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Continuing Competence Initiative

By Mark Lane

The following article was developed from a session given by Mark Lane at the Federation’s 2007 Annual Meeting in Memphis, Tennessee.

Recently, I pulled out an old book that was given to me by my staff at Good Samaritan Hospital in Washington. It included memorabilia including an article I had written when I was Chapter President of the Washington State Physical Therapy Association. I had this great idea that we were going to establish an exam for competence assessment. It was something we really needed. You can imagine how the thought of an exam went over with members of the professional association. I felt like Hillary Clinton recommending healthcare reform back then.

I’ve been working with continued competence for a long time. It’s comparable to the search for the Holy Grail. It’s really an adventure and one of the most difficult challenges that we as regulators face. There is danger in our search for continued competence. There is intrigue. There is mishap. Yet we need to be moving forward into continued competence.

Perhaps it’s not as elusive as we think.

The Citizen Advocacy Center (CAC) had a summit a few years ago in San Francisco. It reported, Patients have every right to assume that a healthcare provider’s license for practice is the government assurance of his or her current professional competence and clinicians themselves would like assurance that those within the practice are current and fully competent.

Unfortunately, assurance of continued competence through relicensure is not the case. Certainly, entry-level competence is critical because that’s the gate to getting into the profession, but we have 15,000 - 17,000 new licensees every year. We also have more than 160,000 licensed practitioners. Once they get licensed, do we just let them go?

The 2003 Institute of Medicine report recommended that all health profession boards should move toward requiring licensed and certified health professionals to periodically demonstrate their ability to deliver patient care as defined by the five competencies identified by the CAC summit - patient-centered care, an interdisciplinary team, evidence-based practice, quality improvement and informatics.

The Citizen Advocacy Center’s vision has several important aspects.

  • There needs to be a regulatory mandate for demonstrating continued competence. It can change practitioner performance for the better and result in safer and higher quality care for the public.
  • There should be collaboration. A broadly-based collaboration of stakeholders is absolutely necessary for an effective continued competence program.
  • The purpose is to assure patient safety and improve the quality of healthcare practice - not to find “bad apples” among practitioners.
  • An evidence-based approach is essential. Research should be initiated that focuses on examining a link between periodic and continued competence, assessment and assurance and changes in behavior that leads to improved clinical outcomes.
  • It’s also the clinician’s responsibility. But continued competence programs should be designed as a positive development of the clinician’s career, not as an unwarranted intrusion or punitive burden. That’s one of the challenges we face.

The CAC developed a five-step model that makes a lot of sense.

  • Develop a routine periodic assessment.
  • Devise a personal plan.
  • Implement the plan.
  • Document the plan.
  • Demonstrate and evaluate competence.

Continuing education is not necessarily a good mechanism for assuring competence. CAC recommends that we revamp our continuing education programs. The purpose is not to throw out continuing education but to figure out how it fits into a model for continued competence. There is currently no assessment of needs and there is no final outcome in continuing education. Likewise, a test by itself is not the answer.


If we are going to have a research agenda, continued competence should be at its forefront. CAC believes that initially we should conduct research to validate and compare competence assessments, assurance and methodologies. There is also opportunity to collaborate with other professionals in such research.

Enabling Legislation

CAC believes we should seek enabling legislation. I am very concerned about the number of states that do not have the statutory authority to implement continued competence requirements as opposed to continuing education. You will not have arguments from the legislators. You will not have arguments from external professions. You might, though, have some arguments from your own licensees who don’t want to have to do this.

Educating Students

We need to make sure that we are educating our students to understand that they have a professional obligation to maintain their competence.

Paying for the Program

The CAC makes a very strong case that licensees need to pay for this program.

Professional Acceptance

We now have much more professional acceptance than we ever had before. The work of the Pew Commission, CAC and other public interest groups has moved continued competence into the limelight. Legislators have moved it forward, as have all of the healthcare professions. And so it’s not so much whether to have a continued competence program; it’s how much work and effort might be involved to implement the program.

Purpose of Continued Competence Regulation

The bottom line is protection of the public. At times we are sidetracked, we have a reaction to something that’s happening and we create a regulation that’s not necessarily doing what we intended to do. So we have to be careful. Regulation for regulation’s sake is not where we want to go.

