4
Moving Toward a Continuing Professional Development System

In its current state, continuing education (CE) does not help prepare health professionals to provide care that is of consistently high quality and improves patient outcomes. As detailed in the previous chapters, CE faces many problems, including:

  • The science underpinning CE for health professionals is fragmented and underdeveloped. The lack of a strong science base makes it difficult if not impossible for health professionals to identify educational programs best suited to their needs, and the fragmentation of responsibility for research inhibits the establishment of a cohesive research agenda that can identify what works to best support continued learning.

  • The role and value of CE are not uniformly understood. Health professionals who view CE merely as a mechanism for meeting regulatory requirements are missing the opportunity to attain goals of continued learning for improved practice. Regulators and the public also need to understand CE as a tool for improved practice.

  • There is concern about how CE is financed. Of particular controversy is the role of funding from pharmaceutical and medical device companies and the possibility that such funding inherently creates conflicts of interest. Yet the present system has not identified alternative sources to replace dependence on industry financing.



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 79
4 Moving Toward a Continuing Professional Development System I n its current state, continuing education (CE) does not help pre- pare health professionals to provide care that is of consistently high quality and improves patient outcomes. As detailed in the previous chapters, CE faces many problems, including: • The science underpinning CE for health professionals is fragmented and underdeveloped. The lack of a strong sci- ence base makes it difficult if not impossible for health profes- sionals to identify educational programs best suited to their needs, and the fragmentation of responsibility for research inhibits the establishment of a cohesive research agenda that can identify what works to best support continued learning. • The role and value of CE are not uniformly understood. Health professionals who view CE merely as a mechanism for meeting regulatory requirements are missing the opportunity to attain goals of continued learning for improved practice. Regulators and the public also need to understand CE as a tool for improved practice. • There is concern about how CE is financed. Of particular controversy is the role of funding from pharmaceutical and medical device companies and the possibility that such fund- ing inherently creates conflicts of interest. Yet the present sys- tem has not identified alternative sources to replace depen- dence on industry financing. 79

OCR for page 79
80 REDESIGNING CE IN THE HEALTH PROFESSIONS • In many cases, there is no relationship among the key regulatory components of state licensure, certification, cre- dentialing, and accreditation. Current regulatory processes generally exist as separate systems, leading to inconsistency, duplication, and confusion over what is needed to enhance learning. There is also little consensus about how effectively the regulatory processes are functioning. • Licensing requirements are inconsistent across states and professions. The differences among state requirements do not have a scientific basis and thus reflect uncertainty about what amounts and types of CE are necessary, and in what contexts CE should be provided, for professionals to both maintain their competence and improve their practice. • CE lacks an established research agenda and is supported by a disrupted financing system, making accreditation more difficult. • CE currently lacks a patient-based focus, as quality and patient safety are not often well integrated into CE processes. • There is little recognition of the need for a multidisci- plinary approach to CE. Since health care requires collabora- tion among professionals, providing interprofessional educa- tion holds the most promise for better aligning learning with practice needs. In sum, the current approach to CE has serious flaws. There are major gaps in research, regulation, and financing, and the com- ponents of CE are managed by different stakeholders operating in isolation. What is fundamentally needed is a coordinated vision of what an effective continuing professional development (CPD) system for health professions should entail—and the leadership to fulfill such a vision. Many of the components of a comprehensive, broad-based CPD system are spelled out in previous chapters. This chapter will focus on ways to implement such a system. ALTERNATIVES FOR REFORMING CONTINUING EDUCATION In considering the establishment of an institute such as the one proposed in the committee’s statement of task, the committee identified alternative means of improving health professions learn -

