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Redesigning Continuing Education in the Health Professions 6 Function and Structure of a Continuing Professional Development Institute To achieve the goals of a new culture of continuing professional development (CPD), the recommended Continuing Professional Development Institute (CPDI) must be structured to advance continuing education (CE). Four areas in particular are fundamental to the scope of the recommended CPDI: advancing the science of CPD, data collection and dissemination, regulation, and financing. Furthermore, because one of the motivations for the CPDI is to promote collaboration across state and disciplinary lines, it should be guided by the principles of transparency (so that all stakeholders can participate and understand the results), independence (so that no organization dominates), use of best evidence (to convince diverse stakeholders of the CPDI’s value), and analysis of the practitioner’s experience as a professional development tool (to broaden the scope of CE). This chapter considers establishing the basic function and structure of the CPDI—and of the planning committee that will begin the process of consensus building and recommend the characteristics and operation of the CPDI in much greater detail than can be addressed in this report.
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Redesigning Continuing Education in the Health Professions FUNCTION Scientific Foundations of Continuing Professional Development Congruent with the overall purpose of the CPDI, a research agenda should be developed that has collaboration and integration as its guiding principles, with the goal of enhancing knowledge of continuing professional development and ultimately improving patients’ health outcomes. Research efforts should be developed through the collaboration of all individuals and organizations that conduct CPD, receive CPD, and benefit from CPD research, including the public. To support professional learning and development aimed at improving patient outcomes, research should inform practice, and practice should inform research by translating advances in medical knowledge and techniques into clinical practice much more quickly than now occurs. CPD research should build knowledge about the theory of professional development, the methods used for CPD, and the measurements taken—all as related to the improvement of patient care quality, safety, and value. Other disciplines that are relevant and ought to be integrated into CPD research include adult education, organizational change, psychology, sociology, and systems engineering. These disciplines can shed light on behavior change in complex systems and help evaluate the impact of educational interventions on health outcomes. Role of the CPDI in Research The CPDI should develop the research agenda by establishing a comprehensive, collaborative research structure or center that coordinates CPD research and theory. It will also address its linkages to quality improvement, professional learning, and individual professional career advancement, system performance, and appropriate measurement. To hold the CPDI accountable for the development of a research agenda, the Secretary of the Department of Health and Human Services (the Secretary) should periodically monitor the CPDI’s progress. The CPDI is intended not to be a replacement for current research but to involve current researchers in creating a better system. Thus, the CPDI should serve a collaborating and convening function to foster a more comprehensive and integrated research structure. The focus on research that supports innovation, greater sources of funding, and improved patient care is incentive for researchers to participate in this effort. As part of a convening role, the CPDI
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Redesigning Continuing Education in the Health Professions would build consensus on research directions, set standards, and support the development and strengthening of research methods and the research workforce itself. Determining the success of these efforts will require developing measures and evaluation tool kits for research on knowledge, performance, outcomes, and gaps. The CPDI should promote interdisciplinary and interprofessional research to integrate research being conducted in all health professions, other areas of health care (e.g., quality improvement, information technology, management and policy), and other relevant disciplines (e.g., adult learning, systems improvement). As noted in Chapter 5, other countries leading in CPD research could also be valuable collaborators. Best practices and theories may be gleaned from nonhealth-related industries, such as accounting, education, engineering, law, and transportation (see Appendix D). Current funders of pertinent research will continue to solicit proposals and to award research grants; however, coordinating research areas with other organizations via the CPDI can enable funders to target their funds more effectively. Such collaboration could result in a CPDI that pioneers new, more effective forms of inquiry that would build on current methods. The CPDI should periodically identify gap areas, solicit proposals, and fund research to fill these gaps. The National Quality Forum (NQF) is a model for a networking function that is similar to the objectives of the CPDI—i.e., providing an environment for researchers, professional societies, stakeholder organizations, and the government to learn from each other and exchange needs and desires to further the research agenda. Such a learning network would mirror the breadth of the CPDI and include the broad spectrum of researchers (from novice to expert), clinicians, and educators in all settings. Science of CPD The science of CPD must be considered along with research on CPD effectiveness. The science of CPD includes the theories and assumptions on which hypotheses and models of learning are developed. These theory-based frameworks are fundamental for formulating strong research questions. Inquiry into the science of CPD must include the science of measurement and the science of evaluation. Both quantitative and qualitative methods can be applied to understanding the CPD continuum. For example, randomized controlled trials may not be appropriate for determining whether clinical guidelines change clinician behavior; instead this may require multi-