A Lack of Engagement

We should remember that the opposite of competence is not incompetence but its lack of engagement. When people start losing their competence, they start losing their currencies, they start becoming disengaged in their profession and in their work. So how do we keep physical therapists engaged? And why do they become disengaged? I think there are lots of reasons.

Trying to maintain a life balance is a challenge. Maintaining your practice, your office, your patient load and balancing that with raising a family, with your social obligation and church work sometimes becomes too much for people. They start evolving towards disengagement. A difficult healthcare environment leads to a lack of engagement. For example, all the requirements for documentation make it difficult to focus on treating patients. And there are few incentives to maintain engagement. Continued competence programs should encourage engagement.

Licensing Boards Have Ultimate Authority

In the end, licensing boards have ultimate authority for continued competence. But a collaborative approach dictates that there be an appropriate division of responsibilities and duties between licensing boards, accreditation and certification bodies, healthcare organizations and professional associations and societies in setting standards for continued competence assessment and assurance. While CAC believes these groups should work together, it is the state regulatory boards, as the entrusted entities legally responsible for public protection, which must have the last word on whether the process and outcome of a continued competence program, whether public or private, is serving the public interest well.

At the 1996 delegate assembly, Alabama moved that the Federation continue to address the issue of continued competence to practice physical therapy and report annually to the membership on the progress being made. A task force in 2000 provided the first Standards of Competence. In 2003, the delegate assembly amended the FSBPT vision statement to say that “state licensing boards and the Federation… would achieve a high level of public protection through a strong foundation of laws and regulatory standards in physical therapy, effective tools and systems to assess entry-level and continuing competence, and public and professional awareness of resources for public protection.” Several other motions followed in 2004.

2000 Continuing Competence Task Force Accomplishments

Let’s review the Federation’s 2000 Continued Competence Task Force’s accomplishments. They developed the following definition which was reviewed in 2006 and remains unchanged.

Continued competence is the ongoing application of professional knowledge, skills and abilities which relate to the occupational performance objectives in a range of possible encounters that is defined by the individual scope of practice and practice setting.

This definition does not say that if I am working in an orthopedic clinic, I need to maintain my competence in treating the neonatal infant. It refers to the possible encounters you are going to achieve based on your scope of practice. In an orthopedic clinic, I am not going to see a neonatal infant coming in.

The task force’s discussion paper provided these recommendations:

  • Reach agreement in principle on the need for proceeding with the development of a national model to assure continued competence
  • Adopt the definitions of competence and competence
  • Adopt the regulatory framework
  • Develop a process for further discussion
  • Develop a process to develop standards of competence

The task force also came up with some principles of an effective continued competence assessment system:

  • It should promote continued education and professional development through a physical therapist’s career, and use meaningful incentives.
  • It should provide the public, including employers, third-party payers and other healthcare providers, with a valid and reliable indication of the competence of licensees within their actual scope of practice.
  • It should be administratively feasible, affordable, and justifiable in economic terms.
  • It should incorporate requirements that are acceptable to the profession and based on a national level of evidence.
  • It should be updated to reflect changes in the scope of practice, occupational roles, technological and therapeutic environments and standards of practice and public expectations.
  • It should incorporate and encourage improvements in the technology of measurement and evaluation and be linked to disciplinary programs.

The Standards of Competence1

The Standards of Competence is a position statement of the Federation of State Boards of Physical Therapy. They were originally developed in 2000 by the task force and were reviewed and updated in 2006. They assert that it is a regulatory board’s responsibility in meeting its mission of protecting the public to develop standards and measures for assuring entry level and continued competence to practice physical therapy and to also require remediation for those who do not meet the established standards. The purpose of the Standards of Competence is to articulate a measurable degree of required performance for continued competence. Life-long learning includes development of knowledge, skills and abilities in order to meet current standards of practice.

The Standards of Competence fit in two domains.

Domain one is professional practice, which includes professional accountability, professional behavior and professional development. Some of these elements are not on the NPTE and cannot be tested via multiple choice questions. That’s why it’s important that we have a continued competence assessment program that includes tools related to this particular domain.

