Saturday, December 24, 2005

An Analysis of Continuing Competence Regulation of Occupational Therapy in New York State

Goals of the policy

Regulation of continuing competence is an important current issue for the public consumers of occupational therapy services in New York State. Two bills were introduced by New York State legislators in 2005 to address this issue. Assembly bill A.5160 and Senate bill S.1388 are identical companion bills that establish requirements for occupational therapists and occupational therapy assistants to complete continuing education as part of their triennial license renewal. The proposals also mandate continuing competency fee be paid to help support the administration of this additional requirement.

This proposed policy is being decided in the New York State Legislature and has been referred to the Committee on Higher Education for their review and feedback. No legislative action was taken on either bill during 2005.

There is no uniform licensure or continuing competence requirement among the states. Forty-one jurisdictions currently have continuing competence requirements, ranging from a minimum of six hours of continuing education to a maximum of twenty hours (NBCOT, 2003). New York State does not currently have any continuing competence requirements beyond completing an application and paying a renewal fee.

The primary purpose of policies that regulate continuing competence requirements of health care practitioners is to protect the public. Birkland (2005, p. 144) states that these types of regulatory policies “assure professional oversight over the activities of professionals, who must be trained and regulated to assure competent service to their clients.” The Institute of Medicine (2003) states that “health professionals are not being adequately prepared to provide the highest quality and safest medical care possible, and there is insufficient assessment of their ongoing proficiency.” This sentiment is also repeated by the Citizen Advocacy Center (2004) that states “the oversight system has lost out on a major opportunity for quality assurance in health care delivery and thereby failed the public.” This debate contributes to the urgency for New York State to improve the regulation of occupational therapy practice.

Relevant actors & agencies

The essential and relevant actors in the debate surrounding professional competence are the occupational therapy practitioners and the public who consumes occupational therapy services. However there are many other stakeholders in the process, all of whom are involved for different reasons.

The New York State Legislature is interested in this issue because they are charged with writing the laws that are designed to protect the public. Similarly, the New York State Board of Occupational Therapy is responsible for writing regulations and implementing the laws that are passed. These groups have a legal responsibility to the consuming public to ensure that occupational therapy services are delivered in a safe and appropriate manner.

The National Board for Certification of Occupational Therapy has a certification process (initial and renewal) that provides a national model for jurisdictions to consider using. After successful completion of the initial certification examination, ongoing professional development is required every three years. These requirements are designed to supplement state regulatory requirements toward the end purpose of serving the public interest (NBCOT, 2003).

The American Occupational Therapy Association’s Representative Assembly passed a motion to establish the Commission on Continuing Competence and Professional Development in 2002. This commission was established to “offer strategies that support [practitioner’s] pursuit of the competency requirements outlined by state licensing boards and NBCOT and to encourage use of the standards developed by AOTA” (Moyers, September 30, 2002). AOTA has specified that it will focus on the area of competence as opposed to competency. Competency purportedly implies capacity to perform professional responsibilities and competence implies the development of that capacity through continuing education (Moyers, September 30, 2002). This nuanced distinction is supported in the literature as referenced by Moyers but it seems to be lost in translation on a functional level: the terms competency and competence are used interchangeably by other stakeholders (Mayhan, Holm, & Fawcett, 1999; The Citizen Advocacy Center, 2004). The proposed New York State legislation regulating continued competence for occupational therapy practitioners also does not make the distinction between competence and competency.

Policy Theories

Development of policy can be best understood through frameworks or models. The Advocacy Coalition Framework (Birkland, 2005, pp. 226-228) describes the process that is occurring in New York State related to the proposed continuing competence regulation. The Advanced Coalition Framework states that interest groups are organized and involved in policy development. These groups debate, compete, and eventually compromise around a set of shared values. On the state level, the New York State Occupational Therapy Association provides member input to the State Board for Occupational Therapy regarding the proposed legislation. Some of those suggestions and feedback were important for writing the bill that was submitted in the New York State Legislature and Senate. This activity occurs in the foreground of the larger national debate about continued competence and the activities of national groups like AOTA, NBCOT, the Institute of Medicine, and the Citizen Advocacy Center.

Policy Tools or Instruments

Policy tools are the methods used to create a desired outcome of a policy goal. As stated above, the primary policy objective is protection of the public by ensuring competent occupational therapy practice. There are several relevant policy tools or instruments that will facilitate the implementation of this policy. Birkland (2005, pp. 174-176) identifies law and suasion as types of policy tools; these specific tools should be considered when analyzing policies related to occupational therapy competence.

