Saving Polly: can the regimen of Saving Polly: can the regimen of professional self-regulation be professional self-regulation be

revived?revived?

Daniel Klass MD FRCP, FACPDaniel Klass MD FRCP, FACP

Brisbane, Australia, Brisbane, Australia,

Dec 10, 2007Dec 10, 2007

““Its not who I am underneath, its what I do, that Its not who I am underneath, its what I do, that defines me” (Batman)defines me” (Batman)

““I grew up among wise men, and I grew up among wise men, and learned, it is deeds that count, not learned, it is deeds that count, not

words. Knowledge is not the main thing, words. Knowledge is not the main thing, but deeds. (Moses Maimonides)but deeds. (Moses Maimonides)

“ “ The secret of the care of the patient is The secret of the care of the patient is caring for the patient” ( Francis Peabody)caring for the patient” ( Francis Peabody)

OverviewOverview

Begin with: a tale of perceived disasters, Begin with: a tale of perceived disasters, unmet expectations and failures of unmet expectations and failures of regulationregulation

Describe an emerging model of self Describe an emerging model of self regulation based on a cultural change to a regulation based on a cultural change to a new professionalismnew professionalism

Conclude… challenge of work in progress, Conclude… challenge of work in progress, much of it research and assessment much of it research and assessment based, supporting ongoing adaptations based, supporting ongoing adaptations that may save Pollythat may save Polly

The dead or dying parrotThe dead or dying parrot

““Professional self-regulation exhibits all Professional self-regulation exhibits all the vital signs of a dead parrot: it is the vital signs of a dead parrot: it is definitely deceased; it is pushing up the definitely deceased; it is pushing up the daisies, it has joined the choir invisible; it daisies, it has joined the choir invisible; it is bereft of life; it has met its maker; it is is bereft of life; it has met its maker; it is no more; it is bleeding demised”. no more; it is bleeding demised”.

H.W. Arthurs, former Superior Court Justice, H.W. Arthurs, former Superior Court Justice, Province of Ontario, 1995… quoting Monty Province of Ontario, 1995… quoting Monty Python’s famous Dead Parrot skit.Python’s famous Dead Parrot skit.

Is this the job for a doctor?Is this the job for a doctor?

Diagnosis, prognosis and prescription are Diagnosis, prognosis and prescription are reserved medical acts: (in most jurisdictions, reserved medical acts: (in most jurisdictions, communicatingcommunicating the diagnosis of deaththe diagnosis of death is one of is one of the most tightly guarded acts of the medical the most tightly guarded acts of the medical profession)profession)

Today, I have taken it as my special task, to offer Today, I have taken it as my special task, to offer a a diagnosisdiagnosis, , prognosisprognosis and and prescriptionprescription for the for the medical profession as a self-regulated entitymedical profession as a self-regulated entity

My diagnosis is “My diagnosis is “stillstill alivealive”, the prognosis is ”, the prognosis is ““guardedguarded”, and prescriptions for treatment ”, and prescriptions for treatment arduous and costly, but will make the case that arduous and costly, but will make the case that the bird may already be arising from its ashes. the bird may already be arising from its ashes.

What is the case for self What is the case for self regulation?regulation?

Fourfold Rationale for Self Regulation*Fourfold Rationale for Self Regulation*

Nature of practice; high stakes, highly valued, Nature of practice; high stakes, highly valued, but clouded by inevitable uncertainty but clouded by inevitable uncertainty

Claim that the nature of practice demands such Claim that the nature of practice demands such an unusual degree of knowledge, experience, an unusual degree of knowledge, experience, skill and judgement that no ‘outsider’ skill and judgement that no ‘outsider’ ‘understands’ sufficiently to qualify to ‘understands’ sufficiently to qualify to adjudicateadjudicate

Claim of Claim of collectivecollective responsibility and responsibility and trustworthinesstrustworthiness

Claim of Claim of ability to ensure discipline of its ability to ensure discipline of its membersmembers (i.e. ability to regulate itself) (i.e. ability to regulate itself)