Domain two is patient-client management and includes examination, evaluation, diagnosis, the plan of care, implementation, the education of the patient and the family and the discharge - basically the patient treatment aspects.

Continued Competence Requires Assessment

The conclusions of the task force were that continued competence requires assessment. One has to make an assessment of competence before he or she can devise professional development or competence education.

Categories of Continued Competence Assessment Tools

The three categories of continued competence assessment tools include observation of performance, simulating a clinical situation and objective tests. Each has its validity, strengths and weaknesses.

Simulation, for instance, has a medium to high validity, while observation of performance has a high validity because you’re actually observing someone in the clinic. The task force recommended multiple approaches and tools in all three categories. And they ended up recommending some initial tools.

Competence Assessment Portfolio (CAP)

The Competence Assessment Portfolio (CAP) is a self observation of performance, but a lot more research needs to be done on whether this is an effective mechanism. CAP is not that complicated. It lets a person assess where he/she has been, look at where he/she is now and do a self-assessment of needs. The person knows where to focus, implements the plan and completes a learning tracker. Then it starts all over again.

Practice Review Tool

The Practice Review Tool (PRT) covers domains one and two and is designed to be an optional tool. We don’t call it a test. It’s an assessment tool. It is being developed in a secure environment as a multiple-choice tool based on clinical scenarios where people have to answer questions related to the scenario that’s presented. As opposed to the NPTE, where you have a brief scenario and four options, this would be a longer scenario with three to five questions based on that scenario. It would contain approximately a 100-120 questions to be given in a secure testing environment. There would be a performance feedback. The pilot will begin in January 2008 and probably conclude in May 2008. We are seeking volunteers to take this assessment tool and provide feedback.

Not Overly Burdensome

An important feature of a continued competence model is that it should not be overly burdensome to licensees. Licensees who already maintained their competence should be able to demonstrate their competence through mechanisms they are already using. The intent is to assure that people maintain their competence. If they are already doing it, that’s absolutely great.

A Variety of Vendors and Tools

It should be based on regulatory standards and be open to a variety of vendors offering continued competence tools. It should incorporate tools that account for variation in learning and skills and development styles.

Optional for Jurisdictions

It should be optional for jurisdictions and allow for jurisdiction variants.

Outcome Measures

Outcome measures may be a score on an assessment tool or a specialist certification. It may be a Practice Review Tool passing certificate, jurisprudence test passing certificate, a final evaluation or certificate of successful completion of a residency program, a learning planner and tracker from the CAP and/or a continuing education course. And it might be a structured mentorship review form. But every single tool would have some sort of outcome measures that would demonstrate that someone obtained the competence or had the competence.

The Licensee’s Responsibilities

The licensee’s responsibilities are to plan continued competence activities based on the requirement, submit an affidavit of compliance with continued competence requirements, maintain records of compliance including documentation of appropriate outcome measures and submit the appropriate outcome measures on request. The system could work very similarly to continuing education.

So what needs to be done? We need to:

  • Develop criteria for acceptable tools
  • Oversee, improve and develop a model
  • Determine tools to meet criteria
  • Review and modify the model that gets developed
  • Determine documentation requirements and outcome measures
  • Develop documentation outcome measurement tools and address any state-specific need
  • Develop a plan for audit that will not create undue burden on state boards
  • Develop an optional uniform plan for approval of continued competence tools
  • Review and revamp continuing education to make it more meaningful
  • Develop all the measures and quality improvement tools
  • Conduct research

On Monday, September 10, 2007, the 2007 Federation delegate assembly adopted Motion #DEL-07-08 on continuing competence that will begin to tackle those actions listed above. The motion reads,

That the Board of Directors be charged to move forward with the development of a comprehensive continuing competence program in support of public protection to include, but not be limited to, the following components:
  • Continuing competence tools
  • A framework for integrating continuing competence tools
  • A comprehensive continuing competence certification program
  • Appropriate organizational structure.

Perhaps this is not the search for the Holy Grail.

1The 2006 Standards of Competence can be viewed on the Federation’s public website, Click on Regulatory Tools/Standards of competence.