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Diversity, Equity, and Inclusion (DEI) is important to put balance back into our social architecture and begin to see our human resources with understanding, dignity, respect, and empathy and use in ways that create the greatest potential of, and for, all people. In the practice of healthcare and the practice of professional licensing, if we don’t understand and address the principles of DEI, we will never be able to understand the problems and barriers many of our patients face, and thus, the system breaks down for many who truly need it.

To address DEI principles, first, we must be willing to acknowledge that there is much we don’t understand, and then be willing to bridge those gaps. Second, we must know our public. What is the demographic of the public you serve and are sworn to protect? Do your Board members reflect that demographic? Third, develop a concrete plan to address DEI with sincere and genuine concern. Do your licensees create barriers or establish inequities in care? Do you have a plan to educate your licensees about DEI? Has your Board established a system to look for and monitor bias in patient care? Has your Board established consequences for licensees who are willfully biased toward patients?

Regulatory Boards are tasked with protecting the public by ensuring that a licensed optometrist is competent to practice. DEI issues for Boards do not center around new licensee candidates, but rather around the established licensee and the public that they serve. This can present a bit of a conundrum for DEI issues in the regulatory world. On one hand, Regulatory Boards have the responsibility to license candidates based on objective parameters: graduating from an accredited optometric program, passing the National Board Exams, etc. In this regard, race, color, creed, gender, religion, sexual orientation/identity, and other variables are not factored in. Licensure is solely based on competency to practice optometry. This is certainly in the public interest and fulfills the mission of Regulatory Boards to protect the public while attempting to be completely unbiased regarding licensee candidates.

On the other hand, the Board must also interact with both established licensees and the patients they serve. Regulatory Boards protect the public by knowing who their public is and understanding their demographics. Having Board members that reflect the demographic of the people they serve is a good first step in achieving this goal. Boards also protect the public by educating their licensees on the importance of understanding their patients’ backgrounds, cultures, and identities. To properly diagnose, treat, and manage, optometrists must be able to connect with their patients. That connection starts with knowing the patient, their culture, history, and identity, and then understanding and accepting those characteristics. Boards can help by providing access to DEI education to fill in the gaps for optometrists who do not have the same background or understanding as those they treat. This helps the optometrist establish a more complete case history which is essential, for a proper and more comprehensive patient encounter.

Some takeaways for your Board regarding DEI:

• Always maintain objectivity when granting a license to a new optometrist.
• Educate the board about issues relating to DEI.
• Look at the makeup of your board. Does the board reflect the demographic of the people you serve? If not, consider adding this to the criteria for future appointments to the board.
• Consider requiring ongoing education on issues relating to DEI.
• Establish consequences for unprofessional conduct for doctors proven to be willfully biased toward certain patient demographics.

There has been much discussion about the role of regulatory boards in optometry. We all know the primary mission of any regulatory agency is to protect public health and welfare through enforcement of the practice act. However, it seems that outside influences are attempting to change that mission and create broader responsibilities that do not line up with standard regulatory principles and policies.

How do you define ‘public’?

It has been stated by some state regulatory board members that, “everyone is the public”. The problem with this definition is that it renders regulatory boundaries virtually limitless, which opens the gates of outside influence. This leaves the board not only more vulnerable to regulatory capture but also nearly impotent to keep up with such a broad scope of responsibility.

The ‘public’ in an optometric regulatory setting are those patients under the care of an optometrist. It is that segment of the population (public) that we are responsible for.

Normally, when the point is made that, “we are all the public” it tends to refer to a very specific subset of people…and often comes with an agenda. This is a classic symptom of regulatory capture – that is, to expand or distort the definitions so that the board may be more susceptible to outside non-regulatory influences.

This is easy to do because we are voluntary regulators, it’s not our day job, and it can be very difficult to separate the various roles we play in our profession: optometrist, regulator, optometric advocate, and public protector. This makes us susceptible to outside non-regulatory influences that may want to change the system to their advantage. Most often these influences are friends, colleagues, and people we respect in leadership roles, and as a result, it is easy to be influenced by the relationship.

There was a time when regulators, leaders, legislators, and advocates would wear all their hats at the same time. This was/is called the ‘good ‘ol boy’ system. This system did not always follow accepted regulatory principles or policies. Government entities such as regulatory boards are increasingly being called to task and must prove their effectiveness to both the public they serve and the government who appointed them. The good ‘ol boys are increasingly being exposed as an impediment to proper governance and public welfare.

