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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
Maintenance of CertificationMaintenance of Certification
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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
Maintenance of CertificationMaintenance of Certification
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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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United KingdomUnited Kingdom
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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United KingdomUnited Kingdom
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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United KingdomUnited Kingdom
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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United KingdomUnited Kingdom
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