*modified from Freidson 1970*modified from Freidson 1970

Professional soft spotsProfessional soft spots

High stakes, high Profile regulatory failures High stakes, high Profile regulatory failures and suspicion of protecting doctors not and suspicion of protecting doctors not patientspatients

Evidence for systematic failure to perform at Evidence for systematic failure to perform at expected professional levelsexpected professional levels

Late recognition that competence is resident Late recognition that competence is resident in more than just the doctor and failure to in more than just the doctor and failure to engage in “systems” of care deliveryengage in “systems” of care delivery

Era of High Profile High Stakes Regulatory Era of High Profile High Stakes Regulatory FailuresFailures

Many Jurisdictions: Financial, Public Utilities, Blood Many Jurisdictions: Financial, Public Utilities, Blood Services, Health Care. Services, Health Care.

Dramatic breakdowns of health, safety and Dramatic breakdowns of health, safety and trusttrust Baby Deaths (Surgical incompetence CH of W)Baby Deaths (Surgical incompetence CH of W) Tainted Blood Scandal, (Cdn. Blood Services) Tainted Blood Scandal, (Cdn. Blood Services) Tolerance of Botched Surgery, Incompetent Tolerance of Botched Surgery, Incompetent

PathologistsPathologists High on the list, poisonings, sexual, financial, High on the list, poisonings, sexual, financial,

abuse of patientsabuse of patientsCommon questions, “Who is minding the store”, “is Common questions, “Who is minding the store”, “is

the fox guarding the chicken coop” or “you just the fox guarding the chicken coop” or “you just can’t trust the buggers”can’t trust the buggers”

Case in pointCase in point

Headline from the Times of India*Headline from the Times of India* ““2 docs get jail for boy’s death”2 docs get jail for boy’s death” ‘ ‘Gaurav was operated on for tonsillitis, died of Anaesthesia Gaurav was operated on for tonsillitis, died of Anaesthesia

overdose’overdose’

Convicted under Section 304a ( death by rash and negligent act) Convicted under Section 304a ( death by rash and negligent act) under Indian Penal Code.under Indian Penal Code.

(Beside the article is a grisly cartoon of two snakes (Beside the article is a grisly cartoon of two snakes with blood dripping from their fangs, and, a with blood dripping from their fangs, and, a strangely contrasting insert headlined strangely contrasting insert headlined “Hyderabad docs on strike, 10 infants die”)“Hyderabad docs on strike, 10 infants die”)

*December 04, 2007.*December 04, 2007.

The defeat of trustThe defeat of trust

The centrality of Doctor Harold Shipman…doctor and The centrality of Doctor Harold Shipman…doctor and poisonerpoisoner ““We thought he was a fine doctor, we just didn’t We thought he was a fine doctor, we just didn’t

expect him to poison our father”expect him to poison our father” Post-hoc risk analysis...”a black swan”, Post-hoc risk analysis...”a black swan”,

unpredictable ‘one off’ psychopath…too bizarre to unpredictable ‘one off’ psychopath…too bizarre to preventprevent

Dame Janet Smith, in review of ‘normal’ cases, Dame Janet Smith, in review of ‘normal’ cases, ‘‘benefit of the doubt given to the doctor’benefit of the doubt given to the doctor’….opposite ….opposite of governance in the public interestof governance in the public interest

Who is minding the store? Where is the Who is minding the store? Where is the accountability?accountability?

Consequence: attenuation of autonomy of Consequence: attenuation of autonomy of work-related judgementswork-related judgements

Traditional stance of courts has been to Traditional stance of courts has been to respect the authority of professional respect the authority of professional judgment so long as process standards are judgment so long as process standards are satisfiedsatisfied

More and more, courts have overturned More and more, courts have overturned professional adjudications and substituted professional adjudications and substituted their own judgment for that of expert their own judgment for that of expert committeescommittees

Generalization of the comments of Dame Generalization of the comments of Dame Janet Smith re “benefit of the doubt” and Janet Smith re “benefit of the doubt” and indicative of general “loss of trust”indicative of general “loss of trust”

Jane Jacobs, wise public observer*Jane Jacobs, wise public observer*

In the professional role of self-policing, professions In the professional role of self-policing, professions

not dealing well with fraud, malpractice, behaviour not dealing well with fraud, malpractice, behaviour bordering on the criminal….bordering on the criminal….

