iccp - maintaining standards

8/8/2019 ICCP - Maintaining Standards

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Maintaining StandardsMaintaining StandardsGraham NewsteadGraham Newstead

Chairman ICCPChairman ICCP


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Maintenance of.. What?Maintenance of.. What?

Standards:Standards: Activity within defined parametersActivity within defined parameters

I behave as they want me toI behave as they want me to (and as I think(and as I thinkappropriate)appropriate)

v.v.

Competence:Competence: Quality and safetyQuality and safetyAm I (still) good enough? (i.e. safe)Am I (still) good enough? (i.e. safe)

v.v.

Certification:Certification: Examined and reExamined and re--credentialedcredentialedSomeone has actually checked me out again (?OK)Someone has actually checked me out again (?OK)


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Standards: LIFE STAGESStandards: LIFE STAGES

TRAINING:TRAINING:LearningLearning

EXAMINATION:EXAMINATION: ProofProof

PRACTICE LIFE:PRACTICE LIFE: RefinementRefinement

RERE--CREDENTIALING:CREDENTIALING:

ReassuranceReassurance


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Components of StandardsComponents of Standards

Medical knowledgeMedical knowledge

Patient carePatient care (but compassionate!)(but compassionate!)

Interpersonal & communication skillsInterpersonal & communication skills

ProfessionalismProfessionalism (a profession, not an occupation!)(a profession, not an occupation!)

**Skill &SkillsSkill &Skills

PracticePractice--based learning & improvementbased learning & improvement

Audit, appraisal & assimilation of scientific evidence,Audit, appraisal & assimilation of scientific evidence,Demonstrably improved patient careDemonstrably improved patient care

SystemsSystems--based practicebased practice

Aware of, and responsive to, entire health systemAware of, and responsive to, entire health system

Able to call on system resources for optimal careAble to call on system resources for optimal care


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Maintenance requires EvidenceMaintenance requires Evidence

ofofProfessional standingProfessional standing

Commitment to lifelong learningCommitment to lifelong learning

CME and (?)SelfCME and (?)Self--AssessmentAssessment and / orand / or

Cognitive expertiseCognitive expertiseClosed book examinationClosed book examination

Evaluation of performance in practiceEvaluation of performance in practice

?How?How


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Standardising CriteriaStandardising Criteriafor:for:

Training, Examination & CredentialingTraining, Examination & Credentialing

Minimum Standards:Minimum Standards: Developing CRSDeveloping CRSservicesservices

Developing countriesDeveloping countries

Best Practice:Best Practice: General SurgeryGeneral Surgery

Developed countriesDeveloped countries

(Gold) Standards:(Gold) Standards: ColorectalColorectalsurgeonssurgeons

Established specialty programsEstablished specialty programs


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Colorectal Surgeons:Colorectal Surgeons:

Who are we credentialing?Who are we credentialing?

AcademicAcademic Teaching HospitalTeaching Hospital District HospitalDistrict Hospital Dedicated puristDedicated purist General Surgeon with an (strong)General Surgeon with an (strong)

interestinterest Trainee FellowsTrainee Fellows Surgeons in developing programmesSurgeons in developing programmes


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CredentialingCredentialing

forColorectal SurgeonsforColorectal Surgeons

TrainingTraining Assessment or Exams?Assessment or Exams?

ReRe--credentialing:credentialing: Many options!Many options!

KnowledgeKnowledge v.v. ExperienceExperience

CaseCase--load, Skills, Literature, Evolutionload, Skills, Literature, Evolution

WindingWinding--downdown v.v. RetirementRetirement

SoloSolo v.v. Group PracticeGroup Practice


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Training & CredentialingTraining & Credentialingaround the worldaround the world

ABCRS/ASCRSABCRS/ASCRS

CSSA/RACSCSSA/RACS

ACP GBIACP GBI

EBSQEBSQ

OtherOther

Role of International Council ofRole of International Council ofColoproctologyColoproctology


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ABCRS ProposalABCRS Proposal(current draft)(current draft)

Professional StandingProfessional Standing submitted every 5submitted every 5yearsyears

