PHYSICIAN REVALIDATION IN THE GREAT WHITE NORTH

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PHYSICIAN REVALIDATION IN THE GREAT WHITE NORTH

• Daniel Klass MD
• College of Physicians and Surgeons of Ontario,
• Member, FMRAC Revalidation Working Group

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FMRAC Draft Definition of Revalidation

• A quality assurance process in which members of
  a profession regularly provide satisfactory
  evidence of their commitment to continued
  competence in their practice as a condition of
  remaining licensed
• i.e. educational, quality improvement, formative

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Objectives for SACME 2007

• The theory of maintenance of competence
• The case for CPD as a requirement of practice
• Implementing the last phase of Flexner
  innovations, 100 years later
• Summary of regulatory context US and Canada
• What are the principle events and elements of the
  Canadian revalidation plan?
• The Canadian players licensure and education
• Are there some challenges here?

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• Where do these ideas come from?
• ? A changing view of competence?

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Ballistic (Attributional) Model of Competence
Once in good for life?
? Changing standards
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Normal (Situational) trajectory of competence

• Medicine practiced one patient at a time
• Competence depends on encounters between
• physicians and
• partners with
• patients who have
• problems in
• places

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The decline of competence
Performance
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The bottom line

• The trajectory can be downward
• But it is not an accident, or the inevitable
  denoument of a ballistic trajectory
• It is the consequence of not adding educational
  energy to the system

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Push and Pull for changing philosophy

• Pushsocietal (including professional) demands
  for improving the quality and safety of medical
  care (large forces in Can/US) Are we getting
  our moneys worth and why is health care so
  arbitrary and risky?
• Pullrealization that Boards are struggling in
  the attempt to detect and punish few doctors,
  with little effect on overall qualitycan
  competence be assured in other ways?

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The need for enhanced regulation of professional
actions

• Wennberg et al physician related variance
  contributes to major differences in health care.
• McGlynn et al (Rand) serious discrepancies
  exist across the country in physician performance
  
• Chaudhry et al (Harvard) decline over time of
  physician competence

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Shift in regulatory focus towards QI

• The work of doctors is important outcome
  effect
• Most are doing a good job, few are doing a bad
  job
• Regulation should stop focusing obsessively on
  the few, and start attending to the many, and
  recognize that All doctors can do a better job
• Need mechanisms to help doctors improve and to
  increase professional accountability i.e. need
  for systematic quality improvement

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Origins of revalidation overview

• Combination of
• Professional commitment to value of continuing
  education and competence
• Public expectation and basis of trust how did
  doctors get where they are as a profession?
• Worldwide movement (zeitgeist) to increase
  accountability for educational values and for
  outcomes examples
• Canada FRCP, CFPC (maintenance of competence)
• US ABMS (recertification), SMBs, AMA CME
  requirement
• UK significant changes in accountability NHS
  commitment to safety and quality

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The regulatory context

• Are there clues in how we got here about how to
  move forward?

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Regulation and system safety
Entry to PG test
Entry to practice test
Admissions Test
Accreditation
Accreditation
?Accreditation?
Training component ENTRY UG
TRAINING PG TRAINING
Practice Component Monitoring, CME, complaints,
suits, discipline
Public Health Outcomes
With apologies to James Reason
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Regulation and system safety
Entry to PG test
Entry to practice test
Admissions Test
Accreditation
Accreditation
?Accreditation?
Training component ENTRY UG
TRAINING PG TRAINING
Practice Component Monitoring, CPD, complaints,
suits, discipline
Public outcomes
With apologies to James Reason
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Linkage of education and licensure

• The culture (post-Flexner) of medical education
  and licensure in North America
• Educational requirements (Specified by RA for
  licensure)
• Accreditation requirements undergraduate (LCME),
  post graduate (RCPS, CFPC, ACGME)
• Assessment requirements (MCC, RCPS, CFPC, ABMS)
• Does this framework make sense when extended to
  post licensure maintenance of competence?

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US-Can Comparison Regulation of Practice ( SMBs
vs RAs)

• Regulatory roots and regimens similar
• Mandate for public interest
• Complaints and discipline
• Management of fitness to practice
• Differences (mainly political/cultural)
• Appointment vs Election of Board Membership
• Funding of activities
• Adoption of educational approach to regulation
• Value of performance vs written assessments

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Who We Are
Registers and Regulates Ontarios 26,000
Physicians
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Ontario Background to Revalidation

• Central professional notion of self regulation of
  competenceseems a Canadian preoccupation
• 1995 CPSO Council articulated a preventive
  vision of regulation
• Replace old focus of RAs on getting to
  competence and the bad apple approach
• Rejection of idea of once in, good for life
• new focus of RAs in maintaining competence

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Origins of revalidation in Ontario overview

• Awareness of changing paradigm of education in
  practice
• Growing recognition of the value of practice
  focused CPD as opposed to traditional hit and
  miss CME (?proximity to Dave Davis?)
• Focus on the doctor in the practice, not the
  doctor who is the practice based on long
  experience of value of formal peer assessment

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• What has the chain of events been on the Canadian
  scene?