OCR for page 79
81 TOWARD A CONTINUING PROFESSIONAL DEVELOPMENT SYSTEM ing and evaluated whether the institute or another alternative was preferable. The committee focused on five alternatives: 1. Maintaining the status quo; 2. Developing a program within an existing government agency; 3. Forming a coalition of stakeholders; 4. Creating a new, private structure of professional societies; and 5. Developing a new, public-private structure. The committee compared the ability of each alternative to achieve change in the following areas: research agenda, regulation, financing, conflict of interest, and interprofessional care (see Table 4-1). The committee also considered the long-term costs of the vari - ous alternatives. Alternative 1: Maintaining the Status Quo Maintaining the status quo would leave CE researchers, provid- ers, funders, regulators, and other stakeholders to address problems facing CE on their own. Some important research topics, such as team-based learning and workplace learning, require a degree of col- laboration that is difficult or impossible to achieve under the status quo. Research on the amounts and types of learning to best improve practitioner performance is also needed and currently is not identi - fied as a responsibility of any one particular group or organization. The fact that regulatory responsibilities for CE vary across juris- dictions and professions will impede necessary collaboration as well. Although some organizations are beginning to explore ways to work together, it remains clear that no central vision or force guides change and stakeholders have no incentive to move away from the status quo. The inconsistency of financing across professions also limits the stability of CE in both the short and long terms. Under the status quo, financing does not support interprofessional learning, point of care learning, and other cross-cutting areas of learning. Moreover, although some policies have been developed recently, CE activities are not free from conflicted sources of funding. There is no mechanism to ensure that continued learning is free from conflicts of interest. In addition, the status quo has limited capacity to promote wide- spread interprofessional learning opportunities. Some efforts exist in

OCR for page 79
82 REDESIGNING CE IN THE HEALTH PROFESSIONS TABLE 4-1 Overview of the Alternatives Core Tasks Alternative Actors Research agenda Regulatory • o • o central Status quo Current N N stakeholders coordinated force to call research for regulatory agenda changes • unding from F potentially conflicted sources • ould • egulation not Program AHRQ C R within existing provide currently within government focused its authority • ensitivity agency investment S in CE about unilateral research and federal action to demonstration change state and projects professional roles • ould W promote close ties to QI • ould • egulation not HRSA C R invest in currently within research and its authority • ensitivity demonstration S projects about unilateral • ould W federal action to promote change state and close ties professional roles to research across education continuum • o central • ould develop Coalition Current N C stakeholders convener voluntary • ould raise and other C regulatory quality-focused money to standards organizations fund specific (e.g., NQF) research areas • ould C provide greater emphasis on QI

OCR for page 79
83 TOWARD A CONTINUING PROFESSIONAL DEVELOPMENT SYSTEM Financing Conflict of interest Interprofessional care • o dedicated funding • ome actions to reduce • o incentives N S N sources COI to promote • 8 percent of funding 5 team-based for CE in medicine interprofessional from pharmaceutical care and medical device companies • ould require • acks authority to • ould promote W L C change in mission make widespread team-based to incorporate other impact on COI interprofessional sources of funding for care CE • istorically unstable H funding • ould require • acks authority to • ddresses W L A change in mission make widespread interprofessional to incorporate other impact on COI education through sources of funding for Titles VII and VIII, CE but inconsistently • ould result in more • ould develop • ould promote C C C consistent funding self-enforced COI interprofessional • ould develop self- C guidelines learning, but enforced financing currently no strong regulations research capacity to do so continued

OCR for page 79
84 REDESIGNING CE IN THE HEALTH PROFESSIONS TABLE 4-1 Continued Core Tasks Alternative Actors Research agenda Regulatory • rofessional • ould directly New structure Societies of P C (private) all health societies fund influence professions own research, certification and although accreditation • ould work with somewhat C limited others to enhance • ould C credentialing and yield more licensure profession- specific research • entral • ould coordinate New structure All deemed C C (public/ necessary agenda with stakeholder private) to improve coordinated efforts to achieve quality/patient priorities better regulatory • overnment/ safety G standards • ould conflict private C foundations with efforts to fund by states, professions, and/ or employers NOTE: AHRQ = Agency for Healthcare Research and Quality; CE = continuing edu - cation; COI = conflicts of interest; HRSA = Health Resources and Services Administra- tion; NQF = National Quality Forum; QI = quality improvement. the private sector through collaboration among some accrediting bodies. The public sector has also made investments through Title VII and Title VIII of the Public Health Service Act, administered by the Health Resources and Services Administration (HRSA), further discussed below. But none of these private or public activities has resulted in documented widespread improvements in health profes- sional practice and patient outcomes, in part due to the inadequacies of the science, regulation, and financing of continuing education. As to long-term costs, an important consideration that will help drive future CE efforts, there is no incentive under the status quo to reduce the costs or resources of CE activities and the overall CE system. In view of the serious shortcomings of the status quo, the com- mittee determined that it would be necessary to move toward some other alternative.

