ASA March 2003 Newsletter

The privilege of providing anesthesia care to patients in our society is extended only to individuals who have gained the requisite judgment, knowledge and skills through appropriate education and training. The physician education pathway takes well-prepared undergraduates through a rigorous didactic and clinical course to produce graduates who may ultimately present themselves for board certification. In a similar manner, an educational pathway that produces a competent practitioner to extend the anesthesiologist’s care has been refined and proven. This article describes two key components of the pathway designed to foster the highest standards of competency in anesthesiologist assistants (AAs) — accreditation of educational programs and certification of graduates.

AA Education Program Accreditation
Since their inception more than three decades ago, AA education programs have sought external accountability and validation of their quality through a national accreditation process. Due in part to the accreditation process, AA education programs have been successful in recruiting talented applicants and producing competent graduates.

The American Medical Association (AMA), through its Council on Medical Education (CME), originally founded the Committee on Allied Health Education Accreditation (CAHEA) to engage physicians in the allied health education process. The intent was to address the growing need for physician extenders that arose during and following the Vietnam War. In 1975, ASA initiated AMA/CAHEA participation in the process for accreditation of AA educational programs. ASA worked to approve an AA curriculum in 1981 but ultimately chose to withdraw support from the AMA/CAHEA accreditation process of AA education programs. A nucleus of anesthesiologists founded the Association for Anesthesiologist Assistant Education (AAAE) in 1982 to continue the AA program accreditation process with AMA/CAHEA. Then in 1983, AMA/CME recognized AAs as a “New Emerging Health Occupation” and agreed to work with AAAE and the American Academy of Anesthesiologist Assistants (AAAA) to set up the accreditation process for AA education programs. The first “Standards of Accreditation” for AA education programs were approved by AMA/CAHEA in 1987. The programs at Emory University in Georgia and Case Western Reserve University in Ohio were originally accredited by CAHEA in 1988.

Today, accreditation is conferred by the successor organization to CAHEA, the Commission on Accreditation of Allied Health Education Programs (CAAHEP). CAAHEP also is the national body that accredits educational programs in respiratory therapy (RT), perfusion, emergency medical technician (EMT)-paramedic and 15 other allied health professions. ASA is a CAAHEP sponsoring organization for accreditation of radiologic technologist and EMT-paramedic education programs. The Society of Cardiovascular Anesthesiologists is a sponsoring organization for perfusionist education.

CAAHEP reapproved the “Standards and Guidelines for Anesthesiologist Assistant Education” most recently in 2001. These standards are composed and submitted by the Accreditation Review Committee on Education for the Anesthesiologist Assistant (ARC-AA). Anesthesiologists and graduate AA members of the ARC-AA (representatives from AAAE and AAAA) are considered to be the best experts to define the educational process that produces a competent AA graduate. This partnership of professional organizations has honed the standards to require an integral role for anesthesiologists in AA education that echoes the anesthesiologist/AA relationship in the anesthesia care team.

All CAAHEP-accredited AA programs must go through a rigorous process that includes several specific elements. The accreditation cycle begins with a self-study in which the program does its own analysis of how well it measures up to the established standards. Then ARC-AA sends a team of “site visitors” for an on-site evaluation to determine how accurately the self-study reflects the status of the program and to answer any additional questions that may arise. After review of the site visit report, ARC-AA develops an accreditation action recommendation to CAAHEP. If there are areas where the program fails to meet the standards, these “deficiencies” will be identified, and progress reports will be requested by ARC-AA to assure that each program continues its efforts to fully comply with all standards. Finally, the CAAHEP Board of Directors takes accreditation action based upon the recommendation forwarded from ARC-AA. The CAAHEP board assures that due process has been met and that standards are being applied in a consistent and equitable manner.

The mechanisms of AA education program accreditation are critically dependent on involvement of anesthesiologists. Though the “alphabet soup” of accreditation is sometimes confusing, AAAE has been the primary conduit for participation by anesthesiologists since 1982. AAAE Secretary S. Howard Odom, M.D., is the current chair of ARC-AA and also is the ASA Commissioner to CAAHEP. The Association of Anesthesia Clinical Directors (AACD) appointed Michael R. Murphy, M.D., as liaison to AAAE in 2001. Last year, as a reflection of ASA’s position on the anesthesia care team and interest in AA matters, ASA President, Barry M. Glazer, M.D., responded to a request from AAAE President and former ASA President John B. Neeld, Jr., M.D., to establish a liaison relationship by appointing David C. Mackey, M.D., as ASA liaison to AAAE.

Additional information and resources regarding accreditation, including the standards, are available from AAAE at <www.aaaehq.org>. Also, information on AAAA, our companion organization in accreditation, is available at <www.anesthetist.org>. Finally, general information on the CAAHEP allied health accreditation process may be found at <www.caahep.org>.

AA Graduate Certification
The National Commission for Certification of Anesthesiologist Assistants (NCCAA) was founded in July 1989 to develop and administer the certification process for AAs in the United States. Graduates or senior students in an AA educational program that has been accredited by CAAHEP may apply for initial certification. Initial certification is awarded to an AA who has successfully completed the Certifying Examination for Anesthesiologist Assistants administered by NCCAA. Certified AAs are permitted to use the designation AA-C to indicate that they are currently certified. This process is critical for AAs in clinical practice because Medicare regulations indicate that reimbursement will only be made for care provided by AAs who have been certified by NCCAA.

After passing the initial examination, to maintain certification, AAs must submit documentation to NCCAA that they have completed 40 hours of continuing medical education every two years and every six years must pass the Examination for Continued Demonstration of Qualifications (CDQ). NCCAA annually publishes a list of AA-Cs. This public document is made available to state boards of medical examiners and other bodies responsible for credentialing health care professionals. Failure to meet any of the above Council on Medical Education or examination requirements results in withdrawal of certification for the AA. In 2002, there were 49 candidates eligible for the certifying examination and 35 candidates for the CDQ examination.

NCCAA consists of commissioners representing AAAA, AAAE and ASA as well as At-Large Physicians and AA Commissioners. The 2002 House of Delegates approved the recommendation from the Committee on Anesthesia Care Team to nominate a commissioner from ASA to NCCAA. Michael H. Lasecki, M.D., was appointed to fill this position.

NCCAA has contracted with the National Board of Medical Examiners (NBME) to serve as a consultant for the development of the certifying examination and the CDQ examination for AAs. NBME advises and reviews all portions of the development and administration, including item writing and editing, production and administration, scoring, psychometric analyses and development of technical reports for the certifying and CDQ examinations. The content for the examinations is based on knowledge and skills required for practice gathered from surveys of AAs and physician sponsors conducted in 1990 and again in 1997. A test committee is responsible for writing and evaluating test questions for the examinations and for an item bank containing material that will be used in future years. The first certifying examination was administered in 1992, and the CDQ examination was first administered in 1998. To date, approximately 470 AAs have been certified by NCCAA.

The final testimony to competency is offered at the bedside. The coupled processes of educational program accreditation and graduate certification have helped assure that when an AA stands beside an anesthesiologist at the head of the bed, the ground is very solid beneath all four feet.

Arnold J. Berry, M.D., is Professor of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia. He also is a Commissioner for NCCAA.

S. Howard Odom, M.D., is an anesthesiologist with North Point Anesthesia Consultants, L.L.C., Alpharetta, Georgia. He also is ASA Commissioner to CAAHEP, Secretary of AAAE and Chair of ARC-AA.

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