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Modifications to PA-C Maintenance Process Under Consideration by the National Commission on Certification of Physician Assistants
Background & Rationale
In 2005, the National Commission on Certification of Physician Assistants (NCCPA), the American Academy of Physician Assistants (AAPA), the Physician Assistant Education Association (PAEA) and the Accreditation Review Commission for Education of the Physician Assistant (ARC-PA) endorsed a document entitled Competencies for the PA Profession that had been developed cooperatively by those four organizations over a two-year period. The purpose of the Competencies document, as noted in its introduction, is "to communicate to the PA profession and the public a set of competencies that all physician assistants regardless of specialty or setting are expected to acquire and maintain throughout their careers." It continues, "This document serves as a map for the individual PA, the physician-PA team and organizations that are committed to promoting the development and maintenance of these professional competencies among physician assistants."
The document describes six categories of areas in which PAs should demonstrate competencies: medical knowledge, patient care, interpersonal and communication skills, professionalism, systems-based practice, and practice-based learning and improvement. The Competencies document is available online at http://www.nccpa.net/PAC/Competencies_home.aspx.
Since the adoption of the Competencies document in 2005, NCCPA has been considering whether and how to incorporate a broader range of the competencies described in that document into the PA certification maintenance process. Over the last several years, we have evaluated a wide range of possibilities, ultimately focusing most closely on the physician certifying boards' implementation of the maintenance of certification (MOC) requirements mandated in 2000 by the American Board of Medical Specialties (ABMS). The ABMS uses a four-part model that includes requirements in the categories of (1) licensure and professional standing, (2) cognitive expertise, (3) lifelong learning and self assessment, and (4) practice performance assessment.
Drawing both from what the physician boards implemented and the lessons they learned during the process, NCCPA's Certification Committee - composed of certified PAs and physicians - finalized its recommendations on the matter. Those recommendations are being shared here and now with organizations and individuals for a public comment period. The feedback received will be considered by the NCCPA Board when it takes action on the recommendations later in 2010.
Changes Under Consideration
To encompass a broader range of competencies in the maintenance of certification process, the Certification Committee is recommending a new MOC process involving two new requirements and an extension of the recertification cycle from six years to 10.
The new 10-year MOC cycle would be divided into two-year increments, just as the six-year cycle is today. Existing CME earning and logging requirements would remain in effect. Additionally, during the first four of the five two-year certification maintenance periods of the 10-year MOC cycle, certified PAs would also be required to complete an approved self-assessment activity and a clinical quality improvement project. As illustrated on the following page, those new components would not be required during the last two-year period, enabling the certified PA to focus on preparation for PANRE.
More on the Self-Assessment Activity Requirement
Self-assessment activities are educational and sometimes experiential learning processes that involve an opportunity to gauge one's knowledge or skills for purposes of identifying the need for further improvement or development. There are many such programs already available to PAs from a variety of sources. For examples of this sort of self-assessment activity, see the following:
Those are only two examples. Staff members from the NCCPA and AAPA have already been in close contact about the identification and development of tools to meet this potential new requirement, and AAPA is actively working to open up new self-assessment opportunities for PAs. We expect new programs to be developed once the new requirements are approved and more specific guidelines about what constitutes an acceptable self-assessment activity are published.
Also, while most if not all of these self-assessment activities are also pre-approved for Category I CME credit, for purposes of the MOC process, such an activity may be used to satisfy the self-assessment requirement or logged for CME credit - but not both.
Why self-assessment? In short, self-assessment allows PAs, through an introspective approach, to select educational activities that meet the needs in their own practice setting and specialty. The goal of this added requirement is that it contributes to a more meaningful and productive investment of time in CME activities and other training opportunities that are directly applicable to each PA's practice.
More on the Clinical Quality Improvement Project (ClinQI)
The first item in the Competencies document under the category of "practice-based learning and improvement" is "Physician assistants are expected to analyze practice experience and perform practice-based improvement activities using a systematic methodology in concert with other members of the health care delivery team." That competency is at the heart of the ClinQI project.
