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Redesigning Continuing Education in the Health Professions 7 Implementation, Research, and Evaluation This chapter provides some guidance on implementation of the Continuing Professional Development Institute (CPDI), suggests a framework for research on continuing professional development (CPD), and offers ways to assess the CPDI. IMPLEMENTATION Creating a New Culture The first step toward establishing the CPDI will be to begin the development of an environment and infrastructure that support lifelong learning and interprofessional education. Buy-in and general agreement will be needed from stakeholders at all levels to change their own cultures and to alter current continuing education (CE) practices. Pivotal to such a major culture change is the critical role of leadership in communicating a compelling vision, aligning incentives and accountabilities, and establishing a collaborative and engaged management team to create the infrastructure necessary to improve and support the evolution of the CPDI. Management must also be attentive to its own development and preparation to successfully lead the cultural change. For example, within hospitals and academic health centers, learning could be fostered through the appointment of a chief learning officer who would design and over-
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Redesigning Continuing Education in the Health Professions see a system of interprofessional, team-based learning that focuses on the delivery of evidence-based health care. Health professionals themselves, as well as teachers of CPD and other stakeholders, will need to reorient their ideas of the necessity and purpose for CPD activities and the roles they will have to play as continuous learners in order to consistently deliver the best possible care. Concentrated efforts to begin this movement are needed to prevent further delays in improving health care quality and safety. To this end, the planning committee should cultivate relationships with relevant stakeholders, who in turn need to consider how they can best support the continuous development of the health care workforce. The scope of relevant stakeholders is broader than those directly involved in the learning of the U.S. health professions workforce. The United States can learn from the positive and negative experiences of other countries (e.g., Canada, European Union, United Kingdom) that have systems and structures in place to direct professional development, thus shortening the lead time needed to implement a U.S. CPD system (see Appendix C). International cooperation is a source of mutual learning, and initially the CPDI would likely learn from the best practices of other countries. Once a comprehensive CPD system is in place in the United States, the CPDI would be able to be an active member of the global CPD community by sharing its lessons learned. Best practices could also be learned from and shared with other industries, such as engineering and teaching, which also require continuing education to assure the public of professionals’ competence (see Appendix D). While the content must reflect the needs of the different industries, strategies for encouraging behavior change and learning are applicable across industries. The CPDI could benefit itself and others by being an active part of a continued learning community that spans all industries for which continued learning and development are critical. Development of the CPDI is an important step toward ensuring health professionals’ capacity to provide high quality care, but it is only one part of improving the quality and safety of the larger health care system. A strong connection needs to be created between CPD for clinicians and quality improvement at the micro-, meso-, and macrosystem levels. The microsystem refers to the front line of care, the network of interdependent people, information, and technology working together to accomplish a specific aim (e.g., ambulatory pediatric clinic, labor and delivery room, inpatient unit). The mesosystem creates the environment for transformation and includes the resources, strategies, and measures to guide and track
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Redesigning Continuing Education in the Health Professions change. Mesosystems enable interdependent functioning of multiple microsystems and confront impediments to good patient care—for example, from poor information systems or from relationships that do not recognize true interdependence. The macrosystem sets a vision and goals to guide the micro- and mesosystems by providing an enabling context and leadership for change. Professional development strategies and alignment of incentives are fostered at the macrosystem level. They are a natural point of accountability for the care outcomes of a community (Nelson et al., 2007). Interprofessional, Team-Based Care A concept underlying the CPDI is that by bringing together diverse participants, it will support and advance the team-based nature of health care. Health care often requires coordination among multiple practitioners, both intraprofessionally