The National Commission on Certification of Physician Assistants (NCCPA) has announced a new PA certification maintenance process reflecting similar criteria passed in 2000 by the 24 members of the American Board of Medical Specialties. The current process requires 100 CME credits every two years (50 credits of Category 1 and 50 credits of Category 2) and a recertification exam every six years.
Under the new certification maintenance, there are two major changes:
- The recertification exam requirement will be extended to every 10 years.
- PAs will still have to earn 100 CME credits every two years, but two new categories will be added called self-assessment and performance improvement CME (PI-CME). Within the 50 credits required for Category 1, 20 of them will have to be earned via a self-assessment or PI-CME activity.
In every two-year CME cycle PAs can earn a combination of PI-CME and self-assessment credit, or just concentrate on one of those activities. However, at the end of eight years (four two-year CME cycles) PAs must have earned at least 40 Category 1 CME credits through self-assessment and at least 40 Category 1 CME credits through PI-CME activities. There are no self-assessment or PI-CME requirements in the fifth CME cycle (years 9 and 10). During the fifth CME cycle PAs only need to earn 50 traditional Category 1 CME and 50 Category 2 CME.
Many PAs are concerned about these changes, how and when it will affect them, and how it relates to them and their own unique career. Below are answers to some of the most common questions we have been asked over the past several months.
They are also available as a download.
Basic information
Background information about the changes
Fulfilling the new requirements
For PAs not working in clinical practice
Relevance of new certification maintenance process to clinical practice
Employer support and relationship to physician maintenance of certification model
When does this change begin?
This change to certification maintenance begins in 2014. This applies to new PAs who pass the PANCE in 2014, and practicing PAs who recertify in the 2012-2014 cycle. Others will transition after their next recertification cycle. For example, if you recertified in the 2010-2012 cycle, you will not transition to this new certification process until the 2018-2020 cycle.
To confirm when you will transition to the new certification maintenance process, log into your NCCPA account, click on "my record," and scroll to the bottom.
Recent graduates will continue to follow the current process. Only new graduates who pass the PANCE in 2014 (or after) will immediately begin the new certification maintenance process. Graduates taking the PANCE prior to 2014 will continue with the current requirements and transition to the new certification maintenance process after their first PANRE.
The table below shows when the new CME process will affect you.
Previous PANRE or PANCE
|
Next PANRE or initial PANCE
|
Certification Maintenance Cycle
|
|
Re-
Certification PANRE
|
First
CME Cycle*
New RequirementsEffective
|
Second CME Cycle*
|
Third
CME Cycle*
|
Fourth
CME Cycle*
|
Fifth
CME Cycle
No Self-assessment or PI-CME requirement
|
2008
|
2014
|
2014-2016
|
2016-2018
|
2018-2020
|
2020-2022
|
2022-2024
|
2024
|
2009
|
2015
|
2015-2017
|
2017-2019
|
2019-2021
|
2021-2023
|
2023-2025
|
2025
|
2010
|
2016
|
2016-2018
|
2018-2020
|
2020-2022
|
2022-2024
|
2024-2026
|
2026
|
2011
|
2017
|
2017-2019
|
2019-2021
|
2021-2023
|
2023-2025
|
2025-2027
|
2027
|
2012
|
2018
|
2018-2020
|
2020-2022
|
2022-2024
|
2024-2026
|
2026-2028
|
2028
|
2013
|
2019
|
2019-2021
|
2021-2023
|
2023-2025
|
2025-2027
|
2027-2029
|
2029
|
*each of the first four two year CME cycles requires the completion of 20 self-assessment and/or PI-CME credits as a part of the 50 Category 1 CME credit requirement
What are self-assessment and PI-CME activities?
PI-CME
A national task force convened by the American Medical Association developed the initial PI-CME format, which was first implemented in 2005. PI-CME will have been established for nearly a decade when the new NCCPA requirements are implemented.
PI-CME is a PA-centric, data-driven activity. It focuses on the individual PA's needs. It is made up of three stages:
- Stage A – Perform a self-assessment by comparing your current practice in a specific clinical area with national benchmarks, performance guidelines and data submitted by other PAs.
- Stage B – Develop and follow a plan to improve your practice based on your assessment. This will require engaging in educational activities, collecting resources to use in your daily practice, etc.
- Stage C – Reassess your practice to measure the effects of your improvement plan.