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Redesigning Continuing Education in the Health Professions method research approaches (Goering and Streiner, 1996; Morgan, 1998). The biological and social sciences should be used to foster the integration of different disciplines and professions. A multimethod approach has potential to strengthen the evidence for CPD. Just as only appropriate methods should be used to study particular kinds of research questions, only appropriate educational methods should be used to understand and verify different needs and outcomes. An inventory of measurement instruments to evaluate the effectiveness and efficiency of CPD should be developed to support the broad application of validated measures. Recommendation 4: The Continuing Professional Development Institute should lead efforts to improve the underlying scientific foundation of CPD to enhance the knowledge and performance of health professionals and patient outcomes by: Integrating appropriate methods and findings from existing research in a variety of disciplines and professions, Generating research directions that advance understanding and application of new CPD solutions to problems associated with patient and population health status, Transform new knowledge pertinent to CPD into tools and methods for increasing the success of efforts to improve patient health, and Promoting the development of an inventory of measurement instruments that can be used to evaluate the effectiveness and efficiency of CPD. Data Collection and Dissemination As the underpinnings of research, data are the basis for informed decision making. Accurate and reliable data often require measurement validation and audit. Current continuing education efforts typically suffer from a lack of high quality data on which to base decisions and do not adequately couple theory and measurement. The result has been that decisions about continuing education and professional development are not always based on evidence. More importantly, no coordinated effort exists to systematically collect these data, yielding concentrated areas of research that are not necessarily connected to one another. To advance CPD research and support evidence-based decision making, the CPDI should ensure that data are collected, analyzed, and publicly reported to allow for the evaluation of CPD methods
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Redesigning Continuing Education in the Health Professions and providers. These data ought to also clarify and build knowledge about linkages between CPD, better patient care, and better performance of health care systems. Specifically, data should help determine what effectively influences the health professional’s capacity to meet the goals described by the Institute of Medicine (IOM) to deliver safe, effective, patient-centered, timely, efficient, and equitable health care services (IOM, 2001). Collection of such data will require a significant investment of time and resources but is fundamental to creating an effective CPD system. Data should facilitate the alignment of good learning and good health care and should identify the skills required to meet educational needs and choose the appropriate tools to teach and assess the required skills. At the systems level, it will be critical to collect and evaluate data on the cost of CPD and its financing to better understand the value and create a business case for specific CPD activities. These analyses are essential for making decisions about how CPD resources should be invested. Collection of more robust and comprehensive data on CPD would provide a strong evidence-base on which to build through aggregation at the individual professional level, organizational level, and systems level. The CPDI’s role as a central convener would entail endorsing educational measures, determining the data to be collected and reported, identifying the manner in which they are reported, and creating a coordinated network to develop a robust data system that advances current efforts and best practices. These roles can be fulfilled only if the CPDI works with interdisciplinary researchers and health professionals, while serving as a central resource. Researchers in the service and academic communities should continue to develop and store data but, when appropriate, should offer to share data when requested by the CPDI (see Box 6-1). The approaches used by the quality improvement field provide a good analogy for how to collect and disseminate data. Organizations such as the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, The Joint Commission, the National Committee for Quality Assurance, and the National Quality Forum, among others, have distinct roles in data measurement, collection, and reporting. Partnership between CPD organizations and organizations whose purpose is to improve quality and patient safety would provide benefits beyond applying lessons learned. The relationship between continuing professional development and quality improvement suggests that the communities would have overlapping needs for performance measurement standards, data collection and reporting, and ways of gathering and offering feed-