and interprofessionally. Today, care is often not practiced in teams, not because teams are not useful or effective, but because people are not trained in such a fashion. As the health professions are increasingly recognized as interdependent, a new team-based culture will emerge. The professional environment will also change as patients become more active partners in their health care. To embody the principles of effective interprofessional education, the CPDI will need to pursue four goals: Articulate a coherent rationale for implementing interprofessional continuing education, Promote collaboration to achieve patient-centered aims, Reconcile competing objectives between the professions in a way that is accepted by all of them, while reinforcing collaborative competence, and Support the development of methods to recognize interprofessional activities in the credentialing of individual professions. A number of interprofessional experiments in CPD have been developed, resulting in pockets of interprofessional programs. It is important that these experiences could be supported, built on, and expanded in clinical practices in settings such as integrated health care systems and academic health centers. Academic health centers would be particularly interesting, given their important roles in undergraduate and graduate education. Applying these principles
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Redesigning Continuing Education in the Health Professions to CPD will promote a unified educational framework, align communication, and share advances across all health professions. Recommendation 8: The Continuing Professional Development Institute should identify, recognize, and foster models of CPD that build knowledge about interprofessional team learning and collaboration. Regulation The standing Council on Regulation ought to consider how it would best align the various regulatory processes with a broader view of CPD. Several regulatory bodies have announced nascent efforts to streamline some of their processes (ACCME, 2009); historically, similar initiatives have been neither frequent nor interprofessional. Interprofessional cooperation to enhance regulatory processes should be encouraged to the greatest extent possible to support development of comprehensive, team-based care. By encouraging and facilitating action by various regulatory bodies across states and professions to ensure the competence of all practitioners, the CPDI can promote the consistency and alignment of regulations. Policies to align regulatory efforts should be developed based on evidence, allowing for minimum standards to be set in areas such as the methods and amount of CPD necessary for optimal learning. Processes to improve the coherence of regulations will need to take all stakeholders’ perspectives into account. One promising approach, for example, is the development of model laws in state-based licensing. The process used by the National Association of Insurance Commissioners to develop model laws could be adapted to promote regulatory improvements at the level of individual states. Disruptive innovations may be necessary to introduce positive change to the regulatory system. For example, in certification, the Council on Regulation could consider mandatory maintenance of certification programs for all health professions. A program of this nature could also be coupled with mandatory maintenance of licensure programs. These programs could help certification and licensure processes enhance practice performance and become better resources for the public. Maintenance of certification has become mandatory for physician specialties to ensure minimum levels of skill maintenance and competence (ABMS, 2009). This concept has not yet been adopted by all professions that grant certification. However, if minimum standards were applied across the health professions
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Redesigning Continuing Education in the Health Professions (given that different professions require different amounts of learning), the public could be ensured that all practitioners, despite their profession or specialty, have the ability to perform competently and to improve the safety and quality of health care. Similarly, the Federation of State Medical Boards has recently developed some guidance on maintenance of licensure programs to support physician commitment to lifelong learning (FSMB, 2008); these programs have yet to be implemented. To catalyze a movement toward improved learning, the Council on Regulation will need to support disruptive innovations and might consider working with licensing bodies to depart from the traditional credit-based system to a more performance-based system. A credit-based system may fuel health professionals’ indifference toward CPD by allowing a range of activities to count for continuing education that are not related to the maintenance or advancement of competence. A performance-based system, although harder to administer, would do just the opposite by ensuring that all health professionals maintain minimum levels of competence in their specialty areas. Such a