Can Revalidation Deliver What the Public Expects?
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This document discusses public expectations of regulatory revalidation of clinicians and whether revalidation can deliver on those expectations. It notes that public expectations are modest, focusing more on access to care than quality or outcomes. It also discusses different definitions of competency and the complexity of problems in healthcare. While revalidation aims to maintain competency, it has limitations as practice is continuous but revalidation is periodic. The document suggests that for revalidation to meet public expectations, it would need to take a systems approach and include organizational assessments in addition to individual assessments. It also raises the possibility of alternative approaches to evaluation that focus more on intrinsic motivation and attitudes rather than just knowledge and skills.
Can Revalidation Deliver What the Public Expects?
- 1. Can Revalidation Deliver What the Public Expects? IAMRA Revalidation Symposium Montreal, October 29, 2015 1 Steven Lewis Access Consulting Ltd., Saskatoon Adjunct Professor of Health Policy Simon Fraser University slewistoon1@gmail.com
- 2. Public Expectations Are Modest No research on public expectations of regulation Public tends to assume that: Almost all clinicians are competent Their clinicians are competent even if others’ aren’t Incompetence is revealed by adverse events Access and relationships are primary We are cognitively unprepared to deal with the safety and quality problems that plague health care 2
- 3. Framing Competency 3 Competency is a continuum and there is no universally standardized definition If competency is ends-driven, it depends on the ends Basic safety Reasonable command of evidence-based practice Ability to meet typical needs Ability to meet complex needs Self-management A minimalist version of competency reflects regulatory history A more robust version of competency is a game-changer
- 4. So How Competent Is Health Care? It’s excellent The public tends to revere doctors High degree of trust in local institutions Main concern is access, not quality or outcomes It’s terrible Every major study identifies huge toll of harm and death Polypharmacy and practice variations are rampant Chronic disease management and mental health are disaster zones 4
- 5. 5 Complexity of Problems and Needs Regulatory Intensity Needed to Ensure Competency
- 6. The Limits of Revalidation Practice is continuous; revalidation is periodic Difficult to capture the full range of performance Invariably small sample sizes if chart reviews Role of individual competencies varies depending on complexity of needs and care plans Confirmation bias and implicitly high bar for taking action 6
- 7. What the Public (Should) Expect of Revalidation A systems approach to maintaining excellence Effective early warning mechanisms Standards linked to ability to meet more complex needs Combination of individual and organizational assessments Strategy for communicating areas of deficiency with patients Self-rating mechanisms for clinicians Don’t recertify anyone you wouldn’t send your family member to 7
- 8. The Revalidation Paradox If revalidation is virtually automatic, it will do little to improve practice If revalidation is too onerous, there will be tremendous pushback from physicians and patients It is difficult to reconcile a summary judgment (however qualified) with a process designed to solve problems However, the mere existence of revalidation may result in some people self-selecting out of the pool and others taking continuing competency more seriously 8
- 9. Thinking Outside the Evaluative Box The holy grail of evaluation is to find low burden, simple, easily available, and cheap proxies that correlate with performance What measure proved to predict the recent Canadian election results most accurately? How do social media assessments of practice correlate with formal review assessments? What can we learn retrospectively from poor performance debacles – was it failure to see; failure to infer; failure to act? 9
- 10. Intrinsic vs. Extrinsic Motivation Performance assessment as we know it focuses on what doctors know and do Alternate hypothesis: performance is at least as much a function of what doctors are Humble and healthy dose of self-doubt Willingness to subordinate tradition and comfort level to evidence Motivated knowledge-seeker Good medical citizen who views improvement as a collective and collaborative responsibility 10
- 11. Implications for Revalidation Consider testing for risky psychological profiles (narcissism, over-confidence, hierarchical predisposition, etc.) Measure attitudes toward care pathways, practice variation, standardization of protocols Less emphasis on quiz performance – in today’s world “just in time” knowledge is easily accessible (to patients too) Test for collegiality, comfort level with interdependence, sensitivity to heightened risks Interview on responses to own experience of failure - do they deny/explain away/learn/adapt 11
- 12. The Desired Future State Health science education would be redesigned to focus on chronic disease management, frailty, and mental health Competency would be layered and clinicians would be certified for different needs just as mechanics are certified to work on different cars Regulation would be more about aspiration and influence and less about formal processes and accounting Regulation would be less about individuals and more about environments Blunt instruments would give way to multi-party interactions and processes that invest in clinicians’ continuous well-being 12
- 13. Regulating vs. Influencing: Success Is A Collective Effort 13 EXCELLENCE Organizational Culture Clinical Policy Accredita- tion Health IT/ Analytics Peer Review Accountability Legislation Regulation
- 14. Revalidation: An Interim Approach? Imagine a health care world where Health information technology was fully developed Real-time measurement was valid and automated Organizations routinely implemented QI theory and practice Clinical autonomy was viewed as risk factor The role of initial and recertified credentials would diminish The need for revalidation may simply be proof that others are not yet doing what needs to be done The sociology of medicine may be the single most important factor in system-wide improvement and collective responsibility 14