Remember, we are optometric regulators, which means we are public members of our board with optometric expertise. Remember also, who your ‘public’ is. The public you are responsible for are those patients being seen by optometrists licensed in your State or Province.

Are Regulatory Boards Responsible for Access to Optometric Care?

Healthcare regulatory principles assume a relationship between a provider and a patient. If an optometrist never sees a patient, then there is simply no patient to protect. However, here again, is where the definitions may become artificially broadened to satisfy other non-regulatory entities: Are state and provincial boards responsible for making sure patients have access to care?

For example, let’s take two people who have developed blindness.

Person #1: Lives in a rural area with very limited access to healthcare. This person had no access to eye care and developed a vision-threatening disease and lost vision permanently.

Patient #2: Has access to optometric care and developed the same disease. This person also went blind due to the optometrist’s misdiagnosis, mistreatment, and/or mismanagement.

Both scenarios are tragic. However, are regulatory boards responsible for both patients? A regulatory board has jurisdiction and authority over the optometrists licensed in their state or province. In other words, if there is no optometrist involved, there is no authority. Regulatory boards do not have the authority to dictate or direct workforce shortages or demographics – it’s simply not their mission or responsibility.

Improving access to eye care is much needed in rural and isolated communities. Professional advocacy groups have long worked to address these issues of access – and due to their efforts, access to eye care has greatly improved, but much work is still needed in this area. The point here is that access to eyecare is not the responsibility of regulatory boards. Entities that attempt to influence boards to take on this burden can distract from a board’s true mission which is considered regulatory capture.

It goes without saying that the role of a regulator can be challenging given that we are human and come with our own individual experiences and biases. However, understanding a regulatory board’s mission, authority and jurisdiction will help to maintain focus and be true to your responsibility as a board member.

Optometry regulators are tasked with the important role of protecting the public through the enforcement of the practice act. But an often overlooked question is why government decides to regulate the professions. Government is the only entity that can require action (or inaction) as a means of meeting its goal of a civilized and protected society. Government regulation of the optometry profession provides protection to all persons involved and the public as a whole. Applicants, licensees, and consumers of optometry services are afforded rights that ensure a fair process of granting a license and a mechanism of enforcement for the benefit of all. The regulation of the professions is state and provincial-based, meaning each jurisdiction has the right to determine how to regulate in the interest of the persons residing in and seeking the services of a professional. That is why there may be slight differences in the requirements for licensure eligibility and renewal. The Association of Regulatory Boards of Optometry assists its Member Boards by providing programs and services intended to promote uniformity and increase the efficiencies and effectiveness of the optometry regulatory community.

Optometry boards follow the statutes in determining how to license and renew the credential granted to applicants seeking to engage in the practice. The statutes establish the scope of practice which determines what activities can (and cannot) be undertaken and when licensure is required. The intent of these requirements of licensure is to ensure that only qualified persons be granted the authority to practice optometry. Optometry boards gather information about applicants to determine if they qualify for licensure. The gathered information includes education, examination(s), experience, and criminal background checks. If qualified, the board issues a license authorizing that individual to practice optometry. Optometrists periodically renew their licenses after establishing the completion of qualifying continuing education. Boards are authorized to sanction persons that failed to adhere to the legal requirements.

Imagine where we would be without the government licensure of optometrists?

What is the Association of Regulatory Boards of Optometry (ARBO)?

ARBO represents the national and international regulatory arm of the optometric profession. ARBO serves the regulatory agencies responsible for initial and continued licensure. Those regulatory agencies (State and Provincial Boards of Optometry) are responsible for protecting a very specific subset of the general public – that being the public that the profession serves – optometric patients. These regulatory agencies do not protect or advocate for the profession, the doctors, the educators, or the students – these entities have their own organizations that advocate for them. In order for state and provincial regulatory boards to be effective and responsible for their mission and their public, it is important that there is a well-defined line between advocacy groups and the regulatory boards.

The ARBO is a 501(c)3 corporation. ARBO’s mission is to serve its member regulatory boards. ARBO’s only interests are those of the member boards and of the laws that the boards are charged with enforcing.

• ARBO creates and provides services and programs to lessen the burden on state/provincial government for:
  • Initial licensure
    • NBEO/NBERC
  • Maintenance of licensure
    • COPE
    • OE TRACKER
    • CELMO
• ARBO also provides programs and guidance to educate Board members on how to think, act and perform as a regulator.