OCR for page 79
85 TOWARD A CONTINUING PROFESSIONAL DEVELOPMENT SYSTEM Financing Conflict of interest Interprofessional care • ould result in more • ould develop • ross-cutting group C C C consistent funding self-enforced COI could convene to • ould develop self- C guidelines set standards enforced financing regulations • ould develop • ould develop • ould promote C C C financing regulations consensus COI interprofessional and more consistent guidelines education funding Alternative 2: Developing a Program Within an Existing Government Agency The two federal agencies the committee considered most closely related to the issues of continuing education for health professionals are the Agency for Healthcare Research and Quality (AHRQ) and HRSA, both within the Department of Health and Human Services. A new program under one of these agencies could be given the authority to encourage collaboration, thereby setting a vision for all current stakeholders. Such a program could, to a degree, also work with current stakeholders to seek expert opinion and contract out some of its functions. The Agency for Healthcare Research and Quality funds research to improve health care quality, safety, efficiency, and effectiveness. Its work includes research on evidence-based practice, develop- ment of guidelines, technology assessments, and comparative

OCR for page 79
86 REDESIGNING CE IN THE HEALTH PROFESSIONS effectiveness—activities that overlap with continuing education. Placing the new program in the agency would explicitly link a research agenda for CPD to quality improvement. Translation from research to practice would also likely become a greater area of investigation, given AHRQ’s past focus on knowledge translation. A program within AHRQ would be a good fit for development of a coordinated research agenda for CPD. AHRQ’s current mission does not include responsibility for coordination or regulation of CPD. It is also not within AHRQ’s current charge to require adoption of strategies to reduce overall costs for private stakeholders. Assignment of these responsibilities to the agency would require action by Congress to establish both the authority and resources for this purpose. It is unlikely that Congress would create this authority in AHRQ, given the substantial vested interests in current arrangements by states, professional societies, and other stakeholders. Alternatively, AHRQ could collaborate or contract with current groups (e.g., Accreditation Council on Con- tinuing Medical Education, National Association of Boards of Phar- macy) to develop a system that would allow it to be involved with regulatory and financing activities. The Health Resources and Services Administration focuses on improving access to culturally competent, high quality health care. Among its activities, HRSA provides grants to reinforce the health care workforce. This includes providing some funds for continuing education and professional development made available through Title VII and Title VIII of the Public Health Service Act. Specific to continuing education, Title VII provides money for the Area Health Education Center program that, among other things, trains health professionals working in underserved populations and local com- munities and supports interprofessional education and training. Title VIII focuses on the nursing workforce and funds some continu- ing education through the Nurse Education, Practice, and Retention Grants program and the Comprehensive Geriatric Education Grants program. HRSA’s capacity to develop and administer a CPD research agenda is promising, given its focus on workforce and experience in postlicensure training through the previously described programs. Placing a CPD program in HRSA would foster greater linkages in research along the entire learning continuum, supporting the notion of lifelong learning. Its work on interprofessional health care also makes it a plausible candidate to guide a new CPD system. However, HRSA does not presently have the authority to address regulation, financing, conflicts of interest, or long-term costs of a

OCR for page 79
87 TOWARD A CONTINUING PROFESSIONAL DEVELOPMENT SYSTEM CPD system. It could be involved in setting and administering a research agenda, but managing a full CPD system would require major changes to the mission of HRSA. In either agency, a new program would benefit from having a system already in place to carry out a research agenda. The pro- gram would need to carefully set priorities and work with current stakeholders to minimize duplication of effort between the private and public sectors. Such a program would need strong leadership and careful planning to fully benefit from the expertise of the cur- rent system. Of particular concern are the preemption of the roles of states and professional associations and the need to greatly expand the agency’s mission. The committee therefore concluded that the government-run alternative would not be able to address the range of problems in the current CE system. Alternative 3: Forming a Coalition The beginnings of this option already may be in place, as some CE stakeholders have joined together for specific professions (e.g., Conjoint Committee on Continuing Medical Education). Groups of this nature could be the basis for building a broader coalition, including organizations whose purposes are to improve health care quality and patient safety, such as the National Committee for Qual- ity Assurance (NCQA) and the National Quality Forum (NQF). This voluntary coalition would extend the current group of stakeholders to include others able to contribute significantly to developing a comprehensive CPD system. Formation of such a coalition would bring CPD more squarely in line with the goal of improving quality and patient safety. With respect to a research agenda, the coalition could raise money to fund specific research priorities and develop a coordinated agenda. Research monies would continue to be raised through private orga- nizations and the government. Regulation of CPD by a coalition of stakeholders could provide an opportunity for stakeholders to work together toward better regulatory standards. More harmonized regulations could be devel- oped through the inherent collaborative work of a coalition. It could strengthen linkages among accreditation, certification, credential - ing, and licensure systems within each profession and across health professions. A coalition could also improve the CPD financing structure. The collaborative nature could result in more consistent funding and generate mechanisms for more focused funding. Identification of