The process is meant to be reflective and meaningful. To that end, it is important to understand that you will not need to demonstrate actual practice improvement to receive credit. This is not a measure of right and wrong, but rather to help you think about things you may have not previously considered. For example, questions such as the following:
- Do you have a system in place to provide multidisciplinary care for your patient with uncontrolled diabetes?
- Do you have tools to help you deliver culturally appropriate information to your patient when educating them on diabetes?
- In your practice, what is the most significant barrier for your diabetic patients to adhere to dietary recommendations?
The results from your assessment will provide guidance on what information, resources or tools may be helpful to improve patient outcomes for your diabetic patients.
Self-assessment activities
Self-assessment is the process of conducting a systematic review of one's own performance, knowledge base or skill set, usually to improve future performance, expand knowledge or hone skills.
Self-assessment activities, in their most common form, are simply an in-depth medical knowledge test. A well-known example is the American College of Physicians Medical Knowledge Self-Assessment Program® (MKSAP®).
Importantly, this is not like taking PANCE or PANRE, where you must get a passing score to practice. Instead, this is exactly what it says – a "self-assessment." You may take it as many times as you like in order to gauge where your own personal knowledge gaps exist. It helps you identify where you need CME or additional self-study in order to improve your knowledge.
AAPA is gearing up to have activities available in every specialty area, since again, unlike PANCE/PANRE's focus on core knowledge, these self-assessment CME activities help you within your practice specialty. Self-assessment activities are meant to help you better recognize gaps in your own knowledge so that you can better serve your patients.
Will the new process take more time than traditional CME?
Many PAs have expressed concerns that the new requirements will take significantly more time to complete. For PI-CME, they're worried it will require more than 20 hours of active participation and effort.
However, this is not necessarily the case. While a PI-CME activity may take three to six months to complete, this includes a substantial period between the initial and final assessments. Other than short educational interventions, some of which will complement daily practice, there are no extra ongoing activities between the assessments. This time period between assessments is intended to facilitate self-reflection on what you have learned about your own practice and allow for any outcomes that result from the intervention to be evident before doing a final assessment.
Of note, you do not need to demonstrate actual practice improvement in order to receive CME credit since the primary intent is to help you reflect on your own practice.
Some PAs have asked about the "20 credits" awarded for a PI-CME activity and if one activity is expected to take 20 hours. It is important to note that the term "credits" and not "hours" is used in reference to PI-CME and self-assessment activities. The credit calculation is not determined solely by the amount of time spent participating in the activity. Instead the credit calculation considers time, significance and the potential impact the activity will have on your practice, and awards a bonus for completing all stages of a particular activity.
Why is this change happening?
There are several reasons for this change in the PA national certification maintenance process. These include:
- Calls for greater accountability and higher quality in healthcare spurred major change in physician certification and certification maintenance programs with movement from CME to continuous professional development. For medical doctors this is referred to as Maintenance of Certification (MOC) and for osteopathic physicians, Osteopathic Continuous Certification (OCC).
- NCCPA felt it appropriate to consider whether similar changes were needed for PAs with a commitment to patient's best interest in mind. This process is meant to foster more practice improvement than the traditional forms of CME, which are not required to be connected to one's own practice. This new certification maintenance presents an opportunity for PAs to engage in a continuing education activity that can lead to improvement of patient outcomes.
- It's a way to incorporate all six PA competencies into practice and evaluate PAs in these core competencies. The six areas of PA competencies, developed by NCCPA, AAPA, PAEA and ARC-PA, are medical knowledge, interprofessional and communication skills, patient care, professionalism, practice-based learning and improvement, and systems-based practice. The current PA certification maintenance process only evaluates one competency: medical knowledge.
- The Federation of State Medical Boards has recommended that all states adopt Maintenance of Licensure (MOL) similar to the Maintenance of Certification (MOC) model set by the major medical boards. The NCCPA changes to PA certification maintenance mirrors this maintenance of certification. With these changes, PAs will be prepared when state medical licensure requirements also change.
- By aligning with the requirements of a majority of physician certifying boards, these practiced-based requirements are intended to encourage team-based practice improvement.
Who came up with these new requirements?
NCCPA considered best practices from other medical boards, emerging requirements for state licensure, input from AAPA and PAEA, public comment and a pilot study all prior to defining the new requirements for certification maintenance.
What is AAPA's role in the certification process?