““there is no quicker way for a profession to lose there is no quicker way for a profession to lose public respect than to cover up, institutionally, for public respect than to cover up, institutionally, for members who have done arrant wrong…”members who have done arrant wrong…”

Since self regulation is based on trust, loss of respect Since self regulation is based on trust, loss of respect is tantamount to loss of self governing statusis tantamount to loss of self governing status

*Jane Jacobs, ‘Dark Age Ahead’, Vintage Canada, 2004.*Jane Jacobs, ‘Dark Age Ahead’, Vintage Canada, 2004.

Professional standards issuesProfessional standards issues

In addition to falling short of public In addition to falling short of public expectations, evidence also exists for the expectations, evidence also exists for the

profession falling short by its own profession falling short by its own standardsstandards

Double edged sword of evidence-based Double edged sword of evidence-based medicinemedicine

Some irony…a great strength in medicine is its Some irony…a great strength in medicine is its empirical grounding and scientific basis for empirical grounding and scientific basis for judgements (EBM)judgements (EBM)

Recent emphasis on systematic use of outcome data Recent emphasis on systematic use of outcome data to guide policies reveals that….more and more, to guide policies reveals that….more and more, Competence really countsCompetence really counts …. ….BUT at the same timeBUT at the same time

Compelling evidence that medicine is not as Compelling evidence that medicine is not as competent (safe effective or caring) as it could becompetent (safe effective or caring) as it could be

Evidence of a quality and safety gap in the delivery Evidence of a quality and safety gap in the delivery of health care as judged by professional standards of health care as judged by professional standards

US Institute of Medicine; US Institute of Medicine; To Err is HumanTo Err is Human CMAJ; Baker, Norton et. al. CMAJ; Baker, Norton et. al. Canadian Adverse Canadian Adverse

Events StudyEvents Study NEJM; McGlynn et al. Quality of Health CareNEJM; McGlynn et al. Quality of Health Care Greenfield/Wennberg; wide individual/regional Greenfield/Wennberg; wide individual/regional

variance in standards and outcomesvariance in standards and outcomes Hard Evidence ( malpractice and complaints) Hard Evidence ( malpractice and complaints)

of unmet expectations (mainly at the level of of unmet expectations (mainly at the level of communication)communication)

Failure to engage in “systems”Failure to engage in “systems”

Bosk* noted Bosk* noted the failure to close the loop the failure to close the loop between individual professional action and between individual professional action and system accountability, remediation and system accountability, remediation and reconciliationreconciliation

In the current context, the drive (public, In the current context, the drive (public, corporate and state) for system corporate and state) for system accountability has become intense but the accountability has become intense but the struggle with the lack of engagement of the struggle with the lack of engagement of the profession continuesprofession continues

**Charles Bosk,Charles Bosk, Forgive and Remember Univ of Chicago, 1979Forgive and Remember Univ of Chicago, 1979

Bottom line: promises are meant to keepBottom line: promises are meant to keep

Profession claims status Profession claims status but on two key but on two key rationales for self governance, has not rationales for self governance, has not verified delivery on promises of a disciplined verified delivery on promises of a disciplined profession or disciplined practitioners profession or disciplined practitioners

The promises cannot be unilateral The promises cannot be unilateral assertions; they must be a result of bilateral assertions; they must be a result of bilateral agreementsagreements

Any profession can expect to lose its Any profession can expect to lose its privileges if it fails to make good on its privileges if it fails to make good on its promisespromises

The place of a profession in societyThe place of a profession in society

What is the proper relationship between the What is the proper relationship between the public and a profession?public and a profession?