Full unrestricted medical licenseFull unrestricted medical licenseHospital privileges to practice CR surgeryHospital privileges to practice CR surgery

Recommendation from Chief ofStaff atRecommendation from Chief ofStaff atprimary hospitalprimary hospital

Lifelong Learning &Self AssessmentLifelong Learning &Self Assessment3 year blocks3 year blocks

100 hours of CME100 hours of CME

CARSEPCARSEP

Maintenance of CertificationMaintenance of Certification


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ABCRS ProposalABCRS Proposal(current draft)(current draft)

Cognitive KnowledgeCognitive Knowledge

Every 10 yearsEvery 10 years

Recertification examRecertification examOperative procedure logsOperative procedure logs

Assessment of Practice PerformanceAssessment of Practice Performance

Every 3 yearsEvery 3 yearsPatient survey:Patient survey: 15 questions from each of 2015 questions from each of 20

patientspatients

Document participation in a qualityDocument participation in a quality

assessment & improvementassessment & improvement



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When?When? 20062006

(Assuming ABMS approves ABCRS proposal)(Assuming ABMS approves ABCRS proposal)

Who?Who?

Diplomates reDiplomates re--certifying in 2006 will start cyclecertifying in 2006 will start cycle

ofof M.O.C. and so on.M.O.C. and so on. (Uh! Oh!)*(Uh! Oh!)*

All residents certifying after 2006 will start theAll residents certifying after 2006 will start theM.O.C. process immediately.M.O.C. process immediately. (Oh boy!)*(Oh boy!)*

Diplomates with nonDiplomates with non--timetime--limited certificateslimited certificateswillwill bebe encouragedencouraged to participateto participate

and will beand will be issued additionalissued additionalcertificates based on thecertificates based on the M.O.C.M.O.C.process!process! (Phew!!)*(Phew!!)*

*Emphases with gratitude to Jim Fleshman, ABCRS

*Emphases with gratitude to Jim Fleshman, ABCRS



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ABCRSABCRS (Summary)(Summary)

Medical knowledge:Medical knowledge: Written exam every 10 yearsWritten exam every 10 yearsEvery 5 years:Every 5 years:

Patient care:Patient care: Outcome data & patient surveyOutcome data & patient survey

Interpersonal & communication skills:Interpersonal & communication skills:Patient surveyPatient survey

Professionalism:Professionalism: Patient survey & reference lettersPatient survey & reference letters

**[[Skills:Skills: No specific testing parameters plannedNo specific testing parameters planned]]

PracticePractice--based learning & improvement:based learning & improvement:

CME requirements, CARSEP,CME requirements, CARSEP, **Outcome dataOutcome data

SystemsSystems--based practice:based practice:

**Outcome data & patient surveyOutcome data & patient survey

Maintenance of Certification (=Standards)Maintenance of Certification (=Standards)


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United KingdomUnited Kingdom

ACPGBI working with EBSQ towards anACPGBI working with EBSQ towards anassessment in coloproctologyassessment in coloproctology

Issues undergoing fairly rapid change in the UKIssues undergoing fairly rapid change in the UK

Biggest problem is gaining recognition fromBiggest problem is gaining recognition fromstatutory bodies that traditional general surgerystatutory bodies that traditional general surgery

has pretty much disappearedhas pretty much disappeared..

Acknowledgement: Jim Hill, ACPGBIAcknowledgement: Jim Hill, ACPGBI


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TrainingTraining

PBAsPBAs (Personal behaviour analyses:(Personal behaviour analyses:standardised criteria for management & surgery)standardised criteria for management & surgery)developed with for JCHST (with assistance ofdeveloped with for JCHST (with assistance of

ACPGBI), but apply to general surgical traineesACPGBI), but apply to general surgical trainees Surgical Advisory Committee ofRCS accreditsSurgical Advisory Committee ofRCS accredits

units and ACPGBI recognises them (but ACPGBIunits and ACPGBI recognises them (but ACPGBIdoesnt have infrastructure to visit units)doesnt have infrastructure to visit units)

ACPGBI is introducing trainee assessment formsACPGBI is introducing trainee assessment forms

