Last spring, (then) AAFP President Michael Munger, M.D., of Overland Park, Kan., urged family physicians to respond to a survey the American Board of Medical Specialties (ABMS) and its 24 member boards fielded as part of an ongoing initiative(visioninitiative.org) to examine the current system of continuing board certification and determine whether and how that process might need to change going forward.
"It's no secret that many family physicians have strongly held beliefs about the current process of continuing board certification," Munger said at the time. "For those who want to see changes in the continuing certification process that would ensure its relevance for physicians and value for patients, this is the perfect opportunity to offer your critical assessment and constructive ideas to help in this important work."
On Dec. 11, the Continuing Board Certification: Vision for the Future (The Vision Initiative) Commission released a draft report(visioninitiative.org) of its findings and recommendations and is inviting further public comment.(visioninitiative.org)
Vision Initiative Background
The commission sought to cast a wide net when gathering input, basing its work on extensive written and oral testimony, as well as existing data, peer-reviewed medical literature, stakeholder surveys, public focus groups, and other resources. The AAFP provided both written and oral testimony that
- pinpointed the need for physicians to be recognized as key stakeholders in the continuing certification process;
- insisted that the process must be meaningful and aligned with clinical practice and, most importantly;
- stated that continuing certification must never be used as the sole or a threshold criterion for employment, credentialing, privileging or payer participation.
- The Continuing Board Certification: Vision for the Future Commission convened by the American Board of Medical Specialties has released a draft report of its findings and recommendations.
- Physicians of all specialties and other stakeholders are invited to comment on the draft report.
- The commission will submit the final report to the ABMS and its member boards for implementation as appropriate.
Judging from what the commission has pulled together in its draft report, those comments have borne fruit.
To generate a conceptual framework on which to base recommendations about a future model of continuing certification, commission members first deliberated and agreed on a purpose statement to support their efforts:
"The purpose of continuing certification is to serve the diplomates, the public and the profession by providing a system that supports the ongoing commitment of diplomates to provide safe, high-quality, patient-centered care. Through participating, diplomates meet specialty continuing certification standards that reflect their commitment to professionalism, lifelong learning and improved care."
The commission then established guiding principles to use in developing recommendations that reflect the desire to achieve the following objectives:
- Clarify the fact that initial certification and continuing certification have markedly different purposes.
- Reinforce the understanding that diplomates are committed to providing high-quality, patient-centered care.
- Support continuous enhancement of clinical care.
- Extend continuing certification programs beyond the assessment of medical knowledge.
- Provide a level of value to diplomates that ensures that the efforts and costs required to maintain certification are commensurate with the benefits.
- Integrate physician practice data into diplomate assessment.
- Meet the expectation that continuing certification programs result in ABMS boards determining diplomates' continuing certification status.
- Evaluate and improve program effectiveness, with the intended outcome being that physicians enhance their knowledge and skills over time.
Recommendations as Categorized
Finally, the recommendations themselves, along with specific findings to support them, are organized into four overarching areas, as follows:
Expectations for Continuing Certification Programs
- Continuing certification should constitute an integrated program with standards for professionalism, assessment, lifelong learning and practice improvement.
- Continuing certification should incorporate assessments that support diplomate learning and retention, identify knowledge and skill gaps, and help diplomates learn advances in the field.
- ABMS boards should use longitudinal and other innovative assessment methods that collectively contribute to the determination of continuing certification status.
- Continuing certification should use multisource data to assess knowledge. judgment and medical decision-making skills, as well as other professional competencies required to sustain and enhance optimal patient care.
- As new advances in medicine and patient care emerge in clinical practice, the ABMS boards should be encouraged to consider what core knowledge, judgment and skills are needed to be a diplomate in their core specialty or subspecialty and create assessments that are preferentially focused on the content of the diplomate's principal area of practice in that specialty.
- ABMS boards should be encouraged to develop and test innovative approaches to diplomate assessment to ensure that diplomates have integrated these advances into their clinical practice.
- ABMS boards must provide timely and relevant feedback as part of any assessment.
