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Redesigning Continuing Education in the Health Professions REDESIGNING CONTINUING EDUCATION IN THE HEALTH PROFESSIONS Committee on Planning a Continuing Health Care Professional Education Institute Board on Health Care Services INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu
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Redesigning Continuing Education in the Health Professions THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. B08-03 between the National Academy of Sciences and the Josiah Macy, Jr. Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-14078-2 International Standard Book Number-10: 0-309-14078-1 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2010. Redesigning Continuing Education in the Health Professions. Washington, DC: The National Academies Press.
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Redesigning Continuing Education in the Health Professions “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.
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Redesigning Continuing Education in the Health Professions THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org
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Redesigning Continuing Education in the Health Professions COMMITTEE ON PLANNING A CONTINUING HEALTH CARE PROFESSIONAL EDUCATION INSTITUTE GAIL L. WARDEN (Chair), President Emeritus, Henry Ford Health System and Professor of Health Management and Policy at the University of Michigan, School of Public Health, Detroit JAKO S. BURGERS, Harkness Fellow 2008-2009, Harvard School of Public Health, Boston, Massachusetts, and Senior Researcher, Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Nijmegen Medical Centre, The Netherlands LINDA BURNES BOLTON, Vice President and Chief Nursing Officer, Cedars-Sinai Medical Center, Los Angeles, California CATHERINE DEANGELIS, Editor-in-Chief and Senior Vice President, Scientific Publications and Multimedia Applications, JAMA, Chicago, Illinois, and Professor, Johns Hopkins University, School of Medicine, Baltimore, Maryland ROBERT D. FOX, Professor Emeritus of Adult and Higher Education, University of Oklahoma, Norman SHERRY A. GLIED, Professor and Chair, Department of Health Policy and Management, Columbia University, Mailman School of Public Health, New York KENDALL HO, Director, eHealth Strategy Office, Associate Professor, Division of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver EDWARD F. LAWLOR, Dean and William E. Gordon Distinguished Professor, George Warren Brown School of Social Work at Washington University in St. Louis, Missouri DAVID C. LEACH, Former Executive Director, Accreditation Council for Graduate Medical Education, Asheville, North Carolina LUCINDA MAINE, Executive Vice President and Chief Executive Officer (CEO), American Association of Colleges of Pharmacy, Alexandria, Virginia PAUL E. MAZMANIAN, Associate Dean for Continuing Professional Development and Evaluation Studies, School of Medicine, Virginia Commonwealth University, Richmond MICHAEL W. PAINTER, Senior Program Officer, Robert Wood Johnson Foundation, Princeton, New Jersey WENDY RHEAULT, Vice President, Academic Affairs, and Dean, College of Health Professions, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois MARIE E. SINIORIS, President and CEO, National Center for Healthcare Leadership, Chicago, Illinois
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Redesigning Continuing Education in the Health Professions IOM Study Staff SAMANTHA M. CHAO, Study Director BERNADETTE MCFADDEN, Research Associate ADAM SCHICKEDANZ, Mirzayan Science and Technology Policy Fellow1 CASSANDRA CACACE, Senior Program Assistant ROGER C. HERDMAN, Director, Board on Health Care Services 1 Served through May 2009.
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Redesigning Continuing Education in the Health Professions Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: ROBERT B. BARON, University of California, San Francisco PAUL B. BATALDEN, Dartmouth Institute for Health Policy and Clinical Practice RON CERVERO, University of Georgia COLLEEN CONWAY-WELCH, Vanderbilt University School of Nursing THEODORE GANIATS, University of California, San Diego LYNN GERBER, George Mason University RICHARD KRUGMAN, University of Colorado, Denver THOMAS J. MONAHAN, West Sand Lake, NY
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Redesigning Continuing Education in the Health Professions DONALD E. MOORE, JR., Vanderbilt University School of Medicine MARLA E. SALMON, University of Washington School of Nursing MIKE SAXTON, Pfizer, Inc. DAVID N. SUNDWALL, Utah Department of Health DAVID SWANKIN, Citizen Advocacy Center JAMES N. THOMPSON, (former) Federation of State Medical Boards Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by NANCY ADLER, University of California, San Francisco, and SUSANNE STOIBER, Stoiber Health Policy, LLC. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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Redesigning Continuing Education in the Health Professions Preface Continuing education (CE) is the process by which health professionals keep up to date with the latest knowledge and advances in health care. However, the CE “system,” as it is structured today, is so deeply flawed that it cannot properly support the development of health professionals. CE has become structured around health professional participation instead of performance improvement. This has left health professionals unprepared to perform at the highest levels consistently, putting into question whether the public is receiving care of the highest possibly quality and safety. Redesigning Continuing Education in the Health Professions is the result of the work by the Institute of Medicine (IOM) Committee on Planning a Continuing Health Care Professional Education Institute. This report does not recommend specific details about the operations of an institute—instead it illustrates a vision for a better system through a comprehensive approach of continuing professional development and a framework upon which to develop a new, more effective system. The report also offers principles to guide the creation of an institute. Refocusing the lens from CE to a system of continuing professional development supports health professionals in achieving the goal of high quality, safe health care. CE is one of many strategies to strengthen and retool the health care workforce and just one of many pieces necessary to improve health care quality and patient safety. Yet it is a critical piece—one