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Redesigning Continuing Education in the Health Professions BOX 6-1 Trusted Agent Model: Compiling Evidence to Support CPD Large amounts of data exist on all physicians, but they are stored in different data repositories. Records of attendance and performance in medical school, residency, board examinations, board certification status, licensing, attendance at continuing medical education activities, and case logs and portfolios of clinical and educational experiences are housed separately. The application process for state licensure is tedious and time consuming—requiring months to verify each primary source—and is repeated each time a physician seeks to be credentialed or licensed, adding substantial burden and expense for the physician and for the state board and/or hospital. The Trusted Agent Model was developed by the National Board of Medical Examiners (NBME) Center for Innovation. It is an example of a datasharing infrastructure that compiles evidence of a physician’s credentials and learning. Data are compiled from several sources (trusted agents) and, after use, can be destroyed without affecting the original data sources. The Trusted Agent Model was tested in a joint demonstration project of 2,810 applicants conducted by the NBME and the Federation of State Medical Boards in Kentucky, New Hampshire, and Ohio, requiring agreement with the regulatory bodies and permission by applicants to release the data. Instead of months, physician credentials were verified in 8 seconds. The Trusted Agent concept has yet to be tested as an interactive professional development tool; however, when coupled with learning portfolios, it could enable documentation of learning from diverse sources for any desired use, including public transparency. Conceivably, the CPDI could deploy the Trusted Agent Model or similar concepts across health professions to foster ongoing professional development, document clinical and learning experiences, identify interprofessional learning experiences and team development, and provide the public with data about the types of patients a health professional team sees and its clinical and educational outcomes. Reduction in the burden and costs associated with documenting health professional credentials could be substantial. back on health care professionals’ performance. The Office of the National Coordinator for Health Information Technology should be leveraged as a partner toward collection of such data and can help develop standardized learning portfolios as a tool for collecting common data on professionals across the country. Recommendation 5: The Continuing Professional Development Institute should enhance the collection of data to enable evaluation and assessment of CPD at the individual, team,
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Redesigning Continuing Education in the Health Professions organizational, system, and national levels. Efforts should include: Relating quality improvement data to CPD, and Collaborating with the Office of the National Coordinator for Health Information Technology in developing national standardized learning portfolios to enhance the understanding of the linkages between educational interventions, skill acquisition, and improvement of patient care. Regulation The recommendation to create the CPDI is motivated in part by a significant need to improve the licensure, certification, and credentialing of health professionals by the various health professions, and to improve the process of accreditation of continuing education providers. The institute should focus first on improving accreditation. Accreditation discerns and publicly recognizes that a CPD provider meets minimum standards of quality. As discussed in Chapter 3, the committee is not proposing that responsibility be given to different accreditors but that accreditation systems be modified to address the entire continuum of CPD and to focus more on discerning, recognizing, and improving professionals’ competence and performance. Such a system would allow health professionals to better understand how to improve their practices. Innovation toward these ends requires cooperation from current accreditors to drive change in the accreditation system toward learner-driven CPD. In most cases, the accreditation and certification processes have been the responsibility of the professions themselves. For the majority of health professions, certification is administered at the national level. Accreditation of CE programs occurs at both the national and the state levels, largely under the direction of professional societies. Accreditation offers a particularly interesting model, where national accreditation bodies can sometimes set standards and accredit the state societies, which in turn sanction local CE providers. The dual system of national and state accreditation should be consolidated to the extent possible. Accreditors tend to accredit providers of educational programs rather than the programs themselves, distancing the accreditors from the improvement of patient care. Today, it is possible to accredit tools, such as individual learning portfolios, which are much more tightly linked to the health professional’s practice. Professional societies that function as regulators (e.g., American Medical Association, American Dental Association, National Council for Therapeutic Recreation Certification, the National League of
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Redesigning Continuing Education in the Health Professions Nursing) ordinarily maintain knowledge and expertise sufficient to conduct various monitoring tasks, but it is outside their scope to conduct rigorous research for improvement or to explain causal relationships of accreditation, credit, certification, licensure, continuing education, and improved quality of care. There is a need for coordination and collaboration among regulators and researchers, both within the same profession and among professions, to explore and test the relationships of regulation to more effective continuing education and health care. Cross-disciplinary regulatory mechanisms will become increasingly important with a greater focus by the system on interprofessional education. The committee concludes that the CPDI should work with current regulatory bodies to develop regulatory policies and establish national standards for all health professions. The CPDI should, in effect, develop standards for and accredit the accrediting bodies. Soon after the CPDI is established, it should establish a collaborative process for gathering