l:':l:~:'l:'l:':'l: t':':':'~:E:'l':~.:~:L'l:':V'~:E:':E:~.:~ - ':':':'~:E:':':':'l':l':':l'~':l':'V:'I' t' :::::::::::::::::::::::::::::::: :::::: ::::::::::::::i::::::::: ::::i:i:::::::::::::::::::::::::::::::: :: ::::::::::::::::::i:: , n T~ n ~ ^^ ~ n A ~-:-~ ~ ~ I i T I A A I t~^ A m ~ ~ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::: :::::::::::1:::::::::::1:::::::::::::::::::1 ::::::::::1:::::::::::::::::::::~::::::::::::~:::: ...~ =va-l--E -aLe~ pall-e-n-ls-j~ a-n- E"""OEUer '-e- '-l-ca`-'o-' ~~ a-n-~-/-o-E~ I--a-oo- alQ-~ lesLs~ l--n~ a=Q-ru-a-n-ce~ wi-L-~ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::~::::::~:::~:~:::::~::::::::::::~::::::::~::::::::::::::~::::::::::::~:::::::::::::~: ................................ A~ ~ t.~.~.l. i.~.^ ~.'t A ?.t.~ . t i.-.^ ''''''''''''''''''''''''''''''''=O'LOi l-l~l--l-~---~-Lal-l~al-~---~-l~ ~l--a~L'~= ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::: :::::::::: ::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::: :::: ':':':':':':':':':':':':':':':':':_:':':':':':':':':':':':'~:\'I=':I':I':':E:=T~:':':':':':'m'^TI:~'m:T:':':':':':'m'rm'i l ~:~ d ''''''''~'~ A ::::::: .r-.~Td i '''''A ~ T i~ A '~''''''TA ':':':':':'~T'i d r''''''" ~'~'l'A ~ _~ ~ VI- td -~ C ?~1~1 1 ~ E I ~1~l I E~ ? d | |~ | ~1 ~1 i d ~1~l 1i? tV ............................. ~ A A A rd ~ r I mT ~ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::A:':'::::::I:':::::::':::::':'-:':::::::':'-:':::::::':' ':':::':':::::::':':::::::::::::::':':::::::':':::::1:':':::::::':::::::::'':'4:':::::::':':::::::::':::::::':':':':':':':': _ ~ ~ m l n, ~:T:~:~:: ~:~^ | . . . :~:T:I A :~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: A E I I I I | | ~ t :~:|:::: t: |: :|:~:~ t |' ~: I :| ~ J:|: :| A ::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::: :::::::::::::::::: :: ::::::::::::::: :: ::::: : ::: .::::::: : ::::::::::::::::::::::: :':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':': ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':': ':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':' ~ ~ lVl-o-n-l--lor~ a-EE-u~ co-u-n-se-l~ n-a-L-IeEEts en-a-ru--l--n-~ l-rl-e~ n-u-~-nos-e-s~ us-es~ a- '''"""""""""""""""""""""""""""""::"':::"'::"::::::::":::"':::':::"::::':::::::":::""""""':::::::::':::"':::"::::::::"""""'::::::::-':::::::'-'::::::::-:::-'-:::-':::::::'-::::::::'-:::-'-'-'-'-'F- ~ A A I A ~ t I ~ ~ ~ ~ A E r~ I ~ t~ t ~ A r A A f ''''''''''''''''''''''''''''''''I''I''I'~'U'I'~='LlC 1'1O'' t't''t' t l Cl=L~ i'''L'I''I='t' A'~'V''''''''''''''''''' :':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':'.'.':'.'.':'.':':'.'.'.':':'.'