Wisconsin Department of Safety and Professional Services Division of Policy Development

1400 E Washington Ave

PO Box 8366 Madison WI 53708-8366

Phone: 608-266-2112

Web: http://dsps.wi.gov Email: dsps@wisconsin.gov

Scott Walker, Governor

Laura Gutiérrez, Secretary

PHYSICAL THERAPY EXAMINING BOARD

Room 121A, 1400 East Washington Avenue, Madison

Contact: Tom Ryan (608) 266-2112

November 29, 2017

The following agenda describes the issues that the Board plans to consider at the meeting. At the time

of the meeting, items may be removed from the agenda. Please consult the meeting minutes for a record

of the actions of the Board.

AGENDA

8:30 A.M.

OPEN SESSION – CALL TO ORDER – ROLL CALL

A) Adoption of Agenda (1-3)

B) Approval of Minutes of September 6, 2017 (4-6)

C) Administrative Updates

1) Department and Staff Updates

2) Introduction, Announcements, and Recognitions

3) Appointments, Reappointments, and Confirmations

4) Board Member Status

a) Shari Berry – 07/01/2020 (Reappointed, not yet confirmed)

b) John Greany – 07/01/2019

c) Sarah Olson – 07/01/2021 (Reappointed, not yet confirmed)

d) Bailey Steffes – 07/01/2021 (Appointed, not yet confirmed)

e) Kathryn Zalewski – 7/01/2021 (Appointed, not yet confirmed)

D) Conflicts of Interest

E) Occupational License Study (7) 1) 2017 Wisconsin Act 59 (enacted in State Budget Bill)

2) 2017 Wisconsin Senate Bill 288 and Assembly Bill 369 (under consideration)

F) Board Chair Conference Call, November 17, 2017 – Report from John Greany (8)

G) Federation of State Boards of Physical Therapy (FSBPT) Matters (9-57)

1) 2017 Leadership Issues Forum Report (9-56) 2) Federation of State Boards of Physical Therapy (FSBPT) 2017 Annual Meeting Report

(57) 3) Update on Compact Status

4) Alternate Approval Pathway

H) Legislative and Administrative Rule Matters – Discussion and Consideration

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1) Update on Other Legislation and Pending or Possible Rulemaking Projects

I) Supervision of Students – Board Discussion

J) Speaking Engagement(s), Travel, or Public Relation Request(s) and Reports – Discussion and

Consideration

K) Credentialing, Education, and Examination Matters

L) National Association of Attorneys General Letter Regarding Alternatives to Opioids

M) Informational Items

N) Items Added After Preparation of Agenda:

1) Introductions, Announcements and Recognition

2) Appointments, Reappointments, and Confirmations

3) Administrative Updates

4) Liaison, Panel, and Committee Reports

5) Education and Examination Matters

6) Credentialing Matters

7) Practice Matters

8) Legislation/Administrative Rule Matters

9) Liaison Report(s)

10) Board Liaison Training and Appointment of Mentors

11) Informational Item(s)

12) Disciplinary Matters

13) Presentations of Petition(s) for Summary Suspension

14) Presentation of Proposed Stipulation(s), Final Decision(s) and Order(s)

15) Presentation of Proposed Decisions

16) Presentation of Interim Order(s)

17) Petitions for Re-Hearing

18) Petitions for Assessments

19) Petitions to Vacate Order(s)

20) Petitions for Designation of Hearing Examiner

21) Requests for Disciplinary Proceeding Presentations

22) Motions

23) Petitions

24) Appearances from Requests Received or Renewed

25) Speaking Engagement(s), Travel, or Public Relation Request(s), and Reports

O) Public Comments

P) Future Agenda Items

CONVENE TO CLOSED SESSION to deliberate on cases following hearing (§ 19.85 (1) (a),

Stats.); to consider licensure or certification of individuals (§ 19.85 (1) (b), Stats.); to consider

closing disciplinary investigations with administrative warnings (§ 19.85 (1) (b), Stats. and §

440.205, Stats.); to consider individual histories or disciplinary data (§ 19.85 (1) (f), Stats.); and to

confer with legal counsel (§ 19.85 (1) (g), Stats.).

Q) Credentialing Matters (58-60) 1) Request to Waive TOEFL Requirement

R) Deliberation on Division of Legal Services and Compliance (DLSC) Matters 1) Administrative Warnings

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2) Proposed Stipulations, Final Decisions and Orders

3) Case Closings(s)

a) 16 PHT 037 (61-67)

b) 16 PHT 046 (68-77)

S) Open Cases

T) Deliberation of Items Added After Preparation of the Agenda

1) Board Liaison Training

2) Education and Examination Matters

3) Credentialing Matters

4) Disciplinary Matters

5) Monitoring Matters

6) Professional Assistance Procedure (PAP) Matters

7) Petition(s) for Summary Suspensions

8) Proposed Stipulations, Final Decisions and Orders

9) Administrative Warnings

10) Proposed Decisions

11) Matters Relating to Costs

12) Case Closings

13) Case Status Report

14) Petition(s) for Extension of Time

15) Proposed Interim Orders

16) Petitions for Assessments and Evaluations

17) Petitions to Vacate Orders

18) Remedial Education Cases

19) Motions

20) Petitions for Re-Hearing

21) Appearances from Requests Received or Renewed

U) Consulting with Legal Counsel

RECONVENE TO OPEN SESSION IMMEDIATELY FOLLOWING CLOSED SESSION

V) Open Session Items Noticed Above Not Completed in the Initial Open Session

W) Vote on Items Considered or Deliberated Upon in Closed Session, if Voting is Appropriate

X) Delegation and Ratification of Examinations, Licenses and Certificates

ADJOURNMENT

The Next Scheduled Meeting is February 7, 2018.

************************************************************************************

MEETINGS AND HEARINGS ARE OPEN TO THE PUBLIC, AND MAY BE CANCELLED

WITHOUT NOTICE.

Times listed for meeting items are approximate and depend on the length of discussion and voting. All meetings

are held at 1400 East Washington Avenue, Madison, Wisconsin, unless otherwise noted. In order to confirm a

meeting or to request a complete copy of the board’s agenda, please call the listed contact person. The board may

also consider materials or items filed after the transmission of this notice. Times listed for the commencement of

disciplinary hearings may be changed by the examiner for the convenience of the parties. Interpreters for the

hearing impaired provided upon request by contacting the Affirmative Action Officer, 608-266-2112.

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Physical Therapy Examining Board

Meeting Minutes

September 6, 2017

Page 1 of 3

PHYSICAL THERAPY EXAMINING BOARD

MEETING MINUTES

September 6, 2017

PRESENT: Shari Berry, PT; Lori Dominiczak, PT; John Greany, PT; Sarah Olson, PTA; Bailey

Steffes

STAFF: Tom Ryan, Executive Director; Laura Smith, Bureau Assistant; and other Department

Staff

CALL TO ORDER

Shari Berry, Chair, called the meeting to order at 8:30 a.m. A quorum of five (5) members was

confirmed.

ADOPTION OF AGENDA

Amendments to the Agenda

Add under Item O – 1. NPTE Attempts for Nathan B. Christopherson, P.T.

Move Item G until after Item N

Move Item Q up before Item P

MOTION: Sarah Olson moved, seconded by Lori Dominiczak, to adopt the agenda as

amended. Motion carried unanimously.

APPROVAL OF MINUTES

Amendments to the Minutes

Please note that Shari Berry would have opened the meeting as Chair.

MOTION: John Greany moved, seconded by Lori Dominiczak, to approve the minutes of

May 24, 2017 as amended. Motion carried unanimously.

FEDERATION OF STATE BOARDS OF PHYSICAL THERAPY (FSBPT) MATTERS

Alternate Approval Pathway

MOTION: John Greany moved, seconded by Sarah Olson, that effective upon execution of

the alternate approval pathway addendum, evidence of further professional

training and education the Board considers appropriate for PT 2.03 is satisfied by

FSBPT guidance following examination failure. Motion carried unanimously.

LEGISLATIVE AND ADMINISTRATIVE RULE MATTERS

Proposals for PT 2 and 9 Relating to Examinations and Continuing Education

MOTION: Lori Dominiczak moved, seconded by Bailey Steffes, to authorize the Chair to

approve the preliminary rule draft of PT 2 and 9 relating to examinations and

continuing education for posting of economic impact comments and submission

to the Clearinghouse. Motion carried unanimously.

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Physical Therapy Examining Board

Meeting Minutes

September 6, 2017

Page 2 of 3

Position Statements of the Physical Therapy Examining Board

MOTION: John Greany moved, seconded by Lori Dominiczak, to revise the Board’s position

statements and FAQ’s as proposed by the Chair and DSPS staff. Motion carried

unanimously.

CLOSED SESSION

MOTION: Lori Dominiczak moved, seconded by Sarah Olson, to convene to Closed Session

to deliberate on cases following hearing (§ 19.85(1) (a), Stats.); to consider

licensure or certification of individuals (§ 19.85 (1) (b), Stats.); to consider

closing disciplinary investigations with administrative warnings (§ 19.85 (1) (b),

Stats. and § 440.205, Stats.); to consider individual histories or disciplinary data

(§ 19.85 (1) (f), Stats.); and to confer with legal counsel (§ 19.85 (1) (g), Stats.).

The Chair read the language of the motion aloud for the record. The vote of each

member was ascertained by voice vote. Roll Call Vote: Shari Berry - yes; Lori

Dominiczak - yes; John Greany – yes; Sarah Olson – yes; Bailey Steffes – yes.

Motion carried unanimously.

The Board convened into Closed Session at 10:18 a.m.

RECONVENE TO OPEN SESSION

MOTION: John Greany moved, seconded by Lori Dominiczak, to reconvene in Open

Session at 11:18 a.m. Motion carried unanimously.

The Board reconvened into Open Session at 11:18 a.m.

VOTE ON ITEMS CONSIDERED OR DELIBERATED UPON IN CLOSED SESSION, IF

VOTING IS APPROPRIATE

MOTION: Sarah Olson moved, seconded by Bailey Steffes, to affirm all Motions made and

Votes taken in Closed Session. Motion carried unanimously.

(Be advised that any recusals or abstentions reflected in the closed session motions stand for the

purposes of the affirmation vote.)

DIVISION OF LEGAL SERVICES AND COMPLIANCE (DLSC) MATTERS

Proposed Stipulations, Final Decisions, and Orders

MOTION: John Greany moved, seconded by Bailey Steffes, to adopt the Findings of Fact,

Conclusions of Law, and Order in the matter of disciplinary proceedings against:

1. 15 PHT 013 – Eugenie B. Riggins, P.T.A.

2. 16 PHT 040 – Heather L. Liacopoulos, P.T.

Motion carried unanimously.

Case Closings

16 PHT 034 (S.L.M.)

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Physical Therapy Examining Board

Meeting Minutes

September 6, 2017

Page 3 of 3

MOTION: Sarah Olson moved, seconded by John Greany, to close the DLSC case number

16 PHT 034, against S.L.M. for No Violation. Motion carried unanimously.

17 PHT 005 (Unknown)

MOTION: Lori Dominiczak moved, seconded by John Greany, to close the DLSC case

number 17 PHT 005, against an unknown respondent, for No Violation. Motion

carried unanimously.

RATIFICATION OF LICENSES AND CERTIFICATES

MOTION: John Greany moved, seconded by Sarah Olson, to delegate ratification of

examination results to DSPS staff and to delegate and ratify all licenses and

certificates as issued.

ADJOURNMENT

MOTION: Bailey Steffes moved, seconded by Lori Dominiczak, to adjourn the meeting.

Motion carried unanimously.

The meeting adjourned at 11:24 a.m.

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AGENDA REQUEST FORM 1) Name and Title of Person Submitting the Request: Laura Smith, Bureau Assistant on behalf of Thomas Ryan, Executive Director

2) Date When Request Submitted: 11/16/17

Items will be considered late if submitted after 12:00 p.m. on the deadline date which is 8 business days before the meeting

3) Name of Board, Committee, Council, Sections:

Occupational Therapists Affiliated Credentialing Board

4) Meeting Date: 11/28/17

5) Attachments:

Yes

No

6) How should the item be titled on the agenda page? Occupational License Study:

• 2017 Wisconsin Act 59 (enacted in State Budget Bill)

• 2017 Wisconsin Senate Bill 288 and Assembly Bill 369 (under consideration)

7) Place Item in:

Open Session

Closed Session

8) Is an appearance before the Board being scheduled?

Yes

No

9) Name of Case Advisor(s), if required: N/A

10) Describe the issue and action that should be addressed: Board review of a provision in the enacted 2017 budget creating an occupational license review council (attached). Board review of similar legislation is pending in the state legislature, 2017 Senate Bill 288 and Assembly Bill 369. The links to the legislature’s web pages regarding Senate Bill 288 and Assembly Bill 369 are included here: https://docs.legis.wisconsin.gov/2017/related/acts/59/9139 (Attached) https://docs.legis.wisconsin.gov/2017/related/proposals/ab369 https://docs.legis.wisconsin.gov/2017/related/proposals/sb288

11) Authorization

Laura Smith……………………………………………………………… 11/16/17

Signature of person making this request Date

Supervisor (if required) Date

Executive Director signature (indicates approval to add post agenda deadline item to agenda) Date

Directions for including supporting documents: 1. This form should be attached to any documents submitted to the agenda. 2. Post Agenda Deadline items must be authorized by a Supervisor and the Policy Development Executive Director. 3. If necessary, provide original documents needing Board Chairperson signature to the Bureau Assistant prior to the start of a meeting.

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AGENDA REQUEST FORM 1) Name and Title of Person Submitting the Request: Shari Berry, PT, Board Chairperson

2) Date When Request Submitted: 11/14/17

Items will be considered late if submitted after 12:00 p.m. on the deadline date which is 8 business days before the meeting

3) Name of Board, Committee, Council, Sections: Physical Therapy Examining Board

4) Meeting Date: 11/29/17

5) Attachments:

Yes

No

6) How should the item be titled on the agenda page? Board Chair Conference Call, November 17, 2017 – Report from John Greany

7) Place Item in:

Open Session

Closed Session

8) Is an appearance before the Board being scheduled?

Yes (Fill out Board Appearance Request)

No

9) Name of Case Advisor(s), if required: N/A

10) Describe the issue and action that should be addressed: Report from John Greany on items and discussion on Departmental Board Chairs conference call on November 17, 2017.

11) Authorization Signature of person making this request Date

Supervisor (if required) Date

Executive Director signature (indicates approval to add post agenda deadline item to agenda) Date

Directions for including supporting documents: 1. This form should be attached to any documents submitted to the agenda. 2. Post Agenda Deadline items must be authorized by a Supervisor and the Policy Development Executive Director. 3. If necessary, provide original documents needing Board Chairperson signature to the Bureau Assistant prior to the start of a meeting.