ACPGBI does not credential traineesACPGBI does not credential trainees

Recommended Colorectal Curriculum based onRecommended Colorectal Curriculum based onACPGBI syllabus (=ABCRS syllabus)ACPGBI syllabus (=ABCRS syllabus)


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ExaminationsExaminations

Current Intercollegiate Examination in GeneralCurrent Intercollegiate Examination in Generalsurgery considered inadequate for specialtysurgery considered inadequate for specialty(CRS)(CRS)

Existing Statutory Examination bodies are notExisting Statutory Examination bodies are notkeen/able to give ACPGBI examination rightskeen/able to give ACPGBI examination rights

Examinations have to meet PMETB standardsExaminations have to meet PMETB standards

An ACPGBI examination will require eligibilityAn ACPGBI examination will require eligibility

criteria to be met (e.g. time in units, numbers ofcriteria to be met (e.g. time in units, numbers ofcases, etc)cases, etc)

Examinations Blueprint recently developedExaminations Blueprint recently developed

Collaborating with Division of CP, UEMS & ICCPCollaborating with Division of CP, UEMS & ICCP


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Credentialing and StandardsCredentialing and Standards

Credentialing being introducedCredentialing being introduced

Quality standards for colonoscopyQuality standards for colonoscopy

determined and trainees required todetermined and trainees required tofollowfollow themthem (JAG guidelines)(JAG guidelines)

Credentialing will start to occur forCredentialing will start to occur for

colorectal & anal cancer via Cancercolorectal & anal cancer via CancerNetworksNetworks (established last 3 years)(established last 3 years)


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Maintenance of StandardsMaintenance of Standards

and Reand Re--CredentialingCredentialing

Only being addressed for colonoscopy andOnly being addressed for colonoscopy andvia Cancer Networks, not yet looking atvia Cancer Networks, not yet looking at

outcomesoutcomes

Will occur only after feeling that trainingWill occur only after feeling that trainingprocess is now rightprocess is now right

Recognised need for consistent standardsRecognised need for consistent standardsthroughout the world, using ASCRS asthroughout the world, using ASCRS asworking modelworking model


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EuropeEurope EBSQ:EBSQ: HG, DeHG, De

7 years Gen Surgery7 years Gen Surgery

2 years CRS in >1 hospital and with >1 mentor2 years CRS in >1 hospital and with >1 mentor

400 procedures required400 procedures required

Most European countries have specialty Societies of CRSMost European countries have specialty Societies of CRS

Lithuania: recognises Colorectal surgical specialisationLithuania: recognises Colorectal surgical specialisation

Hungary: 6 months training in CRSHungary: 6 months training in CRS

Germany: one year in Proctology (3 Societies)Germany: one year in Proctology (3 Societies)

Ireland: 2 years in CRSIreland: 2 years in CRS

Sweden:Sweden: LP, SvLP, Sv

22ndnd monthly regional CR discussionsmonthly regional CR discussions

Attend larger Units to ensure exposureAttend larger Units to ensure exposure

3 Years of theoretical exposure + operative skills3 Years of theoretical exposure + operative skills

Good standard of CR surgeryGood standard of CR surgery

Not formalisedNot formalised


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EUROPEEUROPE

EBSQEBSQ

UEMS, Section ofSurgeryUEMS, Section ofSurgery EBSQEBSQ Meets with ESCPMeets with ESCP (EACP / ECCP)(EACP / ECCP) Accreditation process: SAccreditation process: Submission ofubmission of

specifiedspecified criteria and Exams: written, academiccriteria and Exams: written, academic

and clinicaland clinical85 CRS accredited throughout Europe85 CRS accredited throughout Europe over past 5 yearsover past 5 years

Conflict between national regulationsConflict between national regulations No accreditation process for units as yetNo accreditation process for units as yet

Awaiting international guidelinesAwaiting international guidelines

Trying to:Trying to:identify training units for accreditationidentify training units for accreditation

develop standardiseddevelop standardised trainingtraining criteriacriteria

Acknowledgement: Lars Pahlman, EBSQAcknowledgement: Lars Pahlman, EBSQ


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Asia and LatinAsia and Latin--AmericaAmerica

