Health Care Regulation: Making It Work in Tomorrows Health System SALPLN Annual Conference Saskatoon Inn April 19, 2016 Steven Lewis, President Access Consulting Ltd., Saskatoon Adjunct Professor of Health Policy Simon Fraser University [email protected] Main Themes The state of the system Regulation what it is, how we got here Regulatory challenges
From reaction to anticipation responding to environmental cues Re-imagining regulation: a question of alignment Some dubious advice and immodest proposals 2 Source: Davis K et al, Commonwealth Fund, http://www.commonwealthfund.org/~/media/files/publicat ions/fund-report/2014/jun/1755_davis_mirror_mirror_2014. pdf 3
The Modern Paradox Workforce is better trained than ever Regulation is more sophisticated than ever Technology is better than ever And yet Quality is uneven Major failures occur There is more paperwork but not always better performance 4
What Is the Role of Regulation? Entry-level Continuous Competence Assessment Complaints Cont. Ed. Periodic Quality Resolution Standards Assessment Improvement Formal Recertif.
Formal/Sporadic/Isolated Active/Continuous/Engaged 5 The Triple Aim: The Health System We All Want 6 Critiques of Regulation Too focused on entry-to-practice competence and individuals, too little on continuing competence and teams Deals effectively with extremes but contributes little to general improvements in safety and quality Too fragmented and occupation-centric Too protective of the professions represents them
rather than the public Little evidence that (health) regulation causally improves quality (Sutherland and Leatherman 2006, systematic evidence review, 7 http://www.health.org.uk/public/cms/75/76/313/531/Regul ation%20and%20quality%20improvement%20full%20repo What the Public Deserves and Assumes Is In Place All practitioners are good enough for other practitioners to entrust their families to Reliable early warning systems that identify emerging problems Effective and timely remediation processes for poor performance Redundant quality control systems based on collaboration,
information sharing, and shared responsibilities Truth-telling about the strengths and weaknesses of the practice environment and performance 8 Where the Public Is at Risk Fragmented care from multiple providers Unwarranted variations in practice by fully competent people Time lag between development of problems and addressing them Errors and adverse events resulting from system factors, not (obvious or actionable) individual wrongdoing General acceptance of mediocrity A culture where colleagues know that problems exist but stay silent (except to steer family and friends away from harm) 9
Radical Prostatectomies, SK Rate per 10,000 population 5-year average (2008/09 -2012/13) 11.69 9.04 8.43 6.31 6.23 5.53 3.65 n Su
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Al n er ce h n i rt o Pr N Sk 10 How We Define the Problem Shapes
How We Define the Solution Potential zone of concern Usual zone of concern 11 The Regulatory Niche Regulation is only one (albeit important) element that contributes to high performance All regulators are both enabled and constrained by law, mandate, obligations, capacity, and financial resources Depending on the profession, a lot of money is spent on Investigation/adjudication/discipline Revalidation Continuing professional development
What are the known returns on these investments? 12 Its Canada. Its Complicated Federalism 13 or 14 regulators doing the same thing but differently (credentials checks, licensure) Yet information sharing across jurisdictions is uneven The public owns regulation, but it is funded by the professions Criminals dont fund the judicial system Inmates dont choose the warden, but members of professions elect (most of) their governors Many regulatory functions seem generic, but the industry remains fragmented and individualized 13 Self-Governance in the Public Interest: Optimistic in Theory, Unlikely in Practice?
