Download The Future of Professional Regulation in a Changing Health Care

Seizing the Health Human Resource Future:
Changing the Culture,
Positioning for Success
Presentation to the
CAAHP Annual General Meeting
Ottawa, May 28, 2014
Steven Lewis
Access Consulting Ltd.
Saskatoon SK
(306) 343-1007
[email protected]
What This Presentation Is About
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 Why health care is what it is
 Why health care is about to change
 Implications for the workplace
 Implications for the workforce
 Implications for health science education
 Winning conditions for tomorrow’s workforce
My Perspective
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 How we educate and deploy people should be based on
needs
 There is a mismatch between what people need and
what the system delivers
 Meeting needs successfully will require significant
changes in the classroom and the workplace
 It will require a coalition of educators, employers, and
governments to get this done
 These issues are not settled – feel free to disagree
Part 1
5
History Is Not Destiny:
A Dose of Realism Tempers a
Century of Boundless Optimism
The Century of Achievement and Optimism
6
 The 20th century created modern health care
 Life expectancy rose 30 years
 Major diseases were conquered (polio, smallpox)
 Technological innovation flourished
 Occupations grew in number and became highly
professionalized
 Scientific knowledge increased exponentially
 Dramatic repair work (antibiotics, transplants, CABG,
Tommy John surgery for baseball pitchers)
And We Thought It Would Only Get Better
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 Science will solve every health problem – just a matter
of time and effort
 More is better:
Imaging
Screening
Surgical repair
Drugs
 Specialization is good; sub-specialization is better
Then Reality Set In
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 To Err Is Human in US; Baker-Norton in Canada – the
system isn’t very safe
 The system fails at the basics:
Hand-washing
Evidence-based preventive care (McGlynn et al)
 More can be worse
PSA and mammography screening
Polypharmacy
CT scanning
 Specialization is a risk factor (complexity)
But the Triumphalist Culture Persists
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 Sophisticated diagnostics
 Emergency interventions
 Surgery
 Drugs
 Big Science (genomics, proteomics)
What If We Started Over and Designed the
System to Meet Societal Needs?
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 Chronic diseases consume 70% of health spending
 Mental health problems are under-diagnosed and poorly
addressed
 Science has yet to find cures for the most prominent
pathologies
 Aging and frailty are the most dominant health problems
 The search-and-destroy paradigm of medical miracles
does not apply in these circumstances
What Most People Need to Thrive
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 Providers who listen as much as they talk
 Coaching to support self-management
 Relationships based on trust
 Practical, on-the-ground problem solving
 Emphasis on quality of life and adaptation
 Engagement in their care planning and respect for their
perspectives, values, choices
Or Put Another Way…
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 Patient-centred, holistic care
 Better quality
 Better value-for-money (VFM)
 Reduced disparities between population groups
 More effective prevention and chronic disease
management
 Integrated, effective primary care
 Interdisciplinary collaborative practice
 More self-reliant, health-oriented public
Part 2
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Implications for Health Human Resources
Why the Workforce Looks Like It Does
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 Regulation gave major boost to safety in early part of
20th century
 Increased complexity of health care led to increased
specialization
 Expansion of scientific knowledge created rationale for
longer educational programs
 Intrinsic societal belief in more education, higher
credentials
 Turf = control = power = money
Is the Contemporary HHR Approach
Compatible With System Goals?
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 High degree of specialization a challenge to holistic,
integrated care
 Professions develop distinct theories and cultures of
health and health care which risks fragmentation
 Increasing entry-to-practice credentials makes workforce
adjustments long and difficult
 Entrenched hierarchies and power inequalities
 Battles over scope of practice and gatekeeping role
The Revival of Generalism
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 The reorganization and renewal of primary health care
Interdisciplinary
Holistic
More effective division of labour
 Whole-person focus with integrated approach to care
 Shift from prescriptive interventionist role to coaching
and shared power arrangement
 Repatriation of work from specialists
What Makes Effective Health Care
Workers?
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 Less autonomous practice, more teamwork
 Greater emphasis on communications, coaching,
behaviour modification skills
 More fluid division of labour among occupational
categories
 Relationships and deep understanding of patients at
least as important as technical skills
The Policy Front: Will Frustrations Lead
Governments to Insist on Change?