OCR for page 79
88 REDESIGNING CE IN THE HEALTH PROFESSIONS additional sources of financing could also occur due to the broader group of stakeholders. Conflicts of interest could also be addressed by such a coali- tion. For instance, a subgroup could develop financing guidelines to promote conflict-free CPD activities and build on current efforts. However, in this strategy, conflict of interest guidelines would likely be self-enforced. While a coalition would be interprofessional in nature, inter- professional education and development may not be actively sup- ported. Clear goals toward the advancement of interprofessional learning would need to be delineated. Strong leadership would also need to be identified to successfully support such an agenda. Unless interprofessional, team-based learning is set as a high priority goal, it will not be achieved, because the current incentives for a coalition to support it are inadequate to foster widespread change. Although long-term costs could be reduced in this alternative, it is not within a voluntary coalition’s direct ability to reduce costs and resource use unless it is made a specific goal. Each stakeholder would have the option of supporting decreasing costs in the system, but no overarching source of accountability would exist. A coalition has many positive attributes that would make it a reasonable option to develop and spearhead a CPD system, but it may take many years to develop because of the complexity of the status quo. There is no clear authority capable of pulling these groups together. There is also no precedent in this field to support the notion that all groups would agree on similar goals for a CPD system without such an authority. The lack of leadership and incen- tive for these groups to work with one another may dilute the focus of immediately developing a CPD system, leading to more of the same. Because the committee believes that advancing the system in an effective manner will require strong leadership, this alternative was not recommended. Alternative 4: Creating a New, Private Structure In this scenario, the new structure would be operated by profes- sional societies and organizations across all health professions. The professions would collectively base decisions about the develop- ment of a CPD system on their expertise. Supporting the professions would be at the forefront of such a structure. It could collaborate with other stakeholders (e.g., employers, researchers, state boards, funders) to build the remaining infrastructure needed to support a CPD system.

OCR for page 79
89 TOWARD A CONTINUING PROFESSIONAL DEVELOPMENT SYSTEM A research agenda developed by this structure has the capacity to strengthen research on teams and interprofessional care. It would also foster strong ties between the research agenda and profession- als’ practice needs. However, a CPD research agenda developed in such a structure may become subject to the political agendas of each profession, instead of enhancing an interprofessional approach. Orienting a research agenda toward improving quality and patient safety in this alternative would be more difficult to achieve as com - pared to the coalition described in Alternative 3. A private structure managed by professional societies would likely drive greater coordination and standardization in certifica- tion and accreditation, compared with the alternatives of the status quo and a government-operated program. It is also likely that this structure could collaborate with state boards and employers to align with the licensure and credentialing systems. In a structure operated by professional societies, more consistent funding could be developed, and greater coordination among pro- fessions could address concerns about the currently varied financ- ing mechanisms. Conflict of interest guidelines could also be set across the health professions. But without central leadership, these guidelines would be self-enforced without a source of accountability, leaving the integrity of the system in question. Interprofessional care would need to be identified as a priority. Without agreement by all professions, each profession may indeed advocate for itself and not for shared learning environments and team-based care. A private structure would not have the ability or authority to reduce the long-term costs of a CPD system. Stakeholders are all separated without an incentive to promote change. The development of a structure operated by professional soci- eties shares some of the same benefits of the coalition alternative, perhaps the most important being the ability to explicitly seek input of those representing health professionals. (However, the private structure would not engage as many other stakeholders as the coali- tion.) A private structure also would share some of the negative aspects of the coalition, such as lack of leadership to coordinate and align efforts. Without a source of authority to hold the structure accountable, it would be difficult to implement a culture of contin - ued learning. Given the current state, the committee concludes that a private structure formed by the professional societies, like the coalition alternative, does not have an impetus to come together and make an impact in a timely manner.

