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Charting a course to competency

Bill Kohlhepp, MHA, PA-C; Rick Rohrs, PA-C; Paul Robinson, PA-C

Bill Kohlhepp is Chair Elect of the National Commission on Certification of Physician Assistants (NCCPA), a past president of the AAPA, and Associate Director, Quinnipiac University PA Program, Hamden, Conn. Rick Rohrs is President of the AAPA, a past chairman of NCCPA, and Director of Hospital Medicine at Northwest Hospital Center, Randallstown, Md. Paul Robinson is Speaker of the House of Delegates and Vice President of the AAPA. He practices at Metropolitan Urologic Specialists, St. Paul, Minn.

With the passage of resolution 2005-B-24 in May 2005, the AAPA House of Delegates adopted a position paper entitled “Competencies for the Physician Assistant Profession” (reprinted in this issue of JAAPA). This action was in response to the public’s call for a more intense focus on competence in health care and to the “maintenance of competence” efforts already initiated by our physician colleagues. Before passage of the resolution, the boards of the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) and the National Commission on Certification of Physician Assistants (NCCPA) endorsed that same document; the Association of Physician Assistant Programs (APAP) will consider endorsement at its Education Forum in November 2005.

Call for improved competency

One of the first and clearest calls for an increased focus on competence came in the 1995 report of the Pew Health Professions Commission’s Taskforce on Health Care Workforce Regulation. The report concluded that workforce regulation could be responsive to public expectations if practice acts for the health professions were focused on “demonstrated initial and continuing competence.”¹

Then came the release of the 1999 Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health System. The report grabbed the public’s attention with its estimate that between 44,000 and 98,000 people die in hospitals annually from preventable medical errors. One contributing factor cited was the limited attention that licensing and accrediting efforts gave to patient safety. The IOM suggested that patient safety could be improved if licensing, certification, and accreditation bodies were to “develop and adopt explicit patient safety standards.”²

In 2001, the IOM’s follow-up report, Crossing the Quality Chasm, recommended change at all levels of the health care system to improve quality of care. The IOM called for “training and ongoing certification [to] reflect the need for lifelong learning and evaluation of competencies.” They also pointed out that credentialing efforts should go beyond the current focus on assessment of knowledge to include demonstration of competence.³ The spotlight shone on competence again in the most recent IOM report, Health Professions Education: A Bridge to Quality, which advocated moving to a “competency-based approach to education.”⁴

In response to the IOM’s efforts and media interest in patient safety, purchasers of health insurance are becoming a major catalyst for making needed changes to reduce medical errors. To Err Is Human recommended that large employers use their collective influence to reinforce quality and safety of care. The Leapfrog Group, which brought together large employers with an interest in influencing health care quality and affordability, provides one example.⁵

According to a recent consumer patient safety and quality survey, patients continue to worry about the safety of medical care and have become increasingly familiar with the concept of “medical errors.”⁶ Recently, the Citizen Advocacy Center (CAC)—representing public members who serve on health care regulatory boards and governing bodies representing consumer interest—focused their attention on Health Professions Education, which cited a desire by patients and payers for increased accountability. The CAC called for a move to require licensed health care professionals to demonstrate periodically that they are maintaining competence. The CAC is convinced that safer and higher quality health care will come from improved practitioner performance that will be stimulated by “competency assessment and assurance requirements mandated by regulatory boards.”⁷

Historical perspectives on PA certification

Early in the development of the PA profession, physicians took the lead to put in place a national program for certification focused on developing standards reflective of competency. In 1971, the American Medical Association House of Delegates directed its Council on Health Manpower to work with the National Board of Medical Examiners and other physician organizations to develop a freestanding independent commission—the NCCPA. Their goal was “to assure employers, state boards, and patients that a standard related to the competency of PAs was in place.”^8,9 One of the earliest texts on the PA profession described NCCPA’s function as certifying “the entry level and continued competency of PAs through vehicles of testing, continuing medical education, and periodic recertification evaluation.”¹⁰ At the time, we were the only health profession to require recertification by examination, reflective of a commitment to lifelong learning to keep up-to-date on the core knowledge needed to practice medicine as a PA.

