Charles F. Mullen

The Proposal

Proposed Clinical Optometrist Qualification Standard (COQS) (.doc)
Proposed Clinical Optometrist Qualification Standard (COQS) (.pdf)

Background

Following the creation of the VHA Optometry Service (PL 93-541) in 1976, VHA optometrists were transferred from the Civil Service personnel system into the independent physician-dentist personnel-salary system utilized by VHA under the authority of Title 38 of the U.S. Code.

That transfer was delayed two years, until 1978, while a Clinical Optometrist Qualification Standard (COQS) was established specifying requirements for appointment-promotion of optometrists into the VHA personnel system.

That first COQS has been reissued many times since 1978 for changes in technical and administrative language but its written requirements for appointment-promotion have remained unchanged, word-for-word, as written in 1978 and are now 39 years old.

We believe those requirements must be brought up-to-date to reflect the significant changes that have taken place to the training, licensure, credentialing and clinical responsibilities of optometrists in the past 39 years.

Changes in the Optometry Profession

Since 1978 when the COQS was first issued, the clinical training, credentialing and patient care responsibilities of optometrists have expanded significantly.

The Veterans Health Administration has played, and continues to play, the leadership role in these changes through its establishing the first hospital training programs for optometry students and the first hospital residency training programs for optometry school graduates and its clinical teaching affiliations with the schools and colleges of optometry beginning in 1973. As those affiliations spread, a VA Optometry Service was established to recruit residency-trained optometrists as VA medical staff. Today, VA operates the largest optometry training program and optometry patient care system in the United States with over 700 full-time optometrists treating more than 1.4 million unique enrolled patients per year. Over seventy percent of optometry students now serve a VA extern rotation prior to graduation and VA residency programs have grown to 86 that train over 215 residents each year in the specialties of medical optometry and low vision rehabilitation.

We believe the VHA training programs for optometrists have become a national treasure that deserve better recognition and a new COQS.

Also since 1978:

Expansions in state licensing laws have significantly broadened the medical prescribing responsibilities of optometrists and standards which they must meet.

The appointment of optometrists to the medical staffs at Joint Commission accredited federal and state health organizations, authorized in 1986, requires optometrists be credentialed following the same process and standards as physicians and dentists and has, along with VHA, fostered the specialty of hospital optometry practice.

Board certification programs have more recently become available for credentialing optometrists in general practice and the specialty of medical optometry. At this time there are three recognized, independent national board certifications available for credentialing and each has a companion Maintenance of Competence programs (two for general practice, one for the specialty of medical optometry).

Medical optometry and low vision rehabilitation training that originated within VA residency training programs have emerged as optometry specialties. While once there were no optometry specialty residency programs, today 24% of optometry school graduates elect to serve a specialty residency accredited by the American Council on Optometric Accreditation, and VHA operates the great majority of those specializing in medical optometry or low vision rehabilitation (for example VICTORS and Blind Rehabilitation centers).

Current COQS Must Be Updated

As a result of these significant changes to optometry training and the rise of specialization and Board Certification credentialing (attributable, to a large degree, to the VA) cited above, the Clinical Optometrist Qualification Standard (COQS) issued 39-years ago in 1978 no longer reflects current optometry training, credentialing and patient responsibilities; especially of those optometrists practicing within VA medical facilities.

For example, today’s optometrists are held to the same standards of care required of physicians providing that same care.

In addition, VA and other Joint Commission accredited facilities now utilize the same application-credentialing review committees once only used to credential physicians and dentists and the Centers for Medicare and Medicaid hold optometrists to the same credentialing standards by placing them within its group of “Medicare Physicians”.

The 1978 COQS paid little attention to optometry residency training (1), expanded state licensing laws and board certifications in general and specialty optometry practice did not then exist.

We believe an updated COQS furthers the appointment and promotion of only well qualified, board eligible and board certified optometrists to Senior and Chief Grades and meets current standards of best-practices and credentialing. It also requires supervision/mentoring of inexperienced junior-grade (Associate and Full Grade) optometrists entering VHA service.

This supervision of junior-level optometrists is very important for the maintenance of one-level-of-care since eye patient presentations at VHA eye clinics are typically more prevalent, serious, complex and organic in cause than those encountered in private practice and, in our experience, recent graduates without hospital residency training are not fully prepared for hospital practice; to provide patient care unsupervised; to understand hospital procedures; or facilitate the close cooperation between disciplines required for appropriate, timely referrals and co-management of VA eye patients.

It was for these reasons that VHA optometry residencies were created in 1975 to prepare optometrists to practice within medical facilities as a member of their medical staffs.

Recommendations

Revise the 1978 COQS written requirements for appointment/promotion to the five levels of clinical patient care and teaching responsibility because their wording has remained unchanged since first issued in 1978 and are now seriously dated.

A suggested new COQS utilizes national clinical board certifications adopted by the profession for benchmarks of clinical competence for general and hospital optometry practice; requires supervision of inexperienced junior optometrists and adds other proxies for competence not available in 1978 that include Diplomate status in the American Academy of Optometry and/or election to other learned optometry societies.

This model COQS is more rigorous and specific to the unique demanding requirements for optometrists serving as VHA medical staff members.

Notes

(1) Optometry hospital residency training programs did not exist in our profession until VA created them in 1975 followed by VA residencies in low vision rehabilitation, both highly important to VHA patient care. The 1978 COQS could not foresee the importance these specialty residents would have to VHA patient care.

(2) Changes to the COQS since 1978 have been limited to only technical and conforming administrative updates while its standards for each clinical grade have remained identical for 39 years.

(3) The 1978 COQS had insufficient provisions for recognition of future credentialing of optometry specialists, which have three levels of credentialing; 1.Completion of residency training, 2. Passage of a national specialty examination, 3.Specialty board certification. Stages 2 and 3 did not exist in 1978.

(4) VA was first to establish a hospital optometry residency program and led the development of it and other optometry specialties in the profession.

(5) VASF 171, OMB #2900-0205. (Application for VHA appointment).

(6) It is highly recommended that in the future, passage of specialty examinations and specialty board certifications become one necessary qualification for appointment/promotion to Senior and Chief Grades respectively.

Proposed Clinical Optometrist Qualification Standard (COQS) (.doc)
Proposed Clinical Optometrist Qualification Standard (COQS) (.pdf)

Charles F. Mullen, O.D.
Director, Optometry Svc.
1990-96

Kenneth Myers, Ph.D., O.D.
Director, Optometry Svc.
1974-89