perspectives from all appropriate stakeholders through public hearings and other methods of due process to set national, interprofessional standards for accreditation. In the longer term, a process will be needed to evaluate and update the standards and continually monitor the accreditors. The role of the CPDI should periodically be reassessed to determine whether there is a proper balance between government regulation and professional self-regulation. Recommendation 6: The Continuing Professional Development Institute should work with stakeholders to develop national standards for regulation of CPD. The CPDI should set standards for regulatory bodies across the health professions for licensure, certification, credentialing, and accreditation. Improved CPD Financing The CPDI should have as a major responsibility identifying and acquiring more stable sources of financing to fund a broad-based, comprehensive CPD system. The issues of bias and conflicts of interest arise when discussing who should fund CPD activities and research (Steinbrook, 2005, 2008). The committee believes that all CPD funding should align with the committee’s defined purposes for CPD—improved quality of care and patient safety. All funders whose primary goal is not improved quality of care and patient safety should be restricted from providing either financial or in-kind support to CPD, although it is understood that not all commercial
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Redesigning Continuing Education in the Health Professions funding is conflicted and that there may be many other conflicted sources that do not involve commercial sources. To help the CPDI more rapidly incorporate this into its accreditation standards, the planning committee will need to develop guiding principles to address conflicts of interest. These principles should build on the guidelines already developed on conflict of interest, some of which have been set forth by organizations and partnerships such as the Accreditation Council for Continuing Medical Education (ACCME) and the Pharmaceutical Research and Manufacturers Association (PhRMA), and should build on the work of an IOM report on conflict of interest (ACCME, 2006; IOM, 2009; PhRMA, 2008). These will make a good starting point for the CPDI to establish standardized guidelines on conflicted sources of funding for CPD at the national level for all professions. The planning committee may determine that investments from conflicted sources may still be used if directed in specific ways (e.g., pooling money, with the CPDI or some other neutral body having discretion over how it is spent). Implementation of the proposed restrictions on conflicted funding could mean that the sources of a sizable amount of current funds may no longer be able to invest in the CPDI and improved CPD system. In the absence of evidence, there is very likely enough money in the current system to support a better one, given the proposed changes in the scope of CPD programs and the opportunities to reduce the waste and inefficiencies documented in Chapter 3. Recommendation 7: The Continuing Professional Development Institute should analyze the sources and adequacy of funding for CPD, develop a sustainable business model free from conflicts of interest, and promote the use of CPD to improve quality and patient safety. STRUCTURE OF A CONTINUING PROFESSIONAL DEVELOPMENT INSTITUTE The following section outlines the structure this IOM committee has envisioned for the Continuing Professional Development Institute (see Figure 6-1). The Planning Committee As recommended in Chapter 4, a planning committee should be commissioned with the specific tasks of outlining the CPDI’s
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Redesigning Continuing Education in the Health Professions FIGURE 6-1 Suggested process for the development of a CPDI.
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Redesigning Continuing Education in the Health Professions scope of work, developing the CPDI’s governance model, identifying sources of financial stability for the CPDI, and identifying and managing relationships with new and current stakeholders. This IOM committee believes that the planning committee ought to operate under four principles: The planning committee should be held accountable by the public and the Secretary; The planning committee should be competency-based, flexible, and nimble; The planning committee should broadly communicate with, and gather input from, the rest of the field (e.g., health professions, accreditors, CPD providers, licensing bodies), but only planning committee members should receive voting rights; and The planning committee should use consensus building, not parliamentary procedure, to manage its operations. In designing the CPDI as a public-private partnership, the planning committee should also not be solely public or solely private. The quality of professionals’ performance, which is the focus of CPD, is currently largely the responsibility of the professions and the state agencies that provide licensure, so that embedding the planning committee in a federal agency would not be appropriate. However, no professional organization or group of organizations has the ability or authority currently to develop the collaborative and integrative efforts the committee believes necessary for CPD. Thus, the planning committee should be funded by contracts and grants from the government and private foundations to enable funding for staff and travel. Membership The two main options for the composition of the planning committee are a representational structure and a competency-based structure. Appendix B lists the categories of health care practitioner and technical occupations as identified by the Bureau of Labor Statistics (U.S. Bureau of Labor Statistics, 2008). Professions requiring baccalaureate or higher degrees should be recognized as stakeholders of the CPDI. Although representation from each profession or each category of professions would be ideal in terms of hearing from all perspectives, requiring different representation from all or a large majority of the 54 professions listed in Table B-1 would result in a
