A.    The ecology of the Program should be described.

 

1.      The mission of the program should identify:

a.      A commitment to assessing and educating individual physicians who may have been referred by a regulatory/disciplinary agency or whose clinical competence has been questioned;

b.      A commitment to a comprehensive assessment of the elements of physician competence (knowledge, clinical reasoning, patient care documentation, communication and other areas as determined by the program);

c.       A commitment to the provision of prescriptive/remedial education that identifies specific expected improvements in the individual physician’s practice.

 

2.      The program should be able to provide written information about the following:

             a. The administrative structure within which the program operates, and its formal relationships with other organizations;

             b. The confidentiality policies of the program as well as any agreement between the physician-participant and the program;

      c. The fiduciary responsibilities of the program with respect to reporting requirements to provincial/state licensing authorities and other organizations.

 

3.       The program should be able to document that the physician-participant has been made aware of and/or has received copies of the written information noted above.

B.    The Program should assess the competence and/or performance of an individual physician to identify his/her educational needs.

 

      1. The program should assess the physician-participant’s educational needs independently, not depending solely on information provided by the physician-participant or the referring agent.

 

      2. If substandard patient care may be a concern, the assessment should evaluate the physician-participant’s care of patients in a specific clinical context as well as within the broader scope of the physician’s area of practice.

 

3.      If an organization and/or regulatory agency has referred the physician for assessment, the program should be able to provide an evaluation of the individual physician’s performance that may assist the referrer in determining whether:

a.      The physician can safely remain inor return to independent clinical practice;

b.      What, if any, education activities may be recommended to improve the physician’s clinical performance.

 

4.      The program should have the capacity to assess or to evaluate data relevant to the ACGME/ABMS Competencies or international equivalents. The program should have the capacity to assess for relevant contributory factors such as health status and neuropsychological issues.

 

5.      Inferences drawn from the assessment results must take into account the accuracy, reliability, and reproducibility of the tests.

C. The Program should have the capacity to design a goal-directed educational intervention to address the competency and/or performance assessment findings for the individual physician-participant.

 

1.      Evaluation of assessment results should determine if an educational intervention is indicated.

 

2.       When an educational intervention is appropriate, the program should have the ability to develop a learning plan that meets the identified learning needs and establishes specific educational goals for the physician-participant.

 

3.       When an educational intervention is appropriate, the program should have the capacity to recommend and/or develop feasible educational activities that meet the educational needs of the physician as reflected in the goals set by the education plan.

D.   The Program should have the capacity to develop, implement and monitor the learning activities of the physician as he/she participates in an individualized educational intervention focused on the areas of educational need identified in the competence and/or performance assessment.

 

       

1.      An inventory of available educational resources should be maintained.

 

2.      When requested, the program shall determine the extent to which:

 

a.      Educational activities are addressing the specific educational needs of the physician-participant;

b.      The physician-participant is participating in and in compliance with the educational intervention activities, and

c.       The physician-participant is meeting his/her identified educational objectives.

 

3.      The program should be able to evaluate the individual participant’s change/improvement in competence and/or performance in order to determine the effectiveness of education intervention in addressing the physician’s identified educational needs.

E. The Program should maintain individual reports and appropriate records for all phases of the competence and/or performance assessment and educational process.

 

1.      Physician-participants and referring organizations (as authorized) shall receive formal reports from the program:

a.      After assessment;

b.      Periodically during the educational phase;

c.       At the completion of the educational activities, and

d.      On reassessment.

 

2.      Individual records that document the progress of each physician-participant should be maintained.

F. The Program should use both self-study (internal) and external review.

 

1.      At least every five years, the program should conduct a self-study to determine the extent to which its mission is being met.

 

2.      At least every five years, the program should be the subject of external review by peers who are experts in personalized assessment and education.

 

G. The Program should maintain a process for professional development of faculty and staff.

 

H. The Program has implemented a mechanism to measure, and increase, its effectiveness in conducting comprehensive competence and/or performance assessments of individual physicians and in providing education interventions.