The National Commission on Certification of Physician Assistants (NCCPA) is implementing 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.
Under the new certification maintenance process, there are two major changes:
- The recertification exam requirement is being extended from every six years to every 10 years.
- PAs will still have to earn 100 CME credits every two years, but two new categories have been 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 AAPA accredited self-assessment and/or PI-CME 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 credits, 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 have questions about these changes, how and when it will affect them, and how it relates to them and their own career path. Here 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 (PDF).
When does this change begin?
For some PAs, the transition to the new certification maintenance process began 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.
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.
To confirm when you will transition to the new certification maintenance process, sign in to your dashboard at www.nccpa.net.
Of note, anyone can now earn and log self-assessment and/or PI-CME credits whether or not they are required for you; they will count toward your 50-credit Category 1 CME requirement.
Also, during the year that you transition to the new requirements, you can begin earning and logging self-assessment and/or PI-CME credits on May 1st – for credit in the new process -- 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 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?
There are several reasons for this change in the PA national certification maintenance process. These include the following:
- 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 Maintenance of Certification (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 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 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, provides the ability to locate and track completion of self-assessment and PI-CME activities.
How do I know if a self-assessment or PI-CME activity will satisfy the new requirements?
Only activities approved by AAPA for self-assessment or PI-CME credit can be logged as such. 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 and satisfy the standards we have established for these new types of activities. One benefit of this single-point approval process is that it is easy to determine whether an activity has been approved since definitive lists of approved self-assessment and PI-CME activities are available on the AAPA website.
What are PI-CME 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 have been established for nearly a decade 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 could mean engaging in educational activities, providing new patient education material, changing the sequence in which you approach routine tasks, or making a simple process change, 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 patient with uncontrolled diabetes?
- Is there a particular subset of your patients who are faring more poorly, adhering less often, or otherwise not benefiting as fully from your care as they should?
- Do you have tools to help you deliver culturally appropriate information to your patient when educating them on health maintenance or a particular condition?
- In your surgical practice, what is the most significant challenge for your patients’ adherence to post-op instructions?
The results from your assessment will provide guidance on what information, resources or tools may be helpful to improve patient outcomes and/or your practice.
AAPA has compiled a list of PI-CME activities that are currently approved for AAPA Category 1 PI-CME credit. There are additional activities that are currently in the review process. The list of approved PI-CME activities will continue to grow.
I have just transitioned into the new 10-year cycle. How soon do I need to complete my PI-CME credits?
Now that you have transitioned into the 10-year cycle, you are eligible to complete and log PI-CME credits during your first 2-year cycle but you are required to complete 20 Credits of PI-CME or self-assessment, or any combination of PI and self-assessment so long as the total is at least 20 credits. You have considerable flexibility in how you choose to implement these requirements.
For many PAs, it may make sense to work on self-assessment first. Consider this strategy if you are not currently in active clinical practice but expect that you might return in the near future, or if you are not satisfied with the relevance of any of the currently available PI-CME options to your area of practice. The catalog of approved PI-CME activities continues to expand, and both the number and diversity of PI-CME activities that will be available in 2 or 4 years’ time will be greater than it is today.
I don’t have continuity of care. Can I still do PI-CME?
It is not necessary to have ongoing responsibility for the care of patients to participate in PI-CME. If you have access (or can collect) data about a process or activity that impacts the quality of patient care, you can do PI-CME. Current topics for PAs who do not have continuity of care include assessing and improving the quality of “handoffs” and of communication related to prescribing. Potential topics include patient safety practices, follow-up related to patient referrals, efficiency of patient care delivery, and timely delivery of discharge. If you have difficulty selecting an activity that is appropriate for you, contact Eric Peterson at 571-319-4407 or firstname.lastname@example.org for assistance.
I’ve looked at the list of approved PI-CME activities, and I don’t see anything that applies to what I do. How am I going to do PI-CME?
Given the diversity of PA practice, it is difficult to find PI-CME activities that fit every practice situation. However, just as in all new fields, the number and diversity of choices will increase over time. If you are not satisfied with the relevance of the choices that are available now, consider emphasizing self-assessment during your first 2-year cycle. By the time you enter the 2nd cycle it is likely that many new topics will have been added to the catalog. There will also be new ways of earning PI-CME.
What is AAPA doing to increase the diversity of PI-CME offerings?
PAs practice across the entire spectrum of medicine and surgery making it a challenge to address every PA practice setting simultaneously. We are aware of gaps and are working with individuals and organizations to stimulate the development of new activities. The following are current initiatives aimed at stimulating new PI-CME activity development:
- Tool Kit: AAPA is working with a group of volunteers to develop a Tool Kit for PI-CME activity developers. This Tool Kit is intended to function as a “how-to” guide for organizations and educators interested in developing original PI-CME activities. The Tool Kit will be published online during the Summer of 2014.
- Specialty Organization Outreach: PA specialty organizations are in the best position to understand the needs of PAs who practice in the specialty they represent. AAPA is working directly with a number of specialty organizations to help them address some of the current gaps.
I am not currently in clinical practice. How will I do PI-CME?
Many PAs no longer see patients but want to retain their certification. PAs who are not clinically practicing or who do not find a relevant PI-CME activity on the list of approved PI-CME activities will be allowed to substitute an approved patient safety or quality improvement course to meet the PI-CME requirement. Several suitable courses have been identified and evaluated, and negotiations are currently underway to secure favorable pricing for PAs who fall into this situation. We hope to make an announcement very soon. Patient safety and quality improvement have been chosen as alternatives because they generally support the practice-based learning and improvement competency and will be relevant to those who have administrative responsibilities, and to those who are temporarily not practicing but will return to a system where these topics are receiving a great deal of attention.
