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ProceedingsNational Summit on Regulation of Health Professionals in the 21st Century
Roy Swift: This is an area that gets lots of discussion. Everybody says they believe in it and every health profession should do it. But the question becomes who should do it and how it should be done. Our first speaker is Grady Barnhill. Grady began his psychometric career in 1978 in personnel testing. Three years later he moved into licensure testing with the Georgia State Examining Boards. Here he worked with licensing boards for a variety of professions from architects to optometrists to water well drillers. In 1996 he became Senior Associate for the National Commission on the Certification of Physician Assistants and is now their Director of Psychometrics and Development.
Grady Barnhill: I'm with the National Commission on Certification of Physician Assistants (PAs) and we are the group that does the certifying activities for the physician assistants in our country. Our commission is composed of 12 organizations a lot of which are physician groups, the folks responsible for supervising PA's. We also have groups that are of the PA's; Professional Association of Physician Assistants, the AAPA (American Academy of Physician Assistants); as well as groups that comprise the folks that train PA's. It is a commission and not a federation of state boards. So it's a little different than, for example, the National Council of State Boards of Nursing in that it is not an association of state boards. We do the re-certification activities for the PA's as well as the certification and our certification is required in 49 states. 19 states require our continued certification in order to continue the license, so if you don't continue to keep our certification, then in 19 states you might not be able to continue to have your license.
So we move to the question of designing a re-certification program or continuing competence program. And I want to talk a little bit about the framework. But I think in terms of talking about re-certification programs, it makes sense to talk about who we are certifying and the reasons for that. And to assess that we talk about three different types of practitioners that we deal with.
The first I call "The Angels." Now, these are the groups of practitioners that we would all love to be and we'd all love to have as our doctor or PA. These are the ones that are right on top of the game, reading the journals every night. They are way ahead of the curve in terms of their knowledge. They might sit around and wonder, "How can I be even better?" This is a group of people that, in a lot of ways, we don't have a function in dealing with, because they're already doing so great. I think one of the main things we should try and do is think about how we can not get in their way or not be too burdensome to them. So hopefully the world is populated with angels, but it's probably not.
A lot of people are the "Average Joe." This is a more common group of folks that ask, "well, how can I get by? How can I survive in this fast-paced world? I've got family and kids and social obligations to take care of. I've got to do my practice. Sometimes I have a hard time reading those journals and staying right up with things. I'd like to go to more continuing education, but I can't always schedule it. I'm a little short on money." These are the folks that probably a large group of our practitioners, and I think probably the group that we can do the most good for. For this group a lot of our programs can help shape and structure their existence. Some of the "Average Joe's" actually depend on us, I think, in terms of our requirements. A lot of them perhaps are thinking, "Well, whatever the national folks say is appropriate and is probably what I should do," and they're going to do that.
Then we talked about "The Insects." Now, "The Insects" are the ones we have to really worry about. And I think I could argue that in a lot of ways these are the reason that we all exist, because most of exist, we would say, for a public protection reason. We have a rationale of existence; it's really public protection. And if there aren't insects out there, then in a way perhaps we don't need to exist. So I think it's worth worrying about these people. But these might be folks that would sign up for the continuing education course, go out to Colorado and mostly do the skiing. You know, they might come in at the beginning of this day and sign in. But then they're going to take a coffee break and hit the slopes. They might get those magazines and the journals. And they might look at them and give them to their associate and say, "hey, you know, I'm kind of busy this weekend. Why don't you fill out this little questionnaire at the end here and send it in for me if you don't mind. Don't put your name on it, of course." These are the ones that we're worried about keeping track of. And also today, in today's world, there's a new wrinkle with telepractice and telemedicine: the electronic world. There are even more ways that practitioners can do work-arounds in our system: moving from state to state or practicing in other states electronically. There's a whole new insect I think that we have to worry about too. We talk about the central dilemmas in regulation. We have to balance professional interest versus public protection. And that's something that I think we all struggle with. I won't belabor that too much.
So when we're putting together a re-certification program, we have to worry about a bunch of things. One, we hope that public protection is at the forefront of whatever we're doing. And that's a good thing to keep in mind, because sometimes the professionals are the ones that often get to us with their feedback. A lot of times I think it's hard to have the perspective of the public in mind. What you hear the most from the practitioner? "Oh, this is going to be such a pain. You know, that's not what I want to do." Accessibility is important too. You've got to worry about how the people in Alaska are going to deal with this. Can they get to the education you're requiring or whatever tests that you're requiring. How is the profession going to accept that? That's always a worry. Probably a lot of them work with your professional associations in order to take care of that one. Infrastructure concerns: how is this going to be set up? What forms get sent where and who proc esses those? Are you going to out-source that or do it yourself?