The ClinQI requirement connects PAs with their supervising physician and other members of the health care team to engage in the design, implementation and evaluation of a quality improvement initiative. This project could take many forms. For example, PAs could identify a particular subset of patients and devise and implement a plan to improve a key health indicator or to improve their adherence to a medication regimen. PAs could devise a plan to identify patients who are at-risk for a particular condition earlier or to improve the practice's capacity to serve its patient population. This activity could also focus on developing and evaluating systems to improve patient safety within a practice. Again, those are just a few examples.
Most physicians certified by medical specialty boards are now required to participate in a similar process to maintain their own certification. PAs would be encouraged to partner with their supervising physicians whenever possible so that together the team can satisfy requirements of both certifying bodies with a single project. Other PAs may already be engaging in QI projects in their workplace; those QI activities could be used to satisfy the ClinQI requirement for the MOC process.
What about PAs who are not practicing clinically? In cooperation with others, NCCPA will develop guidelines for an alternative pathway that would allow the non-clinician to demonstrate competencies in locating, appraising, and integrating evidence from scientific studies related to health problems and/or completing an online module through which the PA goes through the process of the ClinQI using sample data and patient profiles.
Prior to the implementation of the ClinQI requirement, NCCPA will provide instruction through a variety of channels - including the Web, teleconferences and presentations at local, regional and national conferences - regarding how to plan, conduct, evaluate and report on a ClinQI project. We will also provide sample project documents. Additionally, when the concept is first introduced to the MOC process, the first ClinQI requirement could be satisfied by participation in an approved training course on the quality improvement process.
At the end of a ClinQI project, PAs may be required to submit documentation developed during the process or to answer a short series of questions about the project online. However, it is the act of participating in the ClinQI project - not the project's actual outcome - that satisfies the NCCPA requirement.
More on the Extension to a 10-Year Recertification Cycle
The new MOC requirements transform the process of maintaining certification into a much more active, robust process that encompasses a much greater breadth of competencies than are covered by the current CME-and-exam process. Furthermore, the self-assessment activities and ClinQI projects position the PA for a more active ongoing learning and improvement process. With that in mind, the NCCPA Certification Committee believes it appropriate to extend the length of time between exams.
In considering this recommendation, NCCPA worked with AAPA staff to assess its potential impact on or conflicts with current state PA practice laws and regulations. Three states reference a six-year retesting requirement for PAs:
- Michigan requires PAs who have lost their license and are seeking reinstatement to have passed an NCCPA exam within the last six years;
- Arizona requires PAs seeking initial licensure in the state to have passed an NCCPA exam within the last six years; and
- North Dakota's licensure requirements require retesting every six years for all licensed PAs.
If the cycle is extended to 10 years, NCCPA would work with appropriate parties to petition those states for revision to those administrative codes to reflect the new recertification interval. If those efforts were unsuccessful, PAs who needed to continue to test every six years to satisfy licensing requirements would be permitted to do so.
Practical Matters
These changes would be implemented a few years following their finalization and approval by the NCCPA Board. NCCPA is committed to developing these new processes and the systems to support them in a way that minimizes cost and maximizes efficiency and service; the new fee structure, once determined, will reflect that commitment.
Next Steps
We believe that these new requirements will make a positive impact on PA practice and on patient care. We also believe that this more robust process is a better reflection of the significant role PAs fulfill on the health care team. That said, before finalizing these changes, NCCPA is reaching out to a number of organizations and to all certified PAs for feedback. If you support the changes, we want to hear your reasons. If you don't, we invite you to help us refine and improve the proposed concepts. While ultimately the NCCPA Board will make decisions on these concepts with the public's interest foremost in mind, we would also like the benefit of the wisdom and ideas from those invited to participate in this comment process.
State medical boards are asked to submit comments to Lisa Robin, senior vice president of FSMB Advocacy and Member Services, to lrobin@fsmb.org by March 15, 2010. The FSMB will compile comments from state medical boards and forward them to the NCCPA.
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