.'.'.':'.':'.'.'.':'.'.'.'.'.'.'.':'.':'.'.'.'.':'.':':'.':'.'.'.':':':':'.'.'.'.'.'.'.':'.'.':'.'.'.'.':':':'.':':'.'.'.'.':'.':'.'.'.'.'.'.'.':'.'.'.'.': ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':': ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':"':':':"':':':':':':':':':""':':':':':':':':':':':':':':"':':':':':':':':':':':':':':"':':':':':':':':':':':':"':':':':':':':':':':':':':':':':':':':':':"':':':':':':':"':"': _ I I n E ~ i ~ T ~ n ~ i ~ I ^` A ~ n T A i T i I tT A I T I A n ~ n A n ~ n n i I A T i ff ~ I ~ ~ :.:.:.:.:.:.:.:.:.:.:.:.:.:::: ::::::::::::V:I::I:~ - I: - L -:E::E: -:::l:~:l~:V: cl:l:L:: E:E:~:L:-::::I::I: E:LI:I:LI:~I::I: ::: - I:I - :::I::I:~I:I - I:~: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: - A . . K~rn' m~n i i itind ~. In ~n E mA nil~r n~ll~nT l l== ~' nA n' r~=' rl' rl- An A ril~= :':':':':':':':':':':':':':':':':'~ ':':':':':':':':':':':':!':':'~'V :~:~:':~:':!':!':'I':'I'~'I':'l' A ~ A~ ~~~ ~ ~ t-~-:-~ t':':':~:':!':'f'~:!':':!':~:~l':':':':' : t'~:~:~'~'~''~'''~!''' ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: . . A ~ ~ A A i t A A .- A f ~ t d ~ r.- ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~:::::::::::::::~:::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':': ':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':':' t:::: - ::::::::::::::::::::::::::::::::::: ::::::::::: j:::::::::::::::::::::: j KelEleve e alE ale ana manage p'QTessl ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::|:::|::::::::::::::::::|: :::::: ::::::::::| | ::::: :::::::: ::::::::::::::::::: ::::::::A:: ~ V ~= ~l l l l l~O t ~ a L a - - - LV ~ ~ [t t l 1 I ~= Ll l ~l ~ ~= U LI ~ t t U ~ l =~ l t l l ~l l ~ ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ~ ~:~ :~:~-:f -.~.~:-~-:~:-:-:~-& t-l:~ ~ ~-~:~ ~:~:~:~ ~-i ~:~:-~-~:~-1-~:~-:~ :~ .:.:.:.:':':':':':':':':':':':':':~:':':':':':':':':':':':~:I':I':~:i -:='I:': - '~:':':':V':'l:'`:E:':E:':':'V :L'I:':'I:='I':':':':E:':E:~.:~-'I:'`:E:':E:':':'~'I':' - :E:~:~'I' - :I':':I'=:I':~': - :':':':':':':':':':':':':':':':':':':':':':': ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::: ::::::::::~:::::::::::: ::::::::::::::::::::::~::::::: ::::::::::::::::::::::::::::::::: j:::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: :: - ::::::::::::::::::::::::::::::::::::::~::::::::::::::::::. ::::::::::::::::::~::::::::::::::::::::::::::::: - ::: - :.:.:::::: ""b' '' '' ' ' ' """"""'~' " '' 1'' ' '' """U' '1'1'' ' '' """ t""'U'l"l"' '1'' - I~ ~-n~ m-- (~Uuu) b~ (~Uuz) ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: 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 103