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FSBPT Leadership Issues Forum

July 29-30, 2017

2017 Final Report

• Risk Based Regulation • Hearing from the Membership • Model Disciplinary Guidelines • Clinical Education • Continuing Competence • Exam, Licensure, and Disciplinary Database • Deregulation and Consolidation of Regulatory Boards • General Updates

o Anti-trust Coalition o PT Compact o Jurisdiction Licensure Reference Guide o Eligibility Requirements & NPTE o Foreign Educated Standards Committee

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Table of Contents Introduction .......................................................................................................................... 1

Continuing Competence: Risk Based Regulation. Getting Where We Want to Go .................. 2

Results of Small Group Discussion .............................................................................................. 4

Hearing from the Membership Part 1 ..................................................................................... 5

Results of Small Group Discussion .............................................................................................. 5

Model Disciplinary Guidelines ................................................................................................ 6

Results of Small Group Discussion: ........................................................................................... 10

Clinical Education ................................................................................................................ 11

Results of Small Group Discussion ............................................................................................ 12

Continuing Competence ...................................................................................................... 12

Exam, Licensure, and Disciplinary Database ......................................................................... 13

Consolidation, Deregulation, or Elimination of Regulatory Boards- a Trend? ........................ 13

Results of Small Group Discussion ............................................................................................ 15

Hearing from the Membership Part 2 ................................................................................... 16

Results of Small Group Discussion ............................................................................................ 16

General Updates .................................................................................................................. 18

Anti-trust Coalition.................................................................................................................... 18

Physical Therapy Compact ........................................................................................................ 19

Eligibility Requirements & NPTE Updates ................................................................................. 20

Jurisdiction Licensure Reference Guide .................................................................................... 20

Minimum Data Set .................................................................................................................... 21

Foreign Educated Standards Committee .................................................................................. 21

Appendix A: Attendees ........................................................................................................ 23

Appendix B: Summary of Small Group Responses & Recommendations ............................... 24

Risk Based Regulation ............................................................................................................... 24

Hearing from the Membership Part 1 ...................................................................................... 25

Model Disciplinary Guidelines .................................................................................................. 25

Clinical Education ...................................................................................................................... 26

Deregulation and Consolidation ............................................................................................... 27

Hearing from the Membership Part 2 ...................................................................................... 27

Appendix C: BPCETF Report on Clinical Education ................................................................ 29

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Introduction The 2017 FSBPT Leadership Issues Forum (LIF) focused on some general updates as well as these main topics:

1. Deregulation and Consolidation of Licensing Boards 2. Model Disciplinary Guidelines 3. Risk Based Regulation and Continuing Competence

The forum was held on July 29-30, 2017 and participants included FSBPT Board of Directors, committee chairs, delegates/board representatives and board administrators as well as identified stakeholders. The purpose of the LIF is to:

• Provide information and data on critical regulatory issues that impact the regulation of physical therapy. • Explore various ways of addressing the critical regulatory issues identified above. • Establish a plan for addressing the regulatory issues identified. • Provide an opportunity for delegates or other jurisdiction representatives to understand and discuss issues prior

to the Annual Meeting. • Provide updates on previous LIF initiatives.

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Continuing Competence: Risk Based Regulation. Getting Where We Want to Go Jeff Rosa, Mark Lane

Some History The Delegate Assembly motion that formed the basis of the Federation of State Boards of Physical Therapy’s (FSBPT) continuing competence program was adopted ten years ago. The components of the 2007 motion included the development of continuing competence tools, a model to integrate the tools, a comprehensive certification program (ProCert), and an appropriate organizational structure. As part of its review of the initiative ten years in, the FSBPT Board of Directors adopted a new Continuing Competence program purpose statement. This statement reaffirms that the purpose of the continuing competence program is to: promote the use of best practices in member jurisdictions, assure competence for re-licensure, provide a level of assurance to the jurisdiction of the licensee’s competence, and instill consumer confidence in the licensure process. At the 2016 Leadership Issues Forum, continuing competence was a key topic addressed by attendees. Feedback gathered at that meeting identified that physical therapy boards really want to know/be assured that when continuing competence requirements are implemented, the impact is to improve clinical outcomes and ensure licensees practicing in an ethical, safe, and effective manner. Unfortunately, most 2016 attendees indicated that their current continuing competence requirements do not achieve this desired outcome. When looking at what changes might lead to the desired outcome, the following items were identified:

• Base the requirements on metrics that measure patient outcomes; • Include assessments; • Embrace strategies to get licensees engaged by offering credit for different types of activities; • Require some element of self-assessment/self-reflection; and • Make the process non-punitive.

Dyscompetence versus Incompetence When addressing the topic of licensee competence, is incompetence really the opposite of competence? In the literature, the concept of dyscompetence is often included as an important distinction from incompetence. In a 2015 policy adopted by the Federation of State Medical Board, dyscompetence is defined as “failing to maintain acceptable standards of one or more areas of professional physician practice.” This same policy defines incompetence as “lacking the requisite abilities and qualities to perform effectively in the scope of the physician’s practice.” In essence, dyscompetence means less than fully competent and may reflect a temporary situation (e.g.: due to severe fatigue or anxiety) or a new status due to a decline of knowledge, skills, or abilities. Risk Based Regulation Risk-based regulation is a new way of looking at regulation that focuses on harm prevention and the promotion of outcomes. It focuses more on proactive prevention of harms through a partnership with the regulated in order to achieve positive outcomes. It also focuses on mitigating those risks that hamper the delivery of public value rather than expending resources on ensuring compliance to laws where no real harm is being caused (‘tick-a-box’ regulation). The historical approach of licensing boards has been this “tick-a-box” approach where the regulator assumes someone is competent if he or she has all the appropriate boxes checked. Risk-based regulation looks at which risks might make someone more susceptible to losing competence as well as identifying the supports that might make someone more likely to maintain competence. It also suggests that regulators should be concerned with “healthy practice.” Healthy practice would minimize the risks to competence while participating in supports to competence.

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It should be noted that having lots of risks to competence does not mean someone is incompetent or dyscompetent, nor does someone participating in a lot of supports necessarily equate to competent. Risks to competence identified in the literature: Transitions between practice settings International education Lack of experience Age Gender Practice features (size, isolation, etc.) Wellness Resources Lower entry exam scores

Supports to Competence identified in the literature: Continuing education Mentorship/coaching Educational information Personal supports and feedback QA participation Supportive Employer Clinical experience Professional organization participation Technology Self-reflection Assessment and feedback through tools Performance review

Risk-based Regulation in Practice A unique application of this approach has been done in British Columbia, Canada where their Board requires all licensees to conduct a self-awareness evaluation, the Annual Self Report (ASR). The ASR is a composed of 3 parts:

Section 1: About you: 8 questions Section 2: About your practice: 3 questions Section 3: Scenario based Jurisprudence Assessment

a. 12 questions b. 4 different practice contexts

The ASR is required annually at registration renewal. It is completely confidential and the College (Board) does not see the individual results. Instead an external agency develops a report that is then shared with the registrant. The individualized report includes the number of risks to competence that the individual has, why each is a risk, and some potential ways to mitigate the risks. It also reports the number of supports and why each is a support. Registrants are given the average number of risks, the percent of registrants that had a certain number of risks; the same thing is reported for supports. This enables the registrants to compare themselves to the average and where they fit within the frequency of risks and supports. It gives a registrant some awareness of their level of risk and their level of engagement in supports. The registrants are encouraged to take steps to mitigate risks and participate in supports if feasible. This process also gives the College aggregate data that can be used in making regulatory decisions. The main “take-aways” from a risk-based approach include: Competence is more than technical skill and knowledge but includes such things as health and wellness Regulators around the globe are focusing on:

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o Promotion of “Healthy Practice” (they use this word and recognize the need to define) A quality assurance approach is one that: 1) identifies the risks to losing competence and the supports to

maintaining competence, and 2) develops individualized reports provided to the registrant on his/her risks and supports

The Board’s action is altered from that of simply being a responder to bad behavior to a proactive preventative approach. Some may not see this as a Board’s role.

Small Group Questions

1. What are the characteristics of a competent therapist? • Can and should a licensing board encourage these characteristics? If so, how?

2. What are the characteristics of a dyscompetent/incompetent therapist? • Can and should a regulatory board discourage or help mitigate these characteristics? If so, how?

Results of Small Group Discussion The small groups came up with variations of the following characteristics of the competent therapist:

• Professional Engagement • Continuous Self reflection

o Know what you know o Know what you don’t know

• Self-aware and self-reflective • Evidence based practice – Are the outcomes positive?

o Keeps up with best practice and industry standards • Practicing within personal and professional scope • Safe and Effective- but how do you define either of those? • Ethical and professional practice

Professional engagement, self-awareness and evidence based practice were the most commonly stated characteristics of competency. For the most part, the small groups felt Boards can and should encourage these characteristics. They identified the following as possibilities for doing this:

• Provide self- reflective/awareness tools o Look at enhancing tools like Minimum Data Set (MDS) and oPTion to lead candidates down this path

(need to develop also for PTA) • Move beyond just a punitive role into a supportive role • Involve employers • Jurisprudence activities • Give credit for multiple types of activities • Create a paradigm shift- to engagement rather than “check the box” • Identify risks, disperse education, and make the professional aware of good characteristics • Educate practitioner on the “top five” issues to watch for. • Guided education on ethics. Target education to those at risk. • Partnering with professional associations to disperse information/education • Encourage mentoring/service • Help to self-identify if they are not engaged or are out of touch • Engage with the licensees between renewal cycles

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By far the most identified characteristics of the dyscompetent/incompetent therapist identified by the groups was lack of engagement in the profession. This lack of engagement included such things as working in an isolated practice, not staying up to date in knowledge and skill and not consulting with colleagues. Ethics and professionalism was also brought up. Lack of self-awareness and the ability to self-assess were also identified. Life circumstances and health and wellness issues were also identified as important. Lack of effectiveness and poor outcomes were identified as signs of the incompetent therapist. For the most part, the groups felt the Boards could be more supportive of a licensee in maintaining his or her competence. There was a feeling that Boards could do a better job of assisting licensees’ understanding of risk awareness, practicing self-care and accessing appropriate resources to assist in self-awareness and maintaining engagement. There were some thoughts that Boards could provide more tools and information via their websites by creating website/app/social media tools that give more ongoing regulatory information and risk screening. Credit could be given for accessing these resources.

Hearing from the Membership Part 1 The Leadership Issues Forum is an opportunity for the FSBPT Board of Directors to hear from the jurisdictions and other important stakeholders on a variety of issues. The Hearing from the Membership sessions were developed specifically to meet this goal. At the first session, attendees were seated in small groups and asked to identify the top two challenges their board is facing. A volunteer recorded them on the flip chart and then each person voted for the two most important challenges. The small groups were then asked to answer the following two questions:

1. What are the top two challenges and how are jurisdictions facing these challenges?

2. What resources would be helpful in dealing with the top two challenges/issues identified? Results of Small Group Discussion Issues: Although many issues were identified and discussed by the 11 small groups, there were a few topics that rose to the top. In no particular order, the following issues were listed the most frequently by the small groups:

1. Board consolidation, deregulation 2. NPTE eligibility and practice act revisions 3. Scope of practice issues including dry needling 4. Compact 5. Telehealth

Amongst the attendees, the Compact was consistently ranked as the number one issue for jurisdictions. Other topics that were identified by the attendees included, but were not limited to, re-entry to practice, implementing criminal background checks, consistency of discipline, and supervision issues related to licensed and unlicensed personnel. Attendees also discussed drug diversion and issues of substance abuse as the abuse of opioids has increased nationwide. Attendees noted that the societal expectation of immediate results is putting pressure on the Boards. Individuals expect that licensure processing should be immediate and do not understand the delays. Pressure is also coming from employers and staffing agencies who then complain to policy-makers, who in turn put pressure on the Boards to increase efficiency and cut processing times. Implementing criminal background checks slows down the licensure

15

process even more. The consolidation of regulatory boards often makes this situation worse rather than better; staff suffers burnout and workloads increase. Resources: The attendees have used many of the resources that FSBPT has available. However, attendees noted additional resources would be helpful on the following topics:

1. Compact- The financial impact, especially on revenue. Further explanation on the discipline processes and disciplinary information. Explaining how the criminal background check gets implemented. Clarification of many unknown issues when rules are published.

2. Board Consolidation- Creation of metrics for the board; how a board can show it is “doing its job.” FSBPT creates the effectiveness indicators for boards and then collects the data? Another idea is to gather testimonials, stories, and advice from states who have dealt with consolidation.

3. Continuing Competence- more information on how FSBPT products could help with audits. FSBPT could develop a supports/risks questionnaire similar to British Columbia that could be available to states for use.

Model Disciplinary Guidelines Leslie Adrian, Larry Ohman The purpose of the FSBPT’s Model Disciplinary Guidelines is to promote intra- and inter-jurisdiction consistency with regard to the application of discipline for a given basis for action. It can cause confusion for the board, the public, and the licensee when an individual is disciplined in one jurisdiction and the same offense has completely different consequences in another jurisdiction. A worse situation is when similar situations are handled differently in the same jurisdiction. Internal consistency may be even more important than the consistency with other jurisdictions. Jurisdictions could use the FSBPT Model Disciplinary Guidelines to stay consistent from case to case, rather than relying on recollection and historical knowledge from Board members/administrator and to help to mitigate vast differences when boards are assigned new Attorney Generals, staff turns over, or new members are appointed. The issuance of disciplinary action is linked to public protection in that it aides in creating an environment that allows competent and ethical practitioners to practice their profession by disciplining those who engage in professional incompetence or unprofessional, unethical, or unscrupulous conduct. Relationship to Mission of Public Protection

• Uniform application of discipline • Board is objective & has a process • Increase trust in the Board to do its work • Transparency in disciplinary • Fairness to licensees and public/consumers

Background The Ethics and Legislation Committee (ELC) began the development of Model Disciplinary Guidelines (MDG) in response to the request of the membership. The idea of MDG first emerged in the 2014 Membership Survey. Almost 78% of respondents “strongly agreed” or “agreed” with developing MDG as a new and future initiative. 100% of committee chairs surveyed chose MDG as one of the top two initiatives FSBPT should pursue. The ELC began the background work for the MDG in 2016. The committee researched disciplinary guidelines from other professions, internationally, and specific guidelines currently used by physical therapy boards in the United States (specifically, CA, KS, MD, TN, and VA). The ELC also accessed information from the FSBPT Exam, Licensure, and Disciplinary Database to gauge the variance of disciplinary sanctions for any given basis for action.

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At the 2016 LIF meeting the concept of disciplinary guidelines was presented. Overall, the attendees valued guidelines that were flexible, acknowledge differences between jurisdictions, and permit boards to exercise judgement. Much of the discussion centered on sanctions and the appropriateness of punitive versus remedial sanctions.

In developing the guidelines, the ELC looked to a number of resources such as the North Carolina Board of Nursing and the Kansas State Board of Healing Arts, which influenced the tone of the MDG: a tone of placing high value on remediation and using the least restrictive discipline necessary to effectively accomplish the stated sanctioning priorities. Discipline too lenient fails to deter potential offenders and negatively impacts the public’s confidence. Discipline too restrictive has been shown in research to lead to fewer reports of violation and encourages a more litigious environment. The ELC also studied the concept of “Just Culture” (previously presented at an FSBPT annual meeting) when making recommendations in the MDG.

The ELC confronted many challenges to development, including: • Terminology variation from jurisdiction to jurisdiction • Range of sanctions in ELDD for any given code • Data- what is needed, getting it, synthesizing it • Personal Bias to what is best • Determine the best format (graph, table, etc.) • Acknowledge “state rights” and independence • Must be flexible

The ELC believes that because of the variation in terminology among jurisdictions, the creation of definitions was very important. Definitions would allow the MDG to have one common language so everyone could understand the intent of the tool. A common definition would allow a jurisdiction to use the MDG by substituting their “word” that matches the definition best. For example, the words “fine”, “fee”, “civil penalty”, and “monetary penalty” are all used in jurisdictions to mean the same thing. The tool defines all sanctions and many other words that were identified as having high variance from jurisdiction to jurisdiction. Definitions should also help to improve the consistency of use of the tool. Process of Development The ELC was mindful of keeping the MDG consistent with other FSBPT and professional documents. The ELC surveyed many different state practice acts and regulations, The Model Practice Act and Basis for Action Definitions and Descriptions, to create a list of the grounds for action, basis for action codes, and possible sanctions. Both the list of the grounds for action and the list of sanctions were ranked in severity and grouped into categories. Five categories were created for the Grounds for Disciplinary Action. Sanctions were categorized as either remedial or punitive in nature.