Wind chimes and regulationWind chimes and regulation

Regardless of the Regardless of the contentcontent and and processprocess of of regulation in society there must be an regulation in society there must be an underlying “contractual” understanding underlying “contractual” understanding about the relationship between about the relationship between professionals and public that defines the professionals and public that defines the limits of professional actions as limits of professional actions as determined by a set of public expectationsdetermined by a set of public expectations

Clear boundaries are to be expectedClear boundaries are to be expected

Levels of Professional Regulation: the wind Levels of Professional Regulation: the wind chime modelchime model

Societal Expectations,

Laws, Regulations

Professional Standards

Individual Practitioner

Actions

Stable state

Levels of Professional Regulation: the wind Levels of Professional Regulation: the wind chime modelchime model

Society

Profession

Individualdoctor

Winds of change

Levels of Professional Regulation: the wind Levels of Professional Regulation: the wind chime modelchime model

Societal

Professional

Individual

Winds of change

Levels of Professional Regulation: the wind Levels of Professional Regulation: the wind chime modelchime model

Society

Profession

Individualdoctor

New steady state

The boundaries and limits of the ‘chimes” The boundaries and limits of the ‘chimes” form the “discipline” of a professionform the “discipline” of a profession

What is referred to loosely as “the What is referred to loosely as “the social contract” is really a social contract” is really a

multidimensional and complex set multidimensional and complex set of arrangementsof arrangements

Control of medical workplaceControl of medical workplace

Three levels of control (logic) in the work Three levels of control (logic) in the work of professional*;of professional*; Free marketFree market State (Rulers, governors, legislators, State (Rulers, governors, legislators,

bureaucracies)bureaucracies) Professions (occupational)Professions (occupational)

Over time there has been a dynamic Over time there has been a dynamic interplay across these levels…mainly interplay across these levels…mainly devolution from state control associated devolution from state control associated with democratizationwith democratization

*Freidson*Freidson

Locus of control in professional situationsLocus of control in professional situations

PROFESSION MARKET

STATE

Locating control in medical situationsLocating control in medical situations

PROFESSION MARKET

STATE

Locating control in medical situationsLocating control in medical situations

PROFESSION MARKET

STATE

Locating controlLocating control

Control depends on the location of Control depends on the location of situations within the triangular envelopesituations within the triangular envelope

Wide range of possibilities…contingent on Wide range of possibilities…contingent on circumstancescircumstances

Control of, autonomy over range of issues… Control of, autonomy over range of issues… form grounds of debate for “social contract”form grounds of debate for “social contract”

Professional Issues; independence of Professional Issues; independence of judgment, freedom to be judged by peers, judgment, freedom to be judged by peers, control of “knowledge”, definition of scopecontrol of “knowledge”, definition of scope, , policingpolicing

System, Institutional Issues; ability to control System, Institutional Issues; ability to control workplace environment, working conditions, workplace environment, working conditions, risk managementrisk management

Market Issues; remuneration, market control, Market Issues; remuneration, market control, profitprofit

The geography of medical The geography of medical governancegovernance

If “trust” is the central value for If “trust” is the central value for professional status, then the professional status, then the priority is on professional issues…priority is on professional issues…and aand a detailed look at the “scope detailed look at the “scope of regulatory activity” in medicine of regulatory activity” in medicine is importantis important

Scope of Regulation for individual and Scope of Regulation for individual and system competencesystem competence

Training component Med school Postgrad trainingEntry training

Standards: Monitoring, Revalidation, CPD, Complaints, Suits, Discipline

Entry to PG test Entry to practice test

Public outcomes

Accreditation Accreditation ?Accreditation?

