October 7, 2008
11:00 AM EDT/4 PM BST
Attending: Tim Willett, Rosalyn Scott, Co-chairs; Susan Albright, Mary Pat Aust, Ronald Harden, David Price, Valerie Smothers.
1. Review minutes of last meeting
Tim reviewed the minutes of the last call. Susan and Isarin reviewed attempts to apply the initial xml specification to dental competencies and the challenges they faced. Valerie reviewed her discussion with technical steering committee regarding the potential to use web ontology language (OWL) and vue. The group also reviewed the discussion of context in competency and agreed to defer that until discussion regarding relating competencies to learning objects and assessment. The minutes were accepted.
Ronald asked about the dental competencies. Joan Clark in the UK wrote up dental competencies using a variation of Scottish doctor. The results were published in the British Dental Journal. He offered to send provided the publication information, and valerie distributed the information to the group via the listserv.
2. Review comparison chart with GMP-USA added and a comparison of relationship types
Tim added that today we wanted to focus on relationships. Tim added GMP-USA to the comparison chart. It's heavily based on ACGME competencies. The format used does not include any new elements. He also added a section on intercompetency relationships to describe what kinds of relationships exist among competencies. He added that there may be a need to qualify relationship, ie indicate whether the relationship is strong or weak. All of the frameworks in the chart have hierarchical relationships; only one had see also. None had enabling or prerequisite.
Rosalyn commented that there are usually qualifiers. Mary Pat agreed. There are also prerequisites. Some of the ones we looked at are very broad. Rosalyn added that she is looking at how they re-privilege physicians at the VA. JCAHO has new standards that require initial and ongoing evaluation using provider data. Each hospital has to define the process for ongoing review. They've identified 6 areas for evaluation based on the ACGME competencies. These must be reviewed for each practitioner every 6 months. Tim asked how hospitals will operationalize the requirements. Rosalyn commented that they started with ACGME competencies and looked at how to measure them. For knowledge, 10 hrs of CMe specific to work done in hospital IS REQUIRED. For professionalism they look at involvement in hospital committees, complaints filed, etc. For clinical judgment, they look at database measures including number of returns to the OR, preoperative preparation for patients, and other items that can be easily gleaned from a database.
David added that many hospitals are defaulting to MoC since that traces back to ACGME competencies.
Tim asked how MedBiquitous could help with this. He asked if hospitals need to be able to express the competency framework and criteria for evaluation, then link to actual data for each practitioner. Rosalyn confirmed that was what was needed. She added that the VA did not consider MOC to be enough. David agreed that some specialties have more rigorous MOC than others, and added that the VA can bring along specialties that are less developed. Many smaller hospitals can't afford to do that. MedBiquitous standards could help that process further.
Tim asked if we should add a use case. Rosalyn agreed. Valerie asked whether the new requirements apply to multiple professions. Roslyn the replied that they apply to anyone approved by medical staff. For surgery that includes nurse practitioners, physician assistants, doctors, podiatrists, dentists, oral surgeons, and optometrists. All have the same competency expectations. The parameters may not be the same, but there needs to be a common structure. One problem in using clinical data is that the data is not risk adjusted for a person's practice. Developing risk adjusted stratagem is very difficult.
Tim asked for the impact on our activities - does it change anything? Roslyn commented that it doesn't change anything, but it does provide a practical application beyond education and makes our work even more important.
Mary Pat agreed. Nursing has been here for a long time. They have to show competencies and data. Valerie asked if Tim's explanation applies equally to nursing: they need to be able to express the competency framework and criteria for evaluation, then link to actual data for each practitioner. Mary Pat agreed, saying that each competency may have different modes of evaluation. An open heart nurse may need to demonstrate removal of a heart tube successfully x number of times. That may be one of several things required to say that a nurse is competent. Valerie stated that given that explanation, evaluation criteria may be considered a new requirement.
Ronald commented that similar discussions took place around reusable learning objects. Some people feel that assessment is built-in, while others do not. It is an important additional feature, but should not be considered required. The group agreed.
Ronald added that relationships were discussed in Scottish doctor. The relationship of circles to one another is not hierarchical exactly. The inner circle consists of technical competencies. The middle circle describes how the doctor approaches each of these. You need both, they are related. The relationship produces a more integrated approach to medical care.
Tim asked whether any level for outcomes appear in multiple places. Ronald replied that there may be a few but those would be the exception rather than the rule. Valerie suggested that the group bring back suggestions for appropriate language describing that relationship between circles.
3. Discussion of relationships among competencies in a framework
Tim had proposed 3 types of relationships - there are some others that have been expressed on the call. Are there other kinds of relationships?
On paper many frameworks are expressed as nested lists. Granular competencies contribute to broader ones. That's hierarchical. Enabling includes prerequisites. If X enables Y, understanding heart sounds enables a cardiac exam competency. Similar to is see also. Breaking bad news may refer reader to truth telling, etc.
Ronald commented that one relationship that was missing was is part of. If you competence has three different sub competencies, you would want to note that. It's not quite the same as the parent child relationship for the enabling relationship. You need to know that this is just one part the competence.
David suggested that there may be another: X. and Y enable each other. He did not have an example. Ronald asked if the relationship is one where one competency complements or supports another. That's important in into professional practice.
Rosalyn asked if the relationship was too soft. Valerie recommended comparing the relationships to relationship descriptions in owl. Ronald recommended looking at concept mapping as well. Valerie agreed to consult with the technical steering committee about owl and concept mapping relationships.
4. Open discussion
- The group will bring back suggestions for appropriate language describing that relationship between circles.
- Valerie will review the relationships we've discussed with the Technical Steering Committee and compare them to the relationships available in OWL.