system could provide leverage for the CPDI and licensing and certification bodies, anchoring CPD efforts in performance improvement. Financing The first challenge for the Council on Financing will be to stimulate the adoption of conflict-of-interest guidelines for all health professions to prohibit conflicted sources from funding CPD activities and CPD research. While many organizations at all levels of CPD have developed such guidance, no single industrywide standard exists for CPD. Although conflicted sources of funding more intensely permeate some professions than others, a single set of guidelines across the health professions would help protect the integrity of a CPD system. Additionally, the council will need to consider development of processes that would require CPD funders to declare their conflicts of interest to the institute. Conflicted sources of funding can be reduced or eliminated only if there is a parallel effort to identify nonconflicted sources of funding for CPD and CPD research. This effort will need to involve a broad group of stakeholders and a reconsideration of how CPD is funded and the roles of employers and government in directly supporting CPD. By strengthening the link between professional development and patient outcomes, collaboration with groups such as the quality improvement community may lead to investments in
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Redesigning Continuing Education in the Health Professions CPD that meet conflict of interest guidelines. A reconstitution of the mix of CPD funders or, at a minimum, diversification of funders that limits the financing from any one source may be necessary. For example, in the absence of conflicted sources of funding, academic health centers and health care organizations may provide greater levels of financial support, along with individual practitioners themselves, as discussed in Chapter 3. All models should be considered and assessed for the ability to strengthen CPD financing. As discussed in Chapter 6, a small number of research gaps might be identified for funding from the CPDI. A central pool of money could be created to distribute funds to support this research and other activities deemed necessary by the CPDI that would otherwise not be funded. For example, one likely area for research is in analyzing data to determine the value proposition for CPD, and cost-benefit analyses should be performed. These calculations might not be of interest to professional societies, which would be more likely to sponsor research on particular CPD activities and learning methods. In the absence of an appropriate funder, the use of central funds could allow important research to move forward. The mechanisms and guidelines for creating such a system need to be considered by the planning committee and, in the beginning stages of the CPDI, the Council on Financing. Another aspect of improving financing for CPD is the creation of incentives for CPD stakeholders to do the right thing. Both monetary and nonmonetary incentives could be designed to achieve the vision of a better CPD system. Nonmonetary incentives might include professional recognition and career advancement in the workplace. RESEARCH As discussed in Chapters 5 and 6, research is a core function of the CPDI and must be strengthened if truly effective advancements are to take place in CPD to discover what works where and to what degree. Research needs to be practical and to be based on practice needs. Coordination and communication systems should be facilitated by the Council on the Science of CPD. Because research relies on data, the council should be supported by the Council on Data Collection and Dissemination. The two councils should work together to advance research and the state of CPD.
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Redesigning Continuing Education in the Health Professions Setting Priorities In an inclusive, deliberative process, the CPDI should set national priorities on which research areas and topics should be funded. Doing so will require identification of criteria. The committee considered criteria used by other organizations to set priorities (see Table 7-1), including the Agency for Healthcare Research and TABLE 7-1 Criteria Adopted by Select Organizations Criteria AHRQ EPOC HRSA NPP CPDI Urgency of the problem Gaps in current knowledge Opportunity to improve practicea Innovation in methods Ability to advance the science of CPD Appropriateness (priority population or condition) Desirability of new research documentation Feasibility Improve health outcomesa Improve delivery of effective health care services, quality of care provided Improve access to health care services Eliminate harm, improve patient safety Eradicate or eliminate disparities Reduce disease burden Remove waste NOTE: The difference between CPDI criteria and those of other groups largely stems from the difference in each organization’s purpose. a AHRQ combines these criteria into one criterion, “potential value,” that also includes the potential for significantly impacting health and reducing unnecessary burden (cost) on those with health care problems.
