By Robert C. Shaw, Jr., PhD, Vice President, Examinations
The first people who received a credential from the National Board for Respiratory Care (NBRC) did so in 1961. Some seminal changes have occurred since then including the following:
- Four specialty areas of practice are credentialed today in addition to general respiratory care.
- Licensure of generalists has become part of the professional work environment in 49 states within the United States.
- A set of credential maintenance programs was implemented in 2002; however, people credentialed in general respiratory care and some specialties continue to be recognized under the old rules in which credentials were permanent.
These changes have left the NBRC with populations of people who have achieved credentials as generalists plus some who are credentialed in one or more specialty. Most in the population must maintain a license. A growing percentage of the approximately 170,000 licensed therapists are required to document evidence of maintained competence to keep the credential they had earned.
Additionally, the NBRC interpreted changes to NCCA Standards for credential maintenance programs as more robust in 2016 than those implemented in 2002. However, the NBRC also anticipated risks of antagonizing participants in credential maintenance programs. If participants perceived new requirements as onerous and lacking added value, then the NBRC would invite a rough transition and even litigation.
With the 2016 NCCA Standards on the horizon, the NBRC convened a focus group in 2015 to explore ideas leading to modifications of the credential maintenance programs. Stakeholders were represented as follows:
- Patients who received respiratory care as understood by the trustee of the board who was designated as the public advisor.
- People subject to recredentialing requirements who were initially credentialed on or after 2002.
- People who held each NBRC credential.
- Agencies that licensed general respiratory therapists.
- The professional membership association (American Association for Respiratory Care-AARC).
- The accreditor of programs that educated general respiratory therapists (Commission on Accreditation for Respiratory Care-CoARC).
- Physicians who worked with and provided medical direction to therapists and specialists.
The focus group evaluated programs of other organizations that credentialed health professionals. For example, the Oncology Nursing Certification Corporation (ONCC) had innovatively linked individual assessment performance to learning activities in which each practitioner would subsequently engage. The American Board of Anesthesiology was in the pilot phase of what it called MOCA 2.0, which was intended to provide opportunities each quarter to maintain competence in a longitudinal way that participants were likely to find more convenient than taking a long, securely-administered examination every decade. Some of the NBRC trustees were anesthesiologists who participated in MOCA 2.0, so information was evaluated from the perspective of participants as well as program administrators. Information about these programs plus details about the 2016 NCCA standards were evaluated by the focus group culminating in a set of proposals.
Focus group recommendations were evaluated by the NBRC Continuing Competency Program committee. As program features were developed and implemented, the name of the program changed to the Credential Maintenance Program (CMP).
The committee in charge of the CMP tried to thread the needle so that value would be added for participants and patients who received respiratory care while avoiding the feeling among participants that new requirements were terribly onerous, which could lead to an extreme response. An example of an extreme response has been new legislation in a few states allegedly protecting a physician’s right-to-care for his or her patients while freed from a credentialing board’s recertification requirements.
The new CMP is planned for a pilot launch in 2019, which will involve all but the general participants listed in Table 1, below. The CMP program for general respiratory therapists will be added in 2020 when all the programs will be formally implemented.
The committee opted for quarterly releases of assessment item sets as described in Table 1. Participants will have the option to complete their assessments using a device, time, and place that he or she chooses. Except for pulmonary function technology, the eligibility pathway to each specialty must start with a credential in general respiratory therapy, so those who recertify in a specialty also will receive the 10 general assessment items each quarter.
Table 1. Details about Assessments
|Type of Participant
||Items Each Quarter
|General Respiratory Therapy
|Pulmonary Function Technology
|Sleep Disorders Specialty
|Adult Critical Car Specialty
Each assessment item will allow a 5-minute response window. This duration was chosen to allow some more complex assessment items to be included. In other words, only presenting items that require that a respondent recall a fact will not satisfy the goals behind the CMP. Giving participants permission to quickly look up information was another reason a 5-minute item expiration was chosen. The ability to look up information was thought to be true to clinical experiences of therapists/specialists. The full set of terms and conditions to which a participant agrees before an item is viewed are as follows:
I agree to the following:
- submit answers that are mine alone.
- access content when needed to help me choose an answer.
I will not
- accept help from any other person.
- copy, disclose, or distribute any part or portion of the assessment.
- violate these terms because doing so could initiate an investigation into potential misconduct by the Judicial and Ethics Committee.
