The National Commission on Certification of Physician Assistants (NCCPA) announced a new PA certification maintenance process reflecting similar criteria to the recertification programs of the 24 member boards of the American Board of Medical Specialties (ABMS), which were approved in 2006. The current process requires 100 CME credits every two years (50 of which must be Category 1) and a recertification exam every six years.
Under the new certification maintenance process, 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: performance improvement (PI-CME) and self-assessment CME. Within the 50 credits required for Category 1, 20 of them will have to be earned via AAPA-accredited PI-CME and/or self-assessment activities.
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 the traditional 100 CME, with at least 50 being Category 1. That leaves PAs free to choose whatever form of CME is most helpful to them during the two-year timeframe for their recertification exam.
Many PAs are concerned about these changes, how and when it will affect them, and how it relates to them and their 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: Certification and CME FAQ
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 when your current six-year recertification cycle ends.
To confirm when you will transition to the new certification maintenance process, log into your NCCPA account and scroll to the bottom to read the message titled, "Transition to the New Certification Maintenance Process."
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.
Of note, you can begin earning and logging self-assessment and/or PI-CME credits on May 1 of the year that you transition to the new requirements, even if you have not yet taken your PANRE for your current cycle.
The table below shows when the new CME process will affect you.
PANRE or PANCE
PANRE or initial
|Certification Maintenance Cycle
|First CME cycle*
|Second CME cycle*
||Third CME cycle*
||Fourth CME cycle*
||Fifth CME cycle
or PI-CME requirement)
||2014 - 2016
||2016 - 2018
||2018 - 2020
||2020 - 2022
||2015 - 2017
||2017 - 2019
||2019 - 2021
||2021 - 2023
||2016 - 2018
||2018 - 2020
||2020 - 2022
||2022 - 2024
||2017 - 2019
||2019 - 2021
||2021 - 2023
||2023 - 2025
||2018 - 2020
||2020 - 2022
||2022 - 2024
||2024 - 2026
||2019 - 2021
||2021 - 2023
||2023 - 2025
||2025 - 2027
* 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.
I’m planning to regain my certification. How do these new requirements affect me?
For those regaining certification in 2013 or 2014, you will not have to complete any PI-CME or self-assessment activities to be eligible to regain certification via the PANCE or PANRE. For those regaining in 2015 and beyond via the PANCE or PANRE, there will be a self-assessment and PI-CME requirement. If you successfully regain your certification in 2014 or after, you will be subject to the new certification maintenance requirements. Please see NCCPA’s website for further information.
Why is this change happening?
- 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, this is referred to as Osteopathic Continuous Certification (OCC).
- NCCPA felt it appropriate to consider whether similar changes were needed for PAs with a commitment to patients’ 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 is 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, interpersonal 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 MOC model set by the major medical boards. 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 practice-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 from the PA profession, 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, AAPA gives PAs opportunities to meet NCCPA certification maintenance requirements through the development and/or accreditation review of CME activities that meet those requirements. Learning Central, AAPA’s new learning management system, will provide the ability to locate and track completion of PI-CME and self-assessment activities.
What are PI-CME and self-assessment activities?
A national task force convened by the American Medical Association developed the PI-CME format, which was first implemented in 2005. PI-CME will be nearly a decade old when the new NCCPA requirements are implemented.
PI-CME is a PA- or practice-centric, data-driven activity that focuses on the individual PA's practice improvement needs in the context of team-based care. 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, PI-CME can address questions such as the following:
- Do you have a system in place to provide multidisciplinary care for your patients with uncontrolled diabetes?
- Do you have tools to help you deliver culturally appropriate information to your patients 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 outcomes for your diabetic patients.
AAPA has compiled an extensive list of PI-CME activities currently available to PAs. That list will continue to grow.
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 in-depth medical knowledge tests. A well-known example is the American College of Physicians Medical Knowledge Self-Assessment Program® (MKSAP®).
Importantly, self-assessment activities are not like taking PANCE or PANRE, where you have one chance per test to get a passing score. Instead, this is exactly what it says – a "self-assessment." Most activities allow you to take the self-assessment as many times as you like in order to gauge where your 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.
AAPA has compiled an extensive list self-assessment activities currently available to PAs. That list will continue to grow.
How do I know if a self-assessment or PI-CME activity will satisfy the new requirements?
In order for a PA to claim specific self-assessment and/or PI-CME credit, the activities will have to be approved by AAPA. Unlike traditional Category 1 CME, there is no reciprocity with other credit systems. AAPA approval ensures that the activities meet the unique practice needs of PAs.
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. Learning Central is your destination for CME activities to help you meet your certification maintenance requirements.
The new CME requirements do not start until 2014, and PAs will transition to the new process over the following six years. 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 1 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 Physicians (AAFP) METRIC program and the American College of Physicians (ACP) 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 or who believe that practice improvement activities they are already engaging in may qualify for credit. We are currently developing these guidelines and plan to have something in place by early 2014. 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 a wide range of 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 have pursued in the past.
As mentioned above, AAPA is working to acquire and develop PI-CME and self-assessment activities. Many of these activities will be offered through Learning Central in a format that is simple, accessible and user friendly. As PAs begin to take advantage of these new CME opportunities, we will collect and share insights from their experience to provide a clearer view of what self-assessment and PI-CME entail and how they are benefiting practice. In addition, we are committed to working on a streamlined process so that credit for activities completed on AAPA’s Learning Central will be transmitted directly to NCCPA, simplifying the CME logging process.
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, PAEA 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 multiple 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 far from impossible. An AAPA and PAEA workgroup is nearing completion of work on the first of multiple PI-CME activities designed for nonclinical PAs.
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 as follows:
Courses/modules based on self-assessment or performance data in a professional practice setting.
- As a PA healthcare administrator, lead a system initiative to improve patient communications and patient satisfaction measures.
- Based on documented peer or student feedback, pursue communications coursework followed by a reassessment based on the same data source.
- 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.
- 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.
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 are not 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 and take action on.
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 (PDF). 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 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 lifelong learning from episodic learning to more of a professional development approach where PAs can seek and apply knowledge relevant to their practices. This will lead to improved patient care and is the right thing to do for our 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 are 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.
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?
We have heard many PAs say, “A PA does not have time to do this.” However, we truly believe that these activities encompass some of what PAs are already doing, and now PAs 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.
As far as self-assessment, many PAs change specialties and spend hours studying and taking practice exams in board review books. However, many board review books do not allow you to claim Category 1 CME for that, only Category 2. Self-assessment exams will allow you to do the same thing—to test your knowledge for your own learning and information—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.
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 are back in practice.
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, some activities will allow you to 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). However, some activities require you to complete the entire module to claim CME credit, such as AAFP’s METRIC program. If there is a chance that you might not be able to complete the entire activity, it is important to determine if you can claim partial credit prior to starting the activity.
Will a future employer buy into the new self-assessment and performance improvement 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 authorities adopt 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.
Why are these changes happening if there are still things that AAPA is working on and has 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.
Is PI-CME just another research or quality improvement project?
No. Unlike quality improvement projects, PI-CME uses learning and engagement as the pathways to change and improvement. There are no research or quality improvement skills required. Furthermore, there are no process or systems changes necessary. And there is no “final” paper to get credit; there is value in the process itself.
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 a tool for monitoring and improving provider practice, which typically does not require IRB review because it is not considered human subject research.
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.
Contact AAPA staff:
Daniel Pace, AAPA Senior Director of Education, 571-319-4419, firstname.lastname@example.org
Alison Moore, PA-C, MSHS, AAPA Senior Manager of Education, 571-319-4413, email@example.com