Profession Selects Governors Accountable Only to the Public 14 What Makes Great Practitioners? Graduates equipped with knowledge, tools, and above all a mindset of continuous improvement A collegial work environment where everyone is committed to the same patient-oriented goals A system that invests in and promotes lifelong learning The ability to reinvent oneself with new capabilities Permission to experiment, evaluate, fail, and reboot Teams that break down hierarchy and listen to each other
15 Game-Changing Environmental Factors Systems thinking, team responsibility, and designed interdependencies More sophisticated real-time performance-oriented data mining, reporting, feedback Independent rating sites, outcome reports, experience surveys Organizational commitments to CQI, measurement, collective accountability, life-long learning Educational programs that build in data-seeking, data-mining, and continuous feedback loops (e.g., NYU medical school) 16 Regulatory Culture Change HISTORICAL
TRANSITIONAL Quality assurance Quality improvement Individual performance Team performance Competence = knowledge Competence = performance Entry-to-practice focus Lifelong career focus
React, hear, discipline Engage, prevent, assist 17 Prevention: The Holy Grail of Regulation and Improvement Regulators seek the perfect lab test Perfect sensitivity they can identify everyone at risk Perfect specificity they identify only those at risk Regulation is designed for a world of decent and well-motivated human beings Many notorious purveyors of harm are gifted sociopaths Some regulators believe that it is impossible to protect the public from certain kinds of risks 18
Does Competency Need A Paradigm Shift? Most fitness to practice assessments focus on what practitioners know and what they do There is a growing sentiment that the greatest potential for harm (and prospects for remedy) lie in who people are Their fundamental belief systems about evidence Their comfort level with interdependence Their degree of humility Their ability to work in a team environment 19 Plan Your Future for the Best Case Scenario Organizations will get better at QI Real-time, meaningful data will be available Self and peer assessments will become more feasible, valid, comprehensive, and current
Credential checks will be automated and foolproof Team and system performance will supplant individual credentials and competencies as the metrics of choice 20 The Challenging Politics of Regulation Interprofessional rivalries and turf protection (surely not here in SK!) Attempting to regulate standards in a rapidly changing practice and knowledge environment Aligning regulation with the realities of team practice and collective responsibility Disentangling whats good for the profession from whats good for the public 21 Can the Disciplinary Body Also Drive Quality Improvement?
Regulators increasingly want to be more proactive and less reactive Recognition that where QI is effective, the need for complaints and disciplines diminishes QI requires openness, trust, transparency, and disclosure The relationship is at risk when one party has disciplinary power over another It is a fundamental challenge to all regulators (and wait, I have a solution to propose, however far-fetched) 22 LPNs: A Profession on the Move
Major upgrade in educational requirements and standards in past 30 years Filling major gaps left as RN entry credential became a university degree Large increases in numbers across the country Seen as versatile, adaptable profession willing to roll up it sleeves The backbone of long term residential care A profession open to lower income families and students (equity) 23 Can You Lead Regulatory Reform? Governments and the public are looking for leadership in Recognizing and certifying new skills acquired on the job and in continuing education programs Developing methods for assessing team competencies Working with health organizations to assess competency and improve
performance in real time Identifying at-risk practitioners and intervening swiftly to protect the public and help them 24 Stepping Up What Can Regulators Do? Define competency upward and outward only that will move the performance curve to the right Align regulatory measures with a robust definition of performance Identify the roles that regulators are uniquely positioned to fulfill Rigorously evaluate what youre now doing and prune the activities and expenditures that yield little of value Anticipate, monitor, and adapt to what others are doing to improve performance 25
Stepping Up What Can Regulators Do (2)? Sever the disciplinary roles from the QI roles Develop a coherent theory of performance that speaks to individual, team, organizational, and policy dimensions Cooperate and collaborate to minimize the burden and redundancy of federalism Develop a rigorous research and evaluation agenda for regulation Promote the soft side of regulation difficult conversations, interdependencies, learning cultures 26 Stride Confidently Among Your Peers Being relatively new means that you have less historical baggage to jettison in order to make regulation hum Promote interdisciplinary efforts to make regulation more relevant, responsive, and helpful (BC is a promising example)
Continue your efforts to make scope of practice rational, evidence-based, and focused on meeting peoples needs Keep tabs on innovations in regulation Take the high road even when others dont respect earns respect, and the future bends in your direction 27 YOUR TURN! Questions? Comments? Challenges? Rebukes? Everything is debatable lets have a dialogue. 28
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