ARBO serves to protect its members by acting as a watchdog for regulatory capture. That does not mean that we work against various professional advocacy organizations. We are a proud profession and our professional organizations understand the importance of excellent patient care and protection. In many ways, we fight the same battles for providing quality care for patients. Still, as noted, our roles in the optometric profession are distinctly different and must remain distinctly separate organizations.

ARBO’s purpose is stated in our bylaws (ARTICLE II):

The purpose of this Association shall be to exchange information and engage in programs and joint activities relating to the professional education, licensure, and continuing education of optometrists, to improve reciprocal relations and help in solving the mutual problems of the member Boards, and to engage in other activities as the Association may determine, for the purpose of improving the standards of the profession, the delivery of health services and the services of the regulatory licensing agencies, all for the welfare and protection of the general public.

The lifeblood of any volunteer organization is the willingness of its members to volunteer their time and talent to the organization. ARBO has been blessed with the generosity of its many members who have contributed to the continued success of the organization for over 100 years. There are many committees that can fit your time and commitment requirements. ARBO staff provides support and guidance, and fellow committee members can develop relationships to last a lifetime.

If you’re looking for a way to get more involved try one of our committees – you won’t be disappointed!

ARBO Volunteer Committee Options

COPE (Council on Optometric Practitioner Education)

Description: The objectives of COPE are:

• To accredit optometric continuing education providers and activities for the public welfare.
• To monitor programs to help assure the quality and independence of continuing education in appropriate settings with adequate administration.
• To reduce duplication of effort by member boards.
• To create a uniform method of recording continuing education activities.
• To be the reference source for member boards for information about continuing education providers and activities utilized by licensed optometrists to fulfill their continuing education requirements.

Term: Eligible for two 3-year terms (Note: This committee is set through 2024. Volunteers are not currently needed)

• 1 monthly virtual meeting.
• 1 annual in-person meeting.

OE TRACKER (Optometric Education Tracker)

Description: OE TRACKER captures and stores continuing education attendance data for optometrists. The information can be accessed online by optometrists and licensing boards. OE TRACKER saves time and reduces paperwork by tracking/auditing CE credits electronically. The OE TRACKER committee reviews the program annually and makes recommendations for changes and updates.

Term: 1 year

• Virtual meetings every other month.
• 1 annual in-person meeting.

NBERC (National Board Exam Review Committee)

Description: The NBERC verifies the quality and integrity of the National Board Examinations.

Term: 2 years+

• All work is done between October and December:
  • Via email and 2-3 virtual meetings.
  • One in-person 3-day meeting in Charlotte, NC in October.

CELMO (The Council on Endorsed Licensure Mobility for Optometrists)

Description: CELMO assists ARBO’s member optometry boards in reviewing applications for licensure from established practitioners in other jurisdictions in a uniform and consistent manner.

Term: 1 year +

• Virtual meetings every other month.
• One annual in-person meeting.

Judicial Council/Resolutions

Description: Prior to the Annual Meeting, the Judicial Committee will review prior resolutions for relevancy. The Resolutions committee will review and present any new resolutions to the House of Delegates at the Annual Meeting.

Term: 1 year

• 1-2 virtual meetings prior to the Annual meeting in June.
• Possible in-person meeting at the Annual meeting.

Nominating

Description: The Nominating Committee reviews and interviews candidates, and makes a slate of nominees to present to the ARBO House of Delegates for open positions on the ARBO Board of Directors.

Term: 1 year

• 1-2 Virtual meetings prior to the Annual meeting in June.
• Possible in-person meetings at the Annual meeting in June.

Bylaws

Description: The Bylaws Committee reviews any proposed amendments and presents them to the House of Delegates at the annual meeting along with the committee’s recommendation regarding the amendment.

Term: 1 year

• 1-2 Virtual meetings prior to the Annual meeting in June.
• Possible in-person meetings at the Annual meeting in June.

Communications

Description:

• To establish a timely, accurate, effective and efficient system of communication between the ARBO organization and relevant stakeholders.
•  To develop, write and edit content that will be of value to the ARBO member boards.

Term: 2 years+

• Quarterly virtual meetings.
• Draft writing and editing.
• One in-person meeting at the Annual Meeting in June.