OCR for page 79
90 REDESIGNING CE IN THE HEALTH PROFESSIONS Alternative 5: Developing a New, Public-Private Structure All of the prior alternatives could lead to improvements in CE. But none strikes a good balance between a collaborative effort going forward and recognizing the role of professional societies and other stakeholders. The committee therefore concluded that a hybrid strategy that yields the benefits of the first four alternatives but is structured to avoid the negatives is needed to make timely progress toward a comprehensive, effective CPD system. A new, public-private structure is just such a hybrid. The goal of such a structure would be to convene and work with the stake- holders, not preempt them. The presumed federal role in a public- private structure would be to convene relevant groups and develop a mechanism to hold them responsible for achieving an aligned set of goals toward creating an improved CPD system. A broad group of stakeholders—including states, the professions, employers of health professionals, and organizations that focus on quality and patient safety—would collectively develop and work toward improving quality and patient safety, while building on their collective exper- tise to create a collaborative culture of CPD. The structure would have the capacity to build a comprehen- sive research agenda and set priorities across all health professions. Similar to the coalition and private structure alternatives, it would have more consistent sources of research funding through a pooled approach. The number of activities sponsored by conflicted sources could also be greatly reduced upon broad adoption of conflict of interest policies. In a public-private structure, current bodies in charge of licen- sure, certification, credentialing, and accreditation would continue in their roles but would also work together to develop better regu- latory standards based on research findings. The goal of such a structure would be to convene and work with the stakeholders, not preempt them. For example, a model could be implemented that would enable states to provide input to the development of regula- tory standards, but each state would retain authority to modify its laws, make any changes to its own regulatory processes, and find the resources needed to institute changes. A process could be estab- lished analogous to the National Association of Insurance Com- missioners, which develops model laws that are then passed to the states to either adopt in their entirety or modify to meet the needs of the local circumstances. These model laws have served to encour- age the collaboration of states on issues surrounding the insurance commissioners’ roles through committees and task forces. Further, organizations that represent the state boards, such as the Federation

OCR for page 79
91 TOWARD A CONTINUING PROFESSIONAL DEVELOPMENT SYSTEM of State Medical Boards and its equivalent bodies, would participate with other regulatory bodies in the development of widely agreed upon standards and goals for CPD. A somewhat analogous organization is the National Quality Forum, a not-for-profit membership organization that convenes stakeholders to endorse measures of health care quality. The NQF was developed by the 1998 President’s Commission on Consumer Protection and Quality in the Health Care Industry. The commission recognized the need to develop standards for measuring health care quality and performance because of the promulgation of numerous highly varied sets of measures, resulting in unreliable data on which to base decisions. The NQF was established with private funding matched by the Department of Health and Human Services to over- see development of measures of health care quality, data collection, and reporting. A structure of councils is used to obtain input from its member stakeholders. This alternative is more complex than the others and would therefore be more complicated to implement. Active participation and acceptance by a wide range of stakeholders would be needed to identify and implement changes. Developing a public-private structure would likely be resource-intensive, although a more coor- dinated CPD system would more efficiently and effectively manage resource utilization in the long term, resulting in a higher-value system compared to a system without such leadership. The committee concludes that with strong leadership, a new public-private partnership is the best alternative to effect change. The committee therefore calls on the federal government to work with current stakeholders and act as the initial convener to stimulate change toward the development of a public-private central body tasked with integrating the key components of CPD. The Secretary of the Department of Health and Human Services should take the lead, but also should coordinate with directors of other government bodies such as the Department of Veterans Affairs and the Depart- ment of Education. Recommendation 1: The Secretary of the Department of Health and Human Services should, as soon as practical, com- mission a planning committee to develop a public-private institute for continuing health professional development. The resulting institute should coordinate and guide efforts to align approaches in the areas of: (a) Content and knowledge of CPD among health professions,

OCR for page 79
92 REDESIGNING CE IN THE HEALTH PROFESSIONS (b) Regulation across states and national CPD providers, (c) Financing of CPD for the purpose of improving profes- sional performance and patient outcomes, and (d) Development and strengthening of a scientific basis for the practice of CPD. The institute, which the IOM committee has called the Continu- ing Professional Development Institute (CPDI), should be designed as a neutral body that promotes and catalyzes collaboration. With the benefit of stakeholder input, dedicated resources, and sufficient time in which to plan and develop a CPDI, a planning committee should be commissioned as soon as determined by the Secretary. CONCLUSION Continuing education is deeply embedded in both the public and private sectors. Of the alternatives the committee considered, only the hybrid public-private structure recognized the tensions and relationships that exist among stakeholders. The committee has no illusion that the CPDI is a perfect option or that generating the continuing financial commitment from the government or private sector stakeholders will be an easy task. But the committee believes that mounting a carefully planned, strong effort to improve continu- ing professional development across health professions is worth the effort and will result in better and safer care for patients.