Assessing the Value of Certification in a Changing Health Care System

Transcription

1 Assessing the Value of Certification in a Changing Health Care System Jack Needleman, PhD FAAN Professor and Chair, Department of Health Policy & Management UCLA Fielding School of Public Health Presented at National Convening - The Value of Certification: Building the Business Case for Certification Las Vega, NV March 4, 2016

2 The Value of Certification in a Changing Health Care System Ambitious conference Build action agenda around demonstrating value of certification Initially identified long list of benefits to be explored: Advances safety Clarifies/defines roles and work of health care providers and other team members Improves culture Improves job satisfaction, empowerment, confidence Improves processes of care Improves quality Improves recruitment and retention Improves employability/job prospects Is recognized as validation of knowledge in the specialty Provides a measurable return on investment (cost) Provides professional support Shapes future practice Explore three questions Who is the audience for your work, for certification? What do they want/need to know about the value of certification? What are the challenges to providing those answers? 2

3 Scope and extent of credentialing/certification From nursing but more broadly applicable A definition of credentialing, from the International Council of Nurses (2009) A term applied to processes used to designate that an individual, programme, institution, or product has met established standards set by an agent (governmental or nongovernmental) recognized as qualified to carry out this task. The standards may be minimal and mandatory or above the minimum and voluntary 1979 American Nurses Association (ANA) study identified seven forms of credentialing, including licensure, registration, certification, accreditation, charter, recognition, and approval 3

4 Individual credentialing/certification Three categories of credentialing/certification and example questions: Initial licensure for entry into practice Are services better from those with higher levels of training? Certification of specialized skills or training within scope of basic professional license Are better patient experiences/outcomes associated with treatment by certified/credentialed providers? Do organizations employing more certified/credentialed staff have better patient experiences and outcomes? Why? Training, experience, nature of individuals who seek credentials Licensure for advanced practice, e.g. APNs Patient experience/outcomes for APNs vs. MDs Organization and efficiency of teams with APNs 4

5 Institutional credentialing/certification Joint Commission accreditation, Magnet certification for nursing, certification of individual services such as vascular imaging labs Is care/service better at a certified or credentialed facility? 5

6 Explore three questions Who is the audience for your work, for certification? What do they want/need to know about the value of certification? What are the challenges to providing those answers? 6

7 Potential audiences and their core decisions Individual clinicians/staff Should they invest the time and money to seek credential/certification? Similarly, facility making same decision regarding institutional Organizations employing or hiring staff Should they prefer credentialed/certified staff? Regulators and payers Should the encourage through regulation or payment incentives employment of certified staff or institutional accreditation? Accreditation/certification agencies Can they justified/sell the seeking of credentials/certification? Patients, consumers, and their families Should they prefer or seek care from credentialed/certified providers? 7

8 Individual clinicians and institutions Factors in decision Factors influenced by home institution policy (Extrinsic value) Increased income Increased opportunities for promotion Validation of skills and abilities (Intrinsic value) Creation of skills and enhanced ability Education and certification process as ability building For institutions considering investing in accreditation/credentialing Business case Lower costs/greater efficiency/cost reductions due to avoided adverse events, readmissions, shorter LOS, reduced turnover Increased revenue due to consumer preference for facility Increased revenue due to value based purchasing All these depend on payment models and incentives 8

9 Organizations employing or hiring staff Perceived value of credentialed staff in: Improving quality in reduces costs Improved quality that increases revenue Reduced turnover All these are business case (extrinsic) considerations In this environment, motivation to improve quality is subject to business case considerations Business case driven by payment models and incentives Most inclusive payments (capitation and per admission/per episode) and value based payment offer strongest incentives Employee extrinsic, income-based decisions influenced by decisions of employing facilities to reward certification, which will be influenced by their assessment of value for the organization 9

10 The other parties Regulators and payers May create mandates or incentives based upon higher quality regardless of cost savings or revenue impacts And payers may be willing to pay for higher quality, although this is less certain CMS value based payment systems cost neutral Accreditation and certification agencies need to justify value of credential Quality improvement/patient outcome or satisfaction improvements first, but Cost savings/revenue gains may dominate Patients, consumers and their families Decision making complicated by physician or hospital referrals Evaluating based on individual credentials of staff unrealistic Evaluating based on multiple measures of quality unrealistic Overall choice possibly influenced by single high level certification 10

11 Complexity of certification/credentialing environment complicates both consumer and individual use of certification/credentialing information Nursing as an example: American Board of Nursing Specialties 34 nursing certification member organizations 2014 survey 26 organizations offering 88 credentials for basic practice 14 offering 48 credentials for advance practice 3 offering 8 credentials for non-rn practice American Nurse Credentialing Center Largest credentialing organization 28 individual certification programs 12 APN programs 11