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The ELC attempted to “build in” to the model some of the most common mitigating and aggravating factors a Board considers. The MDG have built in increased sanctions for the individual if there is a history of practice act violations, if the individual has multiple events of grounds in one investigation, and/or if it is an isolated event. Harm, real or potential, to the patient is also addressed in the MDG. Additionally, the ELC looked to discern between an error and a purposeful, intentional action to cause harm. The MDG require the Board member to consider a variety of factors to best determine if the violation occurred unintentionally or willfully.

All of the above considerations were taken into account and the Matrix was created to help assign disciplinary action for a given grounds for action. The matrix is the culmination of the decision points the Board has worked through to get the appropriate disciplinary sanction- remedial, punitive, or both. The matrix always includes an element of remediation; the ELC determined that in almost all cases where punitive action is taken, it should be coupled with remediation.

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The ELC also used state practice acts and the Model Practice Act to create a list of potential mitigating and aggravating factors for a Board to consider. The Board should determine if these factors should influence the severity of the remediation or punitive sanction. The Board may modify the sanction regarding the number of total sanctions or severity of the sanction.

The MDG follows a step-by-step process that ends in a determination of a disciplinary sanction for the individual. The ELC cross-walked all the potential Grounds for Disciplinary Action to the appropriate Basis for Action code to improve reporting to the National Practitioner Data Bank and the Exam, Licensure and Disciplinary Database (ELDD). Being more specific in reporting is important for consistent reporting across jurisdictions, improves the quality of data, and improves research usefulness. Next Steps The ELC will use the information from the small group questions in this report to revise the MDG as necessary. The MDG will be presented to the full membership at the 2017 FSBPT Annual Meeting with Board of Director approval. Final publication is expected by January 2018.

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Small group questions: In the small groups, each table was given a write-up of a real disciplinary case. Three different cases were distributed to the tables. The attendees used the model disciplinary guidelines to determine the disciplinary sanction/remediation in each case. Following the case, the attendees answered these questions:

1. What did you like about the Model Disciplinary Guidelines? 2. Would you recommend any changes to the Model Disciplinary Guidelines? 3. Could the Model Disciplinary Guidelines be implemented in your state? What are the barriers to

implementation? Results of Small Group Discussion: Responses to Question 1 Generally, the response to the model disciplinary guidelines was very positive. Attendees liked the objectivity and systematic, structured approach, which encouraged discussion to stay more focused on the details of the case. The attendees found the guidelines easy to use and understand and determined they may help new board members feel more confident and comfortable when faced with disciplinary cases. They noted that there was no need for institutional knowledge or Board history with these guidelines. Attendees also thought that the guidelines could be easily modified and used by other types of Boards (for those PT boards under an umbrella board structure). They also liked that the guidelines allow for some flexibility and customization for the individual state. Responses to Question 2 The attendees provided a few recommendations for the Ethics & Legislation Committee to consider:

• Increase the number of examples in the “factors to consider” under unintentional error, poor judgement, and recklessness

• Consider changing the labels of unintentional error, poor judgement, and recklessness • Define more clearly the difference between Orange and Red (clinical issue and public at large) • Modify and expand the purple category with more grounds for action; allow for option(s) for something other

than just Class A. Class A needs to be expanded with additional options. • Reconsider color coding for those individuals who are color blind • Increase the options for remediation • Clearly show that these are guidelines and should have discretion of the Board • Consider how to differentiate between a “few times” versus “many, many times” • Aggravating/mitigating situations

o The mitigating situations should allow you to change class o Increase examples of aggravating and mitigating, list the common ones, or advise the board to develop

their common lists Responses to Question 3 There were zero responses stating that the model disciplinary guidelines could not be implemented in their state. There was some concern that the guidelines would not hold up for a formal hearing. Implementation was not without barriers however. Some felt that approval from their AG was required first, others felt that the guidelines could be implemented through board policy rather than rule. Several attendees thought it could be as a guide and it is not overly prescriptive/mandatory. Many thought that these guidelines, with minimal changes, could even be helpful within a consolidated board that deals with multiple professions.

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Clinical Education Nancy Kirsch, Mark Lane Currently there is no uniformity in how clinical education is delivered in physical therapy educational programs. There are a variety of models including integration of clinical education within coursework that can range from 1-2 days per week to 8-12 weeks. This might be followed by a final end of program full time clinical from anywhere between 8-12 weeks to 6-12 months. In some of the latter models, the student may obtain licensure prior to completion of clinical. There are many variations on these models and time frames. In addition to the lack of consistency, there is a significant demand for PT Clinical Sites caused by the proliferation of programs. Limitations in the number of sites may lead programs to send students to clinical sites where the quality of care is questionable. Beyond this, there are some payment and reimbursement issues; Medicare will not pay for care under part B that is provided by a student. This increases the reluctance of clinics to accept students- particularly in the outpatient setting. Recently some clinics are charging to take students. The American Physical Therapy Association (APTA) was charged by its House of Delegates to establish a task force to review physical therapy clinical education. APTA established the Best Practices in Clinical Education Task Force (BPCETF). The BPCETF submitted its report to the APTA Board of Directors in spring of 2017. The Board determined that more stakeholder input was needed on the Task Force recommendations and established a task force to solicit this input and report to the APTA Board at its November 2017 meeting. The entire Task Force report is included in the appendix of this LIF report. The BPCETF made the following recommendations:

1. That formal preparation for practice includes physical therapist professional education, followed by clinical internship and mandatory post-professional residency, and is accomplished through a process of staged licensure and specialty certification;

2. That a structured physical therapist clinical education curriculum be developed and implemented; 3. That a framework for formal partnerships between academic programs and clinical sites that includes

infrastructure and capacity building and defines responsibly and accountability for each be developed; 4. That clinical education be incorporated into the recommendations approved by the Board and forwarded to the

Education Leadership partnership regarding education data management systems; 5. That the physical therapy profession’s prioritized education research agenda include a line of inquiry specific to

clinical education; and 6. That the BPCETF report submitted for the January 2017 Board meeting be made available to the education

leadership partnership and other stakeholders within the physical therapist education community. Modified Recommendation 6- That the APTA design a plan for dissemination of the BPCETF report for

receiving widespread stakeholder input prior to consideration by the Board for adoption at its November 2017 meeting.

Because regulators have a role in determining educational requirements of physical therapists and physical therapist assistants and because the BPCETF recommendations include a significant increase in regulatory requirements, the LIF participants were asked to comment on the recommendations. Small Group Questions:

1. From a regulatory perspective, what evidence (complaints, violations, etc.) is there that regulatory requirements need to be increased (is there a regulatory problem)?

2. Would the recommended staged licensure approach: a. Solve any perceived or real issues related to adequacy of current clinical education? b. Create any additional regulatory challenges in your jurisdiction?

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3. Do you have any general comments or concerns about the recommendations that should be shared with the Stakeholder Task Force?

Results of Small Group Discussion In general the small groups did not perceive that there is a regulatory problem with clinical education. There did not seem to be any evidence from a regulatory perspective that new graduates were not clinically competent. The groups felt that new graduates should not be expected to practice at the same level as the experienced therapist. Disciplinary cases seem to be linked more to professional behavior documentation or billing and not actual application of practice and seemed to occur more after some years of practice. There was some general concern in the groups that the solution would not solve clinical education challenges and in fact might create additional problems. There was general consensus that the tiered licensure model would create significant regulatory burdens as well as exacerbate workforce issues. There was one group that felt that recommendation 2 (research) needed to occur prior to any consideration of a new clinical education model. There were many additional concerns including costs to the student, the role of the physical therapist assistant, the impact on the foreign trained therapist and workforce, adding a greater gap between number of students and number of clinical sites, the need for generalists, implementation of regulatory requirements and other professions filling the gap created. There was overall agreement among the groups that there should not be additional regulatory requirements added to students without clearly defining the problem and then providing evidence that the added requirements are necessary for public protection. Continuing Competence Heidi Herbst-Paakkonen, Michele Thorman This presentation addressed the current implementation and utilization status of the FSBPT continuing competence tools and services: aPTitude, oPTion, ProCert and the Jurisprudence Assessment Modules (JAMs). Additionally the presentation provided insight into future activities and efforts for these tools and services. Finally, a summary report on the work of the Continuing Competence Committee was delivered. Meeting participants learned aPTitude use by PTs, PTAs and students continues to grow with 33,000 registered users. Additionally, continuing competence activity vendor registration is nearly 600 users. While a handful of states have fully implemented the aPTitude system, FSBPT is collecting data on how, and to what degree, they are promoting and partially implementing aPTitude. Examples and implementation models will be further explored at the 2017 Annual Meeting. Recent and future system enhancements were highlighted, including the user benefits associated with those changes. The oPTion discussion focused on FSBPT’s efforts to promote this self-directed assessment tool for PTs through improved messaging and communication, and by securing credit awards in partnership with the jurisdictions. Jurisdictions using the JAM as a continuing competence tool were highlighted; special attention was devoted to the Texas JAM as also including ethics content, and as creating a new administration model allowing the state to also require the JAM for initial licensure with no fee for initial licensure applicants (in the absence of statutory authority to require a fee).

The ProCert portion of the presentation reported the program as having certified nearly 3,900 activities for 185 activity vendors in its five-year history. Jurisdiction acceptance of ProCert has remained at 30 in 2017, but more jurisdictions are

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working to join this list in the coming months. FSBPT continues to roll out program enhancements to the aPTitude system to improve ProCert, including those that improve data and account management, bring efficiencies to the submission and review processes, and monitor reviewer consistency and accuracy to identify training and improved guidance needs. Additionally FSBPT is reviewing other accreditation organizations’ programs and processes for benchmarking purposes, and to glean valuable guidance (e.g. best practices, lessons learned). The future will likely bring more engagement opportunities for FSBPT with these organizations. The current work of the FSBPT Continuing Competence Committee was highlighted to include a review of terminology in use; consideration of risk-based regulation, outcomes and compliance incentivizing; continuing promotion of the importance of engagement; the value of ethics and jurisprudence; and the need for collaboration among the stakeholders to achieve the ultimate goal of sustaining safe, effective and competence physical therapy practice by all licensees. Exam, Licensure, and Disciplinary Database Seif A. Mahmoud The Exam, Licensure, and Disciplinary Database (ELDD) continues to be one of the most important public protection tools FSBPT has to offer its member jurisdictions. Full participation by the members in the ELDD allows FSBPT to report disciplinary actions taken against an individual in one state to all other states in which the person is licensed. FSBPT has begun to increase the frequency of measuring participation in the ELDD from twice per year to four times per year. The following trends are significant when reviewing the history of the measurements from 2013 - 2017: Overall the number of jurisdictions participating at the 5-star level are increasing. The number of jurisdictions participating at the 1-star level has stayed relatively constant. Individual jurisdiction ratings fluctuate over time.

The takeaway: Participation requires consistent effort on an ongoing basis. Beginning in 2018, the ELDD will serve as the Physical Therapy Compact Commission’s Data System, therefore Jurisdictions who are members of the compact will be required to participate fully by providing licensure data on a weekly basis and discipline information immediately after an action is finalized. Participation for Jurisdictions who are not members of the Compact continues to be optional but is highly encouraged to maximize public protection. FSBPT continues to work with each jurisdiction interested in improving their participation to develop a customized work plan. Jurisdictions interested in improving ELDD participation may reach out to eldd@fsbpt.org. Consolidation, Deregulation, or Elimination of Regulatory Boards- a Trend? Mark Lane, Charles Brown, Ron Barbato As regulators, some important questions we must be able to answer include: How effective is the physical therapy licensing board in your state at protecting the public from incompetent

practitioners? Can the licensing board in my state demonstrate its effectiveness at protecting the public? When describing your Boards effectiveness, what do you base your response on?

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Which is the most effective Board Structure?

We need to be able to answer these questions because regulators are coming under increasing scrutiny from economists, public policy groups and Federal and state agencies. The following is a quote from the CATO Institute’s publication:

Instead of vetting physicians, the licensing apparatus provides an avenue for professional influence that has been used to restrict entry, limit competition, and preclude innovation in the provision of health care.

Shirley Svorny, Beyond Medical Licensure, Regulation, The CATO Institute, 2015

And from the Federal Trade Commission:

This is an important moment for economic liberty. Governors, state legislators, and many other stakeholders want to move forward to remove or narrow occupational licensing regulations and open doors to opportunity, enhancing competition and innovation.

FTC Website

State governors are also challenging licensure as it now exists:

Working with my agencies, we were able to identify areas where Nebraska’s licensing requirements were onerous or out-of-step with other states. Unnecessary licensing restrictions are a barrier to Nebraskans seeking careers in licensed professions, and especially to those who may be looking for a career change or upward mobility. Removing restrictions will grow job opportunities for Nebraska.

Governor Pete Ricketts, Nebraska

In his February 2017 Budget Address, Governor Scott Walker of Wisconsin included a proposal to create a panel to review occupational licenses “to determine which are truly needed to protect public health and safety and which of those are just barriers to employment,” and also to make recommendations for reducing or eliminating continuing education requirements for licenses not recommended for elimination. Kentucky’s Governor has recently issued an executive order to consolidate boards into several “super” boards. While the consolidation has not occurred yet, Ron Barbato, Chair of the Kentucky Board, shared the following “take-aways:”

1. Reorganization will affect many boards. The North Carolina case set the stage, but also gave others the idea that Boards could be challenged in

antitrust suits. Governors, legislators and affected public are taking note – be prepared to act.

2. Determine what side of the fence your board will stand - line up resources accordingly. 3. Many licensees and the public feel licensing as a burden, and part of big brother oversight.

• Be prepared that board reorg will be a change that will be supported by some 4. Know where your efficiencies rest, know and be able to speak about your weaknesses; have data to support

your position. 5. Important to have professional member side support – open up dialog with your professional

organization/lobbyists. 6. Legal council is a must for these discussions and for options 7. Who is on your team?

• Know who would be affected • How can they help

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Over the years, Arizona has had multiple challenges to its Boards. Chuck Brown, the Physical Therapy Board Administrator, shared the following key points:

1. Reorganization in Arizona has been an idea around for many years from both political parties. 2. It has never succeeded on a large scale, but has been heavily pushed for the last two plus years. 3. The idea has many motivations, but is primarily rooted in accountability, efficiency, and effectiveness.

Perception is the reality in this discussion. Have your facts to address concerns. The general public in Arizona supports the idea of less Government. Can you make changes now to begin reducing unnecessary burdens before reorganization becomes a

trend in your State? 4. The North Carolina Dental Board case is a timely influence, but not a primary motivation. 5. In Arizona, Boards are not part of the discussion on the Executive side, but are sometimes being communicated

with on the Legislative side. Be open for discussion when possible, but know your limits and the limits of Board staff. We are all a part of a branch of government and should respect the people in the highest positions of

responsibility. 6. Regardless of who may be asking questions, a collective voice with researched and planned questions or options

is best. • Do not wait until action is being taken to discuss the issue with stakeholders. • Understand the questions that need to be answered to form a strong plan for reorganization.

