The following are basic elements and practices that are recommended as components when developing personalized competence and/or performance assessment and education programs.
The characteristics of the Program should be described.
1. The mission of the Program should identify:
a. A commitment to assessing and educating individual physicians who have been referred by a regulatory/disciplinary agency or whose clinical competence and/or performance has been questioned;
b. A commitment to a comprehensive assessment of elements of physician competence as defined in the ACGME/ABMS Competencies or international equivalents (“core competencies”)
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 reporting policies of the Program with respect to release of physician-participant performance data to provincial/state licensing authorities and other organizations.
3. The Program should be able to document that the physician has been made aware of and/or has received copies of the written information noted above.
Competence/Performance Assessment: The Program must provide a comprehensive assessment of an individual physician to identify his/her educational needs or deficiencies that negatively impact the practice of medicine.
1. The Program must have the capacity to assess or to evaluate data relevant to the physician’s abilities as related to the core competencies. The Program must have the capacity to assess or to evaluate data regarding relevant contributory factors such as health status and neuropsychological issues.
2. The Program must assess the physician’s educational needs independently, not depending solely on information provided by the physician or the referring agency.
3. If substandard patient care is a concern, the program should have the capacity to evaluate the physician’s care of patients in the specific clinical context of the concern, as well as within the broader scope of the physician’s practice.
4. The Program must be able to provide an assessment of the individual physician’s performance that may assist the participant and/or the referring agency in determining:
a. Whether the physician can safely remain in or return to independent clinical practice;
b. The physician’s strengths and weaknesses, as well as educational or other needs;
c. Whether an intervention is indicated to improve the physician’s clinical competence and/or performance.
5. The Program should have the capacity to use multiple modalities in the assessment process. Inferences drawn from the assessment results should take into account accuracy and reliability of the modalities.
The Program should have the capacity to design and implement a goal-directed plan to address the assessment findings for the individual physician.
1. When educational needs are identified, the Program should have the ability to develop a learning plan that meets the identified educational needs and establishes specific educational goals for the physician.
2. The Program should have the capacity to monitor the educational intervention.
a. The Program should have the capacity to determine the extent to which:
b. Educational activities are effectively addressing the specific educational needs of the physician-participant;
c. The physician-participant is participating in and in compliance with the educational intervention requirements, and
d. The physician is making appropriate progress toward achieving their educational objectives.
3. The Program should be able to evaluate the individual participant’s change/improvement through a post-test or appropriate evaluation process in order to determine the physician’s successful achievement of his/her educational objectives.
The Program should prepare and maintain individual reports and appropriate records for all phases of the competence and/or performance assessment and educational interventions.
1. The Program must supply physicians and referring organizations (as authorized) formal reports of the assessment results.
a. Physicians and referring organizations (as authorized) should receive formal reports from the Program if applicable:
b. Periodically during the educational phase;
c. At the completion of the educational activities, and
d. On post-testing.
2. Individual records should be maintained for a period of time that is determined by the Program’s policies.
Program Evaluation and Development
1. The Program shall engage in a quality improvement program.
2. The Program should maintain a process for professional development of faculty and staff.
Revised November 2011