AFCPAFCP:: 22ndnd yearly meetingsyearly meetings FSFS--CC China: emerging rapidlyChina: emerging rapidly

India: one major Unit only; lots of interestIndia: one major Unit only; lots of interest

Japan & Korea: many Units; established SocietyJapan & Korea: many Units; established Society

Singapore: CRS not recognised as specialtySingapore: CRS not recognised as specialty

(by Govt. or(by Govt. or Med Council); excellent specialty UnitsMed Council); excellent specialty Units

ALACPALACP:: Most countries have Coloproctology SocietiesMost countries have Coloproctology SocietiesAHAH--GG

Brazil: 1400 members; 39 residency programs, 114 residentsBrazil: 1400 members; 39 residency programs, 114 residentspa; Gen Surg 2 years, CRS 2 years, Fellowship 1 year:pa; Gen Surg 2 years, CRS 2 years, Fellowship 1 year:CertificationCertification

(Also 1700 Digestive surgeons)(Also 1700 Digestive surgeons)

Sao Paulo: provide legal advice and reduce variability ofSao Paulo: provide legal advice and reduce variability ofresultsresults

Litigation: 66% anoLitigation: 66% ano--rectal; >90% inadequate experience; 70%rectal; >90% inadequate experience; 70%not Board certifiednot Board certified


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CollaborationCollaborationExamplesExamples

ABCRSSyllabusABCRSSyllabus Basis ofBasis ofACP GBIACP GBISyllabusSyllabus

ASCRS PracticeASCRS Practice Adopted by CSSAAdopted by CSSAParametersParameters

etc..etc..


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International Council ofColoproctologyInternational Council ofColoproctology

ICCPICCP

Develop standardised guidelines for TrainingDevelop standardised guidelines for Trainingprogramsprograms

Collaborate to share optimum maintenance standardsCollaborate to share optimum maintenance standards

47 countries with National Societies of Coloproctology47 countries with National Societies of Coloproctology4 International Federations of Coloproctology4 International Federations of Coloproctology

Develop universal minimum standardsDevelop universal minimum standards

154 countries without specialty Coloproctology154 countries without specialty Coloproctology

Provide scholarships & Exchange training programmesProvide scholarships & Exchange training programmes

Database:Database: Societies, Training, Scholarships, MeetingsSocieties, Training, Scholarships, Meetings

Communication, Facilitation, and OutreachCommunication, Facilitation, and Outreach


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(NSW)(NSW) Medical BoardMedical Board

Code of Professional Conduct:Code of Professional Conduct:

Good Medical PracticeGood Medical Practice

Standards:Standards:

Clinical Competence & Performance 4:20Clinical Competence & Performance 4:20 Professional & EthicalProfessional & Ethical 11:6111:61

Relationships with ColleaguesRelationships with Colleagues 5:235:23

ProbityProbity 5:165:16TotalsTotals 25:12025:120


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RACSRACS

Surgical CompetenceSurgical Competence

ATTRIBUTES:ATTRIBUTES:

Medical expertiseMedical expertise

Technical expertiseTechnical expertise

JudgementJudgement CommunicationCommunication

CollaborationCollaboration

Management & LeadershipManagement & Leadership

Health AdvocacyHealth Advocacy

Scholar &

Teacher

Scholar &

Teacher

ProfessionalismProfessionalism

DEMONSTRATED AS:DEMONSTRATED AS:

CognitiveCognitive

IntegrativeIntegrative

PsychomotorPsychomotor RelationalRelational

Affective & MoralAffective & Moral


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RACSRACS

Code ofConductCode ofConduct

Good Patient CareGood Patient Care

Maintenance of Professional StandardsMaintenance of Professional Standards

Professional RelationshipsProfessional Relationships

Responsibility in Teaching, Training &SupervisionResponsibility in Teaching, Training &Supervision

ResearchResearch

Business & Commercial responsibilitiesBusiness & Commercial responsibilities

The Surgeons responsibility to SocietyThe Surgeons responsibility to Society

Sections: 7Sections: 7Standards: 21Standards: 21Musts &Shoulds: 192Musts &Shoulds: 192