7. Put yourself and your team in the best position possible to be part of a solution, regardless if it is your preference for reorganization.

8. We are government operators not the policy makers.

Based on the trend to eliminate or consolidate regulatory boards, here are some questions for Boards to reflect on: How effective is your state’s Board at protecting the public? Can the Board demonstrate its effectiveness? What might be some legitimate criticisms of the Board? What would happen to the public if your Board was eliminated? What would be the impact if your Board was

consolidated (more than it is)?

In 2001, FSBPT developed a Board Assessment Tool to help Boards compare their efficiency and effectiveness to other similar PT Boards in other states. Both Medicine and Nursing have developed similar tools. The tool was based on annual survey data collected from member states. In 2007, FSBPT stopped collecting and compiling the data due to lack of participation and some questions about the accuracy of the data. The attendees were asked if perhaps it was time to relook at the benefits of developing a similar tool.

Small group questions

1. What are the driving forces for consolidation/de-regulation? 2. Is deregulation or consolidation a bad thing? Why? Is the regulatory criticism justified? 3. How might a Board respond when faced with consolidation/de-regulation?

Results of Small Group Discussion What are the driving forces for consolidation/de-regulation? Many of the groups identified politics and the political climate to be a driving force for this trend. Economic factors (state budgets) and unemployment numbers seem to contribute to this. Some groups identified lack of understanding of the benefits of regulation on the part of legislators contributed. Lack of efficiency on the part of licensing boards and health departments was also identified by multiple groups.

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Groups had a tendency to identify external factors as the main drivers. Only a couple of groups identified poor performance by the licensing board and boards acting more in the interest of profession than the public as a driver. One group identified the lack of data collection on the part of regulators as being a driving factor. Is deregulation or consolidation a bad thing? Why? Is the regulatory criticism justified? Most of the groups concluded that it was not necessarily good or bad. It depended on the people involved, the professions that were combined and the efficiencies gained. There was a general thought that if Boards were combined, the professions needed to be somewhat similar so there was shared knowledge. There was also a thought that some professions did not need to be regulated and some of the criticism was justified. How might a Board respond when faced with consolidation/de-regulation? All the small groups thought that collecting data and demonstrating the regulatory value of licensure was critical. There was also shared sentiment that Boards needed to be politically savvy and that they have a responsibility to educate politicians and policy makers. One group suggested that boards needed to stay current and efficient and not work with outdated regulations. Several groups suggested it was important for regulators to be part of the solution and be proactive versus reactive. The sunset process was identified as a helpful process. Finally, several groups identified the need for licensing boards of various professions to collaborate in streamlining processes and creating efficiencies. Hearing from the Membership Part 2 The final session was used to reflect upon and discuss the topics presented over the two days. In small groups, attendees were asked to list two “take-aways” from this meeting. Additionally, the groups were asked to identify, as a result of the weekend discussions, topics on which the regulatory community should focus or should not be as focused. Results of Small Group Discussion Topics identified on which to focus included:

• Board assessment tools o Determine metrics

• How to measure “public protection.” What is a true measure of public protection? What are metrics that are meaningful? o Collecting data to support evidence-based regulations o Research to support the regulatory need for public protection

Look at more of the data from the ELDD and MDS Look at types of discipline administered. Are we effective?

• Develop a guide to help boards going through consolidation (or even sunset review) • Increasing communication between the education and regulatory communities

o How do we educate licensees before they start their career – and throughout their career - convince them that regulation is to their benefit?

• Recruitment of regulatory board members- professional and public • Continuing evolution of disciplinary guidelines • Continuing Professional Development/Continuing Competence

o Encouraging engagement o Shift from continuing education to continuing competence; leveraging oPTion o More information about the use of a portfolio and development of a portfolio o Identification of risks/supports

• Public information campaign o Tools boards can use to encourage the public and other licensees to report to the board

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Other suggestions include:

• Inviting a voice of PTAs as special guest to LIF- e.g. PTA SIG representative Topics on which the regulatory community should not be as focused:

• The regulatory community should not focus on increasing licensees’ engagement with APTA. Engagement needs to be much broader.

• The BPCETF clinical education proposal was a topic identified by multiple tables as one on which the

regulatory community should not focus, however, this was not unanimous amongst the small groups. Some felt that more detail and information should be fleshed out about clinical education issues. Others felt that the recommendations should be acknowledged, take a stance opposing them, but nothing more should be done. Overall, there was no support from attendees for the recommendations presented by the task force.

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General Updates Anti-trust Coalition William A. Hatherill A Journey: Professional Licensing Coalition In overview, this “Journey” began as a result of the U.S. Supreme Court’s decision involving the North Carolina Dental Board, along with the acknowledgement of certain environmental factors which lead to the formation of the Professional Licensure Coalition and its purpose to introduce federal legislation to exempt licensing boards, board members and staff from the weighty consequences of the antitrust laws. The journey continues as the Professional Licensure Coalition attempts to get a bi-partisan bill introduced into Congress. Investigation of a Ruling In reviewing the Professional Licensing Coalition, it was noted that our journey began in February 2015, with the U.S. Supreme Court’s ruling on the North Carolina Dental Board vs. Federal Trade Commission. It was noted that this dispute was borne out of a “Scope of Practice” dispute between dentists and dental hygienists. Prior to the U.S. Supreme Court ruling, anti-trust laws did not apply to state licensing boards. State licensing boards were protected under the “State-Action Doctrine” which substituted regulation for competition or restricting entry. Response to a Ruling With the U. S. Supreme Court ruling that determined that licensing boards, as a result of being comprised of active market participants, could be considered private organizations, if not actively supervised by the state, licensing board members and their staffs (and hence the state tax payers) were subject to treble damages and attorney fees. This threatened state treasuries, along with state licensing board members and staff, and may potentially decrease the willingness of individuals to serve on licensing boards. Along with the chilling effects the U.S. Supreme Court ruling has had on licensing boards, there are multiple other environmental factors that have also come into play and are challenging the regulatory community:

• States are attempting to find solutions to address their fiduciary obligations in an effort to protect their respective state’s treasury; they are exploring various new means of oversight of licensing boards, including board consolidation, veto power, or altering board make-up.

• There is a concern for over-regulation or unnecessary regulation in our society and the associated cost implications and the anti-competitive impact it may place on the price of services and availability of these services.

• There is a concern about the rapid number of occupations that are seeking licensure and, in turn, building barriers to entry into historically unlicensed professions that have minimal health and safety risks to the public (hair braiders, interior decorators, etc.).

The Coalition’s Initial Response FSBPT, in the spring of 2016, joined in the formation of a “Professional Licensing Coalition” with the regulatory bodies for accountancy, architecture, athletic trainers, landscape architecture, medicine, occupational therapy, psychology, social work, veterinary medicine, and the Federation of Associated Regulatory Boards. The Professional Licensure Coalition’s purpose was to seek federal legislation to eliminate the potential antitrust liability to licensing boards, members and their staff. The Coalition membership looked to the precedent entitled: “The Local Government Antitrust Act of 1984 (LGAA). The Coalition’s simple approach (one page) was to amend the LGAA to include “state licensing boards” and their officers and employees acting in an official capacity, which the Coalition anticipated would obviate the need for state legislative or state executive branch action. This approach would provide any plaintiff with the ability to achieve injunctive relief, just without the financial hardship on the board, its members or employees. The Coalition also noted that time was of the essence and that it has not yet been successful in getting a bill introduced in the past year.

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Reevaluation and Steps Ahead In reevaluating the Professional Licensing Coalition’s approach after this first year of effort, the Professional Licensing Coalition membership eliminated the full-time lobbyist at the end of May 2017, engaged the associated professions’ professional associations and their respective lobbying efforts, and began to rely on the Federation of State Medical Boards to take the lead role in the lobbying effort. FSBPT was pleased with the American Physical Therapy Association’s (APTA) willingness to agree conceptually to support the Professional Licensing Coalition following the introduction of a bill into Congress. As a result of these efforts by the Professional Licensing Coalition, Capitol Hill staffers have begun to respond. The current discussions and proposals from Capitol Hill staffers have been presented as two doors. “Door one” holds that immunity is only applicable to professions licensed in the vast majority of states. “Door two” is that immunity would apply to those boards meeting the following conditions:

• Unregulated conduct of the profession demonstrated harm or endangers the health, safety or welfare of the public

• Public can benefit from occupational licensing • Public cannot be adequately protected by other means or in a more cost-effective manner • State legislature engages in a periodic independent sunshine review process (cost vs. benefit) • Due process provision • Mobility provision recognizing the decisions from other states and for veterans

The members of the House and Senate Judiciary Committee were reviewed in the presentation with a request for individuals attending that had a personal relationship with any of these Senators or Representatives on the respective Judiciary Committees to contact William A. Hatherill for possible future assistance in meeting with their Representatives and Senators. The Professional Licensure Coalition’s goal remains to have a bill introduced in 2017 with potential passage in 2018 or beyond. Two days preceding the FSBPT Leadership Issues Forum (LIF) conference (or as of July 27, 2017), a bill (20+ pages) was introduced by Senator Lee (UT), Senator Cruz (TX), and Representative Lee (CA) entitled: “Restoring Board Immunity Act.” While staff have not yet fully analyzed this substitute bill, it appears to place many requirements upon states. When we polled the LIF attendees on the question of the existence of any potential litigation and its potential effect on board members, the “yes” response votes were less than 50%. When we asked if the LIF attendees were concerned regarding possible changes or consolidation of their boards, the ”yes” votes were again less than 50%. In response to the third question, more than 50% indicated that they currently had a periodic sunset review processes in place. Physical Therapy Compact Jeffrey Rosa and Troy Costales This session provided an update on the current status of the Physical Therapy Compact (PTC). On April 25, 2017, Governor Inslee signed HB 1278 and Washington became the tenth state to adopt the Compact. Upon reaching the ten state threshold, the PTC officially started. From March 2016, when Oregon became the first state to pass the Compact legislation, to June 2017, 14 states enacted the Compact. The idea of a licensure compact in physical therapy was first discussed in 2010. At that time, the Delegate Assembly adopted a motion for the Board of Directors to explore the feasibility of a compact. In its report back to the Delegate Assembly in 2011, the Board of Directors recommended against a licensure compact. Two years later, the Delegate Assembly passed a motion supporting the concept and exploration of a licensure compact. The 2014 Advisory Task Force met and determined that a compact made sense for physical therapy and outlined its framework.

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Compact privileges will be the legal basis authorizing a physical therapist or physical therapist assistant to provide physical therapy in another compact state. The individual must be licensed in good standing in their home state, which must be a member of the compact, to be eligible to obtain a compact privilege. Once system development is completed, the first compact privilege should be issued in the first half of 2018. Prior to that time, the full Compact Commission must meet and adopt rules and bylaws. Those adoptions should occur at the Commission’s meeting on November 5, 2017. Eligibility Requirements & NPTE Updates Susan Layton and Lorin Mueller The National Physical Therapy Examination (NPTE) is one of our most important public protection tools as regulators. This session focused on discussing changes to the requirements to be eligible to take the NPTE, implementation of future eligibility requirements, and general updates relating to the NPTE. Ensuring consistent and defensible NPTE eligibility requirements continues to be an important initiative for FSBPT and our members. Consistent eligibility requirements help to ensure that the candidates who are taking the NPTE are eligible for licensure in a jurisdiction and adequately prepared to pass the NPTE and practice physical therapy in a safe and effective manner. The first part of this presentation focused on the history and background of what FSBPT has done relating to benchmarking, NPTE research, and gathering member and stakeholder input on potential changes to the NPTE eligibility process. The presentation also presented pass rates prior to the announced changes, in the year immediately prior to implementation (2015), and following implementation of the six-attempt rule and two very low score rule. The data showed that pass rates rose slightly after FSBPT announced the rule changes, suggesting some candidates might be preparing better for the NPTE, and that the number candidates getting very low scores has dropped drastically since the rules have been announced. Next, the presentation covered updates to the web pages communicating the changes to the eligibility process, so members can better direct their candidates to the most current information. The current process for determining eligibility was presented and compared to the 2018 transition period during which TOEFL scores and educational equivalence will be collected (but not required to meet a particular standard), as well as the final planned period in 2020 when the new TOEFL standard will be enforced along with the Coursework Tool (CWT) requirement. The presentation then moved to general NPTE updates, starting with a fee increase as of January 2018 (and the history of the decision-making process). The changes to the NPTE Content Outlines, effective January of 2018, were also presented along with the timeline for announcing updated passing scores, Practice Exam and Assessment Tool (PEAT) forms, and various score reports. The presentation ended with a discussion of initiatives to study the costs and benefits of using scenario and video-based questions on the NPTE. Jurisdiction Licensure Reference Guide Leslie Adrian This session was used to introduce the attendees to the updates and revisions to the licensure reference guide. The objective of the project to revise the guide was to create meaningful, useful tables that are easy to use, current, and linked to a statute or regulation. The project began in 2016, with a concentrated effort to publish new tables in 2017. FSBPT now maintains the data in the guide and all data is referenced to statute or regulation. The tables themselves are dynamic and sortable, easier to update and have improved graphics. Previous tables required the states to fill out the survey and verify the data. The tables were static PDFs that were very difficult to update.