The profession’s willingness to adopt a single respected system of national certification and recertification is considered one of its seminal attributes. Embracing such a system has yielded many benefits, including geographic mobility for practitioners and, perhaps more importantly, significant and early legitimacy in legislative and policy arenas. However, as other health professions’ certifying and accrediting organizations have enhanced their programs in response to the IOM reports, the current certification and recertification programs of the PA profession have lagged behind.

Development of “Competencies for the Physician Assistant Profession”

At its January 2003 retreat, the NCCPA board renewed its commitment to examining PA competence and taking a critical look at how well the current certification and certification maintenance processes measure competencies. NCCPA’s Eligibility Committee was charged with developing a definition of PA competence that would later provide the foundation for further discussions. The following year, representatives from AAPA, APAP, and ARC-PA joined in the committee’s efforts in that area, and the expanded group discussed and edited the draft document that later became “Competencies for the Physician Assistant Profession.”

In developing the “Competencies,” the workgroup drew heavily from work done in the physician community so that the finished product would include language familiar to the rest of the health care community while appropriately reflecting the PA profession’s close ties to physicians at both the organizational and clinical practice levels. Also, building on the work of the physician community and involving the PA profession’s certifying and accrediting bodies, PA educators, and the principal membership association is an approach espoused by the IOM.⁴ Coordinating the four organizations in this effort will reduce redundancies moving forward, foster better communication between involved groups, and allow more consistent integration of the core competencies. It also establishes a shared definition of PA competencies, a critical first step in making any changes to the education, professional development, or certification programs for the PA profession.

Using the framework of general competencies adopted in 1999 by the Accreditation Council on Graduate Medical Education and the American Board of Medical Specialties,^11,12 the four-organization workgroup incorporated our profession’s own body of knowledge about PA competencies. Key resources included information from practice analyses conducted by NCCPA and reflected in the certification and recertification exams’ content blueprint, ARC-PA’s accreditation standards, APAP’s work on educational program content and design, and research on PA competencies conducted by AAPA.

A principal goal of the workgroup was to ensure that the finished document reflected the unique aspects of PA practice and the PA’s role in the health care system. Another goal was to reflect the supervising physician’s role in fostering skill building and monitoring the quality of care delivered by the PA. The workgroup also endeavored to ensure that the document reflects generalist competencies across all specialties, an approach particularly important given the generalist nature of PA education and the certification and recertification exams.

Next steps

As they lend support first to the effort to define PA competencies and then to the actual document that arose from that work, ARC-PA, NCCPA, AAPA, and APAP are playing critical roles in this profession’s response to the public call for greater accountability in health care. The “Competencies” is a significant milestone in the evolution of the PA profession. However, this shared definition of competencies is just the first step in a much farther reaching effort to refine the way the profession instills, hones, maintains, and assesses the competencies of its practitioners.

During the next phase of this work, each of the four organizations will explore opportunities to refine or even reinvent their various programs to reflect the shared definition. The cross-organizational communication will continue with discussions about questions such as who has (or should assume) responsibility for fostering the development of each competency, which of the competencies should be assessed, how, when, and by whom.

The four organizations have joined together to answer the public’s call for improved quality and accountability in health care and ultimately elevate the profession. So, too, can individual PAs—by seeking opportunities to enhance personal development in these competencies, supporting the PA educational process (by teaching, precepting, mentoring new graduates, or giving financially to educational institutions), earning and maintaining certification, and participating in PA membership associations. The profession is once again positioned to assume a leadership role in competency development and assessment, which should bring new opportunities and growth as we work together not to cross or bridge the “quality chasm” but to close it.  

REFERENCES

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