AAPA does not develop the requirements for certification maintenance. Instead, it gives PAs opportunities to meet NCCPA certification maintenance requirements through the development and/or accreditation review of CME activities that meet those requirements. In addition, AAPA will create a unique member learning portfolio available in 2013 that will make it easy to keep track of and log your requirements.
When do I start PI-CME and/or self-assessment activities, and where do I begin? Do I go online, or are there packets of information that I need to request?
AAPA will both acquire and develop specific activities for PI-CME. The Academy is launching an online learning management system where many PI-CME and self-assessment activities will be made available to PAs.
The new CME requirements do not start until 2014, but we are communicating now to ensure you understand the changes, your questions are answered and that you are aware of solutions AAPA is creating to support you in the transition.
Prior to the arrival of the new requirements for PI-CME and self-assessment credits, any PA can participate in a PI-CME or self-assessment activity and receive traditional Category I CME credit. Many self-assessment and PI-CME programs are available through other allopathic and osteopathic physician associations. Examples include the American Academy of Family Physician METRIC program and the American College of Physicians Medical Knowledge Self-Assessment Program (MKSAP). Several other activities are already available on websites such as Medscape.
In addition, AAPA will provide specific requirements for PAs who want to create their own PI-CME activities. We are currently developing these guidelines, and plan to have something in place by mid-2013. Stay tuned.
Will there be suggested topics for PI-CME and self-assessment activities per specialty?
Yes, there will be PI-CME and self-assessment activities for different specialties. AAPA is working with several physician organizations, PA specialty organizations and PAs in different clinical areas to gather and develop options for PI-CME and self-assessment activities in several clinical specialty areas.
This maintenance process should be more streamlined and user friendly. I understand the requirements, but as professionals shouldn't our goal simply be to educate ourselves and stay current?
PI-CME and self-assessment activities are designed to be relevant to your clinical practice, and help you improve and stay current in your clinical practice in ways that may be even more relevant and more practical than some other CME activities you've pursued in the past.
As mentioned above, AAPA is working to acquire and develop PI-CME and self-assessment activities. These will be offered through a learning management system in a format that will be simple, accessible and user friendly. In addition, we are committed to working on a streamlined process so that credit for activities completed on AAPA's learning management system will be transmitted directly to NCCPA, simplifying the CME logging process.
Will the requirements present a challenge for PAs working per diem or locum tenens?
These PAs should not face any barriers in completing self-assessment.
For PI-CME, see our response to the question about PAs who are not in clinical practice and/or who have temporarily left the workforce. There may be options in these situations that would relate to PAs who work per diem or locum tenens only. You can select an activity that does not require specific patient follow-up, but does relate to a core PA competency.
For example, a PI-CME activity may focus on communication and how you disseminate information to your patients at the end of a visit. Or if you do procedures, choose something relating to quality assurance and safety measures taken.
Also, if you cannot complete a PI-CME activity you started due to extenuating circumstances, you can still get partial credit. For example, if you complete stage A and B but due to a job change you cannot complete stage C because it requires specific patient follow-up, you still get credit for stage A and B (5 credits each for total of 10 credits).
Why are these changes happening if there are still things that AAPA is working on and have not yet produced for all PAs?
Both NCCPA and AAPA are committed to making sure that all PAs, including nonpracticing PAs who want to continue to maintain certification, will be able to do so. Because NCCPA and AAPA are two different organizations filling two very different roles, the new process had to be established by NCCPA before AAPA could begin work on identifying and/or developing products and programs that would fulfill the requirements of the new process.
As a first step, last year AAPA established the criteria for designating activities as PI-CME and self-assessment CME—including activities that would be accessible for nonpracticing PAs. This was done with a committee of PA volunteers, including a PA who is an expert in quality improvement in continuing medical education, and a representative from AAPA and NCCPA. We are now actively working on the identification and development of a range of PI-CME and self-assessment CME options that will be in place prior to the requirements being put into practice in 2014.
How do PAs who want to retain certification meet the new self-assessment and PI-CME requirements if they’re teaching or in administration?
NCCPA is committed to making sure that nonpracticing PAs who want to continue to maintain certification will be able to do so. AAPA is working with NCCPA and others to make sure that even those who work in nonclinical roles have options available to satisfy the new requirements.