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Redesigning Continuing Education in the Health Professions that has been overlooked for too long. In the current era of health reform, transformation of CE offers an actionable agenda to begin the alignment of learning with public expectations and the needs of health professionals. I would like to extend my gratitude to the members of the committee for their commitment and dedication in developing a report based on the evidence and sound reasoning. I would also like to thank the many individuals and organizations who contributed their time to provide input to the committee’s deliberations. Finally, I would like to express my appreciation to the IOM, in particular IOM senior staff and Samantha Chao, study director, for their tireless efforts. Gail L. Warden Chair Committee on Planning a Continuing Health Care Professional Education Institute December 2009
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Redesigning Continuing Education in the Health Professions Acknowledgments Many individuals and organizations contributed to this study. Most specifically, the committee and staff would like to thank those experts who testified at the public workshop held on December 11, 2008, and February 12, 2009, in Washington, DC: Cathryn Clary, Pfizer, Inc. Linda Coogle, North American Association of Medical Education and Communication Companies Jeanne Floyd, American Nurses Credentialing Center David Gibson, Association of Schools of Allied Health Professions Dwight Hymans, Association of Social Work Boards John T. James, Patient Safety Advocate Murray Kopelow, Accreditation Council for Continuing Medical Education Patricia Lane, National Black Nurses Association and Inova Fairfax Hospital Michael A. Moore, Danville Regional Medical Center Lisa Robin, Federation of State Medical Boards Mike Saxton, Pfizer, Inc. Rebecca Snead, National Alliance of State Pharmacy Associations David Swankin, Citizen Advocacy Center Peter Vlasses, Accreditation Council for Pharmacy Education
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Redesigning Continuing Education in the Health Professions We would also like to acknowledge the individuals who provided insight and expertise, supporting the committee’s efforts throughout the report process: Karen Adams, National Quality Forum Neese Boston, American Psychological Association Ashley Byrd, American Psychological Association Stephanie J. L. Chambers, National Association of Social Workers Credentialing Center Richard Cole, Federation of Chiropractic Licensing Todd Dorman, Johns Hopkins University Bill Dubbs, American Association for Respiratory Care Martin Eccles, Cochrane Effective Practice and Organisation of Care Group Thomas W. Elwood, Association of Schools of Allied Health Professions Kelly Evans, American Therapeutic Recreation Association Michelle Fiander, Cochrane Effective Practice and Organisation of Care Group Jan Frustaglia, Association of Occupational Health Professionals in Healthcare Marc Goldstein, American Physical Therapy Association MaryAnn Gruden, Association of Occupational Health Professionals in Healthcare Karen M. Hart, American Dental Association Sarah D. Hertfelder, American Occupational Therapy Association Norman Kahn, Council of Medical Specialty Societies Gabrielle Kane, University of Washington Alain D. Mayhew, Cochrane Effective Practice and Organisation of Care Group Kathleen McGovern, Cochrane Effective Practice and Organisation of Care Group Mindi McKenna, American Association of Family Physicians Sherry Merkur, London School of Economics and Political Science Greg J. Neimeyer, American Psychological Association Karen L. Niles, American Speech-Language-Hearing Association Elizabeth J. Paulsen, Cochrane Effective Practice and Organisation of Care Group Laure Perrier, University of Toronto Joan Polancic, American Society for Clinical Laboratory Science
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Redesigning Continuing Education in the Health Professions Kate Regnier, Accreditation Council for Continuing Medical Education Lisa Robin, Federation of State Medical Boards Robert Rogers, Institute for Health Policy, Harvard Medical School Corina Schmidt, American Society of Radiologic Technologists Marcia Segura, American Psychological Association Greg Thomas, American Academy of Physician Assistants Dimitra V. Travlos, Accreditation Council for Pharmacy Education Emma L. Wong, Nuclear Regulatory Commission We extend special thanks to David Blumenthal and Eric Campbell, Institute for Health Policy, Harvard Medical School, and Dave Davis, Association of American Medical Colleges, who were unpaid consultants to the committee in their capacities as grantees of the Josiah Macy, Jr. Foundation. Drs. Blumenthal and Campbell offered support and advice about the financing of continuing education, most specifically about estimating the costs of continuing medical education; Dr. Davis provided guidance on lifelong learning. Many within the Institute of Medicine were helpful to the study staff. The staff would like to thank Susan McCutchen, William McLeod, Janice Mehler, Joi Washington, and Benjamin Wheatley for their time and support to further the committee’s efforts. Finally, the committee would like to thank and recognize the support from George Thibault of the Josiah Macy, Jr. Foundation for sponsoring the study.