PAEA is currently developing an alternative option designed especially for those who are full-time faculty in PA programs. This activity will focus on the incorporation of the principles and competencies of interprofessional collaborative practice into PA curriculum development and teaching activities and will be available by the time of PAEA’s Annual Conference in October 2014.
However, if the PA’s exit from clinical practice 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 there be other ways to earn PI-CME credits other than the typical online PI-CME module?
Yes! There are at least two new ways of earning PI-CME credits that you can expect to see soon, and they are as follows:
- Institutional Quality Improvement Model: This model is intended for PAs who work in a hospital, health-system, or clinic setting where there is access to quality improvement expertise (i.e. a QI department) and will enable PAs to receive credit for quality improvement activities in which they already participate. This model assumes that the applicant will be the hospital, health-system, or clinic, and that more than one PA would be able to participate. The project will need to have an affiliation with the applicant organization’s quality improvement department. Watch for a new CME application type to appear during the Summer of 2014. We will work with NCCPA to announce this broadly when it is available so you in turn can make your QI department aware of this new opportunity.
- Self-directed Model: This model will allow an individual PA to build his or her own PI project by selecting from a library of approved measures. The entire process will be facilitated online. Because this will require some technology development, we do not expect this option to be available until sometime in 2015.
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?
As discussed above, AAPA will be rolling out a new Institutional Model application during the Summer of 2014 that is intended to cover the situation. The PI-CME requirement is intended to get PAs involved in practice-based improvement. For those PAs who are already involved in quality improvement, our goal is to make sure you get credit for what you are already doing.
What are 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 that provides feedback on your performance and the opportunity to learn from the experience. 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 own personal knowledge gaps exist. It helps you identify where you need CME or additional self-study 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 a list of self-assessment activities that are currently approved for AAPA Category 1 Self-Assessment CME credit. There are many additional activities that are currently in the review process. The list of approved self-assessment activities will continue to grow.
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 and self-assessment. Learning Central is your destination for CME activities to help you meet your certification maintenance requirements.
The new CME requirements started in 2014, and PAs will transition to the new process over the next 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 transitioning to the new requirements for PI-CME and self-assessment credits, any PA can participate in a PI-CME or self-assessment activity and satisfy part of their 50-credit Category 1 CME requirement. Many self-assessment and PI-CME programs are available through other allopathic and osteopathic physician associations and have been approved by AAPA for PA credit. An example of PI-CME is the American Academy of Family Physicians (AAFP) METRIC program, and an example of self-assessment is the American College of Physicians (ACP) Medical Knowledge Self- Assessment Program 16 (MKSAP 16) Digital. Visit AAPA’s website to view the complete list of approved self-assessment and PI-CME activities.
As discussed above, 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 2015. 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 has worked, and is continuing to work, 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.
Can I complete the same self-assessment or PI-CME activity more than once?
Yes, PAs can complete and claim credit for the same self-assessment or PI-CME activity more than once, as long as the activity is completed in different 2-year logging cycles. PAs cannot claim credit for the same activity more than once in the same 2-year logging cycle. Of note, be sure to check with the provider of the CME activity to see if they will allow you to complete the activity more than once; some providers only allow you to complete an activity one time.
For self-assessment and PI-CME activities, do the start and completion dates both have to be within the 2-year cycle in which I am logging the credit?
No, only the completion date has to be between the start and end dates of the 2-year cycle in which you are logging the credit. In other words, it is ok to start a self-assessment or PI-CME activity in one cycle and complete it during the next cycle, as long as you log it during the cycle in which you completed it.
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 has worked and is continuing to work to acquire and develop PI-CME and self-assessment activities. Many of these activities are 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.
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 and pay 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, self-assessment, and the recertification exam provide a meaningful way to engage in the purposeful development and assessment 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 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.
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. Approved self-assessment activities will allow you to do the same thing—to test your knowledge for your own learning and information—and get credit for it.
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 have not yet produced for all PAs?
Both NCCPA and AAPA are committed to making sure that all PAs, including non-practicing 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, in 2013 AAPA established the criteria for designating activities as PI-CME and self-assessment CME—including activities that would be accessible for non-practicing 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 representatives from AAPA and NCCPA. We are continuing to work on the identification and development of a range of PI-CME and self-assessment CME options for PAs in all specialties.
Does PI-CME require statistical expertise and will I need to write a final paper?
No, there is no statistical expertise or specific research skills required. Many activities facilitate the analysis of your data. 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?
PI-CME focuses on the process of improving the consistency with which current standards of care are applied to actual patient care within a practice setting. By contrast, clinical research usually tests the effectiveness of one intervention over another and aims to generate new medical knowledge (i.e. intervention A is superior to intervention B). Because of this distinction, PI-CME and quality improvement are exempt from IRB review. Only those who may want to publish the results of their improvement effort are advised to check with their IRB manager, as an IRB exemption letter may be required by a journal editor.
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.
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.
For more information from AAPA staff, contact:
Eric Peterson, AAPA Senior Director of Performance Improvement CME, email@example.com, 571-319-4407
Daniel Pace, AAPA Senior Director of Education, firstname.lastname@example.org, 571-319-4419
Alison Moore, PA-C, AAPA Senior Manager of Education, email@example.com, 571-319-4413