Prevalent varieties of (medical) regulatory Prevalent varieties of (medical) regulatory failurefailure

Failure to Failure to preventprevent, , detectdetect, , educateeducate or or correct ‘non professional acts’ correct ‘non professional acts’ over the over the broad spectrum of regulatory activity,broad spectrum of regulatory activity, from entry to professional education from entry to professional education through training for practicethrough training for practice Entry to practiceEntry to practice Occupational educational discipline: Occupational educational discipline:

maintenance of competence in practicemaintenance of competence in practice Corrective Discipline in practiceCorrective Discipline in practice

Special task of professionsSpecial task of professions

““The special task of doctors is to inform their The special task of doctors is to inform their patients who they are to be”*patients who they are to be”*…ergo…ergo

The special task of a ‘profession’ is to inform the The special task of a ‘profession’ is to inform the public of what to expect of their members, both public of what to expect of their members, both the scope of authority (expertise) and standards the scope of authority (expertise) and standards of behaviour within that scope …andof behaviour within that scope …and

to be accountable at the highest standards for the to be accountable at the highest standards for the “promises” of the profession of the performance “promises” of the profession of the performance of its membersof its members

……trust must be earnedtrust must be earned

*Erving Goffman, Stigma*Erving Goffman, Stigma

Core of professionalismCore of professionalism

The focus of regulation must be based The focus of regulation must be based on the idea of competent behaviouron the idea of competent behaviour

defining defining implementing implementing measuring measuring reporting reporting improvingimproving correctingcorrecting

Essential ConflictEssential Conflict

Bosk* described the core of conflict Bosk* described the core of conflict between the arguments of the professions between the arguments of the professions for the preservation of “self regulation” for the preservation of “self regulation” and the needs of society for a greater and the needs of society for a greater sense of accountable behaviour from the sense of accountable behaviour from the professionsprofessions

Professions say “trust us” but the public Professions say “trust us” but the public says “provide us the grounds for trust”says “provide us the grounds for trust”

* * Charles Bosk, Forgive and Remember, 1979Charles Bosk, Forgive and Remember, 1979

Key issue is the public expectation of “competent” Key issue is the public expectation of “competent” doctors doctors

Patients expect doctors to meet their needs….they Patients expect doctors to meet their needs….they want performance (not just competence).want performance (not just competence).

Doctors assert competence to merit their place in Doctors assert competence to merit their place in society. society.

The common ground is competence in action; The common ground is competence in action; the capacity to deliver care that keeps the capacity to deliver care that keeps patients patients safesafe, , benefitsbenefits them and them and satisfiessatisfies their reasonable expectationstheir reasonable expectations

The special task of the profession, is toThe special task of the profession, is to be be accountable for these values for the publicaccountable for these values for the public

Competence; the new core of Competence; the new core of professionalism and basis for public trustprofessionalism and basis for public trust

““Competence” is a multidimensional Competence” is a multidimensional relational concept, that describes relational concept, that describes allall of the of the distinctive acts and behaviours that serve distinctive acts and behaviours that serve the public in the special scope of practice of the public in the special scope of practice of the professionthe profession

Ultimately, Ultimately, trusttrust is based upon is based upon competencecompetence Different, more grounded concept than

Freidson’s idea of the “soul” of a profession Competence can be accounted for,

souls are hard to pin down

How does the profession think How does the profession think about its own competence?about its own competence?

A shifting culture.A shifting culture.

Attributional (Ballistic) Model of CompetenceAttributional (Ballistic) Model of Competence

Time

Acceptable performance

Per

form

ance

Time

Acceptable performance

Per

form

ance

? Changing standards

“Once in good for life…?”

The traditional paradigm of competency appraisal The traditional paradigm of competency appraisal in medicinein medicine

Attributional (Ballistic) model has provided the framework of Attributional (Ballistic) model has provided the framework of competence (education and assessment) for most of 20th competence (education and assessment) for most of 20th Century: dominated by the idea of Century: dominated by the idea of “once in good for life” “once in good for life”

Concept has pervaded thinking about competence Concept has pervaded thinking about competence and performanceand performance As consequence, assessment has been front-end loaded; As consequence, assessment has been front-end loaded;

(medical school and PG training)(medical school and PG training) Tools designed to assess “competence” not Tools designed to assess “competence” not

“performance”“performance” MCQ, written tests; MCQ, written tests; direct observation, clinical oral; direct observation, clinical oral;