COPE®. The Council on Optometric Practitioner Education, the only nationally recognized accreditation system for optometric continuing education (CE), was developed by ARBO to assist ARBO’s member licensing boards by providing assurance that the optometric CE courses they accept for license renewal are of the highest quality.

COPE accreditation addresses professional practice gaps and focuses on improving knowledge, performance in practice, and patient outcomes with improved public health as the goal. COPE is the sole entity available to Boards of Optometry that addresses these needs.

COPE’s Accreditation Criteria are designed to change:

• Optometrists’ competence (strategies for translating new knowledge into action) or
• Optometrists’ performance (what they do in practice) or
• Patient outcomes.

COPE is also a valuable tool that can be referenced when looking to expand the scope of practice. COPE’s accreditation process has been designed to be equivalent to CE/CME accreditation in most mainstream healthcare professions including, but not limited to, medicine, pharmacy, and nursing.

COPE also represents optometry in the Joint Accreditation for Continuing Education in the Health Professions collaborative. Joint Accreditation promotes interprofessional continuing education activities specifically designed to improve interprofessional collaborative practice in health care delivery.

COPE has evolved over time from a CE approval process to a true CE accreditation system based on specific criteria and meeting the highest standards in healthcare CE/CME accreditation.

Approval vs. Accreditation

State and provincial optometry boards originally ‘approved’ CE. The process was not standardized and was fraught with efforts by commercial and professional entities to use CE as a method to promote their products or services. ‘Approval’ requirements involved well-meaning volunteers with little or no experience or expertise in adult learning theory or CE/CME accreditation. As a result, almost any CE from any source could be ‘approved’.

Accreditation, on the other hand, requires specific guidelines and standards to be followed. Specifically, COPE accreditation incorporates accreditation criteria and Standards for Integrity and Independence, which ensure a high-quality, evidence-based, non-biased program of education. The COPE accreditation requirements provide not only the highest quality CE that meets industry standards but also the strongest defense against any criticism of optometric CE used for license renewal.

The COPE accreditation program is the gold standard in optometric continuing education and is a model for CE accreditation throughout the healthcare industry.

Top 5 Reasons a Regulatory Board Should Use COPE:

1. Highest Standards in Healthcare. COPE has evolved from an approval process to an accreditation system that meets the highest standards in healthcare.
2. Improved Patient Outcomes. COPE CE addresses practice gaps and focuses on improving knowledge, performance, and patient outcomes.
3. Accredited. COPE CE is designed to be relevant, effective, evidence-based, and free from commercial influence.
4. Equivalency with Medicine. When looking to expand the scope of practice, COPE’s equivalency to medicine’s accredited CME means legislators are assured that COPE accredited continuing education is of the highest quality.
5. Public Health Assurance. Public health is best protected by requiring accredited CE which measures outcomes and incorporates quality improvement measures.

In the 1980s most states had a very limited scope of practice for optometrists consisting of refraction and contact lens fitting. In the 41 years that have followed, the practice of optometry has grown to fill a much-needed gap in primary eye care. Keeping up with the ever-expanding scope of practice is professionally exciting, but can be a challenge for regulatory agencies to ensure that their licensees have mastered the new skills.

When deciding scope-of-practice issues, legislators will ask how this increased scope will be tested to assure competency. This often leaves the State Boards searching for an answer. Fortunately, the National Board of Examiners in Optometry (NBEO), ARBO’s exam partner, can help with this task. NBEO is constantly updating examinations to meet the expanding needs of State Boards and the Laser and Surgical Procedures Examination (LSPE™) is the newest example.

LSPE is the only nationally standardized examination of its kind, in measuring competency in laser and surgical skills, surgical decision-making, and patient management. LSPE is a stand-alone, elective exam containing both a laser and surgical section. Each of these sections contain performance of clinical skills and computer-based multiple-choice items. The exam is offered to fourth-year optometric students, optometric residents, and optometric practitioners.

The clinical skills portion covers the following:

• Selective laser trabeculoplasty
• Peripheral iridotomy
• YAG capsulotomy
• Suturing
• Chalazion excision

The multiple-choice section covers, in addition to the above topics:

• Eyelid surgery
• Injections
• Ocular anesthesia

For States looking to expand into lasers and surgical procedures in the future, LSPE can be an important tool to assure legislators that ‘testing for competency’ is already in place. Like the other NBEO regulatory licensing examinations, LSPE is valid, uniform, and defensible. More information on LSPE can be found at https://www.optometry.org/exams/lspe.