The financial impact is important. How much is it going to cost your practitioners? And the thorny issue of specialization is always a tough one. When the practitioners enter the field they're usually broad based. But all too often they specialize. And that creates challenges for those of us that are doing re-certification testing, for example.
Considerations when you're looking at your programs include whether you have a big screen or a small screen. A big screen is going to be something that the insects can get through. So, for example, we have a continuing medical education category, and we require this for our continued certification, but one of the categories there is a Category Two, which are journals that you read at home. And that's something I would probably call a big screen, because we hope that all the practitioners are doing it themselves, but our process is the big screen. We don't have anyway to catch the people who aren't doing it themselves, or who aren't reading it. A small screen for example, would be a proctored re-certification test. You could have a few insects that could pay somebody to impersonate them and go in and get fake ID's and all that. But I think you're starting to get some very small numbers when you get to that level of effort.
So a bit part of most programs is continuing education. I think it's sort of the cornerstone of most of our programs, what we all do. But there's a lot of controversy as to the value of that continuing education, certainly for the research in continuing medical education. If you look at outcomes research, differences that the patients see or differences in outcomes of their treatment, and look at that with CME, it's not very encouraging. So that's a consideration. A lot of us look at that and think maybe if CME is not the best way to go in terms of keeping current, maybe there's some other steps that we should look at. And I think that's what most of the professions now are doing. So speaking of CME we, like everybody else, have our CME requirements. There's Category One, Category Two. It's probably similar to what a lot of you guys have. Got to have 100 hours for every two years. An example of a smaller screen is the requirement to go in a and sit in on an approved course. That's 40 hours that you've got to have every two years.
We'll talk a little bit on re-registration and re-certification cycle. We have a six-year cycle. Starts with the initial certification exam, just like most folks. Then every two years you have to re-register with us and submit your continuing medical education. Then on that sixth year you have to take a test, or complete an alternative. So our proctored recertification test is called PANRE, the Physician Assistant National Re-certifying Exam, a 300-question multiple-choice exam. This test tends to have more clinically oriented problems than our certification entry level exam. And you go to a site, you'll be signed in, they'll check your ID and they'll take a little digital photo of you. So that's our effort to capture some of the insects on the front end of that. This is the blueprint of our exam. It's broken up by two axis on our matrix. One is Organ Systems like cardiovascular, gastrointestinal, urinary, what you might expect. The other dimension is a taste dimens ion, which has settings like history, physical, health maintenance or clinical therapeutics. This is our alternative. If you don't want to sit for the proctored exam you can do the alternative. You've got nine different categories in. You have to earn 100 points in order to qualify to take the take-home re-certification exam. So you can see that for people who don't want to take a proctored exam this is an attractive alternative. It also is good for folks that are struggling with a specialty area. They feel like they've been in cardiovascular surgery for 20 years and they don't know as much about primary care. So they're worried.
You can get points in as few as two of these categories or in all of them if you want. So it's kind of a nifty little program. What's interesting to me is that the candidates prefer the proctored exam almost two to one over the alternative. And I almost would have expected it to be otherwise. But there's a lot of people that have confidence in their knowledge and they're thinking "I'm just going to go in and get it over with. It's a lot simpler just to show up on one day and take this thing." And so we've seen a ten percent rise in the number of people taking Pathway Two over the past year, but it's not a stampede by any means.
The other thing is a lot of times we've heard about concerns about older practitioners having a harder time on a re-certification exam: the presumption being that they would be more specialized and farther out of school, and so they're not used to that anymore. It's interesting that we've seen that our Pathway Two people. So the Pathway Two and the Three folks actually do better than the Pathway One folks. Part of that probably is restriction in range because all the bad people are perhaps dropping out of the profession. But still it speaks well for the folks that stay in. They do well with our re-certification exam, and in fact do considerably better than the Cycle One people who are taking it for the first time.
Roy Swift: Our next speaker is Anne Paxton. Ms. Paxton is founder, editor and publisher of the Professional Licensing Report on which she has worked for the last 11 years. She has been a columnist for CLEAR News for seven years. Prior to her work on Professional Licensing Report she was a project director for the National Commission for Health Certifying Agencies in Washington, D.C., which conducted a multi-year study of continuing competence. She also worked at the National Center for the Study of Professions, leading a project on public membership on state licensing boards.
