Summary

A workforce of knowledgeable health professionals is critical to the discovery and application of health care practices to prevent disease and promote well-being. Today in the United States, the professional health workforce is not consistently prepared to provide high quality health care and assure patient safety, even as the nation spends more per capita on health care than any other country. The absence of a comprehensive and well-integrated system of continuing education (CE) in the health professions is an important contributing factor to knowledge and performance deficiencies at the individual and system levels.

To be most effective, health professionals at every stage of their careers must continue learning about advances in research and treatment in their fields (and related fields) in order to obtain and maintain up-to-date knowledge and skills in caring for their patients. Many health professionals regularly undertake a variety of efforts to stay up to date, but on a larger scale, the nation’s approach to CE for health professionals fails to support the professions in their efforts to achieve and maintain proficiency.

In one attempt to better understand the possibilities for improving CE, the Josiah Macy, Jr. Foundation convened a conference in 2007 that brought together stakeholders in health care and continuing health professional education. Agreeing that the current state of CE in the United States is inadequate, the stakeholders recommended that a national interprofessional continuing education institute be created and charged with “advancing the science



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Summary A workforce of knowledgeable health professionals is critical to the discovery and application of health care practices to prevent disease and promote well-being. Today in the United States, the professional health workforce is not consistently prepared to provide high quality health care and assure patient safety, even as the nation spends more per capita on health care than any other country. The absence of a comprehensive and well-integrated system of continuing education (CE) in the health professions is an impor- tant contributing factor to knowledge and performance deficiencies at the individual and system levels. To be most effective, health professionals at every stage of their careers must continue learning about advances in research and treat- ment in their fields (and related fields) in order to obtain and main - tain up-to-date knowledge and skills in caring for their patients. Many health professionals regularly undertake a variety of efforts to stay up to date, but on a larger scale, the nation’s approach to CE for health professionals fails to support the professions in their efforts to achieve and maintain proficiency. In one attempt to better understand the possibilities for improv - ing CE, the Josiah Macy, Jr. Foundation convened a conference in 2007 that brought together stakeholders in health care and con - tinuing health professional education. Agreeing that the current state of CE in the United States is inadequate, the stakeholders recommended that a national interprofessional continuing educa- tion institute be created and charged with “advancing the science 1

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2 REDESIGNING CE IN THE HEALTH PROFESSIONS BOX S-1 Statement of Task An ad hoc IOM committee will undertake a review of issues in continu- ing education (CE) of health care professionals that are identified from the literature and from data-gathering meetings with involved parties to improve the quality of care. Based on this review, the committee will consider the establishment of a national interprofessional CE Institute to advance the sci- ence of CE by promoting the discovery and dissemination of more effective methods of educating health professionals over their professional lifetimes, by developing a research enterprise that encourages increased scientific study of CE, by developing mechanisms to assess research applications, by stimulating new approaches to both intra- and interprofessional CE, by being independent and composed of individuals from the various health professions, and by considering financing (both short and long term). of CE.” In response, the foundation asked the Institute of Medicine (IOM) to review issues related to the continuing education of health professionals and to consider the establishment of a national inter- professional institute dedicated to improving CE (see Box S-1). The IOM appointed the Committee on Planning a Continuing Health Care Professional Education Institute. In this report, the committee examines CE for all health professionals,1 explores development of a national continuing education institute, and offers guidance on the establishment and operation of such an institute. In order to add perspective to its deliberations, the committee examined a number of possible alternatives to an institute, and the report describes some of the pros and cons of the various options. The report provides five broad messages: • here are major flaws in the way CE is conducted, financed, T regulated, and evaluated. As a result, the health care work- force is not optimally prepared to provide the highest quality of care to patients or to meet public expectations for quality and safety. • he science underpinning CE for health professionals is T fragmented and underdeveloped. These shortcomings have 1 Health professionals were identified here as those health care practitioners and technical occupations classified by the Bureau of Labor Statistics that require bac - calaureate or higher degrees for licensure.