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Currently the new tables can be found by selecting the “BETA” version of the table at www.fsbpt.org/FreeResources/RegulatoryResources/LicensureReferenceGuide.aspx. Minimum Data Set David Relling What is a Minimum Data Set (MDS)? It is a consistent set of data elements to be collected on all licensees at regular intervals in order to understand workforce needs related to access to healthcare. Workforce issues are complex and regulators can play a key role in helping to identify workforce needs and help resolve them. Specifically, regulators can identify shortages of therapists/assistants or a maldistribution, locate access gaps to specific areas of practice or specialists, and predict future trends in supply and demand for physical therapy services. The information collected by regulators can be used to resolve workforce needs by informing multiple stakeholders, including state legislators, educational programs, and professional associations to name a few. Workforce is not just a regulatory issue but regulators are the only ones who have access to this data. The North Dakota Board made the collection of a minimum data set of workforce information a requirement for renewal in 2018. The interest in collecting health workforce data stemmed from multiple factors within the state. During the past decade, the discovery of the Bakken oil formation caused an unexpected population growth in ND that was nearly double the US average. During this time, workforce data from nursing and medicine demonstrated a shortage of primary care practitioners. The legislature responded by funding a Health Workforce Initiative that increased base funding to all educational programs including physical therapy. The physical therapy programs increased the number of graduates and a new DPT program started within the state. Recent economic challenges in ND have stemmed the population influx while the legislature has decreased funding to educational programs. Future challenges for the state include an aging population and shifting priorities of millennial generation workers. The state ranks fifth in the US for the percentage of the population age 65 and older. There are many counties with an expected growth rate of 50-140% for individuals age 65 and older. At the same time, the millennial generation (born 1980-1996) are now the largest generation in the US workforce. A Gallup survey in 2016 reported 21% of millennials in the workforce expected to change jobs that year, nearly three times the rate of non-millennial workers. A minimum set of workforce data will allow ND to align healthcare workers to the needs of the aging population and prepare for shifting priorities of millennial healthcare providers. North Dakota performed a workforce study in the summer of 2014. It was an electronic survey that was sent to all Physical Therapists (n=754) and Physical Therapist Assistants (n=164) licensed in ND. The overall response rate was 33% with 35% of PTs responding and 16% of PTAs responding. Because the response rate was low, conclusions could not be drawn from the study. At the same time, the study highlighted the need for current and complete workforce data. For this reason, as well as the fact that many other states have started collecting workforce data in response to legislative concerns about workforce and planning, the North Dakota Board of Physical Therapy determined a need for a coordinated effort to obtain regional and national data. They are partnering with FSBPT to start collecting this data from licensees at renewal. They will be using the survey tool that was developed by FSBPT in conjunction with the American Physical Therapy Association. The survey tool is available on-line at:

http://www.fsbpt.org/freeresources/regulatoryresources/minimumdataset.aspx Foreign Educated Standards Committee Charlotte Martin

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This presentation focused on updating the attendees on the activities of the Foreign Educated Standards Committee (FESC) over 2016-2017. In 2014 CAPTE published changes to their Evaluative Criteria which necessitated an update to the current CWT. Whenever CAPTE makes substantial changes or updates to the Evaluative Criteria and Standards for Education, the CWT needs to be reviewed for relevancy as well as content validity. CAPTE published the new criteria in 2014, with the full implementation required by January 1, 2017 for PT and PTA programs. CWT 6 was developed from these criteria. CWT 6 will increase the number of clinical education hours required for a PT. A large number of PTs who did not graduate from a CAPTE-accredited educational program will have difficulty meeting this new criterion. Responding to member interest expressed during the 2014 Delegate Assembly, the FESC developed criteria for graduates from a non CAPTE-accredited educational program to provide evidence of post-graduate clinical practice experience to meet a deficiency in clinical education hours. A maximum of 300 hours of direct patient care that meet certain criteria such as, but not limited to, working an average of 20 hours/week in the three years prior to applying with at least two other experienced physical therapists may be used to supplement actual clinical education hours. Educational credentialing agencies will receive and review a verification form from a representative of the facility where the hours were worked, preferably the supervisor with direct knowledge, or the ability to confirm the patient care hours for the applicant attesting the criteria was met for the post-graduate experience. If jurisdictions do not want post-graduate experience to be used to supplement clinical education, they must specifically make the credentialing agencies aware that they are opting out. The new TOEFL score requirements, planned for implementation for earlier than January 2020 for NPTE eligibility were reviewed. The recommendations are for a total TOEFL score of 89, broken up as follows:

TOEFL Section Minimum Score

Reading 22

Listening 21

Writing 22

Speaking 24 Finally, the FESC introduced the project of focus for 2017. The Committee is creating a series of one page information sheets on a variety of topics related to foreign educated PT and PTA licensing. Topics in the primer cover: determining educational and clinical competence, English language proficiency, immigration, and other best practices. The Committee plans to complete the primer and publish for membership by the end of 2017.

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Appendix A: Attendees

Reed Argent Kathleen Arney Wendy Baltzer Fox Ron Barbato Ronald Barredo Betsy Becker Barbara Behrens Jade Bender-Burnett Raymond Bilecky Lauren Boner Charles Brown Thomas Caldwell Gillian Cavezzali Sandra Champlin Lisa Cooper Troy Costales Steven Crandall Carlton Curry Jeanne DeKrey Manuel Domenech Ellen Donald Justin Elliott Ginger Fenter Lisa Finnegan Christina Frank Zach Frank Heather Freeman Dorothy Gaskin Karen Gordon Linda Grief Linda Gustafson Janice Haas Rae Harman Natalie Harms David Harris James Heider Robert Hill Chad Hobbs Erin Hofmeyer William Hopfinger Angela Hunter

Robin Jenkins Allen Jones Jason Kaiser Joni Kalis Tina Kelley Kelly King Nancy Kirsch Whitney Lawrence Sandra Levi Sara Maher Charlotte Martin Timothy McIntire Ajay Middha Ana Mulero Portela Larry Ohman Sarah Olson Phillip Palmer Adrienne Price Alicia Rabena-Amen Nonnie Ramsey David Relling Deborah Richardson-Peter Richard Rutt Thomas Ryan Barbara Sanders Steven Scherger Angela Shuman Jerry Smith Sherise Smith Michael Sobowale Tami Struessel Michele Thorman Corie Tillman Wolf Timothy Vidale Kelsey Wadsworth Jill Wakabayashi Talia Weinberg Brian White Andrew Wodka John Young

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Appendix B: Summary of Small Group Responses & Recommendations

Risk Based Regulation The small groups came variations of the following characteristics of the competent therapist:

• Professional Engagement • Continuous Self reflection

o Know what you know o Know what you don’t know

• Self-aware and self-reflective • Evidence based practice – Are the outcomes positive?

o Keeps up with best practice and industry standards • Practicing within personal and professional scope? • Safe and Effective- but how do you define either of those? • Ethical and professional practice

Professional engagement, self-awareness and evidence based practice were the most commonly stated characteristics of competency For the most part, the small groups felt Boards can and should encourage these characteristics. The identified the following as possibilities for doing this:

• Provide self- reflective/awareness tools o Look at enhancing tools like MDS and oPTion to lead candidates down this path (need to develop

also for PTA) • Move beyond just a punitive role into a supportive role • Involve employers • Jurisprudence activities • Give credit for multiple types of activities; • Create a paradigm shift- to engagement rather than “check the box” • Identify risks, disperse education and make the professional aware of what are good characteristics. • Educate practitioner on the “top five” issues to watch for. Require/encourage attend • Guided education on ethics. Target education to those at risk. • Partnering with professional associations to disperse information/education. • Encourage mentoring/ service. • Help to self-Identify if they are not engaged or out of touch • Engage with the licensees between renewal cycles

By far the most identified characteristics of the dyscompetent/incompetent therapist identified by the groups was lack of engagement in the profession. This lack of engagement included such things as working in an isolated practice, not staying up to date in knowledge and skill and not consulting with colleagues. Ethics and professionalism was also brought up. Lack of self-awareness and the ability to self-assess were also identified. Life circumstances and health and wellness issues were also identified as important. Lack of effectiveness and poor outcomes were identified as signs of the incompetent therapist. For the most part, the groups felt the Boards could be more supportive of licensees in maintaining his or her competence. There was a feeling that Boards could do a better job of assisting licensees understand risk awareness, practicing self-care and accessing appropriate resources to assist in self-awareness and maintaining engagement. There was some thoughts that Boards could provide more tools and information via their website by create website/app/social

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media tools that give more ongoing regulatory information and risk screening. Credit could be given for accessing these resources.

Hearing from the Membership Part 1 Issues: Although many issues were identified and discussed by the 11 small groups, there were a few topics that rose to the top. In no particular order, the following issues were listed the most frequently by the small groups:

1. Board consolidation, deregulation 2. NPTE eligibility and practice act revisions 3. Scope of practice issues including dry needling 4. Compact 5. Telehealth

Amongst the attendees, the Compact was consistently ranked as the number one issue for jurisdictions. Other topics that were identified by the attendees included, but were not limited to, re-entry to practice, implementing criminal background checks, consistency of discipline, and supervision issues related to licensed and unlicensed personnel. Attendees also discussed drug diversion and issues of substance abuse as the abuse of opioids has increased nationwide. Attendees noted that the societal expectation of immediate results is putting pressure on the Boards. Individuals expect that licensure processing should be immediate and do not understand the delays. Pressure is also coming from employers and staffing agencies who then complain to policy-makers, who in turn put pressure on the Boards to increase efficiency and cut processing times. Implementing criminal background checks slows down the licensure process even more. The consolidation of regulatory boards often makes this situation worse rather than better; staff suffers burnout and workloads increase. Resources: The attendees have used many of the resources that the FSBPT has available. However, attendees noted additional resources would be helpful on the following topics:

1. Compact- The financial impact, especially on revenue. Further explanation on the discipline processes and disciplinary information. Explaining how the criminal background check gets implemented. Clarification of many unknown issues when rules published.

2. Board Consolidation- Creation of metrics for the board; how a board can show it is “doing its job.” FSBPT creates the effectiveness indicators for boards and then collects the data? Another idea is to gather testimonials, stories, and advice from states who have dealt with consolidation.

3. Continuing Competence- more information on how FSSBPT products could help with audits. FSBPT could develop a supports/risks questionnaire similar to British Columbia that could be available to states for use

Model Disciplinary Guidelines Responses to Question 1 Generally, the response to the model disciplinary guidelines was very positive. Attendees like the objectivity and systematic, structured approach which encouraged discussion to stay more focused on the details of the case. The attendees found the guidelines easy to use and understand and may help new board members feel more confident and comfortable when faced with disciplinary cases. There was no need for institutional knowledge or Board history with these guidelines.

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Attendees also felt that the guidelines could be easily modified and used by other types of Boards for those PT boards under an umbrella board structure. They also liked that the guidelines allow for some flexibility and customization for the individual state. Responses to Question 2 The attendees provided a few recommendations for the Ethics & Legislation Committee to consider:

• Increase the number of examples in the “factors to consider” under unintentional error, poor judgement, and recklessness

• Consider changing the labels of unintentional error, poor judgement, and recklessness • Define more clearly the difference between Orange and Red (clinical issue and public at large) • Modify and expand the purple category with more grounds for action; allow for option(s) for something other

than just Class A. Class A needs to be expanded with additional options • Reconsider color coding for those individuals that are color blind • Increase the options for remediation • Clearly show that these are guidelines and should have discretion of the Board • Consider how to differentiate between a “few times” versus “many, many times” • Aggravating/mitigating situations

o The mitigating situations should allow you to change class. o Increase examples of aggravating and mitigating, list the common ones, or advise the board to develop

their common lists. Responses to Question 3 There were zero responses stating that the model disciplinary guidelines could not be implemented in their state. There was some concern that the guidelines would not hold up for a formal hearing. Implementation was not without barriers however. Some felt that approval from their AG was required first, others felt that the guidelines could be implemented through board policy rather than rule. Several attendees felt it could be as a guide and it is not overly prescriptive/ mandatory. Many felt that these guidelines, with minimal changes, could even be helpful within a consolidated board that deals with multiple professions.

Clinical Education In general the small groups did not perceive that there is a regulatory problem with clinical education. There did not seem to be any evidence from a regulatory perspective that new graduates were not clinically competent. The groups felt that new graduates should not be expected to practice at the same level as the experienced therapist. Disciplinary cases seem to be linked more to professional behavior documentation or billing and not actual application of practice and seemed to occur more after some years of practice. There was some general concern in the groups that the solution would not solve clinical education challenges and in fact might create additional problems. There was general consensus that the tiered licensure model would create significant regulatory burdens as well as exacerbate workforce issues. There was one group that felt that recommendation 2 (research) needed to occur prior to any consideration of a new clinical education model. There were many additional concerns including costs to the student, the role of the physical therapist assistant, the impact on the foreign trained therapist and workforce, adding a greater gap between number of students and number of clinical sites, the need for generalists, implementation of regulatory requirements and other professions filling the gap created.

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There was overall agreement among the groups that there should not be additional regulatory requirements added to students without clearly defining the problem and then providing evidence that the added requirements are necessary for public protection.

Deregulation and Consolidation What are the driving forces for consolidation/de-regulation? Many of the groups identified politics and the political climate to be a driving force for this trend. Economic factors (state budgets) and unemployment numbers seem to contribute to this. Some groups identified lack of understanding of the benefits of regulation on the part of legislators contributed. Lack of efficiency on the part of licensing boards and health departments was also identified by multiple groups. Groups had a tendency to identify external factors as he main drivers. Only a couple of groups identified poor performance by the licensing board and boards acting more in interest of profession than the public as a driver. One group identified the lack of data collection on the part of regulators as being a driving factor. Is deregulation or consolidation a bad thing? Why? Is the regulatory criticism justified? Most of the groups concluded that it was not necessarily good or bad. It depended on the people involved, the professions that were combined and the efficiencies gained. There was a general feel that if Boards were combined, the professions needed to be somewhat similar so there was shared knowledge. There was also a feeling that some professions did not need to be regulated and some of the criticism was justified. How might a Board respond when faced with consolidation/de-regulation? All the small groups felt that collecting data and demonstrating the regulatory value of licensure was critical. There was also a lot of sentiment among the groups that Boards needed to be politically savvy and had a responsibility to educate politicians and policy makers. One group suggested that boards needed to stay current and efficient and not work with outdated regulations. Several groups suggested it was important for regulators to be part of the solution and be proactive versus reactive. The sunset process was identified as a helpful process. Finally several groups identified the need for licensing boards of various professions to collaborate in streamlining processes and creating efficiencies.

Hearing from the Membership Part 2 Topics identified on which to focus include:

• Board assessment tools o Determine metrics o Develop a guide to help boards going through consolidation (or even sunset review)

• How to measure “public protection.” What is a true measure of public protection? What are metrics that are meaningful? o Collecting data to support evidence-based regulations o Research to support the regulatory need for public protection

Look at more of the data from the ELDD and MDS Look at types of discipline administered. Are we effective?

• Increasing communication between the education and regulatory communities o How do we educate licensees before they start their career – and throughout their career - convince

them that regulation is to their benefit? • Recruitment of regulatory board members- professional and public • Continuing evolution of disciplinary guidelines

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• Continuing Professional Development/Continuing Competence o Encouraging engagement o Shift from continuing education to continuing competence; leveraging oPTion o More information about the use of a portfolio and development of a portfolio o Identification of risks/supports

• Public information campaign o Tools boards can use to encourage the public and other licensees to report to the board

Other suggestions include:

• Inviting a voice of PTAs as special guest to LIF- e.g. PTA SIG representative Topics on which the regulatory community should not be as focused:

• The regulatory community should not focus on increasing licensees’ engagement with APTA. Engagement needs to be much broader.

• The BPCETF clinical education proposal was a topic identified by multiple tables as one on which the

regulatory community should not focus, however, this was not unanimous amongst the small groups. Some felt that more details and information should be fleshed out about clinical education issues. Others felt that the recommendations should be acknowledged, take a stance opposing them, but nothing more should be done. Overall, there was no support from attendees for the recommendations presented by the task force.

