APPROACHES TO ACCOUNTABILITY Andrea Baumann Presented to College of Nurses of Ontario (CNO) February 27 th, 2015 Funded by:

HEALTHCARE POLICY/ LONGWOODS 2

Funded by: RESEARCH PAPERS & COMMENTARIES/APPROACHES TO ACCOUNTABILITY 3

Funded by: BACKGROUND/ APPRAOCHES TO ACCOUNTABILITY Accountability A key component of healthcare reforms. Challenging and critical to the improvement of health systems. Accountability Regime 1. Clear definition of desirable goals/objectives 2. Ability to measure and monitor goal achievement 3. Consequences for providers and organizations is achievement/objectives are not satisfactory One size does not fit all 4

Funded by: PUROPOSE/ APPRAOCHES TO ACCOUNTABILITY To examine how accountability is structured within various sectors and organizations in the Ontario healthcare system. 5

Funded by: KEY FINDINGS/ APPRAOCHES TO ACCOUNTABILITY 6 Accountability for funding and service volumes has expanded to include quality and patient safety. Accountability requirements are misaligned at the different levels. Lack of a common set of indicators makes accountability a challenge. Reporting is a valuable mechanism. Smaller organizations struggle with reporting. Accurate and sophisticated reporting tools that capture performance data do not exist.

Funded by: KEY FINDINGS/ APPRAOCHES TO ACCOUNTABILITY Highly measurable and controlled indicators are reported on. Over-measurement is a concern. Financial incentives are a key lever to affect change. Increased accountability requirements do not always lead to performance improvement. Delivering quality and safe care is a top priority. Meeting the demands of all stakeholders creates tension. Increasing expectations for quality of care, value for healthcare dollars and accountability. 7

Funded by: CONCLUSION/ APPROACHES TO ACCOUNTABILITY Accountability is important. Multiple parties are seeking accountability. Accountability efforts should be coordinated. Factors that are less easy to measure, however not less important, may be ignored. Poorly applied accountability mechanisms divert resources from crucial activities. 8

Funded by: CONTRIBUTION/ APPROACHES TO ACCOUNTABILITY Provides a description of how accountability regimes are developed and structured across the health system. Highlights the strengths and weaknesses of various accountability mechanisms. 9

Funded by: Accountability: The Challenge for Medical and Nursing Regulators 10

Funded by: BACKGROUND/ CHALLENGE FOR REGULATORS Accountability is often defined in many ways and poorly operationalized*. Accountability has become a major issue in healthcare**. Little is known about health professional regulatory accountability. 11 * Brinkerhoff (2004). **Brown, Procellato, & Barnsley (2006).

Funded by: STUDY PARTICIPANTS/ CHALLENGE FOR REGULATORS Sample: 22 nursing and medical provincial/territorial regulators. 12

Funded by: Exploratory descriptive study Literature review Semi structured interviews Document analysis of key published materials 13 METHODS/ CHALLENGE FOR REGULATORS

Funded by: FINDINGS/ CHALLENGE FOR REGULATORS No common definition of accountability. Common concepts were identified such as responsibility, answerability, fairness and transparency. The majority agreed that they were accountable to a triad of constituents – the government, the public and their regulatory membership. 14

Funded by: ACCOUNTABILITY/ GOVERNMENT Influenced by legislated requirements, funding, types and categories of registration. Perception that growing prescriptiveness leads to restricted flexibility. Government relations categorized as formal and informal. 15

Funded by: ACCOUNTABILITY/ THE PUBLIC Accountable first and foremost to protect the public and act in their interest. Accountable to the public through legislation. Encouraged public input and representation in certain regulatory activities. 16

Funded by: ACCOUNTABILITY/ REGULATORY MEMBERS Due diligence with members’ fees. Keep members’ informed on standards of practice and regulatory changes. 17

Funded by: ACCOUNTABILITY/ METRICS Legislation dictated required analytics and statistics. Legal requirements varied across the regulatory bodies. Smaller jurisdictions reported fewer metrics. Larger jurisdictions linked metrics to improve performance. 18

Funded by: ACCOUNTABILITY/ CHALLENGES Stakeholder understanding of the regulatory role. Reconciling transparency with privacy. Appropriately utilizing social media. Organizational costs. 19

Funded by: SUMMARY/ COMMON PERCEPTIONS Accountability was a key regulatory concept. There was variation in the definition and perception of accountability. Self-regulation was valued as essential and a privilege granted by government. There was a need for a common set of indicators. There was a trend to provide more metrics to increase accountability. The public and members should have more awareness of the regulatory presence. 20

Funded by: RECOMMENDATIONS A national set of accountability indicators is recommended – it would facilitate regulatory comparison and reduce duplication. National dialogue about shared accountability would be welcomed by regulators. Social media engagement is a key emerging area for discussion. 21

Funded by: Benton, D. C., M. A. Gonzalez-Jurado, M. A. and J. V. Beneit-Montesinos "Defining Nurse Regulation and Regulatory Body Performance: A Policy Delphi Study." International Nursing Review 60(3): doi: /inr Brinkerhoff, D. W., (2004).; Accountability and health systems: toward conceptual clarity and policy relevance. Health Policy and Planning, 19(6), doi: /heapol/czh052 Boyatzis, R. E Transforming Qualitative Information: Thematic Analysis and Code Development. Thousand Oaks, CA: SAGE Publications. College of Licensed Practical Nurses of Alberta "Code of Ethics for Licensed Practical Nurses in Canada." Retrieved February 16, Emanuel E. J. and L. L. Emanuel "What is Accountability in Health Care?" Annals of Internal Medicine 124(2): doi: / Federation of Health Regulatory Colleges of Ontario n.d. "Who We Are." Retrieved February 24, Government of Saskatchewan "Health Providers: Self-Regulating Health Professional Associations." Retrieved February 25, Koppell, J. G "Pathologies of Accountability: ICANN and the Challenge of 'Multiple Accountabilities Disorder.'" Public Administration Review 65(1): doi: /j x Labour Mobility Coordinating Group. n.d. "Agreement on Internal Trade." Retrieved February 16, Marchildon, G. P Canada: Health System Review (Vol. 15). Copenhagen, Denmark: European Observatory on Health Systems and Policies. 22 REFERENCES

Funded by: THANK YOU/ QUESTIONS? 23

Funded by: CONTACT Andrea Baumann, PhD Scientific Director Nursing Health Services Research Unit McMaster University Michael DeGroote Centre for Learning MDCL 3500 (905) ext

Funded by: RESEARCH TEAM McMaster University Andrea Baumann, RN, PhD Patricia Norman, RN, Med Jennifer Blythe, PhD Sarah Kratina, BScN University of Toronto Raisa Deber, PhD 25