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3 SUMMARY made it difficult if not impossible to identify effective edu- cational methods and to integrate those methods into coor- dinated, broad-based programs that meet the needs of the diverse range of health professionals. • ontinuing education efforts should bring health profes- C sionals from various disciplines together in carefully tai- lored learning environments. As team-based health care delivery becomes increasingly important, such interprofes- sional efforts will enable participants to learn both individu- ally and as collaborative members of a team, with a common goal of improving patient outcomes. • new, comprehensive vision of professional development A is needed to replace the culture that now envelops continu- ing education in health care. Such a vision will be key in guiding efforts to address flaws in current CE efforts and to ensure that all health professionals engage effectively in a process of lifelong learning aimed squarely at improving patient care and population health. • stablishing a national interprofessional CE institute is a E promising way to foster improvements in CE for health professionals. This report proposes the creation of a public- private entity that involves the full spectrum of stakeholders in health care delivery and continuing education and that is charged with developing and overseeing comprehensive change in the way CE is conducted, financed, regulated, and evaluated. THE CURRENT STATE OF CONTINUING EDUCATION For health professionals, continuing education encompasses the period of learning from postlicensure to career’s end. CE is intended to enable health professionals to keep their knowledge and skills up to date, with the ultimate goal of helping health professionals pro- vide the best possible care, improve patient outcomes, and protect patient safety. The reality of continuing education, however, is far different. Although there are instances of programs focused on those goals, on an overarching level the U.S. approach to CE has many flaws: • ealth professionals and their employers tend to focus on H meeting regulatory requirements rather than identifying per- sonal knowledge gaps and finding programs to address them. Many of the regulatory organizations that oversee CE tend

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4 REDESIGNING CE IN THE HEALTH PROFESSIONS not to look beyond setting and enforcing minimal, narrowly defined competencies. • he current approach to CE is most often characterized by T didactic learning methods, such as lectures and seminars; traditional settings, such as auditoriums and classrooms; spe- cific (frequently mandated) intervals; and teacher-driven con- tent that may or may not be relevant to the clinical setting. • E is operated separately in each profession or specialty, with C responsibility dispersed among multiple stakeholders within each of those communities. • he scientific literature offers guidance about general prin- T ciples for CE but provides little specific information about how to best support learning; for the most part, CE provid- ers cannot determine the effectiveness of their instructional methods, and health professionals lack a dependable basis for choosing among CE programs. Further, the inability to draw definitive conclusions about the effectiveness of specific CE methods has clouded discussions about the larger value of continuing education for health professionals. • n medicine and pharmacy—and nursing to some extent— I pharmaceutical and medical device companies have taken a lead role in financing the provision of and research on CE. Such commercial funding has raised and continues to raise concerns about conflicts of interest and whether some com- panies are using CE to influence health professionals so as to increase market share. • egulations vary widely by specialty and by state, as state R boards generally are responsible for determining the num - ber of CE credits required for profession-specific licensure. Certification and credentialing, two other major parts of the regulatory environment, are characterized by wide varia - tions as well. Accreditation of CE providers may be based on an evaluation of the quality of specific CE activities or of CE providers. Such wide variations in CE regulation lead to inconsistent learning and conflict with efforts to achieve high levels of competence and practice for every health professional. TOWARD A SYSTEM OF CONTINUING PROFESSIONAL DEVELOPMENT The hallmarks of a well-prepared health professional have been delineated in several previous IOM reports. Crossing the Quality