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AustraliaAustralia

CSSA / RACS: PoliticsCSSA / RACS: Politics

SectionSection historyhistory SocietySociety development (11/88)development (11/88) Mark Killingback & Graham NewsteadMark Killingback & Graham Newstead Training programmeTraining programme conjointly with Sectionconjointly with Section

Jack Mackay, Jim Sweeney, Andy McLeishJack Mackay, Jim Sweeney, Andy McLeish

Training BoardTraining Board within RACS structure:within RACS structure:Phil DouglasPhil Douglas MOUMOU with RACSwith RACS

Mike Solomon, Ian JonesMike Solomon, Ian Jones

?Board ofTraining?Board ofTraining &Standards&Standards:: Whole of Life TrainingWhole of Life Training

+ Integrated Training Programme+ Integrated Training Programme Bruce WaxmanBruce Waxman Credentialing:Credentialing: Training Board assessments and ExaminationsTraining Board assessments and Examinations ReRe--credentialing:credentialing: CPD or Examination?CPD or Examination? FCSSA:FCSSA: Required criteriaRequired criteria


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AustraliaAustralia

CSSA:CSSA:

Criteria to Maintain CRCriteria to Maintain CRFellowshipFellowship StandardsStandards

Membership Criteria:Membership Criteria:Commitment to CRSCommitment to CRS

Majority of practice in CRSMajority of practice in CRS

Recognised period of training in CRSRecognised period of training in CRS

Hospital Appointment as CRSHospital Appointment as CRS

Maintain RACS CPDMaintain RACS CPD

National database participationNational database participationReRe--certification examination processcertification examination process

ReRe--credentialing process 5 yearlycredentialing process 5 yearly (Details in(Details inpreparation)preparation)


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MusingsMusings

What happened to the Hippocratic Oath?What happened to the Hippocratic Oath?(not cutting unnecessarily for the stone)(not cutting unnecessarily for the stone) Whats wrong with theWhats wrong with the Golden Rule?Golden Rule?

(do unto others)(do unto others)

Selection processesSelection processes for:for:Students, Surgical Trainees and Colorectal Fellows:Students, Surgical Trainees and Colorectal Fellows:

Do we have it right? Clearly not!Do we have it right? Clearly not!Then how should we do it & who should we choose?Then how should we do it & who should we choose?

[Difficult choice: Old school tie or Female, beautiful, 30][Difficult choice: Old school tie or Female, beautiful, 30]History of the Harvard selection processHistory of the Harvard selection process

(Getting In, Malcolm Gladwell, New Yorker, October 2005)(Getting In, Malcolm Gladwell, New Yorker, October 2005)

Why should I have to be reWhy should I have to be re--examined?examined?Majority: No need to review us, were just fine!Majority: No need to review us, were just fine!Minority: The current system sorts them out, (doesnt it?)Minority: The current system sorts them out, (doesnt it?)Some: Why penalise everyone just for those few?Some: Why penalise everyone just for those few?

and.. anyway, its ridiculous; Im so experienced!and.. anyway, its ridiculous; Im so experienced![GLN certainly doesnt need to be re[GLN certainly doesnt need to be re--assessed!!]assessed!!]


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ConclusionsConclusions (reality!!)(reality!!)

Nationally Accredited Training Programs inNationally Accredited Training Programs inColorectal Surgery exist only in the USAColorectal Surgery exist only in the USAand Australia & New Zealandand Australia & New Zealand (thusfar!)(thusfar!)

The assessment / examination process inThe assessment / examination process in

A&NZ is evolutionary (but happening)A&NZ is evolutionary (but happening) Maintenance ofStandards is nowMaintenance ofStandards is now

mandatorymandatory

ReRe--credentialing will inevitably followcredentialing will inevitably follow

CSSA will support reCSSA will support re--credentialing for CRScredentialing for CRS

WeWe should determine the processshould determine the process

We can learn from, and teach, otherWe can learn from, and teach, othercountriescountries

iccp - maintaining standards

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