Law is the primary method for facilitating this policy outcome. The proposed occupational therapy continuing competence requirements will be in effect 180 days following their passage into law. The New York State Board for Occupational Therapy will develop specific regulations for occupational therapy practitioners related to implementation of that law.

Suasion is another method for facilitating policy outcome and is closely related to law. Suasion is a hortatory tool that is backed by inducements and penalties. Inducements are represented in the form of continued licensure and sanctions are represented in the form of penalties including loss of licensure.

Historically, state licensing boards have been slow to develop continuing competence requirements (Citizen Advocacy Center, 2004). This contributed to development of NBCOT’s certification renewal program and now most states have adopted some form of this policy tool. The NBCOT certification renewal program continues to serve as a national standard for development of policy tools to protect the public regarding occupational therapy practice.

Analysis

The competence of health care practitioners is a public mandate. The Citizen Advocacy Center report (2004) outlines a history of this debate reaching back into the 1960s. The report outlines a position that health care is increasingly complex and that old methods of regulation and oversight are not applicable to the dynamic nature of modern health care practice. They suggest a five step plan including routine periodic assessment, development of a personal plan, implementation of a personal plan, documentation, and demonstration/evaluation of competence.

Unfortunately, compelling need does not always translate directly into sensible policy. For many years occupational therapy practitioners operated under the assumption of ‘lifetime certification.’ Understanding that this concept did not protect the public, NBCOT developed a certification renewal program. The certification renewal program was hotly debated within the profession and led to a legal confrontation between AOTA and NBCOT (1998) over the right to use the certification marks. Competitive certification organizations were also created (Brown, 2002). These challenges to NBCOT’s certification programs are examples of how policy is debated within the Advocacy Coalition Framework (Birkland, 2005, pp. 226-228). This confrontation was a major obstacle for development of policy governing the competence of occupational therapy practitioners.

Shared dialogue and agreement around common values is necessary in order for sensible policy to be developed. AOTA, NBCOT, and the American Occupational Therapy Foundation (AOTF), announced renewed efforts to collaborate on strategic initiatives important to the long-term health and direction of the occupational therapy profession (AOTF, 2004). The working group is called Occupational Therapy Organizational Partners (OTOP) and represents a beginning step toward shared dialogue. Still, several important obstacles remain.

The lack of consensus on terminology is a basic but important obstacle. AOTA makes distinctions between competence and competency (Moyers, September 30, 2002) and is basing a new certification initiative on these definitions (Hinojosa, December 20, 2004). These updated continuing competence standards were accepted by AOTA’s Representative Assembly during the 2005 national conference (AOTA, 2005). These standards will serve as the basis for specialty certification programs (Glantz, May 10, 2004) that may compete with the NBCOT certification. Walker (December 10, 2004) states that laws regarding use of credentials can be confusing to occupational therapy practitioners. If occupational therapy practitioners are confused about credentialing, it is obvious that multiple points of certification have the potential for confusing the public.

Ronnie Hausheer, the former Executive Secretary for the New York State Board for Occupational Therapy wrote a letter to former NYSOTA President Sue Seiler on July 9, 2003. She expressed that “instead of leading the nation, we are lagging behind.” She asked that the state association “exercise their leadership role in creating meaningful requirements for licensees” when proposing changes to the New York State occupational therapy practice act.

New York State is not adopting the NBCOT model or any proposed AOTA model for certification or certification renewal as it relates to the continuing competence bill. However, the proposed legislation is written so that occupational therapists who meet the standards of NBCOT will effectively meet the proposed standards of the New York State legislation. The bill falls short of explicitly requiring NBCOT certification renewal. The New York State proposal will be effective in mandating a certain level of continuing education and will be effective to the degree that this continuing education can contribute to practitioner competence.

Mandated continuing competence laws will have a direct impact on occupational therapy practitioners. The current requirements center on continuing education, but there is increased dialogue within health care professions about the potential role of re-assessment through performance on proficiency examinations (Andrews, 2003). Canadian occupational therapy regulators are now discussing the merits of periodic re-assessment through examination (James, 2005).


Action Plan

The proposed New York State legislation should be supported, but it could be strengthened through full alignment with a national model. A national model for continuing competence promotes the integrity and value of occupational therapy credentialing and has the additional benefit of crossing all jurisdictions, regardless of geographical regulatory requirements. This leads to the question: which continuing competence pathway is best?

The NBCOT certification and certification renewal programs provide the most comprehensive competency assurance measures. NBCOT requires academic and fieldwork preparation. Certification candidates must pass the NBCOT national certification examination. Certificants must also agree to adhere to the NBCOT candidate/certificant Code of Conduct and participate in ongoing professional development. Additionally, certification renewal is mandatory to maintain active status as an OTR or COTA.

