Implementing Revalidation: the Devil is in the Details IAMRA 2006 Wellington, New Zealand

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Implementing Revalidation the Devil is in the
DetailsIAMRA 2006 Wellington, New Zealand

• David E. Blackmore, Ph.D.
• Medical Council of Canada

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Greetings from Ottawa Canada
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(No Transcript)
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Revalidation of Physicians
Birth - School Training Practice Retirement
- Death
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What problems are being addressed by
Revalidation?

• Declining skills across time.
• Currency of knowledge
• Changing scope of practice
• Change of fitness to practice due to lifestyle or
  health.
• Meet public expectation that ongoing skills are
  linked to ongoing licensure.

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All of which has the potential of translating
into varying problems if not addressed.

• Patient safety issues
• Poor patient outcomes
• Treatment not meeting current best practices
• Inefficiencies
• Higher healthcare costs
• Poorer access to physicians
• A less satisfied patient and public

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Enter Revalidation

• Part of the solution or hindrance to ongoing
  practice?
• Need to maintain a balance.

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Agreement in Principal

• Revalidation is often seen as a process
  whereupon a given professions members
  periodically provide evidence of practice
  competence on condition of remaining licensed.
• Revalidation, in the medical community, is
  advocated and agreed-to-in-principle by
  regulatory authorities (RA) worldwide,
• yet generally remains to-be-implemented
• Why?

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Expectations
When entering practice

• Society expects that people who call themselves
  physicians have the knowledge, skills, and
  attitudes to provide adequate health care to
  their patients.
• Medical schools are reviewed.
• Postgraduate training programs are reviewed.
• Graduates are tested.
• Entrance to the profession is controlled through
  license.
• A lot of time, effort, and resources go into the
  education, training and assessment of physicians
  entering the practice of medicine.

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Expectations during practice

• Physicians will be available to administer their
  craft in order to assess and manage presenting
  patients in accordance to best practices.
  Furthermore, physicians will cause no harm in
  managing their patients problems.
• The public/patients expect physicians to
  demonstrate ongoing competence (just like
  pilots) as a part of licensure.
• Maintenance of competence is a pillar/mandatory
  requirement of self-regulation.
• A professional physician is expected to keep
  abreast of current standards of care.
• Currency of knowledge relates to patient safety
  and good procedural/management outcomes.

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Expectations during practice

• Physicians will be available to administer their
  craft in order to assess and manage presenting
  patients in accordance to best practices.
  Furthermore, the physician will cause no harm in
  managing their patients problems.
• The public/patients expect physicians to
  demonstrate ongoing competence (just like
  pilots) as a part of licensure.
• Maintenance of competence is a pillar/mandatory
  requirement of self-regulation.
• A professional physician is expected to keep
  abreast of current standards of care.
• Currency of knowledge relates to patient safety
  and good procedural/management outcomes.

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Barriers to Implementation Complexity

• Public Expectations
• availability
• best practices
• cause no harm
• ongoing competence
• self-regulation
• standards of care
• good outcomes
• professional
• requirement, etc.

• Environmental Reality
• scope of practice
• variability of knowledge
• variable available resources/knowledge
  translation
• variable requirements to licensure/practice
• time availability
• variable assessment
• accountability, etc.

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Plus Physician Expectations

• Fair
• The process/expectations of revalidation needs to
  be clear, made known to the physician, and use
  fair and standardized measurement instruments.
• Relevant
• The process of revalidation needs to be designed
  to confirm a physicians competence within the
  context of their individual practices.
• Inclusive
• Revalidation needs to apply to all licensed
  physicians, but within their scope of practice.

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physician expectations continued

• Transferable
• Participation in the process of revalidation
  needs to be recognized across certification/regula
  tory authorities within a country/practice
  community i.e., one process for all
  stakeholders.
• Formative
• The process of revalidation needs to provide
  access to relevant CME/CPD i.e., needs to
  accessible and educational.

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Challenges to Implementation

• Agreed definition
• What is it?
• Agreed purpose
• What do with it?
• Agreed methods
• How should it be done?
• Cost
• How should it be paid for?

• Availability of CME/CPD
• Agreed timelines
• Agreed consequences
• Agreed quality assurance measures

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Agreed definition What is in a name?