- Continuing certification status should not be withdrawn solely due to substandard performance on a single, infrequent, point-in-time assessment (e.g., every seven- to 10-year examination).
- Professionalism is an important competency for which specialty-developed performance standards for certification must be implemented.
- ABMS boards should develop new and reliable approaches to assessing professionalism and professional standing.
- ABMS boards should have common standards for how licensure actions for professionalism impact continuing certification.
- Standards for learning and practice improvement must expect diplomate participation and meaningful engagement in both lifelong learning and practice improvement. ABMS boards should seek to integrate readily available information from a diplomate's actual clinical practice into any assessment of practice improvement.
- ABMS boards have the responsibility and obligation to change a diplomate's certification status when certification standards are not met.
- ABMS boards must have clearly defined remediation pathways to enable diplomates to meet assessment, learning and practice improvement standards in advance of any loss of certification.
Stakeholders in Continuing Certification
- ABMS boards should collaborate with professional and CME/CPD (continuing professional development) organizations to create a continuing certification system that serves the public while supporting diplomates in their commitments to be better physicians.
- ABMS boards should share aggregated results and trends in knowledge gaps with other specialty organizations to assist in the promulgation of medical advances to result in safe, higher-quality patient care.
- ABMS boards, specialty societies, CME/CPD providers and other organizations should work together on a uniform ABMS data strategy to create seamless transfers of information to ease diplomate burden in reporting what they have done, ensure patient privacy, minimize costs and enable meaningful engagement (e.g., diplomate feedback, gaps in knowledge, registries, etc.).
- ABMS boards should have structured, at least annual, meetings with major specialty/subspecialty organizations to receive input and feedback about initial certification and continuing certification decisions and programs.
- The ABMS boards through the ABMS should engage and communicate, at least annually, with state medical societies and state medical boards to receive input and feedback about initial certification and continuing certification decisions and programs.
- The certificate has value, meaning and purpose in the health care environment.
- Hospitals, health systems, payers and other health care organizations can independently decide what factors are used in credentialing and privileging decisions.
- ABMS must inform these organizations that continuing certification should not be the only criterion used in these decisions and these organizations should use a wide portfolio of criteria in these decisions.
- ABMS must encourage hospitals, health systems, payers and other health care organizations to not deny credentialing or privileging to a physician solely on the basis of certification status.
Research and Evaluation of Continuing Certification
- ABMS and the ABMS boards should collaborate with other organizations to facilitate and encourage independent research that determines
- whether and to what degree continuing certification contributes to diplomates providing safe, high-quality, patient-centered care; and
- which forms of assessment and professional development activities are most effective in helping diplomates maintain and enhance their clinical skills and remain current in their specialties.
- ABMS boards must collectively engage in a regular continuous quality improvement process and improve the effectiveness and efficiency of continuing certification programs.
ABMS Boards' Support of Diplomates
- ABMS boards must comply with all ABMS certification and organizational standards.
- ABMS boards must include diverse diplomate representation for leadership positions and governance membership and require that a supermajority (more than 67 percent) of voting board members be clinically active. ABMS boards should also include at least one public member.
- Continuing certification should be structured to expect diplomate participation on an annual basis.
- ABMS boards must regularly communicate with their diplomates about the standards for the specialty and to foster feedback about the program.
- ABMS boards should have consistent certification processes for the following elements:
- a uniform cycle length before a decision about certification status is determined;
- grace periods (either before or after the certification end date);
- remediation pathways;
- re-entry pathways to regain certification;
- single set of definitions for how certification status is portrayed and communicated to users of the credential, including the public (e.g., certified, participating in continuing certification, probation, revocation, not certified, etc.); and
- appeals processes.
- ABMS boards should facilitate reciprocal longitudinal pathways that enable multispecialty diplomates to remain current in multiple disciplines across ABMS boards without duplication of effort or excessive requirements.
Now, it's time to offer your comments on the work of the commission to date. Physicians have until Jan. 15 to register their views on the draft report.
After comments have been considered and integrated as appropriate, the commission will submit the final report to the ABMS and its member boards. As independent organizations, each member board will consider how best to implement the report's recommendations in a way that will benefit both diplomates and the patients they serve.
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