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Redesigning Continuing Education in the Health Professions planning committee that is too large to function; 13 to 15 members is a more effective size. Additionally, those who conduct research, those who sponsor CPD activities, and those who benefit from CPD are also stakeholders whose perspectives need to be considered. The planning committee should also have the ability to adapt to emerging realities without undue influence of some members or other stakeholders. The committee therefore concludes that a representational structure would not best serve the goals of the planning committee, and its members should instead be chosen on the basis of competency. Competencies that the committee believes are important to include on the planning committee are listed in Box 6-2. Members may be knowledgeable in more than one of the identified areas; each area should be represented more than once, if possible. Given the planning committee’s significant role in shaping the future of CPD and building relationships with stakeholders, it is important for all planning committee members to be thought leaders in their respective fields, have experience in leading change and improvement, and have some level of experience in interprofessional learning. Planning committee membership should at a minimum include practicing professionals and individuals with expertise in government and CPD research. The need to be mindful of historically underrepresented groups also applies to the planning committee membership. The planning committee chair should be an executive manager with a record of success in setting and implementing visions and building consensus. All members, including the chair, should be appointed by the Secretary of the Department of Health and Human Services, in consultation with other federal departments. Procedures The planning committee should operate on the principle of intelligent consensus building. Operations should therefore not be driven by parliamentary procedure, where the views of individuals often serve the purpose of bias and separation. The planning committee must foster relationships with other stakeholders. Operating under the principles of transparency, the planning committee should hold public hearings to gather a more diverse set of opinions in its decision-making processes. However, only planning committee members would vote. A report should be delivered to the Secretary detailing the outcomes of its deliberations.
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Redesigning Continuing Education in the Health Professions BOX 6-2 Competencies for Planning Committee Membership A competency-based committee formed to plan the CPDI should consist of members who (1) are considered thought leaders in their respective fields, (2) have experience in leading change and improvement, and (3) have experience in interprofessional learning. At a minimum, membership should include practicing health professionals and individuals with expertise in government and CPD research. Competencies that ought to be represented on the planning committee are listed alphabetically below. Accreditation, certification, and licensing Adult learning and clinical education, including design and evaluation of CPD methods Care coordination and team training Economics Ethics and conflicts of interest Health care reform International perspective Measurement Microsystem and macrosystem experiences Payer, not from a federal perspective Quality improvement, focusing on the science and techniques of improvement State perspective with an understanding of the state governments’ roles in licensure Continuing Professional Development Institute The IOM committee based its ideas for the CPDI on the notion that the CPDI’s vision statement should be “supporting competent clinicians for quality patient care.” To fulfill this vision, the mission of the CPDI should be to coordinate and integrate efforts of all stakeholders to enhance professional development for the purpose of improving health care quality and patient safety. Upon its development, the CPDI founding board should adopt its own vision statement, while keeping in mind the original intents. Board The board of directors is the key body that approves the mission, vision, and goals of an organization. The CPDI board should view its role as laying the foundation for a culture of learning to achieve
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Redesigning Continuing Education in the Health Professions high quality, safe health care. Like the planning committee and for the same reasons, it should be competency-based, with competencies similar to those of the planning committee; however, the planning committee should make the final determination of the exact competencies required. It may wish to consider including a member of the public. Membership size and structure of the founding board should also be determined by the planning committee. To facilitate the transition from planning committee to CPDI, some members of the planning committee should serve on the founding board (see Figure 5-1). Upon development of a more permanent structure, board members should rotate in an overlapping manner. Operating Structure With such a broad mission of coordinating and integrating the CPD efforts of all stakeholders, many organizations and categories of individuals should be included in the operations of the CPDI. A limitation to a competency-based board is that more stakeholders exist than can reasonably sit on a board. Therefore, a structure that adopts the use of standing councils and analogous methods, such as ad hoc committees, seems necessary to incorporate the perspectives of a broad group of stakeholders. The rest of this report is written with the expectation that standing councils will be created for each of the CPDI’s four major responsibilities: science of CPD, data collection and dissemination, regulation, and financing (see Figure 