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Appendix C: BPCETF Report on Clinical Education 1 BEST PRACTICE FOR PHYSICAL THERAPIST CLINICAL EDUCATION (RC 13-14) 2 3 ANNUAL REPORT TO THE 2017 HOUSE OF DELEGATES 4 EXECUTIVE SUMMARY In 2014, the House of Delegates approved 2 motions specific to investigating the future of physical therapist education: RC 12-14: Promoting Excellence in Physical Therapist Professional Education, and RC 13-14: Best Practice for Physical Therapist Clinical Education. In response to RC 12-14, The APTA Board of Directors (Board) established the Excellence in Physical Therapist Education Task Force (EETF) that presented 8 recommendations to the Board in 2015. At its November 2015 meeting, the Board approved the recommendations forwarded by the EETF, which included establishment of the Education Leadership Partnership as the vehicle to address those recommendations. Similarly, in response to RC 13-14 the Board created the Best Practice for Physical Therapist Clinical Education Task Force (BPCETF). The work of the BPCETF began in January 2016 and concluded in January 2017. The Board's charge to the BPCETF was to consider strategies and provide a recommendation(s) to the Board of Directors to identify best practice for physical therapist clinical education, from professional level through postprofessional clinical training, and propose potential courses of action for a doctoring profession to move toward practice that best meets the evolving needs of society. The Board identified 4 specific points for the BPCETF to review for the report due to the 2017 House of Delegates. The BPCETF identified 3 principle challenges as it engaged in its work: (1) A comparison of current clinical education models suggested that inadequate clinical education and postgraduate professional development experiences contribute to unwarranted variation in physical therapist practice; (2) The overall capacity for clinical education placements is limited, leading to competition among physical therapist academic programs; and, (3) Economic factors affecting academic institutions, students, and facilities providing clinical education experiences significantly impact clinical education. Six assumptions guided the work of the BPCETF: (1) There are complex factors involved in clinical education and no simple solutions to address the issues of unwarranted variability, capacity, and quality in current models; (2) Recommendations being made are interrelated; (3) Implementation of these recommendations will require engagement of multiple stakeholders; (4) Other professions are facing similar challenges in clinical education; (5) There is no evidence supporting a single superior physical therapist clinical education model; and, (6) Economic factors must be a primary consideration in future physical therapist clinical education, and recommendations should not result in increased student debt. After engaging in a year-long review process, including 2 face-to-face meetings and over 20 conference calls, the BPCETF submitted 5 content recommendations and 1 dissemination recommendation to the Board:

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1. That formal preparation for practice includes physical therapist professional education, followed by a clinical internship and mandatory postprofessional residency, and is accomplished through a process of staged licensure and specialty certification; 2. That a structured physical therapist clinical education curriculum be developed and implemented; 3. That a framework for formal partnerships between academic programs and clinical sites that includes infrastructure and capacity building, and defines responsibility and accountability for each (eg, economic models, standardization, sustainable models), be developed; 4. That clinical education be incorporated into the recommendations approved by the Board and forwarded to the Education Leadership Partnership regarding education data management systems; 5. That the physical therapy profession's prioritized education research agenda include a line of inquiry specific to clinical education; and, 6. That the BPCETF report submitted for the January 2017 Board meeting be made available to the Education Leadership Partnership and other stakeholders within the physical therapist education community. 17 The BPCETF report was submitted for consideration to the January 2017 Board meeting. After reviewing the scope of the BPCETF's work and recommendations, the Board adopted a revised version of recommendation 6: That APTA design a plan for dissemination of the BPCETF report for receiving widespread stakeholder input prior to consideration by the Board for adoption at its November 2017 meeting. The rationale for this recommendation was based on an appreciation for the need to allow all stakeholders to engage in a review of the BPCETF's recommendations, and to let the collective community bring its thoughts and suggestions forward. The Board recommended that the Education Leadership Partnership be charged with leading this stakeholder review and action process, similar to how the recommendations of the EETF were addressed in 2015. The complete BPCETF report to the Board is appended. Clarifications and updates have been added to the BPCETF's report in response to Boards' discussions and questions that emerged during the review process.

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1 2 BACKGROUND The 2014 House of Delegates adopted RC 13-14 Best Practice for Physical Therapist Clinical Education: 5 That the American Physical Therapy Association, in collaboration with relevant stakeholders, identify best practice for physical therapist clinical education, from professional level through postgraduate clinical training, and propose potential courses of action for a doctoring profession to move toward practice that best meets the evolving needs of society with a report to the 2017 House of Delegates. 11 This effort shall include, but not be limited to, the examination of: • Current models of physical therapist clinical education from professional level through postgraduate clinical training; • Mandatory postgraduate clinical training; • Stages of licensure; • Findings from related studies and conferences; and • Models and studies of clinical education in other health care professions. 19 20 (House of Delegates, 2014, pp. 232-244) 21 CHARGE The Best Practice in Clinical Education Task Force (BPCETF) will consider strategies and provide a recommendation(s) to the Board of Directors to identify best practice for physical therapist clinical education, from professional level through postprofessional clinical training, and propose potential courses of action for a doctoring profession to move toward practice that best meets the evolving needs of society. 28 The Board of Directors' determined charge for the BPCETF is as follows. The task force will be disbanded as appropriate by the Board of Directors when the charge has been met. 31 • Investigate current models of physical therapist clinical education from professional level through postprofessional clinical training, including findings from related studies and conferences in physical therapy and other health professions. • Define the scope of current and anticipated future needs in clinical education with particular investigation into how to best prepare physical therapists for practice in an evolving health care environment. • Investigate options for future clinical education models, including but not limited to relationships between academic institutions and clinical education sites, mandatory postprofessional clinical training, and staged licensure. • Describe the feasibility of future clinical education models, including pros and cons. • Provide options to the Board of Directors with recommendations for action and a report to the 2017 House of Delegates. 44 All APTA appointed groups will conduct their work with the Association Organizational Values in mind and in the context of (1) APTA's mission, vision, and strategic plan; and (2) the potential for their work 42 1 to have implications related to physical therapist assistants, women, diversity, and risk management. 2 (Board of Directors, November 2014, pp. 13-14)

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SCOPE OF THE PROBLEM The 2014 House of Delegates' call to identify "best practice in physical therapist clinical education" in order to produce practitioners capable of meeting the ever-evolving societal health care needs is not a new call to action. Rapid proliferation of new physical therapist education programs and expanding class sizes leading to intense competition for clinical sites; burdensome evaluations required of clinical educators, students, and academic faculty; increased variability in academic and clinical education; and lack of absolute standards of clinical performance are among the challenges that have been repeatedly noted over the past 50+ years. (Worthingham, 1965; Hislop, 1975; Moore & Perry, 1976). Compounding these issues are economic factors including the increased debt load of graduates, and changes in reimbursement for physical therapist services. While the entry-level physical therapist degree has evolved over time to the clinical doctorate (DPT), the basic model of clinical education remains relatively unchanged from the early days of physical therapist education. In her 1965 McMillan Lecture, Catherine Worthingham described physical therapy as a profession able to acknowledge "present and obvious inadequacies" when compared with professions that were already established. Many of her thoughts, ideas, and suggestions delivered in that speech continue to ring true for us as a profession today. Worthingham stated, "Physical therapists, both teachers and practitioners, have need for further education, whether in continuous residence, short courses, or by means not yet foreseen or devised" (Worthingham, 1965, p. 939). Worthingham recognized the challenge of establishing a partnership between academic and clinical sites/clinical educators in part attributed to the variability in educational pathways through which one could enter the profession. Ten years after Worthingham's McMillan lecture, Helen Hislop revisited a continued list of professional challenges and provided multiple solutions, stating that ". we must set up absolute standards of clinical performance rather than remain lost in morass of relativity" (Hislop, 1975, p. 1077). Hislop was careful to promote the burgeoning need for clinical specialization amidst the challenge of "capacity of any practitioner to encompass the entire field" of physical therapy knowledge and practice. Furthermore, she recognized that advances in medical science are enormously impactful and drive modifications in our practice, as they continue to do today. Since 1975, multiple professional work groups and task forces have been formed with subsequent consensus conferences or summits to specifically address issues facing physical therapist student clinical education. A partial list of these activities includes: • 1976: "Clinical Education in Physical Therapy: Present Status/Future Needs" (Moore & Perry, 38 1976) • 1981: "Standards for Clinical Education in Physical Therapy: A Manual for Evaluation and Selection of Clinical Education Centers" (Barr, Gwyer, Talmor, 1981) • 1992-1994: "Task Force on Clinical Education" (APTA) • 1998: "Clinical Education: Dare to Innovate" (APTA, 1998) • 2004: "Clinical Education in a Doctoring Profession" (APTA, 2004) • 2007: "Embracing Standards in Clinical Education: A Consensus Conference" (APTA, 2007) • 2014: "Clinical Education Summit" (ACAPT, 2014) • 2015: "Excellence in Education Task Force Report" (APTA, 2015) • 2016: "Physical Therapist Education for the 21st Century" (PTE-21) Report (Jensen et al, 2016) Despite an extensive list of recommendations, innovations, and potential solutions that resulted from

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these collective works, physical therapist student clinical education training has changed little over the past several decades. The status quo persists because by some measures the current models have been effective, in that the educational community continues to produce graduates who successfully become licensed. Additionally, significant changes to academic and clinical education models will require a degree of consensus and cooperation among multiple stakeholders with competing priorities and varied perspectives, that could or might result in uncharted disruptions to practice and education. However, the BPCETF believes the time has come for the profession to acknowledge that DPT program graduates cannot be fully prepared at the conclusion of entry-level education to manage the care of clients and patients of all diagnoses and conditions across the lifespan. The current licensure process, the National Physical Therapy Examination (NPTE), provides a level of competency evaluation, and promotes patient and client safety, by assessing a basic level of knowledge and problem-solving abilities. The current licensure process is limited by assessing competency at a single point in time, and the NPTE does not assess important clinical skills. While opportunities for postprofessional education exist, there is no cultural expectation or requirement driving this phase of learning. Outcomes associated with postprofessional education clinical residency and fellowship programs include improvements in physical therapist clinical reasoning abilities, and patient and client outcomes (Rodeghero et al, 2015; Robertson & Tichenor, 2015). Professional sentiment has long existed that entry-level graduates are novices and require additional support, education, or training to achieve the desired level of physical therapist competence (Black et al, 2010; DiFabio et al, 1999; Furze et al, 2016; Tichenor, 2000; Kulig, 2014). This type of educational structure and professional development ladder has been present in allopathic medical education for decades, representing an understanding that medical school preparation is designed to be the beginning, not the end, of professional training. Even the initial phase of a medical residency includes acquisition of additional general knowledge and skill development before the resident is considered prepared for advancing to higher levels of training and specialization (AAMC, 2016). In the 2012 APTA McMillan Lecture, Alan M. Jette (2012) described 3 major societal storms: lack of access to health care, the age wave, and costs of health care. Jette proposed that to meet societal needs, "physical therapists must possess and use critical systems skills" including ". universal standardized measurement and data collection, widespread quality and improvement and implementation techniques, interprofessional coordination and care management, diffusion of practice innovations and standardized practice models, and health policy leadership for widespread change" (Jette, 2012). Physical therapist education must continue to evolve as physical therapists increasingly position themselves to function as points-of-entry in the complex and evolving health care system focused on outcomes, value, and efficiency. Physical therapist professional education programs should build capacity to increase emphasis related to didactic content and clinical practice experiences in chronic care management, interprofessional collaboration, primary care practice, and population health and wellness. 42 Regarding physical therapist clinical education, we must ask ourselves whether we have met the challenges described by Catherine Worthingham, Helen Hislop, and other past leaders, or whether we are indeed no further along than we were 50 years ago. Based on recent opinions and events, and feedback from multiple stakeholders, it is the opinion of this task force that current clinical education models are unsustainable, suboptimal, and not designed to produce practitioners required by the health care system of the future, nor will they help the profession achieve our vision. 3 The BPCETF took a global approach when forming its recommendations, not wanting to be prescriptive

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but to provide a framework for future consideration. The task force recognizes that the details of any formative plan for the future of clinical education will come from the collective involvement of multiple stakeholders, and that the transition process could take decades. The BPCETF reviewed the 2015 Excellence in Physical Therapist Education Task Force report and recommendations (APTA, 2015) All 8 of the principle challenges in pursuing excellence in education identified in that report were relevant to clinical education, with 2 specifically including clinical education: • There are widespread concerns that students are not optimally prepared for clinical education, practice, and the evolving health care environment • There is unwarranted variation in student qualifications, readiness, and performance across the professional education continuum that impacts academic and clinical faculty's ability to plan and implement a quality educational experience that will optimize patient outcomes 17 The recommendations adopted by the APTA Board of Directors (Board) also included 2 that are most directly relevant to clinical education: • That essential resources to initiate and sustain physical therapist education programs that include, but are not limited to, faculty, clinical sites, finances and facilities, be determined • That the adoption of a system of standardized performance-based assessments that measure student outcomes and establish benchmarks be developed and promoted 24 Standardized assessment for physical therapist students entering their terminal clinical experience was identified as a priority in the second recommendation. 27 Although not specific to clinical education, the Board also approved in November 2015 the development and implementation of a steering committee comprising core member groups-the American Council of Academic Physical Therapy, APTA, and the Education Section-to oversee the implementation of efforts designed to move physical therapist education forward. That steering committee's efforts led to the development of the Education Leadership Partnership (ELP), which was formally ratified in a Memorandum of Understanding in October 2016. The ELP is intended to be a global, decision-making group that brings all stakeholders together to speak with 1 voice toward enhancement of the common cause of promoting excellence in physical therapist education. 36 MEETING HISTORY The BPCETF met 24 times, including 22 web conferences and 2 onsite meetings (APTA headquarters in Alexandria, Virginia, on March 13-14 and November 6-7, 2016) between January 8, 2016, and January 4, 2017. Multiple stakeholders were engaged during the year-long process of the task force's work. While these stakeholders do not serve as a substitute for the larger physical therapy community, receiving diverse views and options helped shape the recommendations that evolved. 43 Stakeholders Engaged • American Board of Physical Therapist Residency and Fellowship Education (ABPTRFE): staff and external consultant • American Board of Physical Therapy Specialties (ABPTS) • American Council of Academic Physical Therapy (ACAPT) NCCE • American Physical Therapy Association (APTA): workforce/policy/payment/legislative staff • Clinical sites/settings: administrators/clinical educators • Acute care (including academic medical centers) • Skilled nursing facility/care • Veterans Administration

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• Outpatient orthopedics private practice, large corporation, and hospital-based practices • Outpatient neurological rehabilitation • Outpatient pediatrics • School-based services • Commission on Accreditation in Physical Therapy Education (CAPTE) • Education Researchers: PTE-21 investigators • Federation of State Boards of Physical Therapy (FSBPT) • New professionals (PTs in first 5 years of practice after graduation) • Other health professions' clinical education representatives; nursing, pharmacy, and physician

assistant • Residency graduates • Education Section, Clinical Education Special Interest Group • Students TASK FORCE MEMBERS Kathy Mairella, PT, DPT, APTA Board of Directors (Chair) Greg Hartley, PT, DPT Lisa Johnston, PT, DPT, MS Mary Keehn, PT, DPT, MHPE Bill McGehee, PT, PhD Christopher Meachem, PT, DPT Colette Pientok, PT, DPT Mary Jane Rapport, PT, DPT, PhD Robert Rowe, PT, DPT, DMT, MHS Kerry Wood, PT, DPT 33 APTA STAFF Bill Boissonnault, PT, DPT, DHSc, Executive Vice President, Professional Affairs Unit (LEAD) Steven Chesbro, PT, DPT, EdD, Vice President, Education, Education Department Libby Ross, MA, Director, Academic Services, Education Department 38 39 DISCUSSION: 40 FINDINGS OF THE BEST PRACTICES IN CLINICAL EDUCATION TASK FORCE Based on its work, the BPCETF identified the following principle challenges facing clinical education: • A comparison of current clinical education models suggested that inadequate clinical education and postgraduate professional development contributes to unwarranted variation in physical therapist practice. There is significant variability in the quality of physical therapist clinical education in structure, process, and outcomes (Jette et al, 2014). Much of the quality is dependent on the clinical instructor, who may or may not be an effective teacher and may lack a strong connection to the academic program. • The overall capacity for clinical education placements is limited, leading to competition among physical therapist academic programs. This capacity problem is exacerbated by the proliferation of new physical therapist education programs and increasing class sizes. Overall capacity is also affected by other demands on clinical sites, including longer clinical experiences, establishment of residency and fellowship programs, observation and volunteer hours for prospective students, physical therapist assistant clinical education programs, and nonphysical therapy