Anne Paxton: When I was asked to speak on this issue it did occur to me, in thinking about some of the changes that have taken place in the last decade, that an optical illusion might be a good reference point to start with in looking at continuing competence. It's a drawing of a vase under the coffee cup; the drawing of a vase that, when you start at it, starts to change and become two identical profiles of faces. As you can see, one image defines the other because it's a negative of the other. But it's difficult, and in fact it's impossible to see both of the images at the same time. What is the relationship of this to continuing competence? When we focus on the continuing competence of individuals, it often prevents us from seeing the problems with the systems.
I'd like to touch on some of what is contained in continuing competence particularly looking at England and Ireland, where the professional groups are embroiled in several very vivid controversies, as well as Australia. And then to just shift gears a little bit and look at the two faces of continuing competence that I see emerging from the background of these concerns which have been with us for so many years. When we talk about the continuing competence professionals it's important to distinguish between professionals who are self-employed (usually the situation of physicians) although that is certainly changing, and those who are employees. Because the issues are very different.
It's true that doctors who tended to be self-employed primarily are now becoming much more often the employees of other organizations. In fact about half are now employed by managed care systems, or they get more than 50 percent of their income through some kind of salaried position. So that's a factor that we really didn't have 20 years ago when we were looking at very similar kinds of concerns and debating some of the very same kinds of issues. It's difficult to remember that it's been 30 years since the American Board of Family Practice set up time-limited certificates. But today we still see some of the same debates, many of the same scandals, many of the same levels of controversy. And I have to say the same scarcity of truly proactive, truly preemptive programs to assured continuing competence.
Just looking at England, the British Medical Association has been very concerned about this, and has produced proposals called The Surest Way Forward. Some of these are going to sound strangely familiar because there is a sense of hopefulness that this will finally serve as a solution. It is set up as a system of what they're calling a constant watch on the performance of doctors; in other words, that having a doctor meet a required standard every few years is a waste of resources, and it's open to legal challenges. What they want to do instead is have the doctor's work always under review by senior doctors and managers. And they would have on hand the doctor's record on in-service training and the doctor's achievements compared with other doctors in the same specialty in the form of clinical audit.
The advantage of this, although it's extremely controversial, according to its promoters is the feeling doctors would be spotted at once and could be retrained or disciplined locally. This would be a way of proactively assuring competence rather than resorting to discipline, which tends to be the most common solution.
In Ireland they are debating this same proposal. They have a discussion paper on competence assurance structures, which was put forward. And it was suggested that this would cause a huge shake-up of the medical profession if it was adopted. What it proposes is a scheme under which doctors would be assessed over five-year periods during which they would be required to accumulate 250 points. Sixty percent of the points would be awarded for continuing medical education or continuing professional development. Another one-fifth would be awarded through peer review of competence. And a final 20 percent would be awarded for performance review, because some systematic audit of practice with effective peer comparison would be included, according to the document. And the audit, they stress, must be practical and associated with a strategy to effect change if appropriate. Now, these papers are both controversial, and they have inspired similar concern in Australia where leade rs of physician groups are saying they do need a program of proactive auditing, where they can look at doctors without having to wait for a series of complaints.
One of the reasons this is happening in all three countries is because of the notorious case of Dr. Steve Bolsin. He was a cardiac anesthetist at the Bristol Royal Infirmary in England. He noticed that the hospital had up to three times the death rate for babies having open-heart surgery as other British hospitals. It turned out that operations at the hospital were taking four hours instead of the normal one hour, which resulted in complications that often led to heart failure. Bolsin, however, complained for six years before authorities took any action. Even though today the cardiac surgeons who were involved faced charges of serious professional misconduct, the scandal resulted, of course, because Bolsen was ignored for so long, and in fact was finally hounded out of the country for having broken ranks with his colleagues. So what issue does this raise? The whole questioning of peer review has been a major issue in all three countries, as well as in the United Sta tes. The whole cost of re-certification, according to a recent article by the American Board of Medical Specialties (ABMS), has become a serious issue. The ABMS says it charges doctors between $533 to $1,255 to sit the written examination, and up to $10,500 for a two-day on-site visit. And on-site review of practice has recently been discontinued. So what does that do with the solution of peer review? It does throw it into a certain amount of doubt.