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 “Credential creep” fatigue – the higher credentials aren’t
creating a better system
 Shift locus of health science education to colleges from
universities
 Expand scope of practice of technicians and aides
 Mandate interprofessional training, team-based
practicums
 Press for inclusion of more systems thinking and quality
improvement in curricula
Part 3
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Opportunities for Allied Health Professions:
Needs, Roles, Strategies
REPLACEABLE WORK IRREPLACEABLE
WORK
Physiological measures
Motivation
Diagnostics based on
pattern recognition
Scheduling and reminders
Calming of fear and
anxiety
Decisions under conditions
of uncertainty
Reasoning based on
Communicating effectively
algorithms
Solutions that are context- Knowing when to deviate
independent
from standard procedure
Lessons from US Manufacturing
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 Old model of US manufacturing: low-skill assembly-line
mass production
 Threat: cheap labour and economies of scale in
developing nations
 Result: major decline in US manufacturing sector
 Insight: identify high-value-added, high quality end of
manufacturing that cannot be outsourced
 New workforce model: diploma-trained personnel
working with complex, computer-based machinery
OLD CULTURE
EMERGING
CULTURE
Hierarchical
Egalitarian
Prescriptive
Collaborative
Tradition-driven
Evidence-driven
Acute focused
Fragmented
Chronic disease
focused
Integrated
Autonomous
Interdependent
OBSOLETE TRAITS
HIGH DEMAND
TRAITS
Narrow set of skills that
Patient-centred skills
can be automated
Non-transferable
Versatility
specialization
Autonomous team members Interdependent team
members
Authoritarian personality
Empathetic personality
High control needs
Comfortable with
interdependence
Ability to adapt and
create
Need for order and
stability
The Evidence Is Already In
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 Most scope of practice expansion has been highly
successful:
Nurse anaesthesia, endoscopy, NPs
LPNs in all settings
Dental therapists
Rehab therapists as diagnosticians
 Main barriers are professional self-protection and
obsolete standards and regulation
 The workplace and experience are great teachers that
expand capabilities
Potential for Substitution
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 “Labour substitution:
 Is a plausible strategy for addressing workforce
shortages
 Can reduce (wage) costs - under certain conditions
which can be challenging to meet
 Can improve efficiency - under restricted conditions
which are difficult to meet”
 Source: Univ. of Manchester, Centre for Workforce
Intelligence, http://www.cfwi.org.uk/publications
Cultural Changes on the Horizon
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 Standardized work (care pathways, diagnostic
algorithms)
 Self-organizing teams with fluid division of labour
 Assertive generation that exercises greater control over
nature of care
 Enhanced transparency and more robust public
reporting about safety, quality, efficiency
Teamwork
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 Fundamental disconnect between health are hierarchy
and optimal team functioning
 Self-organizing teams that allocate work to maximize
value of all members is ultimate goal
 Interdependency and trust are prerequisites for best
combination of quality and efficiency
 Providers prepared to work in teams and understand
team dynamics are key to developing care models
 A relentless focus on safety and quality breaks down
hierarchy – “stop the line” is the new mantra
Skill Sets for a Better Future
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 Ability to apply sophisticated technologies effectively
 Coaching and motivation for self-management and
successful adaptation
 Flexibility and multi-tasking in changing environments
 Data-driven quality improvement
 Team-based problem-solving
What Kind of People Are We Looking For?
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 Versatility and adaptability
 Emotional intelligence in workplace
 Empathy and culture of service toward clients
 Communication
Within teams and organizations
With people served
 Creative problem-solving
Keep Education Short, Modular, and
Experience-Based
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 The workforce needs educational programs that produce
job-ready graduates in a timely manner
 Avoid temptation to lengthen formal training – it reduces
pool of interested students, adds costs, reduces agility
 Enhance life-long modular learning opportunities
 Remove needless barriers to shifts in career direction
Match Program Design to Needs
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 Aging and frailty
 Working with families
 Coaching and self-management
 Recognizing mental health issues
Expose Students to System Concepts
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 Accountability
 Value for Money
 Indicators
 Quality Improvement
 Patient-Centered Care
Influence Regulation and Legislation
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 Champion evidence-based scope of practice
 Question unjustified barriers to deployment of
knowledge and skills
 Make the process transparent and engage employers
and the public in discussions
 Ensure governments and employers understand
changes in competency
Be Careful About Specialization
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 Narrow job descriptions and competency profiles risk
obsolescence
 Workplaces need skilled personnel who can evolve
continuously as the environment changes
 Some highly technical work demands specialization but
a great deal does not
 Knowing how to problem-solve where uncertainty exists
is the value proposition for health care in the future
Create A Service Culture
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 The patient experience is as important as the technical
aspects of care
 Convenience, communication, and relationships are
critical to the patient experience
 Organizing work around the needs and preferences of
patients is revolutionary