Starting in January 2018, panels of credential holders of each type described in Table 1 have produced new items for CMP assessments. These items and future CMP items will be segregated from banks of items deployed for examinations people take to become credentialed for the first time. Panels have convened to edit items and option explanations in 2018; the reference submitted with each item has been verified too. A panel’s correct response, option explanations, and reference will be revealed to each respondent when he or she submits what he or she thinks is the best answer.
Assessment items will be delivered through an extension of the database that has accumulated information about credential holders. The database extension is nearing the end of the design and build phases as of this writing. The extension is a proprietary platform that will administer and score assessment items plus facilitate follow up review and learning by a participant.
Assessment items will be delivered in a system designed to be mobile-friendly by the NBRC’s database designer (DEG, www.degdigital.com). Mobile-friendly capability will allow credential holders to interact with assessment content initially or during a review using mobile phones, tablets, or personal computers. Hyperlinks delivered in emails will allow participants to complete assessments using their browser, bypassing installation of a separate app.
After a set of items has been administered for three months, a credential holder will learn the percentage of his or her peers who correctly answered each item when he or she chooses to review already-answered items. This information will be published after an in-house psychometrician evaluates whether response patterns align with the premise that there is one best response to each item. There will be a contingency in which staff return an item to a panel so multiple correct responses can be considered, which leads to a rescoring of option responses.
The NBRC wanted assessment content to be systematically defined and consistent with the purpose behind credential maintenance. Regarding the latter point, content was sought that changes most rapidly and puts patients at the most risk. Identifying this content began with a second job analysis study for each CMP assessment. Each study picked up with the content found critical to practice by the first study for each type of practitioner described in Table 1. Table 2 compares details about the two studies that were done for each program.
Table 2. Comparison of Job Analysis Studies Done for an NBRC Credentialing Program
Study 1 for Initial Credentialing Examinations
Study 2 for CMP Assessments
- People who work as therapists or specialists
Source of task statements
- The last study plus brainstorming about new tasks and revisions of tasks
- List of critical tasks from Study 1 within the same testing cycle
Basis for evaluating responses and identifying tasks to be linked to items
- Extent to which each task is performed among therapists/specialists
- Risk to patients when improperly done
- Pace-of-change in the underlying knowledge
- A list of tasks critical for evaluation at the point of initial credentialing
- Design specifications for the initial credentialing examination
- A subset of tasks observed to put patients at elevated risk and whose content changes rapidly
- Design specifications for the CMP assessment
Credential Renewal Cycle
Credentials earned since 2002 have expired or required renewal on a 5-year cycle. During the CMP job analysis described in the section just above, evidence was collected so this renewal cycle could be reconsidered. One evidence set came from pace-of-change responses about each task. A second set came from the following item:
NBRC trustees will evaluate qualitative and quantitative response data during reconsideration of the future recredentialing period. When a practitioner holds multiple credentials, the policy remains that these credentials will expire together.
Integrating Assessment Performance and Continuing Education
Instead of revisiting all potential content that could be covered on an examination for initial credentialing, CMP assessment content focuses on the subset of tasks that were high on the risk and change scales within the CMP job analysis results described in the Assessment Content section. The following are important points for assessment participants to consider as they plan their continuing education:
- Participants should pay close attention to items they did not correctly answer.
- A year’s worth of assessment results has something valid to say about maintained competence, so assessment results accumulated over multiple years have something still stronger to say to practitioners.
- Linking evidence from a second job analysis study to assessment content for each type of practitioner supports this assertion.
Each participant will be encouraged to access assessment items again by logging into his or her database account. Within FAQs, participants who incorrectly answer an item are advised that a short-term remediation strategy is to evaluate the explanation that accompanies each option within an item. A middle-term strategy is to study the article or book section cited by the panel of peers who approved the item. A long-term remediation strategy is engaging in continuing education of the participants choosing about the topic related to an item that was missed.
The CMP program links assessment performances accumulated over multiple years to the quantity of continuing education that will be documented in the final year of a participant’s renewal cycle. Assessments cease in a credential holder’s final year so he or she can concentrate on documenting the quantity of continuing education credits that are required. However, a credential holder may choose to document those credits in the database as they are earned in the years leading up to the final year.
Documentation of maintained competence has been based on 30 continuing education credits accumulated over 5 years since 2002. Those who also have been credentialed in specialties have divided these 30 credits between or among each domain in which a credential was earned (for example, 15 credits in general respiratory therapy + 15 credits in the sleep disorders specialty). CMP program changes will modify this structure.