Nonclinical PAs are still able to participate in self-assessment activities, the majority of which are just self-administered exams or tests that focus on medical knowledge for a specific clinical area. With unlimited attempts, you can still use self-assessment activities to identify and address any deficiencies in your own medical knowledge. This may even be useful to a PA who teaches in an academic setting. There is not a requirement to show performance improvement once the self-assessment is complete.
PI-CME presents challenges for the nonclinical PA, but is not impossible. AAPA is working closely with NCCPA to establish criteria for nonclinical PAs to earn PI-CME credits.
In the meantime, here is a summary of AAPA’s recommendations. Eligible nonclinical PAs are those who work in areas that are clinically relevant to improved public health, patient safety or healthcare quality including teaching, public health, policy advocacy, administrative roles in healthcare or a PA professional association setting. Approval for activities designed for PAs in other nonclinical settings can be obtained through AAPA’s Professional Education Commission.
Some examples are:
Communications courses/modules based on self-assessment or professional-practice-setting performance data.
1. As a PA healthcare administrator, lead a system initiative to improve patient communications and patient satisfaction measures.
2. Based on documented peer or student feedback, pursue communications coursework followed by a reassessment based on the same data source.
Healthcare disparities
1. As a teacher, based on student awareness data (survey, observation, etc.), improve the curriculum or methods used during the didactic year to improve student understanding of healthcare disparities.
2. As an administrator, based on an assessment of healthcare-practice-setting data, plan or lead an initiative designed to improve performance in an area identified in your health disparities data. As with other requirements, actual improvement does not need to be demonstrated, but a re-evaluation of the performance data will be required.
What about people who have left the workforce and need to maintain their certification?
For anyone who has left the workforce temporarily and is maintaining their certification, AAPA has suggested the development of virtual cases that nonclinical and not actively working PAs can use for virtual PI-CME. AAPA will work with various groups to explore this option.
However, if the PA’s exit from the workforce is short—say two to four years—then the PA could do all of their self-assessments (which are basically concentrated competency tests) on the front end and finish up the PI-CME once they’re back in practice.
This is a loss of 20 hours of CME time—time that I can spend learning something about clinical practice rather than doing research on my own practice.
PI-CME and self-assessment aren’t research; they are simply practice-based learning and improvement. PI-CME or self-assessment—whichever activity you choose—should be relevant to your clinical practice. It should not take any time away from learning something about your clinical practice. In fact, PI-CME and self-assessment activities are designed to be more relevant to your clinical practice than traditional CME. The intention is for you to learn or discover something specifically about your practice that you can improve.
This is just an extra burden for PAs. Does NCCPA or AAPA understand the day-to-day demands of clinical practice and how busy PAs are?
As a PA who found out about these changes when I (Leocadia Conlon, AAPA Director of Quality Improvement Initiatives) came out of clinical practice last year (after 11 years), and joined AAPA, my first thought was, “A PA does not have time to do this. ”
But the more I’ve learned, the more I think these activities are a lot of what we’re already doing, and now we will get credit for it. For example, have you ever used UpToDate®? It is a point-of-care tool that allows you to quickly look something up, comment on whether or not the results will or have changed your practice, and earn CME credit. This is a great example of earning CME credit for something you are probably already doing in your practice.
While PI-CME is not the same process, it’s the same idea.
For the many PAs already involved in structured quality improvement initiatives within institutions and practices, this will be a way to record what you are already doing to improve your practice and your patient outcomes, and get credit.
For PAs not already actively involved in a structured practice-based improvement effort, the new PI-CME activities in the pipeline will provide an easy-to-follow, step-by-step way to engage in a new activity that will be beneficial to the PA, the practice and most importantly the patient. Again, AAPA is developing specific activities to show to PAs during 2013.
As far as self-assessment: A few years ago I changed from internal medicine practice to family medicine practice. To prepare for this change I studied the Family Medicine Board book. I spent many hours studying that and taking practice exams. However, I could not claim Category 1 CME for that, only 2. Self-assessment exams will allow you to do the same thing—to test your knowledge for your own learning and information only (no pass or fail score) and get credit for it.
Many providers are already doing this in response to quality improvement measures implemented by institutional patient safety and quality initiatives, and/or insurance provider reimbursement policies. Why then are we doubling our work if these measures are already in place?
If you are involved in a quality improvement initiative in your practice, this can potentially satisfy the new PI-CME requirements. Almost all quality improvement initiatives fit the PI-CME model of A) examining your practice, B) implementing an intervention and C) analyzing the resulting outcomes.