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internships. • Economic factors significantly impact clinical education. Recent trends of clinical sites requiring payment for student placements intensifies the debate over the typical current model of financing clinical education. Typically, clinical sites are not paid for their contributions to physical therapist student education, while the student continues to pay tuition to the academic program for clinical education courses (Jette et al, 2014). The static payment for provision of services that does not keep pace with increased costs has resulted in an increased financial burden on clinical sites. This is compounded by the demands for increased practitioner clinical productivity, and the inability to receive reimbursement for work performed by nonlicensed students under supervision. Payer policies are likely to become even more restrictive in the future. 20 As the BPCETF progressed through its charge, the following guiding assumptions supported the development of recommendations. 23 • There are complex factors involved in clinical education and no simple solutions to address the issues of unwarranted variability, capacity, and quality in current models. • Recommendations are interrelated. • Implementation of these recommendations will require engagement of multiple stakeholders. • Other professions are facing similar challenges in clinical education. • There is no evidence supporting a single superior physical therapist clinical education model. • Economic factors must be a primary consideration in future physical therapist clinical education, and recommendations should not result in increased student debt. 32 RECOMMENDATION 1: That formal preparation for practice includes physical therapist professional education, followed by a clinical internship and mandatory postprofessional residency, and is accomplished through a process of staged licensure and specialty certification (Note: The model in Figure 1 is provided to serve as an example only, as it includes the criteria identified in the recommendation. The task force recognizes that any standard process model adopted by the profession will emerge during dialog among all stakeholders). 40 SS: The physical therapy profession continues to evolve and now includes: all graduates earning the DPT degree, all licensure jurisdictions having some form of direct access and practitioners assuming varying degrees of primary care responsibilities highlighted by long-established models in the uniformed services divisions of the United States military and Public Health Service. Additionally, postprofessional residency and fellowship programs continue to grow at an exponential rate. Considering these examples of growth and the escalation of higher education costs, corresponding student debt, decreased payment for provision of clinical services, increased productivity demands on clinicians serving as clinical instructors, and the current variation in student readiness-there is a need for an alternative clinical education model. Any such new model should consider the quality of clinical education experiences, clinical instructor experience and expertise, types of clinical practice experiences, and length of clinical education experiences. The BPCETF developed and considered 5 models for consideration (see Appendix A). After deliberation, and in consideration of key stakeholder comments during the past year, the task force recommends the following framework: 8 9 Figure 1. Model Example of Education of the Physical Therapist. In today's health care environment, the expectation that a new graduate is prepared to practice in any setting, providing care to all age groups, is unrealistic (IOM, 2011; Rapport et al, 2014). There is evidence that new graduates, while possessing the knowledge and skills to ensure patient and client

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safety and provide care for less-complex patients and clients, may benefit from having exposure to additional clinical skill-development opportunities in order to best meet the needs of society in the fast-evolving health care arena (Curtis & Martin, 1993). Yet, many practice settings do not provide the additional mentorship and postgraduate education for new graduates to further develop the necessary clinical skills. The BPCETF also believes it is time to move away from the concept of graduating a "generalist" practitioner, a concept that appears to have evolved without formal adoption or direction. The term "generalist" in the context of physical therapy does not appear to be defined by the Commission on Accreditation in Physical Therapy Education (CAPTE), the Normative Model of Physical Therapist Education (APTA, 2004), or any other seminal APTA documents. 22 This suggestion does not discount the necessity that a core knowledge base and set of clinical skills should be required of all graduates. This foundational level of competence, as determined by the initial (restricted) licensure examination (See Figure 1), would represent a practitioner best described as a "basic-ist": a practitioner capable of independently managing less-complex patients and clients and capable of recognizing when a patient or client referral to another practitioner is indicated. Removing the expectation that a new graduate can, as a "generalist," treat patients and clients of all ages, with any condition, and in every setting, would allow new graduates to begin clinical practice under the expectation that they would continue their formal educational experience and begin a path toward specialization. The concept of graduating a DPT with core knowledge and skills, followed by an intense, structured clinical internship and finally specializing in an area of practice through an accredited clinical residency program, aligns with other doctoring professions (eg, medicine, optometry, pharmacy, podiatry, psychology) (Rapport et al, 2014). The educational pathway portrayed in Figure 1 consists of 3 required phases: (1) professional education, (2) postgraduate clinical internship, and (3) a mandatory clinical residency. While timeframes marked by ranges are presented for each phase, the BPCETF hopes the numerous benefits of reduced variability will lead the educational community to reach consensus and adopt universally accepted timeframes. One goal should be a reduction in the total amount of time required to attain the DPT degree, shifting a significant portion of the clinical training to the postgraduate phase. This shift would require that programs graduate practitioners who have a well-defined core set of knowledge and skills, and are beginning to identify potential desired areas of clinical specialization. Upon completion of the postgraduate clinical internship, where core practice skills are refined the physical therapist will enter an accredited clinical residency program. The professional education curriculum will include a didactic phase combined with integrated clinical education experiences, allowing students to acquire the core set of foundational knowledge and skills to prepare them for the stage of restricted licensure. A structured curriculum will be developed for the integrated clinical education experiences (see Recommendation 2). A written examination, analogous to the current National Physical Therapist Examination administered by the Federation of State Boards of Physical Therapy (FSBPT), would assess student readiness and provide a validation of progression of clinical skills and clinical reasoning, required for the progression to the pathway's second phase, postgraduate clinical internship. Other health care professions (eg, medicine and dentistry) use staged licensure to ensure the progression of knowledge during several developmental time points throughout the educational process and to assess a provider's "ability to apply knowledge, concepts, and principles, and to

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demonstrate fundamental patient-centered skills, that are important in promotion of health and management of disease" (USMLE, 2017). Upon successful completion of the written examination and graduation, the physical therapist graduate would enter a mandatory postgraduate clinical internship. A structured curriculum (See Recommendation 2) would provide a core set of benchmarks, milestones, competencies, or core entrustable professional activities (Ten Cate, 2013; AAMC, 2012) that the graduate would need to achieve before being eligible to proceed to the next pathway phase, mandatory clinical residency. Once the clinical internship is successfully completed, the physical therapist would begin clinical residency training. It is essential to establish clinical residencies as the final required phase of the formal physical therapist professional education pathway; the final step prior to entry into unrestricted licensure (second stage of licensure) clinical practice. The second stage of licensure would consist of an examination consistent with the American Board of Physical Therapy Specialties clinical specialist certification examination. The clinical residency model and curriculum would evolve to build upon physical therapist professional education and postgraduate clinical internships phases. The required postprofessional clinical 1 residency phase of education would promote the following: 2 • Development of physical therapists who demonstrate high levels of professionalism, clinical skills, knowledge for specialty practice, communication, clinical reasoning, evidence-based practice, and systems-based practice; (Furze et al, 2016) • Development of physical therapists who are adequately trained to manage complex patients and clients within general and specialty practice settings; • Development of physical therapists who are able to successfully function in leadership roles within the health care system; • Promotion of physical therapy as a valued service within health care by consumers, payers, and regulators; • Establishment of physical therapists as a portal to the health care system for individuals with movement impairments; and • Improvement of patient and client outcomes and value within the health care system. There would remain an important role for a general practice physical therapist. Physical therapists working in large medical centers, acute care settings, rural hospitals, or home health care provide services that are highly specialized, requiring extensive knowledge and skill. Therefore, the physical therapy profession should expand specialty options and define the general care specialist as akin to the "specialty" of family practice or family medicine in physician medicine, and create a Description of Specialty Practice (DSP) to support this residency option. By successfully passing the second and final stage of licensure, the physical therapist will be recognized as having advanced knowledge in a specific clinical specialty area, including clinical reasoning and clinical skills for provision of care to more complex patient and client populations. There is a notable increase in the level of professional growth and development that occurs in the first year of clinical practice when the novice practitioner receives the appropriate mentorship (Tryssenarr & Perkins, 2001; Corb et al, 1987; Schwertner et al, 1987; Jensen et al, 1992; Black et al, 2010; Wainwright et al, 2011). Mentorship provided by experienced clinicians, who have been vetted during the residency program accreditation and reaccreditation processes, is a key element of the clinical residency experience (See Recommendation 3).

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The development and universal adoption of the formal physical therapist professional education pathway with staged licensure would lead to more structured didactic and clinical education curricula, more standardized and structured levels of student preparedness, reduce the students' overall cost of professional education, and produce a practitioner better prepared to meet the demands of the ever- evolving health care system. Upon successful completion of the first stage of licensure the graduate could begin billing for services, thereby reducing the financial stress on clinical education sites. Adjustments in pay levels based on stages of licensure might help facilities budget more appropriately for novice clinicians, residents, and, finally, the more-advanced clinicians practicing with an unrestricted license. The ability for employers of interns and residents to be reimbursed for clinical services provided by these restricted-license practitioners would help to support this economic model (FSBPT, 2011). Finally, the BPCETF believes this model of physical therapist professional education will also establish a firm foundation for graduates who wish to pursue postprofessional masters and doctoral degrees, and postprofessional fellowship opportunities. Discussion of these learning opportunities was outside the scope of the task force's work but should be considered, in context, by stakeholders as a universal adoption of a new model of professional education is developed and implemented. RECOMMENDATION 2: That a structured physical therapist clinical education curriculum that includes, but is not limited to, the following elements be developed and implemented: 8 9 • Determination of a minimum and maximum amount of full-time clinical education that can be integrated into the didactic phase (prelicensure) of physical therapist professional education. Once determined, this standard shall be universally adopted; • Define the role and structure for clinical education experiences within the didactic phase of physical therapist professional education programs; • Define essential clinical education settings, experiences, and exposure to patient and client populations that shall be required for all physical therapist students in the didactic phase of physical therapist professional education programs Define minimal student competencies required for engaging in integrated full-time clinical education experiences during professional education and postgraduate clinical internship phases, including knowledge, skills, and behaviors; • Define the roles of simulation and learning technologies as part of clinical education in the phase of professional education; • Define essential competencies for transition into entry-level (restricted license) practice, including knowledge, skills, and behaviors; • Enhance existing residency and certification processes to complement the total of the professional education and postgraduate clinical internship phases; • Develop and implement standardized tools for measurement of expected student competencies at all phases of physical therapist education to ensure that student and graduate competencies are consistent with expected student outcomes; and • Identify opportunities for standardization of clinical rotation schedules, onboarding requirements, or other factors that may influence program and site capacities and efficiencies. 31 SS: Graduates from physical therapist professional education programs, beginning with the first day of

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their employment, are expected to be skilled, productive, and contributing members of an interprofessional health care team. The health care environment has rapidly evolved to one in which physical therapists will encounter higher productivity demands, greater acuity and chronicity of patients and clients in all settings, limited time and resources, and payment tied to patient and client outcomes. These conditions leave little to no time for a new graduate to "ramp up" their knowledge, skills, and behaviors, especially without significant mentorship and support. As referenced in the support statement for Recommendation 1, the current models of clinical education, combined with the lack of required postgraduate education experiences, do not support the needs of the evolving physical therapy profession. The BPCETF Recommendation 2 is consistent with Recommendation 2 from the Excellence in Physical Therapist Education Task Force (2015), "That essential, rigorous, and progressively higher levels of outcome competencies [knowledge, skills, and attitudes] for physical therapist graduates that are responsive and adaptive to current and future practice be identified and adopted, and with its Recommendation 5, "That the adoption of a system of standardized performance-based assessments that measure student outcomes and establish benchmarks be developed and promoted". As Jette and colleagues (2014) stated, "Although the problem is complex, to successfully manage clinical education, improve outcomes, and reduce costs, some degree of profession-wide consensus must be reached about best practices related to structure, processes, and outcomes." 5 Based on information gathered by BPCETF members during their work-including interviews with several stakeholders and group deliberations, and individual and collective experiences of task force members, it has become clear that there is a need for a structured approach to physical therapist clinical education to reduce unwarranted variation in education that leads to unwarranted variation in clinical practice (Jette et al, 2014). 11 RECOMMENDATION 3: That a framework for formal partnerships between academic programs and clinical sites be developed that includes infrastructure and capacity building, and defines responsibility and accountability for each (ie, economic models, standardization, sustainable models, etc.). Infrastructure and capacity must be developed across all stages of clinical education, to include: 17 • Models of clinical supervision (eg, trainee to instructor ratios, academic faculty as preceptors); • Mandatory clinical instructor training, certification, and recertification; • Effective communication among all stakeholders across all phases of clinical training; • Student readiness to enter each stage of clinical education; and • A comprehensive evaluation plan for clinical education. 23 SS: In a 2002 PTJ editorial, Jules Rothstein (2002, p. 127) offered the following challenge to the physical therapy profession: "Without a proper ongoing partnership between faculties in schools and people in practice, clinical education will never prepare our new graduates to the level necessary, to the level described by our Association's vision statement, and to the level that justifies the professional doctorate." 29 Despite continuing professional discussions about this concept, little has changed in Rothstein's observation over the past 15 years (Applebaum et al, 2014). Thus, this recommendation is based on sentiments and a vision expressed by leaders in the physical therapy profession for decades. 33 Formal partnerships between academic programs and clinical sites should be expanded to include defined accountabilities for all parties. These partnerships should include opportunities for innovative relationships and care delivery models. During the physical therapist professional education, clinical instruction of students in integrated clinical experiences should be overseen by academic institutions

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that have close, formal relationships with clinical faculty who serve as clinical instructors. The clinical instructors must be vested in the program's curriculum and held accountable to the academic program in some way. 41 A culture of excellence in clinical education requires all stakeholders to have a shared responsibility for setting and upholding standards during every phase of clinical education. The challenges of limited capacity in number and variety of settings, and the variability in the quality of clinical instruction, while not unique to the physical therapy profession, has been a consistent concern among physical therapy leaders for decades (AAMC, 2014). It is impossible to judge whether the current pool of licensed physical therapists is adequate to provide quality clinical education within the current model of clinical education or in the model of clinical education being proposed by the BPCETF. Academic programs face challenges placing students in settings that meet accreditation requirements. The lack of clinical placements is a common reason for CAPTE to deny candidacy status. Two significant challenges to the current models of physical therapist clinical education are (1) a lack of standards that foster excellence in clinical education, and (2) inadequate capacity to provide quality clinical training from the earliest clinical exposure through post-licensure residency and fellowship experiences. Consistency in clinical education is hampered by varied communication strategies among academic programs and clinical sites regarding students' competency level prior to them entering clinical education and the myriad outcome expectations of all stakeholders. Improving quality in clinical education depends on addressing structure, process, and outcomes of clinical education (Jette et al, 2014). A concerted effort to achieve an adequate supply of excellent clinical training sites that are configured to meet trainee needs at every stage of their professional development is vital to the future of the physical therapy profession. Joint development of standards for excellence in clinical education by all stakeholders, with mechanisms to evaluate compliance is necessary to address the quality and capacity challenges facing physical therapist education. CAPTE provides minimum standards for physical therapist education programs, and the standards specific to clinical education have become more defined over that past 10 years. Academic programs are held accountable to CAPTE through the accreditation process. Clinical training sites currently have no direct accountability to CAPTE, and accountability to the academic programs is limited to what is included in written agreements between each academic program and clinical site. The ability of academic programs to hold sites accountable is limited to not sending students to the site for training; an approach that does nothing to motivate training sites to improve their clinical training programs. Likewise, the only recourse of clinical sites that are dissatisfied with the preparation of students, communication with the academic program faculty, or other aspects of clinical education is not to accept students. Including a clinical education accountability model, similar to that found in current residency and fellowship standards, into formal professional education standards would promote consistent quality, to the benefit of the student and ultimately to the profession. 30 Quality clinical instruction and clinical mentoring are at the heart of clinical education. Clinical instructors must demonstrate a commitment to advancing clinical practice, including developing skills relevant to the role of a clinical preceptor. Education for clinical instructors is available but not mandatory. Mandatory education, to include certification and recertification, will advance clinical educators' skills and will decrease unwarranted variation, improve efficiency, and assist with students' skill development. Physical therapists choose to become clinical instructors for a variety of reasons, including a desire to give back to the profession, to stimulate their own learning, or for the enjoyment in the role of teaching. Disincentives to serving as a clinical instructor include difficulty meeting productivity requirements, the paperwork burden, and a perceived lack of support or inadequate