OCR for page 97
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. 104

OCR for page 97
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. 105

OCR for page 97
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 106

OCR for page 97
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 107

OCR for page 97
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 ~0

OCR for page 97
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 97
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 ~2

OCR for page 97
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, ~3

OCR for page 97
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

OCR for page 97
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. References ABIM Foundation. 2002. Medical professionalism in the new millennium: A physician charter. Annals of Internal Medicine 136 (3~:243-46. Accreditation Council for Graduate Medical Education. 1999. "General Competencies." Online. Available at http://www.acgme.org/ outcome/comp/compFull.asp [accessed June, 20023. ~5

OCR for page 97
HEALTH PROFESSIONS EDUCATION Accreditation Council for Graduate Medical Education. 2001. "Annual Report 2001. " Online. Available at http://www.acgme.org/ About/2001AnnRep.pdf [accessed May 31, 2002]. Accreditation Council for Occupational Therapy Education. 1998. "Standards for an Accredited Educational Program for the Occupational Therapist." Online. Available at http://www. aota.org/nonmembers/areal 3/links/LINK31.asp [accessed Aug. 15, 20023. Accreditation Review Commission on Education for the Physician Assistant, I.A.-P. 2001 . "Accreditation Standards for the Physician Assistant." Online. Available at http://www.arc- pa.org/General/standards/standardsO l .pdf [accessed Aug., 20023. American Association of Colleges of Nursing. 1999. Essential Clinical Resources for Nursing's Academic Mission. Washington, DC: AACN. American Board of Medical Specialties. 2000. "Recertification and Time-Limited Certification. " Online. Available at http://www. abms. org/Downloads/General_Requirements/ Table6.PDF [accessed Nov., 20023. American College of Clinical Pharmacy. 2000. A vision of pharmacys future roles, responsibilities, and manpower needs in the United States. Pharmacotherapy 20 (84:991- 1020. American Council on Pharmaceutical Education. 2002. "Criteria for Quality and Interpretive Guidelines for Approval of Continuing Pharmaceutical Education ." Online. Available at http://www.acpe-accredit.org/ frameset_AppProv.htm [accessed Sept., 20023. American Osteopathic Association. 2002a. "Postdoctoral Internship and Residency Standards and Procedures." Online. Available at http://www. aoa-net. org/Accreditation/ postdoctoral/postdocpdf.htm [accessed 2002a]. American Osteopathic Association. 2002b. "Maintenance of Certification." Online. Available at http://www.aoa-net.org/ Certification/maintain.htm [accessed Aug., 2002b]. American Pharmacuetical Association. 2002. "Principles of Practice for Pharmaceutical Care." Online. Available at http://www.aphanet.org/ pharmcare/prinprac.html [accessed 20023. American Society of Health-System Pharmacists. 2001. "The Residency Learning System (RLS) Model ." Online. Available at http://www.ashp. org/public/rtp/Model/model.html [accessed Sept., 20023. Bashook, P.G., S.H. Miller, J. Parboosingh, and S.D. Horowitz. 2000. "Credentialing Physician Specialists: A World Perspective." Online. Available at http://www.abms.org/Downloads/ Conferences/Credentialing/020Physician/O 20Specialists.pdf [accessed Sept. 15, 20023. Batalden, P., D. Leach, S. Swing, H. Dreyfus, and S. Dreyfus. 2002. Generalcompetencies and accreditation in graduate medical education. Health Affairs 21 (54:103-11. Board of Pharmaceutical Specialties. 2002. "Recertification." Online. Available at http:// www.bpsweb.org/BPS/recert-gen.html#top [accessed Sept., 2002 ]. Byrd, G. 2002. Can the profession of pharmacy serve as a model for health informationist professionals? Journal of Medical Library Association 90 (1~:68-75. Cantillon, P., and R. Jones. 1999. Does continuing medical education in general practice make a difference? British Medical Journal 318 (7193): 1276-79. Carraccio, C., S.D. WolLsthal, R. Englander, K. Ferentz, end C. Martin. 2002. Shifting paradigms: From flexner to competencies. Academic Medicine 77~54:361-67. Commission for Certification in Geriatric Pharmacy. 2002. "Fees and Eligibility Requirements." Online. Available at http://www.ccgp.org/ pharmacists/body_fees.htm [accessed Sept., 20023. Commission on Collegiate Nursing Education. 1998. "Standards for Accreditation of Baccalaureate and Graduate Nursing Education Programs." Online. Available at http://www. aacn.nche. edu/Accreditation/standrds.htm [accessed Aug., 20023. Commission on Dietetic Registration. 2002. "Professional Development Portfolio Guide." Online. Available at http://www.cdrnet.org/ pdrcenter/portfoliotoc.htm [accessed Oct., 20023. ~6