Concern has been for Concern has been for PERSONALPERSONAL READINESS TO PRACTICEREADINESS TO PRACTICENot for Not for CONFIRMATION OFCONFIRMATION OF QUALITY IN PRACTICEQUALITY IN PRACTICE

Consequence of Attributional ModelConsequence of Attributional Model

Competence is seen solely as an attribute Competence is seen solely as an attribute of individuals...you get, you have it, you of individuals...you get, you have it, you keep it, it belongs to you…keep it, it belongs to you…

Creates ‘narcissistic’ professional cultureCreates ‘narcissistic’ professional culture Close approximation of “personal” sense Close approximation of “personal” sense

of worth with ‘professional’ statusof worth with ‘professional’ status

Alternative view; situational concept of Alternative view; situational concept of competence*competence*

Competence not ‘built in’ as a permanent set of Competence not ‘built in’ as a permanent set of attributes at entry to practiceattributes at entry to practice

A status earned ‘one patient at a time’A status earned ‘one patient at a time’ Dependent upon interactions among ‘Dependent upon interactions among ‘doctors and doctors and

patientspatients ( and families) with ( and families) with problemsproblems in in places places Verification of competence needs process and Verification of competence needs process and

outcome measures from practice; e.g. a careful , outcome measures from practice; e.g. a careful , systematic examination of performance over timesystematic examination of performance over time

Competence is not resident in who you are, Competence is not resident in who you are, rather in what you do, where you do it and rather in what you do, where you do it and who you do it withwho you do it with* A Laduca

Perf

orm

an

ce

Time (across a practice lifetime)

Acceptable Practice

Maintaining Competence: The Attributional Model

Performance = knowledge, skill and judgment Performance = knowledge, skill and judgment demonstrated during interaction with patientsdemonstrated during interaction with patients

Clinical assessment critical to measure performanceClinical assessment critical to measure performance

Perf

orm

an

ce

Time (across a practice lifetime)

Acceptable Practice

Maintaining Competence: The Situational Model

Educational intervention

Performance = knowledge, skill and judgment as Performance = knowledge, skill and judgment as measured during interaction with patientsmeasured during interaction with patients

Clinical assessment critical to measure performanceClinical assessment critical to measure performance

Normal trajectory of performance over timeNormal trajectory of performance over time

Medicine is Medicine is practiced one practiced one patient at a timepatient at a time

performetence performetence depends on depends on multiple multiple encounters encounters between doctors between doctors and and patientspatients with with problemsproblemsin in placesplaces

Time

Per

form

ance

Diabetes

Hypertension

Cervicalsmears Breaking

bad news

Consequence of a Consequence of a situationalsituational view of competence view of competence

Grounds physicians in their relationship to Grounds physicians in their relationship to practice rather than their “being” the practicepractice rather than their “being” the practice

Values Values competence in practice rather than at entry to competence in practice rather than at entry to

practicepractice relationships with patients, families and system relationships with patients, families and system

( coworkers and colleagues)( coworkers and colleagues) importance of patient outcomes importance of patient outcomes competence is contingent and must be competence is contingent and must be

reasserted over time and place reasserted over time and place Medicine seen as Medicine seen as learning professionlearning profession; trajectory ; trajectory

of competence is a learning curve, of competence is a learning curve,

The changing view of competenceThe changing view of competence

Admiring the Admiring the doctor at doctor at work….work….

What’s wrong What’s wrong with this with this picture?picture?

The changing focus of assessmentThe changing focus of assessment

Admiring the doctor at Admiring the doctor at workwork

Including the nurses Including the nurses and patient’s and patient’s perspectiveperspective

Is a “Situational” concept of regulation also Is a “Situational” concept of regulation also relevant?relevant?