The National Board of Examiners of Optometry is in the process of revamping Part III CSE (Clinical Skills Exam).  This is a major undertaking and will have a lot of moving parts to put it together. The reason for the update follows the path of progressive, comprehensive healthcare. The standards of care have changed so that it is no longer adequate to simply test whether an applicant can perform a specific clinical skill. The applicant must know why the skill is important and how will it help guide treatment.  As doctors in our clinics, we can teach a tech to perform many of the clinical skills we use on a day-to-day basis. What separates the doctors from the tech is the in-depth knowledge of why a procedure is being performed, to accurately interpret the results and develop a treatment plan.

The new Part III will continue to test clinical skills, but will also introduce more cognitive skills relating to specific procedures.  This change will introduce a more accurate and robust indication of entry-to-practice. Your board can be assured that applicants for licensure are meeting the standards for a changing and progressive profession.

The NBEO does not work in a vacuum; feedback from stakeholders is crucial. The NBEO recently conducted a stakeholder survey to understand which skills stakeholders felt were most essential. A job task analysis, tentatively planned for early 2020, will sample a broad base of the profession to ensure that the new test accurately reflects the clinical and cognitive knowledge for entry-level practice.

• What specific clinical skills are important? Why? What is the thinking behind requiring a specific test or procedure? What will the provider gain from the results of a test or procedure?
• How should a minimally qualified candidate (MQC) use the skills test to guide treatment?

These are cognitive processes that we do every day, so is it enough to just test the skill without testing the reasons behind it? This is the future of entry-to-practice testing.

ARBO will keep you informed on the progress of Part III.

This is the third installment in a 3-Article series covering the genesis and maintenance of the National Board Exam for Optometry (the Exam).  There are three individual parts of the National Board Exam (Part I – Applied Basic Science, Part II – Patient Assessment and Management and Part III – Clinical Skills Exam), but this article series discusses the Exam as a whole. The following information should be helpful in providing a basic understanding of this essential tool for ARBO’s member boards.

This is Article 3 in a 3-Article series covering the genesis of the National Board Exam (the Exam). In Articles 1 and 2 we discussed how the Exam is developed and maintained using a ‘validity centered’ approach. Article 3 will finish the discussion with Standard setting and Maintaining the test.

Conduct standard setting

The primary guiding question for this step is:

• How should we determine the cut-point on the test score scale, i.e., what will be the ‘cut score’?

The most critical outcome of a licensure exam is the pass/fail decision.  The passing score must be defensible and reflect the skills necessary for entry-level practice. The National Board of Examiners in Optometry (NBEO) recommended that the passing score[1] be obtained through a systematic standard setting study.

Standard setting is the process of defining the performance expectations of the minimally qualified candidate and translating that performance expectation into a passing score.  For the most recent study, NBEO used the yes/no variation of the Angoff[2] standard setting method (commonly used to determine passing scores for licensure programs).  The standard setting study was conducted with the input of an independent panel of Subject Matter Experts (SME) and facilitated by an independent third-party testing organization.

Maintaining the test

The primary guiding question for this final step is:

• Once a test is created, what are the test creators’ ongoing responsibilities?

To preserve exam security, NBEO periodically publishes new exam forms.  Although these new forms are based on the same Competency Model, the forms contain new items.  To meet this need, item development meetings, item review meetings, and new form constructions are conducted regularly.  Additionally, to ensure that the test items are performing well statistically, periodic analyses (i.e., health checks) are conducted regularly.

The optometric profession is not static; over time, best practices can change and new technologies emerge. The NBEO constantly monitors to ensure that the content and performance expectations remain current and relevant.  To meet this need, NBEO conducts new job task analysis and standard setting studies.

Table 1. Frequency of Test Development Activities

Activity	Frequency
Item Development; Item Review; Health Check; Form Creation	At least yearly
Job Task Analysis; Standard Setting	Approximately every 5 years

 

Thanks to Dr. Brett Foley of Alpine Testing for the content of this series.

 

[1] Each licensing body is responsible to determine if a candidate has demonstrated sufficient competency to be eligible for license.  Licensing bodies who apply passing scores different from those recommended by NBEO are responsible to justify and defend the decisions made using those passing scores.

[2] For information on the specific methodology, see: Impara, J. C., & Plake, B. S. (1997). An alternative approach to standard setting. Journal of Educational Measurement, 34(4), 355-368.