6-1). Councils are envisioned to be relatively small in size, with the board determining council membership. The primary purpose of the councils would be to provide transparency through fair and equitable processes and advise the board on complex issues. The secondary purpose would be to gather stakeholder groups with specific expertise so that the board’s decisions will be based on a broader perspective. The appropriate topics for councils will likely change as the CPD system develops, so the board will need to periodically reevaluate what councils should exist. Ad hoc committees, on the other hand, would be convened to gather public opinion on a specific identified need and would disband after completing its work. For example, a problem-focused committee might be established to advise on how to operationalize team-based learning. The founding board should consider including a broad set of voices on the councils and ad hoc committees. The voices of patients are critical and should not be excluded. Additionally, the breadth of stakeholders should also incorporate the quality improvement community. Together, councils and ad hoc committees would provide
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Redesigning Continuing Education in the Health Professions a process for the voices of those not on the board to be heard, for issues to be debated, and for facilitation of decision making. Other avenues for stakeholder input should continuously be considered and developed, as deemed necessary by the board. Like the CPDI in general, these councils and ad hoc committees should work toward the goal of improving quality and patient safety. Public-Private Partnership The CPDI is envisioned to be an independent body with membership and financing from both the public and the private sectors. This structure allows for the planning committee to operate without undue influences from individual stakeholders, including federal and state governments, professional organizations, and industry alike. Currently, no organization within continuing education or CPD in the United States has the ability or authority to bring together all stakeholders. The federal government, through the Secretary of Health and Human Services, is in the best position to provide initial oversight and serve as the locus for coordination toward development of the CPDI. After formation of the CPDI, the Secretary or any other federal department such as the Department of Education would not have any specific formal role, unless one is identified and recommended by the planning committee. Oversight and coordination should eventually be transferred back to the professions when it becomes clear that the government no longer needs to serve in a leadership and coordinating role, as determined by the CPDI board. As with the planning committee, the CPDI should be sponsored by and receive funding from both government and private foundations. Establishment and maintenance of learning portfolios offers a source of service revenue to support the institute’s work over the long term. Organizational membership fees should be discouraged because board and council members would then be less independent. Determination of the size of the CPDI’s budget depends on its exact functions and breadth, so it will be the planning committee’s job to estimate and project a budget for the CPDI once it has determined the details of those elements. The planning committee should provide guidance for long-term funding for the CPDI and for ensuring that the acceptance of funds from conflicted sources does not bias the work of the CPDI.
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Redesigning Continuing Education in the Health Professions Proposed Activities Communications and dissemination of achievements are necessary components for the growth of the CPDI and acceptance of its role by all stakeholders. Lessons learned, decisions made, and research findings must be shared widely. The CPDI would need adequate latitude from not only its board but also its stakeholders to constantly adapt, allowing it to function as a learning system. Without broad communication, the goals of collaboration and integration cannot be met. A strong communications and dissemination plan should therefore be a core function of the CPDI. For example, the research arm of the CPDI could develop and widely distribute a periodic (e.g., quarterly) consensus document about the state of the art of CPD in relation to specific research areas. Evaluation is also a fundamental component of an institute. Measures of success should be developed by the planning committee to monitor the CPDI’s activities and progress. Feedback on the CPDI’s activities is critical to continuously improving professional development with the aim of better health outcomes. REFERENCES ACCME (Accreditation Council for Continuing Medical Education). 2006. ACCME essential areas and their elements: Updated decision-making criteria relevant to the essential areas and elements. Chicago, IL: ACCME. Goering, P. N., and D. L. Streiner. 1996. Reconcilable differences: The marriage of qualitative and quantitative methods. Canadian Journal of Psychiatry 41(8):491-497. IOM (Institute of Medicine). 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. ———. 2009. Conflict of interest in medical research, education, and practice. Washington, DC: The National Academies Press. Morgan, D. L. 1998. Practical strategies for combining qualitative and quantitative methods: Applications to health research. Qualitative Health Research 8(3):362-376. PhRMA (Pharmaceutical Research and Manufacturers of America). 2008. Code on interactions with healthcare professionals. Washington, DC: PhRMA. Steinbrook, R. 2005. Commercial support and continuing medical education. New England Journal of Medicine 352(6):534-535. ———. 2008. Financial support of continuing medical education. Journal of the American Medical Association 299(9):1060-1062. U.S. Bureau of Labor Statistics. 2008. Occupational outlook handbook, 2008-09 edition. Washington, DC: U.S. Bureau of Labor Statistics.