Clearly we still have, after 30 years, more questions than answers. But one trend has become unmistakable in the last few years, and that is the increasing amount of control over working conditions by large organizations and companies. It used to be pharmacists who led the way, who became the employees of large drugstores. Then increasingly it's become other professions as well, for example optometry. This is what I mean by the two faces of continuing competence. While we focus on the legitimate issues of assuring the skills of individual practitioners, it may be very difficult for us to keep our attention focused on what are even more important responsibilities of the health care system itself.
And I think this conflict has crystallized in the case of the nurses that were disciplined by the Medical Board of Massachusetts at Dana Farber Institute. This occurred in January. Probably most of you have heard about this case. It arose in 1995 when a well-known health columnist with the Boston Globe died as a result of overdoses from chemotherapy at Dana Farber Institute. And there was quite a bit of backlash from this incident. The physician who placed the order was suspended for three years. He is now, although he has left the country, eligible for renewal of his licensure. The pharmacists involved were also disciplined. But in January of this year 18 nurses were disciplined by, or discipline was proposed by the Nursing Board, for having followed through on the orders of the physician. This was a fairly dramatic step which really, I think, dramatizes what kinds of issues professionals face when they're being given orders by an organization or the representativ e of that organization, and still having to maintain a sense of professionalism. The public outcry has been extreme. There have been letters from the Massachusetts Nurses Association and many nurses in the state complaining that this is unfair. The Executive Director of the Massachusetts Nurses Association said, "Extensive investigations into this unfortunate incident by the Department of Public Health, the Joint Commission and the hospital itself have found that the cause of the error was the result of a failure of the systems in place at the institution, not the individual nurses involved." Dana Farber has taken full responsibility for this incident, has publicly stated its beliefs that the nurses should not be held accountable for this situation. Difficult for us to accept if we believe in licensing boards' authority and the value of professionalism.
Some suggest that this may come dangerously close to scapegoating. Now, again, I think the role of licensing boards has become so much more difficult because of these changes in the structure of the health care system, the ownership, the control, the management and the place of a licensee.
A notable example of that is the increase in complaints about Rite Aid. In the State of Washington, Rite Aid, the drugstore, is under investigation because of the number of errors in prescription refills and prescription orders. And this has become an issue that pharmacy boards across the country are having to deal with, because increasingly the pharmacists have been asked to meet a work load which is beyond anything they ever would have contemplated 10 years ago. In North Carolina the board tried to do something about this. In many cases they found the drugstore chains were asking pharmacists to fill 200 prescriptions a day; maybe as many as 300 according to some reports. So last July the board proposed a rule requiring that pharmacists be given two rest breaks a day, including their lunch break. Now, to me this reminds me a little bit of the incident in New York when, in a great reform the state adopted the regulation that medical residents should not be required to work more than 80 hours a week. Of course they shouldn't work more than 80 hours a week. Everyone was shocked to find out they were working many hours over that. But excessive pharmacists' workload has been a concern of the board for some time. The board issued a policy in the cases of errors, that there were more than 150 prescriptions per pharmacist per day filled on the day of the errors. And both the pharmacists and the entity that held the permit - that is, the pharmacy - would be cited for possible disciplinary action. I think this is a very constructive approach. But what happened to the board when they tried to propose the work rule limitation was the State Rules Review Commission struck it down last December and said a mandatory break rule overstepped the authority of the board. So that case is under appeal. But I think it raises extremely pertinent issues for anyone who is concerned about protecting patients.
This same issue of speed-up has long been a point around which unions have organized and workers have been concerned. How is this affecting physicians? Recently I read that among these doctors that are working in managed care systems. Here is an example given by Mark Levy, the executive director of a new alliance of doctors that just organized into a union. He said if you make $90,000 as a pediatrician the health maintenance organization might say, "If you see X number of patients I will pay you $90,000, or if you see more than X I will pay you $110,000." This creates a speed-up, or a fast track system. It also means that if you spend extra time with a sicker patient and his family it could come out of your pay. Now, when this happens, will that be an error of management or an error of personnel that we can control through our efforts to assure continuing competence? All of these controversies and debates show that continuing competence dramatizes the identity confl ict of licensees who must maintain their professionalism amid increasingly strong and pressure to compromise. And that's why I believe until we shift our focus from the individual licensee and devote more concern to the ways we can regulate the health care system, then I believe a true assurance of continuing competence will continue to elude us.
