The certification maintenance program of the National Certification Corporation (NCC) is designed to provide its core and subspecialty certificants with a mechanism to demonstrate their continued specialty competence and professional development during each 3-year maintenance cycle. Core and subspecialty maintenance processes are structured to ensure that certificants are exposed to evolving scientific developments and evidence-based practice in the clinical aspects of their respective specialties.  A key element in NCC’s maintenance approach is a focus on the core competency knowledge content as it is represented in the certification examination for each specialty or subspecialty with established updating timelines based on content validation and task analysis study data. Ongoing maintenance of certification demonstrates to the public and to the profession that the NCC-certified professional delivers a high standard of patient care within their chosen specialty area of neonatal, obstetric, gynecologic and/or women’s health.  A certification maintenance approach of this nature not only validates knowledge, expertise and dedication to a specialty area of practice, but it also affords each certificant with a tangible recognition of their professional commitment. Maintenance is required for everyone certified by NCC, and the maintenance procedure is part of the certification program that certificants must meet to maintain their certification.

 As an accredited certifying body, The National Certification Corporation (NCC) must meet the Standards for Accreditation of Certification Programs established by the Accreditation Board for Specialty Nursing Certification, Inc. (ABSNC) and the National Commission for Certifying Agencies (NCCA). As certification accrediting bodies, ABSNC and NCCA have definitions for recertification and continuing competence. NCC’s definitions are in line with these for both continuing competence and maintenance of certification to include.

• Continuing Competence: “Demonstrating specified levels of knowledge, skills, or ability not only at the time of initial certification but throughout an individual’s professional career demonstrating the ongoing ability to practice safely, effectively and ethically in a designated specialty.” (Adapted from the NCCA Standard 22, Nov. 2014)
• Maintenance of Certification: “The requirements and procedures established as part of a certification program that certificants must meet to maintain current knowledge, skills and abilities, renew certification and provide safe, competent care.” (Adapted from NCCA Standard 22, Nov. 2014)

Rationale for Maintenance of Certification

All certificants must maintain their credential on a three-year basis. The purpose of the program is to ensure that certificants continue to maintain their knowledge, abilities and skills in the designated specialty area. The three-year period was designated based on the belief that a timely renewal of knowledge was needed in a profession in which information changes frequently. It was also felt that the three-year period provided reassurance to the public that the certified professionals had continued to demonstrate their knowledge, skills and abilities. In addition, a current, active, unencumbered licensure is required by everyone who obtains and maintains a NCC certification.  Licensing bodies have their own set of requirements for ongoing licensure which often includes continuing education and unencumbered practice. Certification must be maintained on an ongoing basis every three-years by continuing education. Certificants must provide a current license number, licensing state or province and expiration date for the current/active practice licensure as applicable in the U.S. or Canada.

We live in an era of scientific and technical information explosion with inexhaustible knowledge bases collected millions of journals, books and digests. All aspects of health care are continually changing. The internet has brought about a rapid change in information¹. In the context of today’s digital world and the feelings that technological and knowledge change happen at rapid pace, a literature review was undertaken to identify how rapidly knowledge changes and the certificants view of the maintenance process based on changes in scope of work.

Although Medical knowledge is estimated to double every 7-10 years, it is unknown how often these changes occur in areas that directly affect clinical decision making in Obstetrics, Gynecology, Women’s health care and the Neonatal fields. In 2010 it was estimated that knowledge doubles every 3.5 years and it is estimated that this will be down to 73 days by 2020². Knowledge learned in medical and nursing schools are outdated before graduation.  Knowledge expands faster than our ability to assimilate and apply it effectively. What is key is an expectation that providers have a foundational knowledge that they have mastered when they obtained licensure and subsequently certification. Lifelong learning and new knowledge build on the foundation and is a continual process². It has been demonstrated that approximately 20% of core information that guides clinical practice changes within a year based on new evidence³.  In addition to the rapid change in the evidence, knowledge itself decays over time and it is critical that we remain cognizant of these changes and reeducate ourselves on a continuum. Maintenance of certification is based on the concept that over time knowledge changes and it must be updated.