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Redesigning Continuing Education in the Health Professions Quality (AHRQ), the Effective Practice and Organisation of Care (EPOC) Review Group, the Health Resources and Services Administration (HRSA), and the National Priorities Partnership (NPP). Although AHRQ has no specific agencywide means of setting priorities, the AHRQ Effective Health Care Program aims to improve the quality, effectiveness, and efficiency of the health care delivery system by using systematic reviews when comparing the effectiveness and harms of different health care interventions (Slutsky et al., 2008). The program uses the following criteria: reviews must be relevant and timely, be objective and scientifically rigorous, be transparent and involve public participation, and set a priority list for topics to review, including conditions such as cancer, cardiovascular disease, and obesity (Slutsky et al., 2008; Whitlock et al., 2009). EPOC is part of the Cochrane Collaboration1 and specifically develops systematic reviews of interventions aiming to improve professional practice and the delivery of health care services, through continuing education, quality assurance, financial, organizational, and regulatory interventions. Much like AHRQ, EPOC as a whole does not have a specific set of priorities outlined at present; however, this is a future goal.2 Its Norwegian satellite, however, does have specific criteria to use when setting priorities for its systematic reviews. It focuses specifically on interventions that are relevant to low- and middle-income countries; if the topic is of importance to a low- or middle-income country, a Cochrane-conducted systematic review could help to inform appropriate decisions about how to address this problem. Also, if a review has already been conducted on the specific topic, there has to be good reason to update or conduct a new review (EPOC, 2009). HRSA aims to improve “access to health care services for people who are uninsured, isolated, or medically vulnerable,” through activities such as providing health care services to vulnerable populations, training health professionals, and improving systems of care in rural parts of the United States (HRSA, 2009). HRSA’s priorities seek to provide those who are uninsured, those who are under- 1 “The Cochrane Collaboration is an international not-for-profit and independent organization, dedicated to making up-to-date, accurate information about the effects of health care readily available worldwide. It produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions”; see http://www.cochrane.org/docs/descrip.htm. 2 Personal communication with A. Mayhew, EPOC Managing Editor, April 23, 2009.
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Redesigning Continuing Education in the Health Professions served, and those with special needs with access to health care services they otherwise would be unable to use (HRSA, 2005). The NPP, convened by the National Quality Forum, is a collaborative effort of major national health care organizations that collectively influence every part of the health care system—both the private and the public sectors—including consumers, purchasers, quality alliances, health professionals and providers, insurers, government, accreditation and certification programs, and others (NPP, 2008). When setting its initial six priorities—patient and family engagement, population health, safety, care coordination, palliative and end-of-life care, and overuse—the NPP focused on high-leverage areas that would have the most immediate impact on reaching the goals of eliminating harm, eradicating health care disparities, reducing disease burden, and removing waste from the health care system. The NPP believes that such cross-cutting areas provide the greatest potential to substantially improve health and health care and to fundamentally change the U.S. health care delivery system. Recognizing that these organizations developed criteria for specific purposes that are not identical to those of CPD research, the committee suggests the following five criteria as a basis for prioritizing CPD research: urgency of the problem, gaps in current knowledge, opportunity to improve practice, innovation in methods, and ability to advance the science of CPD. The criteria are all of equal importance. Urgency of the problem. The urgency of the problem being researched can be assessed at the individual, public, and population health levels, using various measures. At the individual level, measures may include severity of conditions, disease burden, and quality of life as a result of a given condition. At the public and population health levels, measures such as prevalence and cost could be used. Gaps in current knowledge. Research topics should also be prioritized according to whether they address gaps in current knowledge. Gaps should be identified by the CPDI in the areas of structure, process, and outcomes. Outcomes can be considered at the level of patients, practitioners, systems, and society. At the CPD provider level, gaps in knowledge occur in understanding the effectiveness and comparative effectiveness of various delivery methods (e.g., lectures, journals) as well as of CPD content (e.g., behavior change, performance improvement). Improvement in the state of CPD science requires continuous reassessment of research gaps.