OCR for page 97
HEALTH PROFESSIONS OVERSIGHT PROCESSES Committee on Accreditation for Respiratory Care. 2000. "Standards and Guidelines for the Profession of Respiratory Care ." Online. Available at http://www.coarc.com/accred/ standards.html [accessed Aug. 15, 2002 ]. Council of Medical Specialty Societies. 2002. "Repositioning the Future of Medical Education." Online. Available at http://www. cmss.org/index.ctm? p=readmore&itemID= 1034&detail=Task/O 20Force/O20/O2D/O20Expert/O2oGroups [accessed Sept., 20023. Council on Credentialing in Pharmacy. 2000. "Credentialing in Pharmacy." Online. Available at http://www.pharmacycredentialing.org/ccp/ whitepaper.htm [accessed Sept., 20023. Council on Education for Public Health. 1994. Accreditation Criteria and Procedures. Washington, DC: CEPH. Daly, ILL. 2000. Telemedicine: The invisible legal barriers to the health care of the future. Annals of Health Law 9:73 - 106, inside cover. Davis, B.E., D.B. Nelson, O.J. Sahler, F.A. McCurdy, R. Goldberg, and L.W. Greenberg. 2001. Do clerkship experiences affect medical students attitudes toward chronically ill patients? Academic Medicine 76 (8~:815-20. Davis, D., M.A. OBrien, N. Freemantle, F.M. Wolf, P. Mazmanian, and A. Taylor-Vaisey. 1999. Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? Journal of American Medical Association 282 (94:867-74. Davis, D.A., M.A. Thomson, A.D. Oxman, and R.B. Haynes. 1995. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA 274 (9):700-705. Decker, P.J. 1999. The hidden competencies of healthcare: Why self-esteem, accountability, and professionalism may affect hospital customer satisfaction scores. Hospital Topic 77 (1~:14- 26. Decker, P.J., M.K. Strader, and R.J. Wise. 1997. Beyond JCAHO: using competency models to improve healthcare organizations. Part I. Hospital Topic 75 (1):23-8. Enarson, C., and F.D. Burg. 1992. An overview of reform initiatives in medical education. 1906 through 1992. lReviewl 122 refs l- Journal of American Medical Association 268 (94: 1141 - 43. Epstein, R.M., and E.M. Hundert. 2002. Defining and assessing professional competence. Journal of the American Medical Association 287 (2~:226-35. Evans, P.P., and C.W. Keck. 1998. Accreditation well-established in higher education; offers useful lessons for other arenas. [Review] [9 refs]. Journal of Public Health Management & Practice. 4 (44:19-24. Federation of State Medical Boards. 1998. "Maintaining State-Based Medical Licensure and Discipline: A Blueprint for Uniform and Effective Regulation of the Medical Profession. " Online. Available at http://www.fsmb.org/ uniform.htm [accessed Jan. 12, 20013. Ferro, L.A., R.E. Marcrom, L. Garrelts, M.S. Bennett, E.E. Boyd, L. Eddinger, R.D. Shafer, and M.L. Fields. 1998. Collaborative practice agreements between pharmacists and physicians. JAm Pharm Assoc (Wash) 38 (6~:655-64; quiz 664-6. Finocchio, L. J., C. M. Dower, N. T. Thick, C. M. Gragnola, and the Taskforce on Health Care Workforce Regulation. 1998. Strengthening Consumer Protection: Priorities for Health Care Workforce Regulation. San Francisco, CA: Pew Health Professions Commission. Finocchio, L.J., C.M. Dower, T. McMahon, C.M. Gragnola, and Task Force on health Care Workforce Regulation. 1995 . Reforming Health Care Workforce Regulation: Policy Considerations for the 21st Century. San Francisco, CA: Pew Health Professions Commission. Fisher, G.S. 2000. Mandatory continuing education: The future of occupational therapy professional development? Occupational Therapy in Health Care 13 (2~: 1-24. Gelmon, S., E. ONeil, J. Kimmey, and The Task Force on Accreditation of Health Professions Education. 1999. Strategies for Change and Improvement: The Report of the Task Force on Accreditation of Health Professions Education. San Francisco: Center for the Health Professions, University of California at San ~7

