Recertification: Aligning your options with your purpose

Andrew Dallas, NCCPA

Timothy Muckle, NBCRNA

Chad Buckendahl, Alpine Testing

Overview of Session

• Defining recertification• Purpose

• Program design considerations• Sources of evidence• Methods/strategies for evidence collection• Evaluating evidence

2

Defining recertification

• Continued competency• Enhanced competency• Purpose• Public protection• Knowledge and skill acquisition/refinement• Continuous learning• Credibility of the credential

• Voluntary vs. mandatory credentials

3

Program Design

• Sources of evidence• Continuing education• Committee contributions• Journal articles, book chapters, conference presentations• Retesting

• Methods/strategies for evidence collection• Portfolios• Online repositories, documentation systems

4

Program Design

• Evaluating evidence• Defining review criteria• Determining relative weighting for systems with multiple

measures• Incorporating an audit function• Equivalence of expectations• Aligning expectations with the purpose of your program

5

Andrew D. Dallas, PhDPsychometrician

Recertification of Physician Assistants

• Background on the organization and the profession

• What the NCCPA has done in the past

• Changes the NCCPA has made recently

• Issues/Topics that will affect further changes

Presentation Outline

About NCCPA

• Independent, not-for-profit organization

• Current Mission: To serve the public through exemplary programs that evaluate critical PA competencies and require the pursuit of life-long learning and improvement

• Previous Mission: To ensure that certified PAs meet professional standards of knowledge and skills

• Over 105,000 PAs have been certified since NCCPA was established in 1975

• Physician Assistants are an extremely flexible profession in the healthcare industry.

• Initially set out to be a Primary Care profession (Family & General Practice/Internal Medicine/ General Pediatrics) but now ~70% practice in non-Primary Care specialties.

• Certification is required for initial licensure in all fifty states. (Continued certification required in ~half of the states; however, employers can also mandate continued certification).

A little about Physician Assistants (PAs)

• If 70% of all PAs are in a non-primary care specialty, should there be different expectations for PAs to recertify?

• The majority (if not all) of the changes to recertification have been in an effort to address the specialization of the profession.

One thorny psychometric/practical issue

• The recertification exam

• Equivalency vs. Equal

• All PAs – regardless of specialty – recertify by passing this exam.

PANRE

• Pathway II was one of the first major changes to the recertification process.

• Started in the late 1990s as an alternative to PANRE. PAs could choose Pathway II or PANRE.

• Discontinued in 2010.

• Take home examination and also included requirements for additional professional/educational activities.

• Thought was that specialists would take the Pathway II. (Analysis of the 2006-2010 testing years, showed a rate of 69% non-PC for Pathways II, 61% non-PC for PANRE).

Pathway II

• PANRE changed to include two components: 60% primary care, 40% practice focused. Blueprint is the same for all exams.

• Practice focused component consisted of three options:• Primary Care (more of the same)• Adult Medicine (removed the Pediatrics from the 40% but not the

exam).• Surgery (General Surgery, not necessarily appropriate for

specialized surgery PAs).

• Thus far, Primary Care is still the most popular of the three options.

Practice-focused PANRE

• Recertification occurred every 6 years.

• Recertification exam (PANRE) was one part of the entire recertification effort.

• CME was required every 2 years between PANRE attempts.• Category I CME: 50 hours. (Formally planned activities)• Category II CME: 50 hours. (Self-reported activities)

The [not too distant] Past

• Big changes to the recertification program started in 2014.

• Recertification occurs every 10 years.

• CME is required every 2 years between PANRE attempts• Category I CME : 50 hours • Category II CME : 50 hours• 20 of the Category I hours must be designated as “self-

assessment”(SA-CME) and/or performance improvement CME (PI-CME).

Today

What is Self-Assessment (SA)?

Self-assessment is the process of conducting a systematic review of one’s own performance, knowledge base or skill set for the purpose of improving future performance, expanding knowledge, or honing skills.

Things you know

Things you know you don’t know

Things you don’t know you don’t know

Why Self-Assessment (SA)?

• 2012 study concluded that more than 20% of core information guiding clinical practice is changed within one year based on new evidence or guidelines.

 • Self-assessment makes CME more

meaningful and practical to one’s practice.

• It requires active engagement in the learning process.

• Approved for 20 AAPA Category 1 Self-Assessment CME credits

• 400 clinical vignette based questions 

• Topics derived from the NCCPA Content Blueprint

• Comprehensive explanation of the correct and incorrect answer choices

• A follow up One Step Further question to reinforce the content just tested

• Performance analysis to track strengths and weaknesses

• Cumulative 50% correct to receive credit

• Cost: $79

What is Performance Improvement (PI) CME?

• PI-CME is active learning and the application of learning to improve your practice.

• Three-step process:1. Compare some aspect of practice to national

benchmarks, performance guidelines or other established evidence-based metric or standard.

2. Based on the comparison, develop and implement a plan for improvement in that area.

3. Evaluate the impact of the improvement effort by comparing the results of the original comparison with the new results or outcomes.

What is Performance Improvement (PI) CME?