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5 SUMMARY Chasm: A New Health System for the 21st Century calls on health pro- fessionals to provide care that is safe, effective, patient-centered, efficient, timely, and equitable. Health Professions Education: A Bridge to Quality recommends that all clinicians possess five core compe- tencies, which include being able to provide patient-centered care, work in interprofessional teams, employ evidence-based practice, apply quality improvement, and utilize informatics. Together, these quality goals represent the foundation for building a better continu - ing education system. Requirements that are based on credit hours rather than outcomes—and that vary by state and profession—are not condu- cive to teaching and maintaining these core competencies aimed at providing quality care. Improving the system for CE will therefore require changes that expand its conventional boundaries. An emerging concept, called continuing professional develop- ment (CPD), includes components of CE but has a broader focus, such as teaching how to identify problems and apply solutions, and allowing health professionals to tailor the learning process, setting, and curriculum to their needs. The principles of CPD already have been adopted in numerous other countries, including the United Kingdom and other members of the European Union, Canada, and New Zealand. Some groups in the United States, including the American Medical Association and the Accreditation Council for Pharmacy Education, also have recognized the broader learning opportunities that CPD offers and have adopted the concept as a guide. In line with such examples, the committee adopted the term CPD to signal the importance of multifaceted, lifelong learning in the lives of all health professionals. In this new vision, a CPD system takes a holistic view of health professionals’ learning, with opportunities stretching from the class- room to the point of care. It shifts control of learning to individual health practitioners and has the flexibility to adapt to the needs of individual clinicians, enabling them to be the architects of their own learning. The system bases its education methods on research theory and findings from a variety of fields, and embraces information technologies to provide professionals with greater opportunities to learn effectively. If coordinated nationally and across the health professions, a CPD system offers the promise of advancing evidence-based, inter- professional, team-based learning; engendering coordination and collaboration among the professions; providing higher quality for a given amount of resources; and leading to improvements in patient health and safety.

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6 REDESIGNING CE IN THE HEALTH PROFESSIONS A NATIONAL CONTINUING PROFESSIONAL DEVELOPMENT SYSTEM The committee ultimately concluded that a continuing profes- sional development institute offered the most promise for redress- ing the flaws in the current approach to CE. But first the committee considered five potential routes for creating an effective system for CPD. 1. Status quo. While some beneficial learning is taking place under the status quo, the flaws documented in this report can- not be remedied by anything short of a coordinated national effort. 2. New program within an existing goernment agency. The com- mittee considered placing responsibility for a national CPD system in either the Agency for Healthcare Research and Quality or the Health Resources and Services Administration, which both fund health care research. Placing responsibility for a national CPD system in one of these agencies would tie CPD to either improved quality or more team-based care. However, a federal program could not as readily incorporate collaborative decision-making, including public and private sector actors, and could also be subject to procedural and/or financial requirements that could diminish its effectiveness. 3. Ad hoc coalition of current stakeholders and organizations. A broad coalition of stakeholders could create a national interprofes- sional CPD system. The committee specifically considered a coalition that includes current stakeholders and organiza- tions whose purposes are to improve health care quality and patient safety (e.g., National Committee for Quality Assur- ance and the National Quality Forum). Expanding to the req- uisite breadth will require a strong central convener; reducing professional and state variability is beyond the ability of such an ad hoc group for the foreseeable future. 4. A priate structure operated by professional societies and organi- zations. Such a structure could include all health professions and develop collaborations with other stakeholders (e.g., employers, researchers, state boards, funders) to build the remaining infrastructure needed to support a CPD system. Two features missing from this approach are an incentive to convene and an oversight body for accountability. 5. A new public-priate structure. Like the purely private struc- ture, a public-private organization could catalyze participa- tion of a broad set of stakeholders in improving health care

