Recertification of healthcare professionals – threat or opportunity for healthcare organisations?

Grant Phelps MBA FRACP FRACMA GAICD

Associate Professor of Clinical Leadership, Deakin University

ACHSM Conference Canberra August 2013

Assumptions

It’s happening to Doctors Other craft groups likely

Terminology doesn’t matter Critical issue is “fitness to practice”

The professions have a critical role Standards, Tools, and maybe assessment

Wont apply to clinicians in training Not yet “fit to practice” independently

Must be based in performance, not competence Does do vs. Can do

Why performance?

Provide an assurance to the public Public presume that doctors are performing and that they are

being monitored

Very essence of professionalism The health system exists for the public

Trust of the public is earned, not automatically given

Trust is based in performance ….”the lived experience”…

The vast majority of doctors are ‘good enough’ (and are trying to be better……)

Understanding performance

Work context is criticalTeam based care modelsCollective accountability vs individual accountability

Clinical ‘governance’ and organisational accountability

Engaged clinicians are more effective clinicians

How Clinicians See it

Clinician

Profession Provider Organisation

Patient

Government

CommunityPurchaser Organisations

Smith P et al WHO European Ministerial Conference on Health Systems 2008

Ministerial review of Victorian public health medical staff 2007

Poor moraleDisengagementPoorly valuedThreat to staff retention and patient safety

Declining commitment to public sectorNeed for clinical leadership

Morey, S., Barraclough, B. and Hughes, A. (2007)

Knowledge vs. Performance?

Knowledge deteriorates with time Wisdom increases with experience

Is there fundamental knowledge that every clinician should have?

Compliance obligations Core attributes of professionalism Practice changes significantly over time What do you examine??

What matters to patients is performance

That’s about quality

Why not self assessment?

A recertification cycle

Recertification

Ongoing performance assessment

Multiple inputs

Improvement opportunities

The work Context

• Organisation• Scope of Practice• Peer group• Patient mix• Community• Clinical practice

Design Principle #1:Recertification must be based in a meaningful demonstration of performance

MustTruly reflect performance of an individualBe based in continuous improvement Be verifiable – i.e. evidence based Peer based – judging technical qualityInvolve consumers – judging service quality and professionalism

#2 Peer based assessment

Peers are well placed to judge technical performance

Context is criticalPeers need insight and reflection too

But …. Peers tend to up rate colleagues “There but for the grace of God go I…”

Doctors and the work context?

59,000 on specialist registersMajority of specialists have a hospital appointment ( 60% of FTE are in public hospitals)

Of doctors working in private practice 70% in group practices 30% in solo practices

161 specialists in remote practicePhysicians approximately 34% of specialist workforce

?? 55 genuinely geographically isolated physiciansAIHW Medical Workforce 2011

Other design principlesEmbedded in & reflect work processes

make it easy to do it right is based in the work of the clinician Not ‘one size fits all’

Minimise negative impact, maximise benefit

Avoids replication Properly resourced Manage the poor, celebrate the good

Meets regulatory and college requirements e.g. by supporting professional learning

Supports organisational engagement by and with clinicians

Highly engaged employees are 50%

more likely to exceed expectations

Companies with highly engaged staff

outperform firms with disengaged staff By 54% in employee retention

By 89% in customer satisfaction

By fourfold in revenue growth

“Creating the best workplace on earth”

Goffee R, Jones G. Harvard Business Review May 2013

Engagement is…?

“Engagement relates to the

degree of discretionary effort

employees are willing to apply in

their work in the organisation”

Alimo-Metcalfe B. , J. of Health Org Management 2008

Engagement of Doctors

Better patient and organisational outcomes

Mortality rates Infection ratesComplaints Financial outcomesBetter leadership

The business of Health Care is…

The clinician patient interaction

Supported by ManagementInfluenced by policy

This is where value is created….. or lost

www.health.vic.gov.au/clinicalengagement

Recertification

Questions remain..#1 Who manages this?

Hospital setting Clinical leaders External clinical leaders

Community setting Groups of peers Nominal head External clinical leaders

Properly appointed, clear duties and processes

#2 Role of the professions & craft groups?

Self reflectionTeam based learning

External rater feedback

#3 What about the truly isolated clinician?

? Is this a viable practice styleRole for the professions in supporting these colleagues

? Insist on peer groupBroker their conversations & peer groupsProvide toolsIdentify medical leaders

Grey areas

Training and support in having performance conversations

Engaging the professionsRisk adjustment for contextual factors

Leadership Culture …..resourcing….

Consumer input?What will the community accept?

Summary Demonstrating ‘good enough’ performance

Demonstrable professionalism Our commitment to the community Must guide recertification

Existing organisational approaches Acceptable Performance in an organisational context should be

evidence of Performance sufficient for demonstration of ‘fitness to practice’

Opportunity to drive engagement by focusing systems on core business of organisations AND clinicians

If based in continuous improvement it will improve patient care and organisational outcomes