AAPA is developing a process for individual PAs who plan to participate in a QI initiative that will provide the option of submitting a request for PI-CME credit approval. QI activities, however, will not satisfy the criteria for self-assessment.
Will a future employer buy into the new self-assessment and performance CME?
AAPA is developing a standard letter that PAs can give to their employers. The reasoning behind the new certification maintenance process is in line with many quality improvement and safety initiatives recommended in healthcare since the late 1990s and early 2000s. They also align with physician Maintenance of Certification (MOC), quality reporting measures and recommendations made by the Federation of State Medical Boards that all state licensing adopt an MOC-like processes for maintenance of licensure.
Employers should see the changes as a positive update that aligns with their goals, and it prepares PAs to be not only an agent in healthcare change but a leader in quality improvement initiatives.
Will I need to get institutional review board approval to perform a PI-CME activity since I will be entering information that comes from patient data?
No, a PI-CME activity does not require approval from an institutional review board (IRB). PI-CME activities should be viewed as quality improvement or quality assurance (QI/QA) activities, which typically do not require IRB review if the information is only being used to monitor and improve provider practice.
PI-CME activities are not intended to generate scientific knowledge or to be applied beyond your specific practice. They are not developed to test a new intervention, service or program and therefore not considered human subject research. Think of a PI-CME activity as being a self-management tool for monitoring and improving your own practice.
In 2011 the Institute of Medicine published a discussion paper, "The Common Rule and Continuous Improvement in Health Care: A Learning Health System Perspective," to help inform the discussion around IRB review for QI/QA projects and initiatives.
The IOM developed the vision of a learning health system as one that "...gets the right care to the right people when they need it, and captures the results for making improvements." Collecting information about a provider's performance as it relates to patient care is thus necessary and should be considered a normal routine activity of any healthcare organization.
To facilitate practice improvement activities, the IOM developed a framework for a "Common Rule" in continuous improvement, which states that unless you are evaluating something other than what is already accepted practice or posing more than minimal risk, the IRB process for human subject research should not be warranted.
PI-CME activities will be based not only around an already accepted practice, but around practice guidelines that are established and supported by existing research. Participation in an assessment and then re-evaluation of how well you incorporate well-proven guidelines into practice is something that should be considered a normal part of giving and receiving care.
For further information you can access the IOM paper here. In addition, you can follow up with your local or a central IRB. Often they will provide information related to QI/QA activities and may provide a flow chart for determining if an activity is considered human subject research.
When employers realize that more than one-third of our Category 1 CME is being provided for at work we’ll see an equal reduction in CME money available to us over the next few years.
There should be no reduction in the CME money made available to you. Even if some of the activities are directly related to your clinical work, there is still an education component, and you still need to register for the activity. There are still associated fees to be covered by your CME allowance, and you should make this clear to employers.
In addition, physicians also have requirements for self-assessment and PI-CME activities, so your employer is likely already well informed about these activities, and your CME allowance should not be reduced. Also, to further prevent these sorts of reductions, AAPA will continue to advocate on behalf of PAs and educate employers about the benefits of these new requirements.
Even though other professions are adopting PI-CME and self-assessment activities, why should PAs follow?
These changes are happening for several reasons:
- PI-CME and self-assessment provide a meaningful way to engage in the purposeful development of all six competencies of the PA profession. The current CME and PANRE model only adequately addresses one of the competencies, medical knowledge, while touching on patient care and professionalism.
- These changes will keep PAs ahead of potential future changes to state maintenance of licensing requirements. The Federation of State Medical Boards has recommended that all states adopt maintenance of licensure similar to the physician Maintenance of Certification (MOC) model implemented by all major medical boards. The new PA certification maintenance process mirrors the physician MOC process and may well head off significant changes to the licensing process for PAs.
- The changes are in line with healthcare changes that emphasize quality improvement and pay-for-performance measures.
- These new requirements transition life-long learning from episodic learning to more of a professional development approach where PAs can seek and apply knowledge relevant to their practice. This will lead to improved patient care and is the right thing to do for our patients.
For more information from AAPA staff, contact:
J. Leocadia Conlon, PA-C, MPH, AAPA director of quality improvement initiatives, lconlon@aapa.org, 571-319-4405
Daniel Pace, AAPA director of CME services, dpace@aapa.org, 571-319-4419
PAsConnect.org, a community for PAs, also offers a forum for open discussions on CME topics.