• Revalidation
• Validation of practice
• Maintenance of competence
• Re-licensure (Relic ensure as offered by MS
  spellchecker)
• CME/CPD
• Maintenance of professional standards
• Recertification

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The Name Sends the Message and Sets the Tone

• Revalidation
• Validation/Monitoring
• Maintenance of Competence
• Re-licensure
• CME/CPD
• Maintenance of professional standards
• Recertification

SUBSET
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Revalidation
However, note the subtle difference

• Literally - To declare valid again
• Does this imply that a person or something that
  was once valid is not currently valid? Hence the
  need for revalidation?
• which is a to substantiate, corroborate, or to
  confirm.

Validation
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Open to interpretation, unless

• You clearly define what it means to you.
• GMC 2004 Draft
• From 1 April 2005 doctors will be required to
  satisfy the GMC, on a regular basis, that they
  are up to date and fit to practise. They will do
  this using evidence derived from their medical
  practice. This process, known as revalidation,
  will be a condition of a doctors continued
  licensure with the GMC.

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A start in Canada at a National
levelProfessional Revalidation of Physicians

• 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.
• Purpose To reaffirm in a framework of
  professional accountability that physicians'
  competence and performance are maintained in
  accordance with professional standards.

Draft Federation of Medical Regulatory
Authorities of Canada (FMRAC)
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The Other Challenges! Need agreement on

• Definition
• Purpose
• Methods
• How should it be done?
• How do you know when it is done?
• How do you know it meets standards?
• Cost
• How should it be paid for?

• Availability of CME/CPD
• Timelines
• Consequences
• Quality assurance measures

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Methods

• How should it be done?
• Linking to Scope of Practice/Community of
  Practice
• Assessment/portfolio/office visit
• Peer, co-worker, patient involvement
• Fitness to practice (Health/Mental/Physical)
• How do you know when it is done?
• How much is enough?
• Self- reflection component?
• How do you know it meets standards?
• Linkage to patient outcomes/ billing
  practices/prescribing habits?
• Do you meet expectations?
• Meets best practice?
• How to set standards?

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Cost

• How should it be paid for?
• By the physicians as a separate fee.
• Through registration/Licensure fees.
• By the Government/Society
• Other?

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CME/CPD

• Availability of CME/CPD
• Can you require it if it is not universally
  available to all physicians?
• Is all CME/CPD the same?
• Can specific topics be mandated?
• How much is enough?
• Does it make a difference to a physicians
  practice.
• How to link to outcomes?

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When should it be done?

• Timelines
• When should it start?
• How often should it occur/cycle?
• Appeals
• Second chances?

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Linkage to Licensure

• Consequences
• Suspended license
• Restricted license
• Loss of license
• Prescribed remedial program/retraining
• Supervised practice

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A good program?

• Quality Assurance Measures
• CME/CPD accredited
• Is it doable? Can a physician complete the
  program without undue hardship to their practice
  or their patients?
• Can it be related to patient care or outcomes?
• Cost effective?
• Accountable to where?

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Need to . . .

• allow the incompetent the opportunity to
  demonstrate their incompetence . . .
• act to control and correct the deficiencies
• link the participation in revalidation to
  licensure and/or practice privileges.

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The Devil is in the Details. Dealing with Reality.

• The challenges are real and will need to be
  addressed in a thoughtful manner in order to
  facilitate the implementation of revalidation in
  the field of medicine.

and remember
Reality is merely an illusion, albeit a very
persistent one. Albert Einstein via John
Norcini
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Ultimate Goal

• Increase patient safety and improve the quality
  of overall healthcare.

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I would like to acknowledge and thank the British
for all the work that they have done in this
area. The world awaits the outcome of your
current efforts to implement revalidation on a
national level.
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Discussion Checklist

• Definition
• Purpose
• Methods
• How should it be done?
• How do you know when it is done.
• How do you know it meets standards
• Cost
• How should it be paid for?

• Availability of CME/CPD
• Timelines
• Consequences
• Quality Assurance Measures

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A man without ethics is a wild beast loosed upon
this world. Albert Camus Let no physician
without ethics practice their art lest their
patients fall victim to the good intentions of a
profession unable to regulate itself.
Validation of a physicians ongoing practice is
important.
Thank you for your attention and
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Thank you Wellington!