Roy Swift: Our next speaker is Dr. Michael J. Reed, who currently serves as Professor of Oral Biology and Dean of the University of Missouri Kansas City School of Dentistry. He has held these positions since 1985. Under his leadership the number of faculty in academic programs has been improved despite shrinking fiscal budgets and increasing operating costs. Dr. Reed earned a doctorate in oral biology and served as an instructor and assistant professor and associate professor. He left SUNY Buffalo in 1979 to serve as a visiting scientist at the University of Florida in Gainesville for one year on a research career development award. In 1980 Dr. Reed accepted the position of Assistant Dean for Research and Educational Programs at the University of Mississippi in Jackson, where he later was promoted to Assistant Dean. In 1985 he assumed his present position as Dean of the University of Missouri Kansas City School of Dentistry. Dr. Reed is a Fellow of the Americ an College of Dentists, the International College of Dentists, the Academy of Dentistry International and Pierre Fauchard Academy. Dr. Reed is also a charter member of the American Association of Oral Biologists.
Michael Reed: As you will see from the program, I am said to be here as a representative of the American Association of Dental Examiners (AADE). Before I describe for you just exactly what that is, I have to say that I'm not a member of that organization and I'm precluded from being so because, like church and state, there's a separation between dental board examiners and educators in most states. And as a result the AADE is made up of state board members from the 50 states of the union plus the U.S. territories. And as a result of that I couldn't be a member of the AADE. I'm a friend of theirs, though, so they're allowing me to speak on their behalf.
The E is for "examiner" as I explained. And that's because the major role of the state boards of dentistry is to examine candidates for licensure, either directly or indirectly. Indirectly by regional boards that are organizations made up of dental examiners that examine candidates for licensure in dentistry on a regional basis. There are four of these regional boards; the Northeast Regional Board, the Central Dental Testing Agency, the Western Regional Board and the Central Regional Testing Agency. And they cover probably up to as many as 40 states in the Union. There are several non-aligned states. Those are states that give their own licensing examination. And among those are California, Alabama, Mississippi, Louisiana, North and South Carolina, and probably one or two others that I don't know about.
On the other hand, the American Association of Dental Schools, is an organization of which I'm a member. And we work and collaborate very closely with the American Association of Dental Examiners, for obvious reasons. The most obvious reason is that every year they test between 3,900 and 4,000 recent graduates from dental school - our graduates from dental school - for a licensure examination. And I think it behooves us to be on the ball and find out what it is that makes the AADE tick and what it is that we can do to make that examination trauma a little less for our students than it has been.
So why am I making this presentation? The first reason, as you will gather from further pieces of my presentation: I'm a founding member of the Committee on Continuing Competency. And the second reason is that all my examiner colleagues right now are out examining my students in different places in the country, and clearly can't afford to be here, as they have the important job of examining our students before admitting them for licensure.
The AADE Executive Council responded directly to the most recent Pew report with a letter to Ed O'Neil with their perceptions of the reports on the recommendations. These are the Executive Council's responses, and not necessarily mine. Basically there are three areas that are of concern to the AADE Executive Council: opposition to any form, federal or state, of oversight advisory committee, or any authority other than their own, relating to policy formulation, board membership or professional mobility across state lines. And they see these issues totally as state's rights issues, and should not be interfered with by the federal government or anyone else who is so inclined.
There is also concern about increasing public membership on state boards. They go on to say, "Generally public member participation is being deemed positive." The AADE, however, has concerns with dilution of professional expertise in both regulatory and discipline areas. A disproportionate number of consumer members on boards may allow movements such as denturism and relaxation of supervision regarding their freedom of practice for dental hygienists to adversely affect the quality of care. Now, for time immemorial dentistry has had a running battle, unfortunately, with dental hygiene and with denturism. And you can see, therefore, why they would take the position on public membership that they do.
The third area is a much more positive response. And that relates to Recommendation Ten, which I will read to you, and then the response of the AADE Executive Council. Recommendation 10 reads, "States should require that their regulated health care practitioners demonstrate their competency in the knowledge, judgment, technical skills and interpersonal skills relevant to their jobs throughout their careers." You're all familiar with that recommendation. The comment from the AADE is that it is prepared to address these concerns and has developed several mechanisms which state boards can utilize regarding competency assurance. And that basically is my stepping stone to the rest of my talk.