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FMRAC Revalidation (relicensure) Process, initial
developments

• 1990- Canadian RAs, CME educators, Specialty
  Colleges created an educational framework, the
  Aylmer process
• Three level continuum of self, external and
  focused educational assessments of practicing
  doctors
• Each RA recognized the value of this educational
  approach to regulation and attempted to address
  some, or all, of these approaches in their own
  way
• At the same time Specialty Colleges developed
  comprehensive MOC programs that are in the same
  framework

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Aylmer Process examples of ongoing developments

• Alberta, then Nova Scotia, developed PAR
  (360) program ( Paul Ramsey to Jocelyn Lockyer
• Quebec and Ontario focused on direct peer
  assessments ( different models)
• RCPS, CFPC developed multi-dimensional MOC
  programs ( based on defined MD Roles (CanMeds/
  FP Principles cf ACGME Principles)

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FMRAC Revalidation (relicensure) Process

• 2004 consensus across Canadian medical licensing
  bodies
• Need for programs to maintain competence in
  practice, linked to licensure
• Specialty College CPD programs provide an
  educational platform for about 80 of doctors
  (remainder TBD), but
• Requirement needs to be universal and accountable
• Provincial LA programs will provide
  accountability steps

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FMRAC Revalidation Process

• 2005-6 FMRAC development of working definition
  and revalidation principles
• Establishment of working group with
  representation of CMA, RCPS, CFPC, AFMC, MCC to
  define program requirements
• Moving toward consensus policy to be adopted and
  implemented by each regulatory authority
• Ongoing reconfiguring of CPD components as
  standards in new educational system, with
  beginning of structure for CPD accreditation

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FMRAC Draft Definition of Revalidation

• A quality assurance process in which members of
  a profession regularly provide satisfactory
  evidence of their commitment to continued
  competence in their practice as a condition of
  remaining licensed
• i.e. educational, quality improvement, formative

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Statement of Purpose

• to reaffirm in a framework of professional
  accountability that a physicians competence and
  performance are maintained in accordance with
  professional standards (i.e. their abilities
  and their actual work)

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Satisfactory Evidence Means

• Evidence that the individual has completed an
  accredited practice-based CPD program
• assertion of competence in practice based on
  educational activity...programs of CCFP and RCPS
  and/or.
• Evidence from the individuals actual practice
  that their performance is up to current standard
• evidence of competence in practice based on
  practice assessment programs of RAs
• Both of these forms of evidence will have audit
  steps for individual and system accountability

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Principles of Revalidation
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Features of revalidation important to the
practicing doctor

• Valid ongoing practice based education is a
  requirement
• Programs will be
• Synergistic, not overlapping among hospital,
  specialty, licensure
• Not onerous in time or resources recognize the
  realities of practice
• Based on and valid for what doctors actually
  do, not academic paper exercises

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Current CPSO Model

• Part A Requirement (Regulation in law pending)
  that all physicians participate in a system of
  accredited CPD either RCPS, CCFP or
  satisfactory accredited alternative(s)
• Part B All physicians subject to a peer audit of
  practice, including their CPD. This assessment
  will serve as the accountability measure for
  individual and system outcome (audit and
  validation)

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Brave new world for CME

• Central idea develop a systems approach to
  continuing professional development
• Integrate into an quality assurance framework
• Currently missing from CPD are
• A governance structure
• elements of accredited educational programs
• standardized performance assessments

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Creating the elements

• Who is to deliver the education?
• Who is to accredit the education?
• Who is to develop the assessments?
• Who is to administer the assessments

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Regulation and system safety
Entry to PG test
Entry to practice test
Admissions Test
Accreditation
Accreditation
?Accreditation?
Training component ENTRY UG
TRAINING PG TRAINING
Practice Component Monitoring, CPD, complaints,
suits, discipline
Public outcomes
With apologies to James Resaon and the
Cheesemakers of America
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Evolving Model
AUDIT/VALIDITY Assessment FMRAC (?CMA, RC, FP,
CMPA, MCC) and Public
ACCREDITATION for Revalidation by AFMC, CMA,
RCPS, CCFP, FMRAC
Level 3
Level 1
Specialty Streams
Scope of practice streams
Level 2
Curriculum design CME programs Curriculum
delivery marketplace and CME programs Individual
program accreditation status quo
Assessment Programs (RA Specific-Aylmer
like) Aggregation of malpractice, complaints, MD
specific outcomes data
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Some healthy challenges

• To create CPD that is standardized requires a
  broad educational approach and needs curricula
• Physicians will no longer hunt for hours
  validity, practice specificity and relevance,
  will become accreditation values
• Will ownership of the agenda for CPD change?
• What will be gained in recognizing that there is
  an actual benefit to MDs, patients,
  organizations and systems in maintaining
  competence? (P4EP?)

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Additional Challenge

• Will thinking in this frame of reference
  stimulate a research agendaso that we can stick
  to the target of evidence based education at the
  CPD system level?

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Crossing the Quality Chasm

• Traditional silos of
• Professional physician MOC and assessment
• Quality improvement processes
• Can they be breached in new paradigm of the
  regulatory system which recognizes the doctor in
  system
• Will this return professional self regulation to
  main stream of medicine

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Rethinking the nature of physician competence

• EFPO project 1988-96 what does the population
  of Ontario expect of their doctors?
• RCPSC CanMeds Roles
• CCFP Principles of Family Medicine
• ACGME/ABMS CompetenciesCommon sets of
  roles/behaviors expected of physicians across all
  specialties in North America
• a common statement of objectives of medical
  professionalism in performance dimensions

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