OCR for page 97
HEALTH PROFESSIONS EDUCATION F. ranclsco. Gelmon, S.B. 1997. Accreditation, core curriculum and allied health education: Barriers and opportunities. JournalofAllied Health 26 (3~: 119-25. Gelmon, S.B., D.M. OBrien, D.A. Conrad, and S.M. Shortell. 1990. Educating healthcare leaders for the 21 st century: evolution not revolution. Healthcare Executives 5~1~:34-7. Grossman, J. 1998. Continuing competence in the health professions. American Journal of Occupational Therapy 52 (9~:709-15. Health Resources and Services Administration. 1999. Building the Future of Allied Health: Report of the Implementation Task Force of the National Commission on Allied Health. Rockville, MD: Health Resources and Services Administration. Hutcherson, C.M. 2001. "Legal considerations for nurses practicing in a telehealth setting. Online Journal of Issues in Nursing." Online. Available at http://www.nursingworld.org/ojin/topic 16/ tpcl 6_3.htm Inlander, C. 2002. ""Crossing the Quality Chasm: Next Steps for Health Professions Education"; Panel Discussion." Online. Available at http:// w w w . k a i s e r n e t w o r k . o r g / h e a 1 t h _ c a s t / hcast_index.ctm?display=detail&hc=601 [accessed Nov. 12, 20023. Institute of Medicine. 1995. Dental Education at a Crossroads. Vol. Committee on the Future of Dental Education and Marilyn J. Field, eds. Washington, DC: National Academy Press. 1996. Telemedicine: A Guide to Assessing Telecommunications for Health Care . Marilyn J. Field, ed. Washington, DC: National Academy Press. . 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press. . 2002. Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence. Vol. Committee on the Training Needs of Health Professionals to Respond to Family Violence, Board of Children Youth and Families, Institute of Medicine, and F. Cogn M.E.S.a.J.D.S., Eds. Washington, DC: National Academy Press. Joint Commission on Accreditation of Healthcare Organizations. 2000. Age-Specific Competencies. Joint Commission on Accreditation of Healthcare Organizations. 2001. "Hospitals Face New JACHO Patient Safety Standards on July 1." Online. Available at http://wwwJcaho.org/ news+room/press+kits/ hospitals+face+new+j caho+patient+safety+stan dards+on+july+l.htm [accessed 20023. Jost, T. 1997. Regulation of the Healthcare Professions. 1997: Health Administration Press. Kinnersley, P. 2000. Randomised controlled trial of nurse practioner versus general practitioner care for patients requesting same day consultations in primary caret British MedicalJournal 320 (7241): 1043-48. Leach, D.C. 2002. Building and assessing competence: the potential for evidence-based graduate medical education. Qual Manag Health Care 11(1~:39-44. Liaison Committee on Medial Education. 2000. "Overview of the Accrediation of the LCME." Online [accessed Aug., 20023. Ludmerer, K. 1999. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. New York, NY: Oxford University Press. Mundinger, M.O., R.L. Kane, E.R. Lenz, A.M. Totten, W.Y. Tsai, P.D. Cleary, W.T. Friedewald, A.L. Siu, and M.L. Shelanski. 2000. Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial. Journal of the American Medical Association 283 (14:59-68. Murray, E., L. Gruppen, P. Catton, R. Hays, and J.O. Woolliscroft. 2000. The accountability of clinical education: Its definition and assessment. Medical Education 34 (104:871-79. National Accrediting Agency for Clinical Laboratory Sciences. 2001. Standards of Accredited Educational Programs for the Clinical Laboratory Scientist/Medical Technologist. Chicago, IL: National Accrediting Agency for Clinical Laboratory Sciences. National Association of Boards of Pharmacy. 2002. "Examinations -- NAPLEX." Online. Available at http://www.nabp.net/ [accessed Aug. 10, 20023.

