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 caring professions are changing  From craft based practice  Individual doctors working alone  Handcrafting a customised solution for each patient  Based on a core ethical commitment to the patient  Vast personal knowledge gained from training and experience  To profession based practice  Groups of peers in a shared setting  Using coordinated processes ( e.g. protocols / standing orders)  Adapted for individual needs  Professional autonomy is a myth  Understanding performance in the context of this myth

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

Understanding performance  Work context is critical  Team based care models  Collective accountability vs individual accountability  Clinical ‘governance’ and organisational accountability  Engaged clinicians are more effective clinicians

The organisational context: “No-one runs hospitals”  Major disconnect between corporate and clinical governance  Clinical decisions drive corporate outcomes  Command and control style ill equipped for clinical environment  Doctors frustrations reflect limited organisational power Menadue J. RACMA Quarterly March 2008

How Clinicians See it Clinician Profession Provider Organisation Patient Government Community Purchaser Organisations Smith P et al WHO European Ministerial Conference on Health Systems 2008

Ministerial review of Victorian public health medical staff 2007  Poor morale  Disengagement  Poorly valued  Threat to staff retention and patient safety  Declining commitment to public sector  Need 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 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  Must  Truly reflect performance of an individual  Be based in continuous improvement  Be verifiable – i.e. evidence based  Peer based – judging technical quality  Involve consumers – judging service quality and professionalism

#2 Peer based assessment  Peers are well placed to judge technical performance  Context is critical  Peers 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 registers  Majority 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 practice  Physicians approximately 34% of specialist workforce  ?? 55 genuinely geographically isolated physicians AIHW Medical Workforce 2011

Other design principles  Embedded 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

Who is the medical workforce?  95,330 registered doctors ( MBA 2013)  89.6% in workforce (HWA 2102)  58,978 on specialist registers  23,200 GP’s  35,978 non GP specialists  RACP 34% of the specialist workforce  8655 Adult Physicians  2132 Pediatricians  1478 Other HWA Doctors in focus 2012 / Medical Board of Australia 2013

 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 rates  Complaints  Financial outcomes  Better leadership

The business of Health Care is… The clinician patient interaction Supported by Management Influenced by policy This is where value is created….. or lost

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 reflection  Team based learning  External rater feedback

#3 What about the truly isolated clinician?  ? Is this a viable practice style  Role for the professions in supporting these colleagues  ? Insist on peer group  Broker their conversations & peer groups  Provide tools  Identify medical leaders

Grey areas  Training and support in having performance conversations  Engaging the professions  Risk 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