Put another way, there are three stages for which you can earn CME credit:

Stage A - Identify evidence-based measure and assess practice (5 PI-CME credits)

Stage B - Intervention(s) (5 PI-CME credits) Stage C - Re-measure; document improvement

(5 PI-CME credits) Completing all 3 stages (bonus of 5 PI-CME

credits)

• METRIC is offered by the American Academy of Family Physicians

• Can be completed individually or as group• Cost to PA non-members: $125• Each module = 20 PI-CME credits• Modules available in

• Diabetes• Asthma• Hypertension• Geriatrics

• Additional credential for specialty practitioners.

• Voluntary program, no effect on recertification.

• Must be renewed on a similar 10 year cycle.

CAQs

What Specialties?

• Emergency Medicine

• Cardiovascular & Thoracic Surgery

• Orthopaedic Surgery

• Nephrology

• Psychiatry

Exam Debuted in 2014:

• Pediatrics

• Hospital Medicine

• Further consideration of the issue of specialization.• Is practice-focused PANRE working as we intended it to do

so?

• Empirical analysis of the changes to brand new recertification policies.• Do the new types of CME engender a stronger PA workforce

and better outcomes for patients?

Issues which remain

• Recertification programs should never be written in stone. • The NCCA standards are not specific on what has to exist;

there is room for different models.

• Continued research should help inform decisions made on recertification.

Conclusions

Tim Muckle, PhDDirector, Testing Services

Recertification of Nurse Anesthetists

• A little bit about nurse anesthesia, and • Environment in which the NBCRNA operates• Current recertification requirements• Comprehensive revision resulting in Continued

Professional Certification (CPC) Program• Issues related to testing and psychometrics

Topics

• Advanced practice nurses• Highly critical field• Personality type ‘A’• Highly charged political environment

Nurse Anesthesia

• Current, unrestricted license• Practice requirement – 850 hours• 40 hours continuing education• Affidavits• Fee• Renew every 2 years

• This is has been the recertification model since 1978.

Current Recertification Reqs

Why Change?

So… Why Change?

So…Why Change?

• Changing certification requirements/healthcare trends

• Evolving knowledge and skills• Lifelong learning throughout your career• Technology provides new opportunities• Gain credit for activities nurse anesthetists already

do

Comparisons

Recertification Components

Nurse Anesthetists

(Current)

Anesthesiologist Assistants

AnesthesiologistsCertified Nurse

Midwives

Nurse Practitioners

(AANP)

Nurse Practitioners

(NCC)

Frequency Every 2 years Every 2 years Every 10 years Every 5 yearsEvery 5 years

Every 3 years

Current Licensure

Yes NA Yes Yes Yes Yes

Continuing Education

40 hours 40 hours 350 hours

20 hours 3 Self

Learning Modules

75 hours 15 - 50 hours

Examination NAYes

Every 6 years

Yes7 to 10

of each CycleProposed Optional Yes

Practice 850 hours Not required Yes Not required 1,000 hours Not required

So…Why Change?

According to research conducted by the Citizen Advocacy Center in 2007, consumers:• expect healthcare providers to be competent

throughout their professional careers.• believe that professional regulatory bodies ensure

licensees' competency.

So…Why Change?

• 52% believe being licensed means periodic evaluation and assessment.

• 95% believe healthcare professionals should be required to show up-to-date knowledge as a condition of re-licensure.

• 90% believe it is important for healthcare professionals to be periodically re-evaluated.

• 84% believe healthcare professionals should be evaluated on their qualifications.

Shift to Continuing Competency

• Initial certification is only a start

• Knowledge gained at one point in time is no longer enough

• Competency demonstrated through evidence-based learning and assessment

• Professional growth and development must be lifelong and integrated into practice

• Credentialing organizations and other advanced practice nursing professions have made the change

New and Improved!

CPC Program

• 8 years, comprising two 4-year CPC Cycles

• Class A Credits, Assessed CE

• Class B Credits, Professional Development

• Core Modules

• CPC Examination

• RN Licensure and Active Practice

Class B Credits Professional Development

Core ModulesCPC Examination

Class A Credits Assessed CE

Psychometric Issues

• Class A: Assessed CE• How does NBCRNA influence quality of assessments?• Reliability: 10 questions per credit hour• Quality item writing?

• Competency modules• Require vendors to report assessment data, reliability,

item statistics, item revision and replacement• Cut scores

Examination

• Airway management techniques (28%)• Applied clinical pharmacology (28%)• Human physiology and pathophysiology (28%)• Anesthesia technology and equipment (16%)

Examination – Psychometric Issues

• Pass/Fail is phased in over 20 years• First administration will be “Diagnostic”. • If examinees do not meet “performance standard,”

they do not lose certification, but are required to complete additional CE in identified core areas

Examination – Psychometric Issues

This has implications for:• Test specifications (mainly, length)• Standard setting

Examination – Psychometric Issues

• “The CPC examination is NOT the same examination you took to first become a CRNA.

• Rather, it will be based on “the expert knowledge and clinical judgment gained through practice.”

Examination – Psychometric Issues

• Implications for Item Design• How do we create a test that is:• Distinct in format from certification exam• Clinically applied• Not focused on minutiae and esoteric knowledge

• Clinical simulation?• Items based on clinical scenarios?

Examination – Psychometric Issues

• CPC will be largest testing program• Reconsider item development models• Will test be subject to heightened risk of

compromise?• What’s the right number of items to develop?• Enhance Test Security Practices, P&P• Test security audit