From the perception of the ‘profession’ as From the perception of the ‘profession’ as an isolated entity, toan isolated entity, to

The idea of the profession in a context of The idea of the profession in a context of relationshipsrelationships

Move away from regulation of individuals Move away from regulation of individuals only to regulation of individuals engaged only to regulation of individuals engaged in systemsin systems

Promoting Regulatory CompetencePromoting Regulatory Competence

Multidimensional concept… recognize Multidimensional concept… recognize spectrum of regulatory responsibilityspectrum of regulatory responsibility

In today’s environment, regulatory In today’s environment, regulatory competence means dealing in balance and competence means dealing in balance and being accountable for challenges to being accountable for challenges to competence at level of competence at level of individualindividual and and organizational/systemorganizational/system

Paradigms of governance, Paradigms of governance, attributional vs situationalattributional vs situational

Based upon a case by case Based upon a case by case perspectiveperspective

Views role of doctor as unique and Views role of doctor as unique and freestandingfreestanding

Standards issues adjudicated by Standards issues adjudicated by adversarial methods, pits patients vs adversarial methods, pits patients vs doctors, doctors vvs doctors etcdoctors, doctors vvs doctors etc

Error seen as individual, blame and Error seen as individual, blame and shameshame

Focus of governance on Focus of governance on individualistic and legalistic individualistic and legalistic approaches, “due process” , approaches, “due process” , defensibility, and primacy of defensibility, and primacy of ( duelling) expert professional ( duelling) expert professional judgement (black and white)judgement (black and white)

Built upon and supportive of “silo” Built upon and supportive of “silo” mentalitymentality

Closed doors; Closed doors; Fidus in ArcanisFidus in Arcanis

Population based perspectivePopulation based perspective Views doctors role in context of Views doctors role in context of

patients, health care teams and patients, health care teams and systemssystems

Standards seen as contextual, Standards seen as contextual, arbitration is by benchmark and arbitration is by benchmark and educational approacheseducational approaches

Error seen in context of system, Error seen in context of system, “just culture” approach“just culture” approach

Focus of governance on risk Focus of governance on risk management, development of management, development of evidence for processes, use of evidence for processes, use of outcomes and performance outcomes and performance assessments assessments

Promotes engagement in Promotes engagement in “organization and system” rather “organization and system” rather than standoff; working with than standoff; working with teams, sharing liabilityteams, sharing liability

Values transparencyValues transparency

Achieving accountability for regulatory Achieving accountability for regulatory processesprocesses

Historical accountabilityHistorical accountability Notion of Notion of retrospective accountabilityretrospective accountability; ;

legislative, due process and appeal based, legislative, due process and appeal based, dependence on credentialling vs performance dependence on credentialling vs performance assessmentassessment

Are there other routes to accountability?Are there other routes to accountability? Is it enough just to “do current processes Is it enough just to “do current processes

better”? better”?

Alternative routes to accountability: what Alternative routes to accountability: what ‘verification’ of regulatory competence currently ‘verification’ of regulatory competence currently

exists? exists?

External audits or control? External audits or control? Severe threat to principle Severe threat to principle of professional self regulationof professional self regulation

Educational Models?Educational Models? Accreditation and Performance Assessment modelsAccreditation and Performance Assessment models

Evidence based regulation? Research based Evidence based regulation? Research based measurement and transparent reporting of measurement and transparent reporting of outcomes of regulatory processes with outcomes of regulatory processes with comparators ( benchmarking)comparators ( benchmarking)

Transparency measures? Direct public Transparency measures? Direct public involvement in policy and decision makinginvolvement in policy and decision making

Key features of accountabilityKey features of accountability

at the at the individualindividual level: level: Entry to practice; validated Entry to practice; validated

education/assessment underlying education/assessment underlying licensure and certification processes licensure and certification processes

In practice; definition of scope of In practice; definition of scope of practice, monitoring of performance, practice, monitoring of performance, mandatory maintenance of competencemandatory maintenance of competence

New dimensions; accountability includes New dimensions; accountability includes communication and behavioural communication and behavioural dimensions disruptive behaviour, dimensions disruptive behaviour, system accountability, requirement to system accountability, requirement to report and participate in self regulationreport and participate in self regulation

Key features of accountabilityKey features of accountability

RegulatoryRegulatory level level

Assure validity, transparency, consistency of Assure validity, transparency, consistency of process and outcomeprocess and outcome

Risk management, decision consistency, lack of biasRisk management, decision consistency, lack of bias

Assure validity and reliability of medical Assure validity and reliability of medical standards;standards;

Scientific basis of the practice and discipline of Scientific basis of the practice and discipline of medicinemedicine

What needs to be done?What needs to be done?