New York State’s current and proposed requirements already align with the NBCOT certification and certification renewal programs. New York State licensees are required to meet academic and examination requirements. Licensees must personally maintain documentation of continuing education activity and this documentation of continuing education activities must be provided upon request.

As another measure of alignment, the NBCOT and New York State Board for Occupational Therapy share a common purpose of public protection. The commonality of purpose is critical for a cogent policy that will meet the stated objectives.

Occupational therapists in New York State are becoming increasingly aware of the continuing competence debate as the NBCOT certification renewal program has been implemented. Several workshops were provided to New York State Occupational Therapy Association local districts and to educational programs as the NBCOT programs were implemented. These workshops focused on the certification renewal program and specifically on the continuing education requirements of that program. This year a presentation was provided at the New York State Occupational Therapy Association conference. The presentation focused on The NBCOT Certification Renewal Program and proposals for continuing competence requirements in New York State (Alterio, 2005). These presentations have assisted in promoting dialogue about continuing competence among occupational therapy practitioners in New York State.

Occupational therapists in New York State have to continue the dialogue about continuing competence. State senators and assemblymembers must be lobbied about the importance of this proposed legislation. The language in the proposal can be strengthened through specific alignment with the national NBCOT model. Finally, competing certification models need to be closely monitored so that they do not dilute the value of occupational therapy credentialing. Most importantly, it is critical for the profession to avoid confusing the public with competing competence standards.



References: (links take you off the page; use your browser's back button to return)

Alterio, C.J. (2005, October). The NBCOT Certification Renewal Program and proposals for continuing competence requirements in New York State. Paper presented at the New York State Occupational Therapy Association Conference, Hempstead, NY.

American Occupational Therapy Association (2005, May 19). 2005 Representative Assembly meeting highlights. Retrieved November 12, 2005 from http://www.aota.org/nonmembers/area29/links/link05.asp

American Occupational Therapy Foundation (2004). AOTA, AOTF, NBCOT announce collaboration on strategic initiatives. Retrieved November 3, 2005 from http://www.aotf.org/html/strategic_initiatives.shtml

Andrews, L.W. (2003). Maintenance of competence: The debate heats up. Journal of Medical Licensure and Discipline, 89, 11-15.

Birkland, T.A. (2005). An introduction to the policy process: Theories, concepts, and models of public policy making, 2nd ed. Armonk, NY: M.E.Sharpe.

Brown, E.J. (2002, January 14). Texas OTs launch new certification board. Advance for Occupational Therapy, 5.

Glantz, C.H. (2004, May 10). Recommendations for AOTA certification programs. OT Practice, 9-10.

Hinojosa, J. (2004, December 20). AOTA standards for continuing competence: Proposed revision. OT Practice, 12-13.

Institute of Medicine (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press.

James, S. (2005, Winter). Gaining entry through competency confirmation. College of occupational therapists of Ontario: On the Record, 3.

Mandatory continuing competency requirements for occupational therapists and occupational therapy assistants, A. 5160, NY State Assembly. (2005).

Mandatory continuing competency requirements for occupational therapists and occupational therapy assistants, S. 1388, NY State Senate. (2005).

Mayhan, Y.D., Holm, M.B.; Fawcett, L.C. (Eds.) & the National Commission on Continued Competency in Occupational Therapy. (1999, June). Continued Competency in occupational therapy: Recommendations to the profession and key stakeholders. Gaithersburg, MD: National Board for Certification in Occupational Therapy.

Miller, S.H., & Horowitz, S.D. (2003). Maintenance of certification: Relationship to competence. Journal of Medical Licensure and Discipline, 89, 7-10.

Moyers, P.A. (2002, September 30). Continuing competence and competency: What you need to know. OT Practice, 18-21.

National Board for Certification in Occupational Therapy v. American Occupational Therapy Association 24 F.Supp 494 (1998). Retrieved November 12, 2005 from http://www.gamingip.com/Cases/FullText/CF-OccTherapy.html

National Board for Certification in Occupational Therapy (2003). State Regulation. Retrieved December 12, 2005 from http://www.nbcot.org/webarticles/anmviewer.asp?a=59&z=13

The Citizen Advocacy Center (2004, April). Maintaining and improving health professional competence: The Citizen Advocacy Center road map to continuing competency assurance. Washington, D.C.: Author.

Walker, B. (2004, December 20). Professional titles: Consumer protection, practice integrity. OT Practice, 7.

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