Maintenance of Certification Program Evaluation Phase 2. Executive Summary

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1 Maintenance of Certification Program Evaluation Phase 2 Executive Summary Prepared by Craig M Campbell MD FRCPC Director, Office of Professional Affairs In collaboration with Expert Panel Advisory Working Group Dr. Jocelyn Lockyer Associate Dean, Continuing Medical Education and Professional Development, University of Calgary Dr. Elizabeth Wenghofer Assistant Professor, School of Rural and Northern Health, Laurentian University Ms. Lynda Buske Dr. Glenn Regehr Dr. Gavin Stuart Dr. Bernard Marlow Dr. Réjean Laprise Dr. Susan Brien Ms. Jennifer Gordon Director of Workforce Research, Canadian Medical Association Associate Director, Centre for Health Education Scholarship, University of British Columbia Dean, Faculty of Medicine, University of British Columbia Director, Continuing Professional Development, CFPC Research and Development, FMSQ Associate Director, Office of Professional Affairs, RCPSC Manager, Continuing Professional Development & Membership Services, RCPSC

2 Introduction A formal program evaluation strategy for the Royal College of Physicians and Surgeons of Canada s Maintenance of Certification program was initiated in January 2007 and designed as a series of interconnected and overlapping phases. This report summarizes the quantitative and qualitative data from an electronic and paper survey developed to obtain direct feedback from Fellows on their perceptions and experiences with the MOC program. The survey was designed to address the following questions: 1. What motivates or impedes Fellows of the Royal College to participate in the MOC program? 2. What are the perceptions of Fellows regarding the MOC program s current standards and educational processes? 3. What aspects of the MOC program are important or valued for professional practice? 4. What gaps exist in the MOC program s ability to promote learning in practice? 5. What are Fellows views regarding the future development of the MOC program? 6. What additional learning strategies and innovations would enhance the relevance of the MOC program for Fellows? An expert panel advisory working group served as a resource in the design, development of the survey instrument and the analysis of the findings. A communication advisory working group was created to recommend strategies to enhance participation in the survey process. The final web-based survey, launched on October 8, 2008, included 10 questions with a standardized 5-point rating scale. The paper (mail-in) survey was distributed shortly after the electronic survey launch. Demographic Characteristics of Respondents A comparison between the demographic variables of Fellows who completed the electronic and mail-in surveys in comparison to the component of the Royal College membership required to participate in the MOC program is summarized in Appendix A. Survey Response Rate 2,592 electronic and 322 paper surveys were completed for an overall response rate of 9.3%. Given the total number of items, the response rate was deemed adequate for the purposes of developing conclusions and establishing future strategic directions. Descriptive Analysis Summaries The number of responses, minimum, maximum, mean, standard deviation, and percent of positive responses for each item in the electronic survey is summarized in Appendix B and for the mail-in surveys in Appendix C. The variation around the mean number of positive responses for the electronic survey responses was analyzed 2

3 using five demographic variables: language (French and English), geographical location of practice (regions in Canada, US, international), year of graduation from medical school, specialty (divided into 11 groups) and gender. Variations of >10% from the overall mean positive response were considered significant. A series of histograms describing all significant variations in positive response rates are summarized in Appendix D. Variation in the frequency of positive responses was influenced the most by geographic location of practice (51 times), specialty (41) and year of graduation from medical school (27). The mean and percent of positive responses (response 4 or 5 on the 5-point rating scale) for the electronic and paper surveys were compared and summarized in Appendix E. Finally, the findings from the qualitative analysis (coding nodes and thematic analysis) are summarized in Appendix F. Overall Results Motivation to participate in the Maintenance Certification program was driven primarily by internal factors: remaining up-to-date (4.43); CPD as a personal professional responsibility (4.40) and maintaining fellowship (4.19), rather than by regulatory requirements or peer pressure. These findings provide support for the educational philosophy and goals of the MOC program reflecting the importance Fellows place on lifelong learning as members of a knowledge intensive selfregulated profession. Attending conferences and courses (4.56), learning when caring for or treating patients (4.55), teaching others (4.37), and participating in rounds or journal clubs (4.25) were deemed the most helpful activities in enhancing behavior or performance. The greatest barriers to participation in the MOC program were workload (3.75) and lack of time (3.74). These findings are consistent with the excessive strain the health system has placed on the professional practices of physicians and how learning activities must be embedded within this context. Fellows appreciated the opportunity to receive cycle extensions (3.95) and there was general agreement that the 5 year cycle duration was appropriate (3.83). However, Fellows were neutral (3.16) that the activities included within the six sections of the MOC program reflected how they learned. The limits placed on reading were a strong and consistent concern. The strongest level of agreement regarding MAINPORT related to the ease of reviewing the credit summary (4.09), accessing the activity summary (4.04) with more modest agreement regarding the ability to confirm reported activities (3.81) and make revisions to activities in MAINPORT (3.72). The lowest levels of agreement related to the inclusion of CanMEDS roles within Pro-File (3.03) and the respondents indicated that the outcome boxes did not easily reflect what was learned (3.21). The provision or development of accredited self-assessment programs (3.67) and practice assessment strategies or tools (3.57) received the highest ratings as future 3