Very large agendaVery large agenda

proposal is to proposal is to foster a culture of enquiry foster a culture of enquiry to make the outcomes of regulation to make the outcomes of regulation explicitexplicit

These outcomes will provide the needed These outcomes will provide the needed evidentiary basis for accountabilityevidentiary basis for accountability

Some examples of changing cultureSome examples of changing culture Studies of validity, reliability of assessment systems Studies of validity, reliability of assessment systems

(Tamblyn, Papadakis, NCAS) (Tamblyn, Papadakis, NCAS) Use of performance measures by Regulatory Use of performance measures by Regulatory

Authorities (Canada) for entry to practice, and Authorities (Canada) for entry to practice, and maintenance in practicemaintenance in practice

Increasing requirements for “Revalidation” of Increasing requirements for “Revalidation” of CompetenceCompetence

Specifications of “Competency Standards” (GMC, Specifications of “Competency Standards” (GMC, others)others)

Engagement in team education, practice Engagement in team education, practice arrangementsarrangements

Inclusion of public membership at various policy and Inclusion of public membership at various policy and decision making levelsdecision making levels

Development of programs for disruptive doctorsDevelopment of programs for disruptive doctors Focus on preventive, educational approach vs blame, Focus on preventive, educational approach vs blame,

shame and “hang them high”.shame and “hang them high”.

Questions?Questions?

Can regulators adopt a new culture of Can regulators adopt a new culture of research and evidence based activity?research and evidence based activity?

Can momentum be built for researchers to Can momentum be built for researchers to connect with regulators, governments to connect with regulators, governments to collaborate for evidence based policy collaborate for evidence based policy making?making?

Can sufficient targeted funding be found to Can sufficient targeted funding be found to support this complex research?support this complex research?

Shifting culture of professionalismShifting culture of professionalism End of ‘once in good for life’; End of ‘once in good for life’;

Recognition that assessment drives performance Recognition that assessment drives performance and acceptance of need for scrutiny of and acceptance of need for scrutiny of professional work…the quality improvement professional work…the quality improvement imperative and accountability imperativeimperative and accountability imperative

acceptance of ‘contingency’ of competence and acceptance of ‘contingency’ of competence and system relationships ( individual responsibility system relationships ( individual responsibility within system accountability)within system accountability)

willingness to recognize that competence counts; willingness to recognize that competence counts; relationship between relationship between personal performance and personal performance and outcomesoutcomes drives need for “due diligence” drives need for “due diligence”

Preserving Self RegulationPreserving Self Regulation

Self regulation, by definition implies some Self regulation, by definition implies some control of issues of professional competencecontrol of issues of professional competence

At issue is not a struggle over that control: At issue is not a struggle over that control: the publicthe public wants assurance of regulation in wants assurance of regulation in

the public interestthe public interest The key to “Saving Polly” is recognition by The key to “Saving Polly” is recognition by

the profession that the profession that the assurance that the assurance that regulation stays in the public interest is not-regulation stays in the public interest is not-negotiable…it is up to the professions to negotiable…it is up to the professions to develop and implement these tools to develop and implement these tools to maintain accountable self regulationmaintain accountable self regulation

““Its not who I am underneath, its what I do, that Its not who I am underneath, its what I do, that defines me” (Batman)defines me” (Batman)

““I grew up among wise men, and I grew up among wise men, and learned, it is deeds that count, not learned, it is deeds that count, not

words. Knowledge is not the main thing, words. Knowledge is not the main thing, but deeds. (Moses Maimonides)but deeds. (Moses Maimonides)

“ “ The secret of the care of the patient is The secret of the care of the patient is caring for the patient” ( Francis Peabody)caring for the patient” ( Francis Peabody)