In 1991 the AADE had its first meeting of a continued competency committee. This committee was formed of four members of the AADE, of which one was a dental hygienist, two members of ADS, one member from the Academy of General Dentistry, which is an organization representing somewhere between 30,000 and 40,000 general dentists in the country, and a member from the ADA, which has a membership probably of about 100,000.
The committee was instructed by the AADE, AADE General Assembly as follows: "Resolved, that the AADE General Assembly direct the Continuing Competency Committee to develop criteria and mechanisms that might be used in evaluating the ongoing competency of licensees." Note here that the licensees are both dentists and dental hygienists. And the AADE made it clear that they were not going to be directly involved in conducting any of these assessments. We would develop mechanisms and models but were not going to get into the business of examining people for continued competency.
We worked together over a period of several years but didn't meet very often simply because there was little funding. We did receive a grant from the U.S. Department of Health and Human Services which helped us. And each of the organizations having participants in the committee was responsible for paying for their members to attend. So most often we met when we were going to be there anyway for some other reason. And so the budget was often sufficient. We worked hard and developed nine potential models for assessing continued competency in dentistry and dental hygiene. Four of these models used existing vehicles one of which modified an existing vehicle: continuing education. And three were new to the business and consumed a great deal of time and attention.
The four that were already available included state board examinations or regional clinical examinations, the examinations that are being conducted now for entry level dentists entering into the profession trying to acquire their license for the first time. And that's a possible way that we could reexamine on a five- to seven-year basis the competency of dentists. Another mechanism was to re-take Part 2 of the National Dental Boards. There's a national board examination, as there is in medicine, which students are required to take in order to graduate from dental school and be eligible for licensure. And Part 2 is a case-based predominantly clinical examination. So that was another model that could be used.
The Academy of General Dentistry has a fellowship program that requires a certain number of hours of continuing education, which is then examined in a multiple-choice fashion. Several specialty boards in the U.S. have already instituted re-certification examinations for their diplomates, which usually occur on a five-year basis. So that system is already in place. And the Department of Defense and the Veterans Administration have a credentialing process which is quite thorough, which requires all dentists in any of the uniformed services and the VA (including the Public Health Service) to satisfy in order to continue at the rank and with the job that they have in the service. So all those were readily available as possible mechanisms for assessing continued competence. Continuing education without some form of outcomes-assessment is not really effective as far as assessing any form of competency. And as far as continuing competency is concerned, I think it's rather difficult to do so using that ramp. So we suggested a continuing education program that had significant outcome measures with practical components that needed to be demonstrated in the practice by the practitioner, and assessed by a panel of unbiased participants to see the methodology and knowledge they had acquired was indeed applied.
The three areas that were new were case presentations in which, after the scope of a practice had been determined, the candidate would be allowed to present three or four cases demonstrating their scope of practice to a group of examiners who would evaluate those case documentation and models, etc. of the patient and the patient care against a set of standards. The next was an in-office audit in which a group of individuals would go to an office and audit the record, evaluate the managerial aspects of the office, get some input from patients, then again see some completed work by examining patients of the dentist in the practice, or patients of the dental hygienist. And the third area was what we call DISC, which stands for Dental Integrated Simulation Corporation. And they are developing CD-ROM's which can be used for continuing education, for continued competency, or for general education of the dentist. Now, that technology is probably the most exciting technolog y that we have right now in this particular area, because it's possible to use CD-ROM's in this particular instance, or Web-based interactive programs, to assess many aspects of a dentist's competency. Other outcomes of the work of the committee were the determination that continued competency could not be voluntary. And the other was that it would not be grandfathered. And that the mechanism for assessing continued competency would occur on a five to seven-year basis.
So where are we at this point in time? I certainly can offer praise to the AADE for taking on his responsibility. The people who are members of the General Assembly of the AADE, when this began in 1991 are no longer members. So they don't have to reap the rewards or other aspects of this process. And, believe me, as a member of the committee for so many years I sometimes feel that I'm a real pariah among my colleagues, because we don't receive a great deal of support for the activities that we're pursuing.
The AGD, the Academy of General Dentistry, has expressed its opinion of the peer reports in a recent publication of theirs. It's called "Impact," in the newsletter, which is really not extremely positive about the outcomes of the Pew process or the recommendations made. And they don't really consider any other mechanism other than continuing education as a real assessment of performance. And that's because their whole revenue stream is based upon their sponsorship and delivery of continuing education programs.