- First, each participant who has just documented competence through renewal or by passing the examination for initial credentialing is assumed to start the next 5 years at the top of the highest competency level (green) described below.
- Second, a global determination of performance level (green, yellow, or red) over general and specialty assessment results will be made
- The general content domain overlaps each specialty to some extent, which is a rationale for making a global determination.
- The approved use of each specialty credential is linked to one of the general credentials (CRT or RRT), for example,
- RRT-ACCS is for the adult critical care specialty at the registry (high) level of respiratory therapy
- CRT-SDS is for the sleep disorders specialty at the certification (low) level of respiratory therapy.
- Third, assessment performance and credits to be documented will be linked.
- Moderately high assessment performance (yellow) will require documentation of half of the full quantity of credits linked to maintained credentials.
- High assessment performance (green) will cause credits to become unnecessary because maintained general and specialty competence has been directly documented.
Assessment Performance Thresholds
Each participant will observe his or her color code (green, yellow, or red) in the dashboard that will be accessed by logging into the database for credential holders. Separating high (green), moderate (yellow), and low (red) levels of assessment performances requires thresholds. Defining thresholds involves first calculating a mean probability-of-success value for each item after collecting those estimates from the peers on the panel who approved each item. Instead of linking estimates to minimal competence at entry as is common for a modified Angoff study, peers are instructed to envision someone who remains barely competent years after entry.
The sum of mean item probability-of-success estimates across the sets that have been released identifies a mid-point for a participant while being reminded that participants enter the system at different points in a year. A confidence interval will be calculated around a participant’s mid-point based on an estimated standard error of measurement. The upper and lower confidence boundaries become the two thresholds that determine the quantity of continuing education credits that will be documented as described in the section just above.
While rationalizing that scores inside the confidence boundaries reflect uncertainty in comparison to the competence point, the NBRC will assert that a participant who scores at or above the upper confidence boundary has certainly maintained competence (green). Likewise, a participant who scores at or below the lower boundary certainly has not maintained competence (red). A participant will find information updated each quarter about his or her accumulated performance level in comparison to the two thresholds.
Credentials that Do Not Expire
The NBRC committee in charge of the CMP considered an option in which credential holders who had a permanent claim by achieving the credential before 2002 could choose to relinquish their claim by opting into the new system. The committee chose instead to allow these credential holders to participate in the new system while keeping their permanent claim on the credential. The committee expected this policy would garner more participation from permanent credential holders, an outcome ultimately better for respiratory patients.
The following factors are worth explaining since they contributed to this decision:
- A holder of a permanent credential in general respiratory therapy must still comply with competency maintenance requirements of the state agency that administers the license held by the person.
- While requirements vary among states including two that do not require continuing education credits, the 30-credits-in-5-years requirement falls toward the bottom of what many states require.
- Virtually all therapists/specialists work in systems (hospitals, labs, centers) with peers, so most instances of truly degraded competencies are likely to be locally detected and mitigated inside those systems.
- This assertion is supported by results from human resource studies done by the AARC and by the fact that no therapist can legally practice alone like a physician, nurse practitioner, or physician’s assistant.
Respiratory therapists who today hold NBRC credentials have evolved from solely generalists in 1961 to a diverse group that also includes specialists. Licensure has been added to the work life of practically all general respiratory therapists.
The NBRC convened a focus group of stakeholders in 2015 to help guide recommendations about new CMP features. These new features will be evaluated during a pilot year in 2019 with full implementation planned for 2020.
A key feature of the CMP is an open-book assessment linked to each general and specialty credential. A new set of CMP assessment items will be released each quarter. The assessment platform is mobile-friendly making it accessible with a wide range of devices.
Because a second job analysis study identified content of each CMP assessment while focusing on tasks observed to be high in risk and high in change, support is strong for two types of guidance participants receive:
- Study the content related each item that is missed because this content is vital to maintained competence in the topics that matter.
- If needed, document continuing education informed by assessment performance in the final year of a credential cycle.
Participants who start a renewal cycle are assumed to be competent, so they start at the top of the green performance level. Performances on general and any specialty assessments determine whether a participant remains in the green zone or whether documentation of maintained competence will require supplementation with continuing education credits.
Participation of permanent credentials holders in the CMP will be evaluated in the years that follow full CMP implementation.