4 strategic directions for the program. However, there a significant rejection of mandating any learning activity with the possible exceptions of enhancing webbased group learning (3.36) and attending a specialty meeting once per cycle (3.31). There was a strong rejection of mandating recertification examinations (2.03), demonstrating improved patient outcomes (2.42), or for engaging in any self-learning or assessment strategies. There was significant agreement that credits should be provided for preceptorships and teaching (4.34), designing educational or clinical tools (4.23) and curriculum development (4.15). Finally there was significant agreement that the MOC program should support the automatic transfer of participation in group learning activities (4.04), simplify the number of templates used to document learning activities in MAINPORT (3.99) and modest agreement that strategies to enhance the documentation of outcomes of learning (3.69) should be pursued. Conclusions or Recommendations The quantitative findings described above and the rich commentary included within the qualitative results supports the following conclusions (themes) and recommendations. Theme 1: Clarify the philosophy and reduce the complexity of the MOC program There is a clear perception that the MOC program has too many items to remember too many sections. This complexity makes it difficult for Fellows to know how to categorize what I do within the MOC classifications. Some Fellows expressed support that the general principle [of the MOC program] is good and noted that demonstrating active MOC [participation] is a minimum standard that society can expect from us and the MOC program provides an organized format and encourages [CME/CPD and lifelong learning] amongst specialists, which makes our profession unique. However, many other Fellows continue to question the evidence the program ensures the development of competence and expressed their lack of enthusiasm for a process that is not evidence-based. Addressing the perceptions that the MOC program is inflexible, bureaucratic and is not based on evidence will promote the value of the MOC program as a member benefit. Recommendations: 1. Summarize and disseminate evidence from the continuing professional development research literature regarding the validity and effectiveness of learning activities included within the MOC program. 2. Simplify the MOC program structure by eliminating the six sections and creating three learning streams: group learning, self-learning and assessment. 3. Develop a multi-faceted educational strategy to explain the educational philosophy, principles and goals of the MOC program, the evidence that underlies its development, and address the misperceptions expressed about the program. 4

5 Theme 2: Simplify the documentation of activities and outcomes in MAINPORT Many Fellows commented that MAINPORT must evolve to make it clear, concise and intuitive. The burden and complexity of documenting learning activities resulted in Fellows consistently urging the College to streamline the process of reporting. The burden of documenting learning activities and outcomes in MAINPORT was multifactorial and included a lack of interest, failing to remember to enter activities or not develop[ing] the habit of regularly reporting except in a sporadic fashion, and lack of computer literacy. These perspectives were coupled with the perceptions that the user interface and documentation templates on MAINPORT were deemed by many as intimidating and not user friendly. As a result, Fellows reported that 50% of learning goes undocumented and I use MAINPORT to document the minimum number of hours to complete a cycle. I generally chose items that are easily documented. Included within the many practical and constructive suggestions for revisions to the documentation templates were eliminating confusing jargon, revising the restrictiveness of the drop down menus (for example the outcome boxes), providing more space to document, and the development of the option for partial credits. The clear and predominate message was to make the process simpler, as easy as the folder in my drawer and enable automatic transfer of activities to make it easier to submit credits. This direction to simplify the documentation process presents a dilemma that the format for registering activities can be distinct from the patterns of learning in solving diagnostic problems. The data support the perception that many Fellows view the MOC program as a documentation of learning process (which could be made far simpler) and not a learning enhancement program. Re-designing MAINPORT to meet the goals of being an effective documentation platform will require consideration of additional education strategies and technical tools to enhance and support the learning process. Recommendations: 4. Simplify the documentation process to focus on essential elements that support reflection on learning and the identification of learning outcomes for practice. 5. Accelerate the development of strategies to support the automatic transfer of documentation of participation in group learning activities (rounds and conferences), self-assessment programs and simulation directly in MAINPORT. 6. Re-build MAINPORT within the CRM/Portal project as part of phase 2 Business Transformation to leverage portal technologies for implementation in mid Create one documentation template for each learning stream within the revised MOC program. 8. Simplify the language, drop down menus and introduce strategies for partial credits. 9. Actively explore the integration of hand held devices (blackberry, i-phone) as part of the learning / documentation process within MAINPORT. 10. Complete a review of the structure and cost of existing e-learning portfolios that are compatible with MAINPORT to enable Fellows to describe their scope of practice, develop CPD plans and document reflections on practice. 5