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7 SUMMARY quality and patient safety, but it would also be accountable to the federal government. Of the five alternatives, creating a new organization with so many interested parties will be complicated. The committee concluded that alternative 5, establishing a public- private body that would promote collaboration among a variety of stakeholders and be held accountable by the federal government, offers the most promise. By fostering collaboration among diverse groups, it could develop and oversee a comprehensive research agenda that would reach across health professions; it could serve to coordinate current licensure, certification, credentialing, and accredi- tation activities and encourage the groups in charge to work toward regulatory standards for CPD that reflect research findings. Col- lectively, the stakeholders could develop and adopt broad conflict- of-interest policies and identify new and more consistent funding sources for CPD to replace conflicted funding. The committee therefore calls on the federal government to work with stakeholders and act as the initial convener of efforts to develop a public-private institute devoted to improving continuing professional development that will foster the delivery of high qual- ity health care. Recommendation 1: The Secretary of the Department of Health and Human Services should, as soon as practical, com- mission a planning committee to develop a public-private institute for continuing health professional development. The resulting institute should coordinate and guide efforts to align approaches in the areas of: (a) Content and knowledge of CPD among health professions, (b) Regulation across states and national CPD providers, (c) Financing of CPD for the purpose of improving profes- sional performance and patient outcomes, and (d) Development and strengthening of a scientific basis for the practice of CPD. The remainder of this report refers to the proposed public-private institute as the Continuing Professional Development Institute (CPDI). An effective CPD system would offer significant improve- ment over today’s fragmented approach to continuing education. In designing an institute that will accomplish the broad goals of Rec- ommendation 1, the planning committee will need to consider how to achieve each of the components of an effective CPD system.

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8 REDESIGNING CE IN THE HEALTH PROFESSIONS Recommendation 2: To achieve the new vision of a continu- ing professional development system, the planning committee should design an institute that: (a) Creates a new scientific foundation for CPD to enhance health professionals’ ability to provide better care; (b) Develops, collects, analyzes, and disseminates metrics, including process and outcome measures unique to CPD; (c) Encourages development and use of health information technology and emerging electronic health databases as a means to provide feedback on professionals’ and health system performance; (d) Encourages development and sharing of improvement tools (e.g., learning portfolios and assessment resources) and theories of knowledge and practice (e.g., peer review systems for live documentation, such as wikis) across professions; (e) Fosters interprofessional collaboration to create and evalu- ate CPD programs and processes; and (f) Improves the value and cost-effectiveness of CPD delivery and considers ways to relate the outputs of CPD to the quality and safety of the health care system. A central tenet of this report is that collaboration among various stakeholders, including patients and members of the public, is essen- tial to developing an improved CPD system. By working together, the CPD community and the health care quality improvement com- munity will be best able to drive more efficient resource allocation and increase the overall value of CPD. Recommendation 3: The planning committee should design the Continuing Professional Development Institute to work with other entities whose purpose is to improve quality and patient safety by: (a) Collaborating with the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Ser- vices, the Joint Commission, the National Committee for Quality Assurance, the National Quality Forum, and other data measurement, collection, cataloguing, and reporting agencies to evaluate changes in the performance of health professionals and the need for CPD in the improvement of patient care and safety; and (b) Involving patients and consumers in CPD by using patient- reported measures and encouraging transparency to the public about performance of health care professionals.

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9 SUMMARY Advancing the Science of CPD The current body of literature does not conclusively identify the most effective CE methods, the correct mixture of CE methods, or the amount of CE needed to maintain competence or to improve clini - cal outcomes. The literature does offer some guidance for improved learning, suggesting that CE should be guided by needs assess- ments, should be interactive, and should provide multiple learning opportunities and multiple methods of education. Future research needs to include identifying theoretical frame- works, determining proven and innovative CPD methods and the degrees to which they apply in various contexts, defining CPD out - come measures, and determining influences on learning. The fields of adult learning, education, sociology, psychology, organizational change, systems engineering, and knowledge translation can sup- port the advancement of how CPD should be provided. Recommendation 4: The Continuing Professional Develop- ment Institute should lead efforts to improve the underlying scientific foundation of CPD to enhance the knowledge and performance of health professionals and patient outcomes by: (a) Integrating appropriate methods and findings from exist- ing research in a variety of disciplines and professions, (b) Generating research directions that advance understand- ing and application of new CPD solutions to problems associated with patient and population health status, (c) Transforming new knowledge pertinent to CPD into tools and methods for increasing the success of efforts to improve patient health, and (d) Promoting the development of an inventory of measure- ment instruments that can be used to evaluate the effec- tiveness and efficiency of CPD. Collecting and Disseminating Data The data required to assess a health professional’s educational needs, identify effective programs to meet those needs, and evalu- ate CPD programs are derived from a diverse range of professional fields and geographic locations. As a result of gaps in data collection, validation, and analysis, decisions about continuing education and professional development are often not based on evidence. Spe - cifically, data should help determine what effectively influences a health professional’s capacity to deliver high quality health care.