The ADA, on the other hand, is taking some significant steps. There is a committee that the board of the ADA has recently formed, which is looking into continued competency. And there's a member of that committee here in the audience. The ADA also has a journal called The Journal of the American Dental Association. I'm going to finish by reading a little part of it, which I think sums up some of the ways that the ADA might be engaged in this process. "If you believe outsiders can't force changes in dental practice that are opposed by dentists, think again. Read or ask about the Minnesota Care Law. This legislation requires all dentists who provide dental care to people working for the State of Minnesota also to provide dental care to residents eligible for medical assistance, Medicaid." Originally you have to have 20 percent of your patients who were Medicaid patients before you could participate in the Minnesota program. Now it is 10 percent. "However," he g oes on to say, "can you imagine a federal or state consumer initiative that sends its state employees only to dentists who have passed their continuing competency exam?" So that in a way presents it very clearly just exactly where this issue might be going, and how we all ought to prepare for such an occurrence. But prepare for it in a way in which we as dentists take the leadership role, and not follow some mandate from an oversight committee or federal legislation, which might curtail the best way of doing it.
So really, then, where are we? I think we're on our way. We definitely are on the starting line. I think the AADE did a fine job in approaching this issue in very timely fashion. We're going in the right direction, but believe me the mountain we have to climb is really huge.
Roy Swift: Our next speaker is Rita Storey-Grandgenett. Rita Storey-Grandgenett is a registered dietitian, member of the Commission on Dietetic Registration and Chair of its Competency Assurance panel. Ms. Grandgenett has a Bachelor of Science in Foods and Nutrition from Washington State University, and a Master of Science in Human Nutrition from Cornell University. Her professional experiences greatly assisted the commission in the redesign and communication of its new re-certification process. Her career includes education of dietetic students in sales and marketing of nutrition products, including physicians with ConAgra Frozen Foods in Lincoln, Nebraska. And her current position as Manager of Nutrition Communication at the Kellogg Company in Battle Creek, Michigan. In 1995 Ms. Grandgenett was a recipient of the American Dietetic Association's Medallion Award, one of the highest awards bestowed by the American Dietetic Association, for her contributions to the field of dietetics.
Rita Storey-Grandgenett: As was indicated, I am a registered dietitian, and I'm going to be talking about activities of the Commission on Dietetic Registration (CDR). The Commission on Dietetic Registration is the credentialing agency for the other ADA, the American Dietetic Association and we certify over 65,000 registered dieticians and dietetic technicians. I'm going to be introducing you to what we're calling our "Professional Development Portfolio," and I'll go through and identify the steps in this. We're going to talk about why we created this and how we feel it strengthens our current continuing professional education activities, the role of professional accountability in this model, and some of the lessons we've already learned.
We started our continuing education model, or credentialing actually, in 1969. So actually we've had 30-year experience now with this attempt to improve dietetic certification and then the re-certification process. However, as you all know, times have certainly changed. And so in 1994 we hosted a "Futures Conference." What we are trying to do is create a vision for the whole practice of dietetics as we, of course, go into the famous millennium. So we took a look at dietetics education, getting our students out into the practice; actually taking a look at dietetics practice as it's evolving. And then taking a look at dietetics credentialing.
It was at that time that it was suggested and really mandated that CDR redesign our re-certification system which basically was the classic continuing education model. Because we felt very strongly that we had to be more accountable to the public. And so this is when we embarked on the journey that we are presently on. As you would expect, the issues that came up were identical to the ones that are being espoused by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), other health professions, the public, and the Pew Commission, which is working closely on this whole issue. The ultimate aim, of course, for this re-certification is to protect the nutritional health and welfare of our public by fostering and facilitating life-long learning. And those, we feel, are the key words: fostering and facilitating life-long learning. And so our challenge was the creation of a professional development system whose value is readily apparent to our various customers, the public, the practitioners such as myself, the employers and the regulatory agencies. And they all have different expectations for what we are all about.
Over the past 30 years since 1969 our certification has been based on mandatory continuing education hour reporting; 75 continuing education units per a five-year period. However continuing professional education is certainly more complex than just transferring of this information. And, again, this is what we really attempted to set up in our model. Number one, we need to identify what needs to be learned, use educational methods that optimize specific learning styles, develop the strategies to implement what has been learned, and then transfer this to practice. So what can we do now to improve this effectiveness of this education? This is where we have developed what we're calling the "Professional Development Portfolio." And the whole point of this is to provide a structure to assist practitioners in this development.