OCR for page 97
HEALTH PROFESSIONS OVERSIGHT PROCESSES National Board for Certification in Occupational Therapy. 2002a. "Practice Exams." Online. Available at http://www.nbcot.org/nbcot/docs/ practice_exam_web~age.doc [accessed Aug., 2002a]. . 2002b. "State Regulations." Online. Available at http://www.nbcot.org/nbcot/scripts/ state_reg/regulations.asp [accessed Aug., 2002b]. National Board for Respiratory Care. 2001. "Examinations." Online. Available at http:// www.nbrc.org/ExamsRRT.htm [accessed Sept., 2002]. National Board of Osteopathic Medical Examiners. 2002. "Guidelines and Sample Exams." Online. Available at http://www.nbome.org/ [accessed 2002]. National Commission on Certification of Physician Assistants. 2002. "Recertification: Overview." Online. Available at http://www.nccpa.net/ REC_overview.asp [accessed Aug., 2002]. National Committee for Quality Assurance. 2002. "What Does NCQA Review When It Accredits an HMO?" Online. Available at http://www. ncqa. org/Programs/Accreditation/MCO/ mcostdsoverview.htm [accessed 2002]. National Committee on Quality Assurance. 2002. "NCQA Releases Draft 2003 MCO, MBHO, and PPO Standards; Changes Streamline Process, Emphasize Results." Online. Available at http:// www. ncqa. org/Co mmunications/News/ mcopubcomment2003.htm [accessed 2002]. National Council of State Boards of Nursing. 2000. "Nurse Licensure Compact." Online. Available at http://www.ncsbn.org/public/ nurselicensurecompact/mutual_recognition.htm [accessed Aug., 2002]. National Institute for Standards in Pharmacist Credentialing. 2002. "Recertification Requirements and Guidelines." Online. Available at http://www.nispcnet.org/ recert_guidelines.pdf [accessed Aug., 2002]. National League for Nursing Accrediting Commission. 1999. " 1999 Standards and Criteria and Interpretative Guidelines." Online. Available at http://www.nlnac.org/Manual/O 20&/020IG/01_accreditation manual.htm [accessed Aug. 14, 2002]. OBrien, T., N. Freemantle, A.D. Oxman, F. Wolf, D. A. Davis, and J. Herrin. 2001. Continuing education meetings and workshops: Effects on professional practice and health care outcomes. Cochrane Database System Review (24: CD003030. ONeil, E. H. and the Pew Health Professions Commission. 1998. Recreating health professionalpractice for a new century - The fourth report of the pew health professions Commission. San Francisco, CA: Pew Health Professions Commission. Pearson, L. 2000. Annual legislative update: How each state stands on legislative issues affecting advanced nursing practice. The Nurse Practitioner 26 (1~:7-57. Phillips, R.L. Jr, D.C. Harper, M. Wakefield, L.A. Green, and G.E. Fryer, Jr. 2002. Can nurse practitioners and physicians beat parochialism into plowshares? Health AJfairs 21 (54:133-42. Reisdorff, E.J., O.W. Hayes, D.J. Carlson, and G.L. Walker. 2001. Assessing the new general competencies for resident education: A model ~ . . ~rom an emergency me' ~c~ne program. Academic Medicine 76 (7~:753-57. Ridenour, J. 2002. ""Crossing the Quality Chasm: Next Steps for Health Professions Education"; Panel Discussion." Online. Available at http:// w w w . k a i s e r n e t w 0 r k . o r g / h e a 1 t h _ c a s t / hcast_index.ctm?display=detail&hc=601 [accessed Nov. 12, 20023. Rosenfeld, B.A., T. Dorman, M.J. Breslow, et al. 2000. Intensive care unit telemedicine: Alternate paradigm for providing continuous intensivist care. Critical Care Medicine 28 (124:3925-31. Safriet, B. 2002. Closing the gap between can and may in health-care providers scopes of practices. Yale Journal on Regulation 19 (2~:301-34. Safriet, B.J. 1994. Impediments to progress in health care workforce policy: License and practice laws. Inquiry 31 (3~:310-317. Sage, W. M., and L. H. Aiken. 1997. Regulating interdisiplinary practice. Regulation of the Healthcare Professions. T. Jost. Chicago: Health Administration Press. Smith, W.R. 2000. Evidence for the effectiveness of techniques to change physician behavior. Chest 11 8 (2 Suppl) :8 S- 17 S. ~9

OCR for page 97
HEALTH PROFESSIONS EDUCATION Stead, W. 2002. "Crossing the Quality Chasm: Next Steps for Health Professions Education; Panel Discussion." Online. Available at http://www. kaisernetwork. org/health_cast/hcast_index. cam? display=detail&hc=601 [accessed Nov. 12, 2002]. Swankin, D.S. 2002. Results of Survey of Selected State Health Licensing Boards and Health Voluntary Certification Agencies Concerning their Continuing Competence Programs and Requirements. Washington, DC: Citizen Advocacy Center. The Royal College of Physicians and Surgeons of Canada. 2002. "Maintenance of Certification. " Online [accessed Oct., 20023. United States Medical Licensing Exam. 2002a. "United States Medical Licensing Examination Steps 1, 2, 3." Online. Available at http://www. usmle.org/stepl/intro.htm [accessed Aug. 10, 2002a]. . 2002b. "Frequently Asked Questions About the USMLE Clinical Skills Exam." Online. Available at http://www.usmle.org/news/ faqscse.htm [accessed Aug. 10, 2002b]. yenning, P.,et al. 2000. Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. British Medical Journal 320 (724 1 ): 1 048- 53. Wasserman, S.I., H.R. Kimball, and F.D. Duffy. 2000. Recertification in internal medicine: A program of continuous professional development. Task Force on Recertification. Annals of Internal Medicine 133 (3~:202-8. Whittaker, S., W. Carson, and M.C. Smolenski. 2000. Assuring continued competence -- policy questions and approaches: How should the profession respond? Online Journal of Issues in Nursing: 18. Yoder-Wise,P.S. 2002. State and association/ certifying boards: CE requirements. Journal of Continuing Educationin Nursing 33~14:3-11. 120