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Redesigning Continuing Education in the Health Professions Opportunity to improve practice. A greater understanding is needed to bridge the gap between research and practice. Research should therefore be given higher priority if it is deemed to have the ability to improve the practical knowledge, skills, and attitudes of clinicians. Innovation in methods. Innovation is critical to making systems changes. With respect to CPD, researchers should be encouraged and rewarded for developing innovations in delivery methods and research methods. Research projects that provide new approaches and perspectives will be important in advancing CPD. Ability to advance the science of CPD. Research is needed to advance the science of CPD. The science of CPD includes the methods of studying CPD and its underlying theories and hypotheses. The Council on the Science of CPD should consider the criteria described above when determining research areas and priorities. A coordinated research agenda could reduce unnecessary duplication of research with other programs, link with other fields in health care to broaden the research base, and provide more evidence on the availability of effective methods and best practices. The planning committee should define a process for setting a research agenda, and an early task for the Council on the Science of CPD is to refine and implement that process. To determine who might set priorities, three nonexclusive options were considered: a broad set of professional groups and other stakeholders, a group similar to EPOC that would specifically focus on CPD, or the CPDI based on advice from the standing council. Since the purpose of a coordinated research agenda is to foster collaboration and integration, learners, experts, and facilitators should all be involved in agenda setting. Central planning is needed to develop a comprehensive research agenda and to reduce bias. For example, a research group similar to EPOC could be developed as a first step to produce systematic reviews examining topics related to CPD. Second, priorities could be set by researchers across professions. Finally, the committee considered the potential role of the CPDI in advancing the scientific foundations of CPD. Its overall role is of encouraging collaboration and establishing leadership in achieving consensus. The committee concluded that research priorities should be set in a collaborative manner and could be performed either by a separate research organization analogous to EPOC or by the CPDI.
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Redesigning Continuing Education in the Health Professions Research Areas CPD activities have not been consistently evaluated. To make a case for investing in CPD, the research enterprise must begin such evaluations. In its evaluation of the literature, the committee identified areas where research is immediately needed. These research areas include evaluation of CPD effectiveness and efficiency methods; best learning methods and lifelong learning; development and validation of measurements and evaluation instruments; impact of CPD on health outcomes; and the effects of planned change initiatives, including regulation. To more rapidly advance the field, efforts in these areas should address what works and why or why not. The existing CPD literature is often limited by inappropriate choice of methods, research goals, and questions and by hypotheses not built on theories that can grow and develop as they are tested. Without an organized body of knowledge about the effectiveness and efficiency of efforts to impact change, the value of CPD cannot be assessed and health professionals cannot depend on it as a vehicle for improving practices and patient health. Research on the effectiveness of CPD must also align CPD activities with the identified needs and appropriate skills to be learned. For example, research should recognize that lectures may be good for transmitting information, but other methods are needed for deeper learning and performance change. Research is siloed by discipline and, although it may have implications for other disciplines, is often ignored but is critical for developers, users of CPD activities, and policy makers. Little evidence compares CPD methods, making it difficult to understand how best to enhance professional development. For example, what methods yield the greatest benefit for improved quality of care? In what contexts? How much interactive learning is necessary? How much feedback and simulation are called for? Research should be conducted on the utility of these methods individually and their particular circumstances to determine the best mix to produce changes in health professional performance, thereby improving patient outcomes. This research is necessary to better understand how resources should best be spent and includes explorations of the lifelong learning process. Strong research requires the development and validation of measurement and evaluation instruments. Current research methods are not necessarily appropriate for addressing the highest-priority research questions; CPD research methods should incorporate methods from the social sciences, in addition to the more traditional clinical sciences. In health services research, qualitative methods in particular are poorly understood and poorly employed, limiting the
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Redesigning Continuing Education in the Health Professions ability to explain randomized trials and systematic reviews. Some of this limitation may be due to the diversity of researchers and research paradigms, as well as the paucity of opportunities to train those who conduct research about CPD for the health professions. It is necessary to define and explicitly describe the specific relationships among variables that explain the success or failure of CPD to achieve the desired health outcomes. It is also necessary to associate explicitly the variety of measures useful to assess whether outcomes have been achieved. In this case, the term health outcomes includes the individual, systems, and population levels. For the individual clinician, enhanced knowledge and skills must be assessed to ascertain whether he is not only learning the necessary information to maintain and improve competence, but also allowing this information to inform practice. This leads to a second type of outcome—performance measures on clinical outcomes, such as treatment efficacy and disease prevention. On a systems level, data on equitable treatment should be collected to ensure that all subpopulations—including racial and ethnic, gender, age, and community—are receiving the best possible care. Systems outcomes must also be evaluated, such as resource management; cost effectiveness; patient safety; and reduction of overuse, misuse, and underuse of services. Finally, the effects of planned change (e.g., process mandates, academic detailing), including regulation, should also be explored, as policies regarding CPD are considered. The CPD system should continuously be evaluated to ensure that it meets its goals of improving quality and patient safety. Many gaps exist in the current literature, highlighting the incomplete nature of the current research system. Research in the above suggested areas and criteria would provide guidance for how to better invest resources and will facilitate future evaluations of CPD. It will also be important to train researchers to use appropriate research methods. To this end, the research workforce needs to be better prepared and provide incentives to develop the research capacity to adequately study the identified research areas. Innovative methods require testing for effectiveness before being broadly disseminated. Newer, innovative CPD methods should be tested through demonstration programs. For example, learning portfolios can be used across professions to improve the learning process, but the effectiveness of learning portfolios in this capacity must be assessed before investments are made to use them to track the performance of health professionals widely. Demonstration programs can be developed using the research and development structures currently in place.