Our standards of professional practice, which has been an updated document over time, has tremendous input from practitioners and employers. And we feel that this defines appropriate practice, and again, inherent in this it holds the individual practitioner responsible for continuing competence. So the CDR embraced this philosophy and incorporated this into a lot of the language in our model. I think the keywords here, that continuous learning has to be self-initiated, self-directed and self-evaluated. Our code of ethics goes under revision with time and we feel this provides additional public accountability by teaching and enforcing appropriate ethical performance. One of the statements in the code that supports our model again is that the professional assumes responsibility and accountability for personal competence in practice. Those external factors that are impacting the practice - and obviously a tremendous amount of change is going on in our health care arena at this day which impinges on the practices.
We conduct a learning needs-assessment and have provided a tool in our guide for professionals if they do not have something already in a work setting. There is a listing of a variety of skill sets, and people can go through and identify what seems germane to where they're going and what they need to be doing. We then develop a learning plan and there we will identify if they're going to go after the usual activities: the workshop seminars, self-study, et cetera. But we also have added a number of other activities as well. As far as reading peer review journals, engaging in sponsored independent learning, and also engaging in national or state leadership. And there are definitions to these. But we tried to broaden up those categories so it isn't just the straight conventional activities. These three steps would be done in that very first year. And it's at this point there is a learning plan submitted from the Commission to the national office. And then during the re mainder period of time basically it is implementation of that learning plan where you are seeking those continuing education activities, or other activities that we've designated. At this time you are looking for activities that are specifically germane to those goals and needs that you have identified.
There are forms for every step of this and it is at that point that we will be able to generate aggregate data identifying learning interests, learning needs of our membership. And so we can supply aggregate data on a regional basis to providers of continuing education, so they'll have some clue as to what people are looking for. And that way it will dovetail their offerings to what people are really seeking. Also I can see our commercial entrepreneurs also getting involved in this and developing tools that are germane to what people are looking for. The last one is evaluating the learning outcomes. And, again, this is where the individual takes a good look at what they have done, and then to demonstrate in some manner how they've been able to apply it. Have they given presentations? Have they written material? Have the satisfaction scores from outpatients risen? Some kind of ideally objective information or data that would support that they indeed have improved or enhanced their practice.
And then we go back to the regular plan. And I mentioned the aggregate data already as far as supplying information to them, our providers of continuing education. And again this is kind of for the insects of the group. Again we have built-in triggers. We will do a random audit and then there will be some triggers. Again, they have to be pretty blatant, where people have not sent in an appropriate form; it's not completed, or have not even sent in one. And we're developing at that as we speak.
As you all know, the Commission of Dietetic Registration operates on a national level and takes care of the registration of about 65,000 practitioners. Obviously we also have states now that have different regulations in effect. Forty-one states do recognize dietetic professionals in various ways. Twenty-seven do have licensure boards for dieticians and/or nutritionists. Thirteen have certification and one has registration. Many of these boards do accept the CDR-approved activities for credit. And right now we're attempting to be in communication with the regulatory agencies in the different states to listen to show what we're doing and obviously, given the rationale why we're doing it. And we're pleased that the Ohio Board of Dietetics and Nutrition has taken the lead in accepting the Portfolio as we're developing it and the materials we've developed as a means for re-licensure. We will be hosting another major meeting with representatives from the regulatory board s at our annual meeting, as we did last year, to engage in further discussion of how we can marry and dovetail the two efforts. We're engaged in a pilot test right now to really go after and understand the feelings of our participants, what they gained from it. And all that input will assist us as we develop our forms and our guide. And we'll have a final report in the Fall of next year.
What are the lessons that we have learned? As you can appreciate, we started this in 1995. And you would seek input very early with your membership and your folks and the various customers, employers, etc. And be prepared. We found that we prepared what we call the ten top frequently asked questions sheet, it was a question and answer. And this was a great tool to use as we went out to talk to groups about what the concerns are, what we are hearing. After the first draft many members were very angry, as you can expect. It's change. They demanded "why are you doing this?" "If it ain't broke why are you trying to fix it?" and not understanding the changing climate for health professionals. But now there's great buy-in. Now everyone is down into specifics. We hear "how do I do this?" "When do I do this?" We have sent out mailings and information four times to our membership. And we're honing and refining as we speak. It will become effective with our first wave of new re-certification in the year 2001, and everyone will be implemented in the year 2006.
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