            Some knowledge is foundational and does not change.  Other information can become quickly outdated.  A research study is considered to be outdated when it is over three years old due to demographic and information changes. Even setting a maintenance date may vary in a year where information changed rapidly compared to a year when there were few changes in the literature. The process for continued competence must provide a way to maintain certificant awareness of recent developments in the field. In a review looking at “When do Systematic Reviews go out of Date?” it was found that the median survival time without substantive new evidence for a meta-analysis was 5.5 years with the median time being 3.0 years⁴. There was significant new evidence available for 7% of reviews by the time they were published, and new evidence was available for 23% within 2 years of publication⁴. The Cochrane Collaboration recommends updating systematic reviews every 2 years.   The Agency for Healthcare Research and Quality (AHRQ) stated that practice guidelines should be reassessed for validity every 3 years based on a review of the validity of guideline they completed in 2001⁵. Another study, that reviewed clinical guidelines to evaluate when they should be updated, validated the previous information stating that waiting beyond 3 years to update clinical guidelines is too long since the evidence changes⁶. They found that the median follow-up time for assessment of guidelines was 3.6 years⁶. At 1 year 92% of the information was still valid with a steady decrease after that.  They did state that some information changes more rapidly than others and that is a key decision maker when changing guidelines. Clinical practice guidelines are used for patient care and provide evidence-based recommendations for best practice by healthcare providers. They are often used to reduce variability in practice and to translate scientific research into clinical practice, thereby improving quality and safety in healthcare. Scientific knowledge in health care is continually changing and the median time in these studies was 3 years for a change to be made.

            In addition to the literature review, NCC conducted a 2017 maintenance timing survey asking certificants the following questions:

1. Based on the speed of which knowledge, clinical guidelines, competencies and clinical practice change your scope of work, do you think the NCC maintenance frequency is just right, too long or too short.
2. How quickly does your practice scope of work change based on new specialty clinical knowledge and evidence?
3. How quickly does your practice scope of work change based on new evidence that impacts clinical guidelines?
4. How quickly does your practice scope of work change based on procedural and skills competencies?
5. How quickly does your practice scope of work change based on changes in equipment your use or new technology (i.e. computers, software, and equipment functionality?

All certificants were surveyed electronically (Total of 83,510) with an overall response rate of 11% (8,838). Between 70-78% of certificants felt the current maintenance cycle of every three years was just right. The data for each type of certification can be found in Table 1. All certificants felt that the scope of practice was impacted by new clinical knowledge and evidence about every 3 years. The majority of the certificants felt new evidence that impacted clinical guidelines, new procedures and skills competence and changes in equipment or new technology impacted scope of work about every 3 years. (See Table 1).

 Based on this literature review and the NCC 2017 maintenance timing survey, the recommendation to the NCC Board of Directors were to keep the current maintenance requirements without change.  In addition to the above information, the other issue that was key to determining maintenance requirements is constituent compliance.  Decreasing interval of maintenance as knowledge rapidity occurs may be counter-productive.  If the maintenance process is so frequent or highly interactive, the compliance with the maintenance requirement may become daunting to the individual so that opting out becomes their decision.   As knowledge changes so does the pace of life in general and individuals may become overwhelmed.  Simplicity and reasonableness in maintenance requirements should be a central attribute of the maintenance program.  As knowledge change continues to be more rapid, NCC believes the 3-year maintenance cycle is still appropriate as it incorporates data from task analyses which reflect knowledge change in the certification specialty and while information may change rapidly there is also a time factor involved in the incorporation and dissemination of that change into knowledge competencies and actual practice. The acquisition of the changing knowledge may not always be immediate. Current information does not seem support to the lengthening or shortening the maintenance cycle.

REFERENCES

1. Masic, I. (2013) The Importance of Proper Citation of References in Biomedical Articles, ACTA Informatica Medica; 21(3), 148-155
2. Densen, P. (2011) Challenges and Opportunities Facing Medical education. American Clinical and Climatological Association;122, 48-58.
3. Alper, B. (2012) “How much does practice-guiding Medical Knowledge Change in one year? Medicine 20. World Congress. http://www.medicine20congress.com/ocs/index.php/med/med2012/paper/view/1028
4. Shojania, K. Sampson, M., Ansari, M. Doucette, S. and Moher, D. (2007) How Quickly Do Systematic Reviews Go out of Date? A survival Analysis. Annals of Internal Medicine. 147 (4); 224-233.
5. Shekelle, P., Ortiz, E., Rhodes, S., Morton, S, Eccles, M. Grimshaw, J. And Woolf, S. (2001) Validity of the Agency for Healthcare Research and Quality clinical practice guidelines: how quickly do guidelines become outdated? JAMA, 286(12) 1461-7.
6. Martinez Garcia, L. et al. (2014) “The validity of recommendations for clinical guidelines: A survival Analysis. CMAJ 186(16), 1211-1219.