Continuing competence in selected health care professions

Journal of Allied Health, Winter 2002 by Lundgren, Burden S, Houseman, Clare A

Health services professionals are confronting the challenge of maintaining and improving competence over the course of lengthy careers in diverse practice specialties. This article reviews the efforts of a selection of health care professions to ensure lifetime competence and reviews some of the challenges encountered in these efforts. Although each profession has its own issues, significant generic questions are common to all. J Allied Health. 2002; 31:232-240.

IN THE FACE OF RAPID developments in science and technology, changes in reimbursement and practice patterns and in expectations of care, health care professionals face a challenge in skills development throughout their careers. State health professions regulatory boards rarely have required, however, demonstration of continuing competence after initial licensure. Disciplinary boards deal with egregious instances of failure in competence for single practitioners. Traditionally, continuing education requirements are imposed across a profession with the belief that such requirements ensure competence. There is evidence to indicate, however, that there is no link between continuing education and improved professional practice.1,2 Hewlett and Eichelberger3 suggested that not only is there no established link between continuing education and competence, but also there is none between continuing education and patient outcomes. It is the consumer who bears the costs of continuing education. Begun4 reported that consumers paid nearly $70 million yearly in higher eye examination costs alone in states that had continuing education requirements for optometrists.

Concern for the continuing competence of health professionals has been an important issue at least since the consumer movements of the 1960s.5 In 1967, the Bureau of Health Manpower of the Department of Health Education and Welfare recommended that physicians undergo periodic reexamination.6 The issue of continuing competence is part of an increased interest in the general concept of competence, which has been manifested in the evolution of reforms since the 1970s. Health care and academic institutions have been prominent in setting competency standards.7 Possibly the most pronounced influence on promoting interest in continuing competence were the Pew Health Profession Commission Reports of 1995 and 1998.8,9 The Commission argued that the accumulation of continuing education credits and the activities of disciplinary boards do not ensure competence. A regulatory solution was recommended. States were advised to develop definitions of competence and criteria by which private sector competence assessments would be deemed to satisfy state requirements. A national policy advisory board would coordinate activities.9 In light of the Pew reports, many states (7 in 1998 and 12 in 1999) introduced continuing competence legislation for health care professionals.10

Although generally favorable, professional responses to the Pew Commission Reports raised questions of responsibility, validity of standardized testing, diversity of practice, economic concerns, and lack of empirical data.ll This article reviews the continuing competence activities of a selection of health care professions and discusses some of the issues involved in ensuring continuing competence.

Dental Hygienists

In general, the only requirement for continuing competence for dental hygienists is mandated continuing education for relicensure in 46 states and the District of Columbia. The average requirement is 8 to 12 hours per year. A few states require active practice to maintain licensure and require retesting or special classes for return to active practice after an extended time away. One state, Utah, has considered performing a dental records review for a sample of patients.12

The profession is experiencing pressures from the American Dental Association (ADA) with regard to ensuring competence. In its 1998 meeting, the ADA adopted resolutions that would allow on-the job training for dental hygienists and a shift from independent agencies to state dental boards as accrediting organizations for dental hygiene programs.13 The ADA has continued to call for alternate pathway programs for the preparation of dental hygienists.14 Although this discussion has centered on initial preparation, it is not unreasonable to expect that a shift in oversight might apply to continuing competence also.

Dentists

In 1991, after 2 years of study, the American Association of Dental Examiners (AADE) established a committee to explore the assessment of the continuing competency of dentists. The committee expanded to include representatives from the American Association of Dental Schools, the American Dental Association, and the Academy of General Dentistry. The committee developed many definitions and criteria and nine models for assessments of continuing competence. The models showed considerable diversity ranging from in-office audits to written examinations.15

The AADE has released "Criteria and Mechanisms for Continued Competency in Dentistry."16 This document establishes 17 criteria for competency mechanisms and suggests that continuing competence could be shown by many different means, including: