PHYSICIAN REVALIDATION IN THE GREAT WHITE NORTH

1. PHYSICIAN REVALIDATION IN THE GREAT WHITE NORTH Daniel Klass MD College of Physicians and Surgeons of Ontario, Member, FMRAC Revalidation Working Group

2. 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

3. 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?

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

6. Ballistic (Attributional) Model of Competence “Once in good for life…?” ? Changing standards

7. ‘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

8. The decline of competence Performance

9. 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

10. Push and Pull for changing philosophy • Push…societal (including professional) demands for improving the quality and safety of medical care (large forces in Can/US) “Are we getting our money’s worth and why is health care so arbitrary and risky?” • Pull…realization that ‘Boards’ are struggling in the attempt to detect and punish few doctors, with little effect on overall quality…can competence be assured in other ways?

11. 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

12. Shift in regulatory focus towards QI • The work of doctor’s 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

13. 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

14. The regulatory context • Are there clues in “how we got here” about how to move forward?

15. 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

16. 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

17. 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?

18. US-Can Comparison; Regulation of Practice ( SMB’s vs RA’s) • 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

19. Who We Are Registers and Regulates Ontario’s 26,000 Physicians

20. Ontario Background to Revalidation • Central professional notion of self regulation of competence…seems a Canadian preoccupation • 1995 CPSO Council articulated a “preventive” vision of regulation • Replace old focus of RA’s on “getting to competence” and the “bad apple” approach • Rejection of idea of “once in, good for life” • new focus of RA’s in “maintaining competence”

21. 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

22. What has the chain of events been on the Canadian scene?

23. FMRAC Revalidation (relicensure) Process, initial developments • 1990- Canadian RA’s, 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

24. “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)

25. 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

26. 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”

27. 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

28. Statement of Purpose “to reaffirm in a framework of professional accountability that a physician’s competence and performance* are maintained in accordance with professional standards” (*i.e. their abilities and their actual work)

29. ‘Satisfactory’ Evidence Means… • Evidence that the individual has completed an accreditedpractice-based CPD program • assertion of competence in practice based on educational activity...programs of CCFP and RCPS and/or…. • Evidence from the individual’s 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

30. Principles of Revalidation

31. 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

32. 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)

33. 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”

34. 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

35. 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

36. 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

37. 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 MD’s, patients, organizations and systems in maintaining competence? (P4EP?)

38. Additional Challenge Will thinking in this frame of reference stimulate a research agenda…so that we can stick to the target of evidence based education at the CPD system level?

39. 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

42. 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”