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Redesigning Continuing Education in the Health Professions Recommendation 9: Supporting mobilization of research findings to advance health professional performance, agencies that support demonstration programs, such as the Agency for Healthcare Research and Quality and the Health Resources and Services Administration, should collaborate with the institute. EVALUATION Continuing professional development is a complex system involving the collaboration of many stakeholders. To ensure that the system and the Continuing Professional Development Institute are functioning properly and progress is being made toward better health professional development, evaluation must be performed continually that is supported by data. Initially, evaluation ought to occur at four levels: individual health professionals, stakeholder organizations, the CPDI, and the overall CPD system. The Council on Data Collection and Dissemination would be helpful in developing strategies for collecting this data. Accountability at each level is critical for success but will require different evaluation metrics. Other levels of evaluation, for example teams and health care systems, ought to be considered upon greater ability to measure effectiveness. Advances or declines in health professional competence are integral to determining how effective the system is. Measures should be developed to evaluate improvement and maintenance of individual health professionals’ competence that might align with higher levels of outcomes that pertain to individual practitioners. Such evaluations could also be reported in ways similar to public reporting of performance measures, holding practitioners responsible for their own learning. It will be important to evaluate the learning methods, context, and outcomes together to further implementation and dissemination. Separate evaluations are also needed of stakeholders, allowing for the specific diagnosis of particular parts of the CPD system, in their given contexts. This includes researchers, CPD providers, regulatory bodies, employers, and payers. These entities would be assessed based on individually identified measures, offering health professionals support in providing cost-effective, conflict-free learning activities to enhance quality care. The CPDI would not necessarily perform the evaluations but would instead hold others accountable for assessing the effectiveness of the components of the CPD system in a timely manner.
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Redesigning Continuing Education in the Health Professions The CPDI itself should also be assessed periodically by an external evaluator. Each of its four main areas should have specific goals and metrics for evaluation. The CPDI should also be held accountable to measures of its relationships with stakeholders, operation of councils and ad hoc committees, and accomplishment of the research agenda. Arguably the most important but most difficult level of evaluation is that of the overall system of CPD. The CPDI should be held accountable by the public for its activities and stewardship of the CPD system, through provision of periodic reports to the Secretary. Reports about the state of CPD would begin after 2-5 years to allow for the start of the CPDI. This would be analogous to Medicare Payment Advisory Commission (MedPAC) reports, which advise the public on the state of Medicare payments and the Congress on how to continuously improve the payment system. Recommendation 10: The Continuing Professional Development Institute should report annually to its public and private stakeholders and should hold a national symposium on the performance and progress of professional development education and its role in enhancing quality and patient safety. HOW WILL WE KNOW WHEN WE GET THERE? It will be necessary for the CPDI to evaluate its progress continuously so that it can adjust its approaches to enhance health professionals’ learning. It will also be necessary to know when the system has achieved its end goals of serving health care professionals, their employers, and payers. An ideal system should also foster functional team-based care, be learner-driven, decrease costs, and improve health outcomes. Interim measures toward these goals will need to be developed to continuously evaluate the CPD system. For example, measures to evaluate the CPD system and the micro-, meso-, and macrosystems could be used to hold the overall system accountable. Tracking advances in the literature and regulatory changes are relatively simple ways to gauge progress and should be considered. Efforts to collect data at the levels of individual professionals, organizations, and professions to determine whether these goals have been successfully achieved should be led by the Council on Data Collection and Dissemination. To this end, the CPDI should foster a learning system, constantly building on its own successes and failures.