6 Theme 3: Create a regional continuing professional development support network. The need for more education and support to understand MOC program and use the MAINPORT system more effectively was a common concern. Fellows expressed the criticism that it would have been helpful if we had received training or education as to how best to utilize the system. There is no useful documentation on how to use this program. I am not aware of any effort made by the Royal College to actually instruct its members on how to use MAINPORT or what the MOC program entails. The current barriers to participation in learning activities and the complexity of the documentation process support the need to implement a broad based educational and development strategy. In addition, despite the inclusion of a broad range of learning activities within the MOC program, many Fellows with limited scopes of practice, non-clinical professional roles, and academic specialists expressed their frustration regarding their difficulty in linking their learning to the MOC credit system. Given the findings and proposed recommendations within theme 1 and 2 represent a significant transformative change to the MOC program, MAINPORT and the MOC credit system, there is a critical need to create an educational CPD support network to facilitate understanding and acceptance of the transformative changes being proposed. Recommendations: 11. In collaboration with the regional advisory committees (RAC), the faculties of medicine and the national specialty societies, design and implement a regional continuing professional development education support strategy utilizing, where applicable, existing educational networks (for example community hospitals). 12. Leverage regional CPD networks to proactively respond to the needs of Fellows and provide education and coaching on strategies and tools on aspects of lifelong learning. 13. Create a certificate program based on the exemplary curriculum on lifelong learning already developed based on the CanMEDS Scholar Role. Theme 4: Complete a revision to the MOC program credit system There was strong support for providing additional credits linked to participation in scholarly activities, reading divorced from structured learning projects and other e- self learning strategies. Many expressed the view that journal reading is still an important way to maintain competence or develop skills/knowledge. Despite frequent comments regarding the need to increase the rigor of the program there was strong rejection for the implementation of recertification examinations or mandating any educational activity or requirement. Mandatory requirements were viewed by the vast majority as an unrealistic intrusion into the practice life of Fellows and that the College should not implement any proscriptive or specific requirements with the MOC [program] other than ensuring that Fellows are demonstrating [a] commitment to lifelong learning. 6

7 Recommendations: 14. Develop and implement a strategy to significantly incentivize the MOC program s credit system within individual streams included in the MOC program. 15. Eliminate section 2 and include journal reading (divorced from personal learning projects) within the self-learning stream. 16. Develop a partial credit system for reading linked to the completion of a reflective assessment tool and/or the documentation of outcomes. 17. Work collaboratively with the faculties of medicine and National Specialty Societies to promote the development of CPD assessment strategies (see Theme 5 below). Theme 5: Expand assessment strategies within MOC program. Despite the lack of availability of accredited self-assessment programs or performance metrics across a significant number of specialties, these strategies were not deemed to be limitations to participation in the MOC program. This finding may relate to the fact that the MOC program has not established any minimal expectations or mandated Fellows to participate in specific activities to successfully complete the program s requirements. However, given the lack of accuracy of physician self-assessment skills separate from a defined process or guided by data, there was modest agreement for the importance of the MOC program creating more self-assessment programs and practice assessment strategies and tools in the future. Promoting assessment strategies will enhance the ability of the program to evolve from being process oriented to outcome oriented based on metrics that establish the program s validity or objectivity. Some Fellows expressed the view that the program needed to be based on direct empirical evidence of how we are doing to address the concern that the program is another measure of mediocrity. The implementation of Physician Revalidation, with its emphasis on engaging in learning linked to competence performance in practice, raised concern about the need to control our destiny or society will correctly demand our autonomy due to societal irresponsibility. Finally, the limited understanding of the relevance of the CanMEDS framework in promoting competence as a measureable outcome of the learning process must be developed to address the perspective that CanMEDS is not the least bit helpful when considering my CPD. Recommendations: 18. Enhance the accreditation and development of self-assessment programs. 20 Promote simulation as a strategy to promote competence assessment within multiple CanMEDS Roles. 21 Develop strategies that enable any Fellow to assess their performance or practice with as an individual, a member of an inter-professional health team, or community. Once developed these strategies will form the basis for the implementation of mandatory practice assessment within 2 years (2012). 22 Create an invitational conference to review the evidence and strategies for performance assessment of physicians within the MOC program in late Fall

8 23 Develop a consensus conference of national specialty societies, CME offices, and other interested stakeholders in spring 2010 to discuss the implementation of assessment strategies within the MOC program. 24 Strengthen the link between the MOC program and CanMEDS by exploring the development of a competency based approach to lifelong learning and continuing professional develop of Fellows. Conclusions Phase 2 of the Maintenance of Certification program evaluation is the first comprehensive review of our Fellows experiences, perspectives and recommendations related to the Maintenance of Certification program and Mainport. The themes and proposed recommendations included within this Executive Summary were developed from and based on the quantitative and qualitative responses of a representative sample of Fellows of the Royal College of Physicians and Surgeons of Canada. These themes establish important strategic directions for the Maintenance of Certification program, the MOC credit system and Mainport. In the coming months strategies to engage our Fellows, the Faculties of Medicine, National Specialty Societies, the Federation of Medical Specialists of Quebec, provincial and territorial regulatory authorities and other relevant CPD organizations will be implemented to ensure there is opportunity to provide further feedback and perspectives on the relevance and importance of each theme and recommendation. Craig M Campbell MD FRCPC Director, Office of Professional Affairs The Royal College of Physicians and Surgeons of Canada Please send your comments and reactions to 8

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