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Redesigning Continuing Education in the Health Professions Contents SUMMARY 1 1 CONTINUING PROFESSIONAL DEVELOPMENT: BUILDING AND SUSTAINING A QUALITY WORKFORCE 15 2 SCIENTIFIC FOUNDATIONS OF CONTINUING EDUCATION 29 3 REGULATION AND FINANCING 55 4 MOVING TOWARD A CONTINUING PROFESSIONAL DEVELOPMENT SYSTEM 79 5 ENVISIONING A BETTER SYSTEM OF CONTINUING PROFESSIONAL DEVELOPMENT 93 6 FUNCTION AND STRUCTURE OF A CONTINUING PROFESSIONAL DEVELOPMENT INSTITUTE 115 7 IMPLEMENTATION, RESEARCH, AND EVALUATION 131
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Redesigning Continuing Education in the Health Professions APPENDIXES A LITERATURE REVIEW TABLES 147 B HEALTH PROFESSIONS TABLE 227 C INTERNATIONAL COMPARISON OF CONTINUING EDUCATION AND CONTINUING PROFESSIONAL DEVELOPMENT 233 D CONTINUING EDUCATION IN PROFESSIONAL FIELDS OUTSIDE OF HEALTH CARE 253 E WORKSHOP AGENDA 263 F COMMITTEE MEMBER AND STAFF BIOGRAPHIES 267
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Redesigning Continuing Education in the Health Professions Boxes, Figures, and Tables Summary Box S-1 Statement of Task, 2 Chapter 1 Table 1-1 Comparing Training, Education, and Professional Development, 18 Box 1-1 Statement of Task, 24 Chapter 2 Figures 2-1 Accredited methods of CE by hours of instruction, 32 2-2 Closing the research-practice gaps for health care professionals and continuing education professionals, 37 Tables 2-1 Methods of CE Reported by Social Workers, 33 2-2 Common Approaches to Providing CE, 34 2-3 Examples of e-Learning, 35
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Redesigning Continuing Education in the Health Professions 2-4 Continuum of Outcomes for Planning and Assessing CE Activities, 36 2-5 Overview of Select Theories of Learning, 42 2-6 Theoretical Assumptions of Andragogy: “The Art and Science of Helping Adults Learn,” 44 Chapter 3 Figures 3-1 Average number of annual CE hours for physicians (M.D.s) (top) compared to physical therapists (bottom), 57 3-2 Hours of directly sponsored CME by organization type, 68 3-3 A convergence-of-interest model of commercial support, 74 Tables 3-1 Examples of CME Activities by Category, 58 3-2 Comparison of CE Providers, Activities, Requirements, and Consequences of Failing to Meet Those Requirements in Four Health Professions, 60 3-3 Overview of Current CE Financing in Medicine, 67 3-4 Financial Support of CME for Different Types of Organizations, 2007, 70 Boxes 3-1 History: Development of the ACCME, 64 3-2 Example of Accreditation Criteria, 65 Chapter 4 Table 4-1 Overview of the Alternatives, 82 Chapter 5 Figure 5-1 The continuing professional development cycle and system, 97 Boxes 5-1 CPD: One Surgeon’s Performance and Value, 99 5-2 Examples of Technology-Enabled CPD, 102 5-3 Interprofessional Team-Based Learning and Care, 106 5-4 Example of a Collaborative on Continuing Medical Education, 108
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Redesigning Continuing Education in the Health Professions Chapter 6 Figure 6-1 Suggested process for the development of a CPDI, 124 Boxes 6-1 Trusted Agent Model: Compiling Evidence to Support CPD, 120 6-2 Competencies for Planning Committee Membership, 127 Chapter 7 Table 7-1 Criteria Adopted by Select Organizations, 137 APPENDIX A Tables A-1 Summary of Systematic Reviews on Effectiveness of CE Methods, 150 A-2 Literature Review on the Effectiveness of CE Methods, 166 APPENDIX B Table B-1 Health Care Occupations Identified in the Bureau of Labor Statistics’ Occupational Outlook Handbook 2008-2009, 228 APPENDIX C Tables C-1 Continuing Medical Education—An International Comparison, 236 C-2 Synthesis of Models for Assessing Continuing Competence, 240 C-3 Continuing Dental Education—An International Comparison, 247 C-4 Continuing Pharmaceutical Education—An International Comparison, 249 Boxes C-1 An Integrated System for CE, 243 C-2 The Role of Industry Funding, 245
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