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Redesigning Continuing Education in the Health Professions CONSEQUENCES OF INACTION A well-educated workforce is necessary for improving health care. But despite the long period of professional training and the nature of today’s information-rich health care environment, it remains unclear whether health professionals are effectively and efficiently learning in ways that maintain minimum levels of competence and help improve performance. During the past 30 years, research shows limited effects of continuing education in applied learning opportunities. This must change toward a system that more definitively asserts the value and effectiveness of learning in health care. The status quo is unacceptable; poor quality of care continues to threaten patient safety, further fragment the system, and potentially increase waste. Inaction would signify society’s unwillingness to support health professional development to systematically improve quality and patient safety in a timely manner. The root of the problem lies with the culture and environment in which health professionals practice, inhibiting them from providing the best possible care. Although difficult, change is possible and needs to overcome the many challenges facing CPD. Reform is needed to provide health professionals with the capacity to perform to their highest potential. The CPD system needs to be coordinated and harmonized, but cannot and will not be without a central convener. With cooperation and central coordination, clinicians can continuously and systemically improve, raising their levels of knowledge and competence in the care of patients by functional teams. Action must result in the advances needed to assure the public of the health care workforce’s ability to provide high quality, safe care. REFERENCES ABMS (American Board of Medical Specialties). 2009. ABMS maintenance of certification. http://abms.org/Maintenance_of_Certification/ABMS_MOC.aspx (accessed April 23, 2009). ACCME (Accreditation Council on Continuing Medical Education). 2009. Joint accreditation for the provider of continuing education for the healthcare team. http://www.accme.org/index.cfm/fa/news.detail/News/.cfm/news_id/a71d122c-0a8145c1-ad90-b71af47739c3.cfm (accessed April 15, 2009). EPOC (Effective Practice and Organisation of Care). 2009. Priority topics. http://epocoslo.cochrane.org/en/publications.html (accessed April 24, 2009). FSMB (Federation of State Medical Boards). 2008. Special Committee on Maintenance of Licensure draft report on maintenance of licensure. http://www.fsmb.org/pdf/Special_Committee_MOL_Draft_Report_February2008.pdf (accessed July 30, 2009).
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Redesigning Continuing Education in the Health Professions HRSA (Health Resources and Services Administration). 2005. Strategic plan FY 2005-2010: Goal #2—Improve health outcomes. Rockville, MD: U.S. Department of Health and Human Services, HRSA. ———. 2009. About HRSA. http://www.hrsa.gov/about/default.htm (accessed April 17, 2009). IOM (Institute of Medicine). 2003. Health professions education: A bridge to quality. Washington, DC: The National Academies Press. Nelson, E. C., P. B. Batalden, and M. M. Godfrey, eds. 2007. Quality by design: A clinical microsystems approach. 1st ed. San Francisco, CA: Jossey-Bass. NPP (National Priorities Partnership). 2008. National priorities and goals: Executive summary. Washington, DC: National Quality Forum. Slutsky, J., D. Atkins, and S. Chang. 2008. Comparing medical interventions: AHRQ and the effective health care program. In Methods guide for comparative effectiveness reviews. Edited by the Agency for Healthcare Research and Quality. Rockville, MD. Whitlock, E. P., S. A. Lopez, S. Chang, M. Helfand, M. Eder, and N. Floyd. 2009. Identifying, selecting, and refining topics. In Methods guide for comparative effectiveness reviews. Edited by the Agency for Healthcare Research and Quality. Rockville, MD.