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10 REDESIGNING CE IN THE HEALTH PROFESSIONS Recommendation 5: The Continuing Professional Develop- ment Institute should enhance the collection of data that enable evaluation and assessment of CPD at the individual, team, organizational, system, and national levels. Efforts should include: (a) Relating quality improvement data to CPD, and (b) Collaborating with the Office of the National Coordinator for Health Information Technology in developing national standardized learning portfolios to increase understand- ing of the linkages between educational interventions, skill acquisition, and improvement of patient care. Enhancing the Effectiveness of Regulation The effectiveness of CPD programs is influenced by every aspect of regulation—i.e., the licensure, certification, and credentialing of health professionals and the accreditation of CPD providers. At present, the fragmentation and variation that now characterize the regulatory landscape inhibit development of a system that system - atically improves professionals’ competence and performance across the entire continuum of CPD. Current regulators have the knowledge and expertise to assess learning and continuing education activities. However, their efforts are “siloed” and ineffective in achieving consistently high quality CE. The role of a national interprofessional organization is to pro - mote collaboration across the entire CPD regulatory system, with the ultimate goal of improving health care quality and patient safety. The CPDI should work with current regulatory bodies to establish national standards that can underpin stronger systems. Recommendation 6: The Continuing Professional Develop- ment Institute should work with stakeholders to develop national standards for regulation of CPD. The CPDI should set standards for regulatory bodies across the health professions for licensure, certification, credentialing, and accreditation. Improving Financing Adequate and assured long-term financial support for the Con- tinuing Professional Development Institute and CPD research will be necessary to realize a fully developed CPD system. Although no data exist to project whether the costs of a comprehensive CPD system would be greater or less than the costs of the current system,

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11 SUMMARY the committee’s judgment is that sufficient funding exists within the current structure to support better learning. Efforts to eliminate or avoid conflicts of interests in the fund- ing of CPD, such as practitioner-sponsored CPD and the pooling of funds contributed by various parties already are under way. By building on these, the planning committee and the CPDI would be well positioned to develop and adopt national guidelines on con- flicted sources of funding for all health professions. Recommendation 7: The Continuing Professional Develop- ment Institute should analyze the sources and adequacy of funding for CPD, develop a sustainable business model free from conflicts of interest, and promote the use of CPD to improve quality and patient safety. Health care often benefits when professionals from within and across disciplines work together. But in many situations today, care may not be practiced in teams because people are not trained in teams. Interprofessional experiments have resulted in pockets of programs whose experiences can be incorporated into better CPD. A shared educational framework can align communication and share advances across all health professions. Recommendation 8: The Continuing Professional Develop- ment Institute should identify, recognize, and foster models of CPD that build knowledge about interprofessional team learning and collaboration. Before they are ready for widespread adopting, new methods for providing continuing professional development must prove their effectiveness through rigorous testing (e.g., demonstration pro- grams). A number of innovative CPD methods remain at that stage. For example, learning portfolios, which are development tools that document professionals’ progress of their practice skills, can be used across professions, but their effectiveness in improving the learn - ing process and health professional performance must be assessed. Demonstration programs can be developed using the research and development structures currently in place. Recommendation 9: Supporting mobilization of research find- ings to advance health professional performance, federal agen- cies that support demonstration programs, such as the Agency for Healthcare Research and Quality and the Health Resources