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resources to address students with challenging problems in the clinic. Creation of standards, and incentives to meet those standards, will build capacity and encourage higher levels of participation by physical therapists in clinical education. 43 RECOMMENDATION 4: That clinical education be incorporated into the recommendations approved by the Board of Directors that were forwarded to the Education Leadership Partnership regarding education data management 1 systems, and include but not be limited to the following elements: 2 ● A unique "professional (secure, or protected) lifetime" identifier is assigned to individuals at the time application or acceptance. ● A national clinical education matching program is used for assigning students to clinical education sites. ● Outcomes of care provided by physical therapist students/interns/residents are included in patient/clinical outcome registries. ● Data entry and data management systems are interoperable with other data systems relevant to physical therapist education (eg, CAPTE, FSBPT, ABPTRFE, CPI, CSIF). ● Data is accessible to researchers, academic programs, regulatory bodies, program evaluators, clinical training sites, and interested parties. SS: The critical need to understand the existing state of all aspects of physical therapist clinical and residency education is hampered by the paucity of relevant research (Jette, 2014). Although data related to physical therapist clinical and residency education is available from various sources (eg, CPI/CSIF, PTCAS, NPTE, ABPTRFE, Physical Therapy Outcomes Registry), these data sets are not connected through a common interoperable framework. Subsequently, the available data is fragmented and does not use common elements, making it difficult to evaluate and compare current models of, and outcomes associated with, pre-licensure and post-licensure education. A unique identifier would connect data among various databases. Besides creating a common database framework, other strategies are needed to facilitate the generation of relevant research. Identifying data elements for the management system that could be aggregated securely should be a high priority. The ROMEO (Research on Medical Education Outcomes) Registry is 1 example of a health professions education data registry that should be reviewed. The establishment of a unique "professional lifetime" identifier for each DPT program applicant would enable longitudinal mapping of student educational and postgraduate career paths and outcomes. The longitudinal data would be invaluable for educational program and workforce evaluation. A national data management system would potentially allow for matching trainees to clinical education sites and residency programs. A great deal of variability exists among academic programs with regard to the number of clinical sites with which they have formal written agreements to provide clinical education. For many academic programs, many of these sites rarely or no longer provide clinical education experiences for their students (http://www.apta.org/CSIF/). A national data management system could include required compliance information (eg, immunizations, criminal background checks, HIPAA), which would facilitate "onboarding" at each clinical education site. RECOMMENDATION 5: That the physical therapy profession's prioritized education research agenda include a line of inquiry specific to clinical education.

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SS: Recent calls for changing physical therapist education to meet the ever-evolving health care delivery climate have been frustrated by the limited research and scientific data necessary to make informed decisions. The profession of physical therapy has long called for an increase in education- related research to identify best practices and improve on them (Education Section APTA, 2013, APTA Excellence in Education Task Force Report, 2015; Gwyer et al, 2015; Jensen et al, 2013; Jensen et al, 2016). However, these calls have frequently been unanswered due to the dearth of research funding and infrastructure, or to the lack of researchers with the requisite skill set. The need to promote interest in education research, and to invest in the development of educational researchers has also been identified (Jensen et al, 2016). In October 2016, the newly established ELP created a subgroup to develop a prioritized educational research agenda and strategy focused on funding, prioritization, and faculty development programming. Building on the education research-related work completed and the recommendations included in those resources, there is a need to ensure the inclusion of clinical education-related topics in any national research agenda. Answers to research questions relative to clinical education costs, best models, culture, environments, outcomes, standardization, variability, and other variables have been cited as a critical need. Future research should address student learning in multiple clinical environments and scenarios, whether they are integrated clinical experiences, terminal internship experiences, residencies, or fellowships as elements of an ongoing learning process. Developing new data repositories and enhancing access to, and quality of, existing data sets (eg, CPI, CSIF, PTCAS, NPTE, Physical Therapy Outcomes Registry) will be essential to aiding education researchers in their work. RECOMMENDATION 6: That the Best Practice in Clinical Education Task Force (BPCETF) report submitted for the APTA Board of Directors January 2017 meeting be made available to the Education Leadership Partnership (ELP) and other stakeholders within the physical therapist education community. SS: Making this report available to the ELP and other stakeholders within the physical therapist education community (eg, FSBPT) will facilitate transparency, trust, and collaboration. The intent is to share the contents of this report, regardless of what recommendations are adopted. Sharing the information with the ELP will help the represented organizations begin to understand the discussions and ideas considered by the BPCETF, and to identify areas of collaboration and different strategies to achieve the common goal of excellence in clinical education. If other recommendations are adopted, successful implementation will only occur with full participation and collaboration among all relevant parties. 32 JANUARY 31, 2017 BOARD OF DIRECTORS ACTION: 33 34 V-1 PASSED (Saladin) 35 That APTA design a plan for the dissemination of the Best Practice in Clinical Education Task Force report for receiving widespread stakeholder input prior to consideration by the APTA Board of Directors for adoption at the November 2017 Board of Directors meeting. SS: Making this report available to the ELP and other stakeholders within the physical therapist education community (eg, FSBPT) will facilitate transparency, trust, and collaboration. The intent is to

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share the contents of this report, regardless of what recommendations are adopted. Sharing the information with the ELP will help the represented organizations begin to understand the discussions and ideas considered by the Best Practice in Clinical Education Task Force, and to identify areas of collaboration and different strategies to achieve the common goal of excellence in clinical education. If other recommendations are adopted, successful implementation will only occur with full participation and collaboration among all relevant parties. REFERENCES American Association of Medical Colleges. Core Entrustable Professional Activities for Entering Residency: Curriculum Developer's Guide. Washington, DC: American Association of Medical Colleges; 2012. 7 American Physical Therapy Association Board of Directors. Excellence in Physical Therapy Education Task Force Report. Alexandria, VA: American Physical Therapy Association; 2015. 10 American Physical Therapy Association Board of Directors. Meeting Minutes (November). Alexandria, VA: American Physical Therapy Association; 2015. 13 American Physical Therapy Association. Normative Model of Physical Therapist Education. Alexandria, VA: American Physical Therapy Association; 2004. 16 Applebaum D, Portnoy LG, Kolosky L, McSorley O, Olimpio D, Pelletier D, Zupkus M. Building physical therapist education networks. J Phys Ther Educ. 2014; 28 (Sup. 1): 30-38 19 APTA's Department of Academic/Clinical Education Affairs. Embracing standards in physical therapist clinical education. Draft conference proceedings presented at: A Consensus Conference on Standards in Clinical Education; December 13-15, 2007; Alexandria, VA. 23 Association of American Medical Colleges. Recruiting and maintaining U.S. clinical training sites: joint report of the 2013 multi-discipline clerkship/clinical training site survey. 2014. Available from https://members.aamc.org/eweb/upload/13- 225%20WC%20Report%202%20update.pdf. Accessed January 13, 2017. 27 Association of American Medical Colleges. Recruiting and maintaining U.S. clinical training sites: joint report of the 2013 multi-discipline clerkship/clinical training site survey. 2014. Available from https://members.aamc.org/eweb/upload/13- 225%20WC%20Report%202%20update.pdf. Accessed January 13, 2017. 31 Barr JS, Gwyer J, Talmor Z. Standards for clinical education in physical therapy: a manual for evaluation and selection of clinical education centers. Washington, DC: American Physical Therapy Association; 1981. Black LL, Jensen GM, Mostrom E, Ritzline PD, Hayward L, Blackmer B. The first year of practice: an investigation of the professional learning and development of promising novice physical therapists. Phys Ther. 2010; 90:1758-1773. 36 37 Clinical Site Information Form. American Physical Therapy Association's website. http://www.apta.org/CSIF/. Accessed 38 January 14, 2017. 39 Cook DA, Andriole DA, Durning SJ, Roberts NK, Triola MM. Longitudinal research databases in medical education: Facilitating the study of educational outcomes over time and across institutions. Acad Med. 2010; 85:1340-1346. 42 43 Corb DF, Pinkston D, Harden RS, O'Sullivan P, Fecteau L. Changes in students' perceptions of the professional role. Phys 44 Ther. 1987;67:2326-233. 45 46 Curtis KA, Martin T. Perceptions of acute physical therapy practice: issues for physical therapist preparation. Phys Ther.

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47 1993; 73:581-594. 48 DiFabio FP. Assessments forgotten. In: Empower the patient. J Orthop Sports Phys Ther. 1999;29:314-315. Education Division, American Physical Therapy Association. Clinical education: dare to innovate. In: A consensus conference on alternative models of clinical education. Alexandria, VA: American Physical Therapy Association; 1998. 52 Education Division, American Physical Therapy Association. Clinical education: dare to innovate. In: A consensus conference on alternative models of clinical education. Alexandria, VA: American Physical Therapy Association; 1998. 56 1 Education Section, American Physical Therapy Association. Clinical Education Summit. 2014 2 3 Ellaway RH, Pusic MV, Galbraith RM, Cameron T. Developing the role of big data and analytics in health professional 4 education. Med Teach. 2014; 36:216-222. 5 FSBPT. Analysis of Practice for the Physical Therapy Profession: Entry-Level Physical Therapists. Alexandria, VA: Human Resources Research Organization; 2011. 8 Furze JA, Tichenor CJ, Fisher BE, Jensen GM, Rapport MJ. Physical therapy residency and fellowship education: reflections on the past, present, and future. Phys Ther. 2016; 96:949-960. 11 Gillespie C, Zabar S, Altshuler L, Fox J, Pusic M, Xu J, Kalet A. The research on medical education outcomes (ROMEO) registry: Addressing ethical and practical challenges of using "bigger," longitudinal educational data. Acad Med. 2016; 14 91:690-695. 15 16 Gwyer J, Hack LM, Jensen GM, Boissonnault WG. Future directions for education research in physical therapy. J Phys Ther 17 Ed. 2015;29(4):3-4. 18 19 Hislop HJ. The not-so-impossible dream. Phys Ther. 1975:1069-1080. 20 21 Institute of Medicine. The future of nursing: leading change, advancing health. Washington, DC: National Academies Press; 22 2011. 23 24 Jensen GM, Nordstrom T, Segal RL, McCallum C, Graham C, Greenfield B. Education research in physical therapy: Visions of 25 the possible. Phys Ther. 2016;96(12):1874-1884. 26 Jensen GM, Shepard KE, Gwyer J, Hack LM. Attribute dimensions that distinguish master and novice physical therapy clinicians in orthopedic settings. Phys Ther. 1992; 72:711-722. 29 30 Jette AM. 43rd Mary McMillan Lecture. Face into the storm. Phys Ther. 2012; 92:1221-1229. 31 Jette DU, Nelson L, Palaima M, Wetherbee E. How do we improve quality in clinical education? Examination of structures, processes, and outcomes. J Phys Ther Ed. 2014; Supp 1, 6. 34 35 Kulig K. Residency education in every town: is it just so simple? Phys Ther. 2014; 94:151-161. 36 Moore ML, Perry JF. Clinical education in physical therapy: present status/future needs. Washington, DC: Section for Education, American Physical Therapy Association; 1976. 39

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Podcast: Physical Therapist Education for the Twenty-First Century (PTE-21). http://www.apta.org/Podcasts/2013/1/24/PTE21/; 2013. Accessed January 14, 2017. 42 Rapport MJ, Furze J, Martin K, Schreiber J, Dannemiller LA, Dibiasio PA, Moerchen VA. Essential competencies in entry-level pediatric physical therapy education. Pediatr Phys Ther. 2014; 26:7-18. 45 Robertson EK, Tichenor CJ. Postprofessional cartography in physical therapy: charting a pathway for residency and fellowship training. J Orthop Sports Phys Ther. 2015;45:57-70. 48 Rodeghero J, Wang YC, Flynn T, Cleland JA, Wainner RS, Whitman JM. The impact of physical therapy residency or fellowship education on clinical outcomes for patients with musculoskeletal conditions. J Orthop Sports Phys Ther. 51 2015;45:86-96. 52 53 Rothstein JM. "Clinical education" versus clinical education. Phys Ther. 2002;82:126-127. 54 Schwertner RM, Pinkston D, O'Sullivan P, Denton B. Transition from student to physical therapist. Changes in perceptions of professional role and relationship between perceptions and job satisfaction. Phys Ther. 1987; 67:695-701. 57 Schwertner RM, Pinkston D, O'Sullivan P, Denton B. Transition from student to physical therapist. Changes in perceptions of professional role and relationship between perceptions and job satisfaction. Phys Ther. 1987; 67:695-701. 3 4 Ten Cate O. Nuts and bolts of entrustable professional activities. J Grad Med Educ. 2013; 5:157-158. 5 The Road to Becoming a Doctor. Association of American Medical Colleges' website. https://www.aamc.org/download/68806/data/road-doctor.pdf. Accessed on January 14, 2017. 8 9 Tichenor CJ. Challenges in clinical practice: making an investment in our future.Royce P. Noland Award of Merit. J Man 10 Manip Ther. 2000; 8:21-24. 11 12 Tryssenaar J, Perkins J. From student to therapist: exploring the first year or practice. Am J Occup Ther. 2001; 55: 19-27. 13 Wainwright SF, Shepard KF, Harman LB, Stephens J. Factors that influence the clinical decision making of novice and experienced physical therapists. Phys Ther. 2011; 91:87-101. 16 17 What is USMLE? United States Medical Licensing Examination's website. http://www.usmle.org/. Accessed January 14, 18 2017. 19 20 Worthingham CA. Complementary functions and responsibilities in an emerging profession. J Am Phys Ther Assoc. 21 1965:45:935-939 APPENDIX A 58

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AGENDA REQUEST FORM 1) Name and Title of Person Submitting the Request: Shari Berry, PT, Board Chairperson

2) Date When Request Submitted: 11/14/2017

Items will be considered late if submitted after 12:00 p.m. on the deadline date which is 8 business days before the meeting

3) Name of Board, Committee, Council, Sections: Physical Therapy Examining Board

4) Meeting Date: 11/29/17

5) Attachments:

Yes

No

6) How should the item be titled on the agenda page? Federation of State Boards of Physical Therapy (FSBPT) 2017 Annual Meeting Report

7) Place Item in:

Open Session

Closed Session

8) Is an appearance before the Board being scheduled?

Yes (Fill out Board Appearance Request)

No

9) Name of Case Advisor(s), if required: N/A

10) Describe the issue and action that should be addressed: Board representatives will provide information on topics and discussion at the National Association of State Boards of Physical Therapy Annual Meeting, November 2-4, 2017 in Santa Ana Pueblo, NM.

11) Authorization Signature of person making this request Date

Supervisor (if required) Date

Executive Director signature (indicates approval to add post agenda deadline item to agenda) Date

Directions for including supporting documents: 1. This form should be attached to any documents submitted to the agenda. 2. Post Agenda Deadline items must be authorized by a Supervisor and the Policy Development Executive Director. 3. If necessary, provide original documents needing Board Chairperson signature to the Bureau Assistant prior to the start of a meeting.

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