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12 REDESIGNING CE IN THE HEALTH PROFESSIONS and Services Administration, should collaborate with the Con- tinuing Professional Development Institute. By its very nature, continuing professional development will be complex, involving many stakeholders playing various roles. Con- tinuous evaluations therefore will be needed to ensure that prog- ress is being made toward better health professional development. Evaluation could occur at four levels that will require different metrics: individual health professionals, stakeholder organizations, the Continuing Professional Development Institute, and the overall CPD system. Arguably, the most important but most difficult level of evaluation is that of the overall CPD system. To hold the CPDI accountable for its activities and stewardship of the CPD system, the institute should be required to make periodic reports, analogous to Medicare Payment Advisory Commission (MedPAC) reports, to the Secretary. The institute should provide its first report after 2 to 5 years of operation, to allow for the usual problems that typically occur in any new venture. Recommendation 10: The Continuing Professional Develop- ment Institute should report annually to its public and private stakeholders and should hold a national symposium on the performance and progress of professional development and its role in enhancing quality of care and patient safety. GUIDELINES FOR PLANNING AND STRUCTURING THE CONTINUING PROFESSIONAL DEVELOPMENT INSTITUTE The Planning Committee In implementing the recommendations in this report, the planning committee will need to define the Continuing Professional Develop- ment Institute’s scope of work, develop a governance model, identify sources of financing, and identify and manage relationships with current and new stakeholders—including determining the extent of the federal role in the public-private institute. The committee should operate under four basic principles. It should be held accountable by the public and the Secretary. It should be competency-based, flexible, and nimble. It should broadly communicate with and gather input from the rest of the field (e.g., professional societies, accreditors, CPD providers, licensing bodies), but make decisions based only on the votes of the committee members. Finally, it should use consensus building, not parliamentary procedure, in developing processes.

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13 SUMMARY The committee should be funded by contracts and grants from the government and private foundations to support staff and travel. The IOM committee envisions the planning committee to consist of 13-15 members. The members should be recognized leaders in their respective fields, have experience in leading change and improvement, and have some level of experience in interprofes- sional learning. At a minimum, membership should include prac- ticing professionals and individuals with expertise in CPD research and government. The committee should be led by a chair who has a record of success in setting and implementing visions and building consensus. The Institute The CPDI should be an independent body with membership and financing from both the public and the private sectors. The federal government initially should oversee and coordinate the development of the CPDI, and a competency-based board should be appointed to lead the CPDI’s activities. Ultimately, upon the decision of the institute’s board, the government’s responsibilities should be transferred back to CPD stakeholders. Unless the board determines otherwise, the Secretary will eventually have no formal role in the institute. The size of the CPDI’s budget should depend on its exact functions and breadth, and its budget should be initially projected by the planning committee and refined by the board. The planning committee should determine the structure of the CPDI’s initial board, its membership size, and the competencies that need to be represented among board members. Several members of the planning committee should be named to the board, in order to facilitate the institute’s transition from planning to implementation. Once the board has achieved a more permanent structure, its mem- bers should rotate off in an overlapping manner. Considering the breadth of issues addressed by the CPDI, the board may find it valuable to establish a number of standing coun - cils and ad hoc committees as needed. The committee suggests four initial standing councils on issues identified in this report—on the science of CPD, on regulation, on financing, and on data collection and dissemination. The councils would involve a larger group of diverse stakeholders in raising issues and providing advice to the board, and would add transparency to the CPDI’s planning and operations.

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14 REDESIGNING CE IN THE HEALTH PROFESSIONS CONCLUSION Developing and implementing a new national system to improve continuing professional development on a broad scale, across dis - ciplines and government boundaries, will be difficult but offers the best hope for addressing the host of problems that prevent CE from adequately serving health professionals, patients, and the nation. To help catalyze the transition to a better CPD system—one that is coordinated, harmonized, and efficient—the federal government can play a key role as a central convener, bringing together diverse stakeholders in health care and continuing education who collec- tively can shape a new national interprofessional institute. In turn, the institute, in collaboration with stakeholders, will be centrally positioned to foster a new CPD system that can prepare all health professionals to perform to their highest potential. Working together, these forces can fulfill the vision of ensuring that the nation has a workforce of health professionals who can provide high quality, safe care and improve patient outcomes.