12 My assessment of primary targets based on belief extrinsic considerations will dominate decision making Organizational decision makers on whether to hire, encourage or require certification, or reward certified/credentialed staff based on cost savings or revenue gains Payers and regulators, whose decisions on payment and regulation will influence the need to have credentialed/certified staff in place Individual clinicians/staff will be guided first by incentives signals from potential employers (extrinsic), and only secondarily by perceived value of credentialing process to upgrading patient care or management skills (intrinsic value) Patients and consumers low level target, notwithstanding billboards on major highways advertising hospitals. 12

13 Explore three questions Who is the audience for your work, for certification? What do they want/need to know about the value of certification? What are the challenges to providing those answers? Levels of evidence (RCTs vs. observational data) What do we know now? With what confidence? What design and research strategies can convincingly fill the gaps? Where will the data come from? 13

14 Research can influence the environment and decisions Example: IOM Future of Nursing call for 80% of nurses to be baccalaureateprepared by 2020 Loosely tied to research showing reduced mortality at hospitals with higher proportion of baccalaureate-prepared nurses Loosely tied because Impacts Hospitals increasingly hiring BSN nurses or requiring ADN nurses to obtain BSN in limited time frame Growth in ADN nurses entering RN to BSN programs Growth of BSN programs, including RN to BSN programs Implications for research on certification/credentialing Demonstrates potential Harder path because: Push for BSN as entry to practice longstanding Effects on high visibility outcomes such as mortality likely to be smaller Variety of outcomes and impacts more diffuse 14

15 State of the science on certification/credentialing research: ANCC Research Council 2012 report Found a stronger research base for assessing organizational credentialing than for individual credentialing [Consistent with some recent published literature reviews] With respect to individual credentialing Several studies on the nurse-reported value of certification, and some relating certification to professional knowledge or behavior. Only a few studies focused on the link between individual certification and patient outcomes. With respect to organizational credentialing, found a substantial literature assessing the association of magnet status with patient outcomes and nurse work environments. 15

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17 RN Certification based on survey of nurse managers, nature of certification not specified % certified: mean: 19.8%, SD 18.1% 17

18 Extensive research comparing Magnet and non-magnet hospitals Solid but not unanimous documentation of better patient outcomes Data comparing magnets to all other hospitals tends to show large differences Data comparing Magnets to non-magnet magnet-like hospitals more equivocal Concerns about matching Substantial, convincing documentation of improvements in work environment, retention, adoption of National Quality Forum (NQF) safe practice standards Better able to do process improvement because of culture of empowerment and flatter hierarchy? Argues for clarifying and testing causal pathways, which requires more extensive framework 18

19 Need for a framework and strategy for pursing research, improving data base for case for certification/credentialing Issues in designing and conducting research: What to research/focus and scope Certification Outcomes or Certification Mechanisms Outcomes Addressing lack of randomization and selection Measurement Data Funding Dissemination 19

20 ANCC framework for understanding the impact of credentialing and designing credentialing research FIGURE 1: ANCC Research Council Model for Credentialing Research SOURCE: Lundmark et al., ANCC framework emphasizes association of credentials and outcomes, minimizes understanding intervening variables and role of environment 20

21 ANCC framework emphasizes association of credentials & outcomes, minimizes intervening variables & environment Issues: Demonstrating causality convincingly Understanding mechanisms by which credentialing has an impact Causality Association is not causality Research strategies for addressing causality Randomization Not going to happen Natural experiments Varying incentives across facilities Variations in state level payment incentives Adjusting for propensity to be credentialed Propensity scoring and matched sample selection Instrumental variables Modeling and researching causal pathways to demonstrate linkages 21

22 Key issues for designing certification/credentialing research Clarifying the value of credentialing and thus outcomes to be studied Why should individual nurses and organizations pursue, support or require credentials? Categorize potential benefits to patients and organizations and quantify impacts Developing better methods to provide confidence in answers Rigor to reduce bias More controls for use of observational data Better strategies for controlling selection Improved sample size, less reliance on convenience samples Modeling and testing causal pathways Measurement and data Certification/credentialing and role in care/organization 22

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28 Challenges to conducting certification/credentialing research Challenges in design and conduct of research Improving methods Need for operational clarity in measures and variables Complexity of pathways and sources of impact Assure rigor and unbiasedness in observational data Limited data availability Extent, scope of credentialed staff and organizations Link patients to credentialed individuals, units, organizations Challenges in underwriting research in this area Low external stakeholder demand for research Mobilizing constituency for research Consequence of increased calls for credentialing? Funding Chicken/egg: perceived value in absence of strong findings Initial funding to test need for/justify larger research program Dissemination to key audiences through relevant mechanisms 28

29 The data challenges For analyses of institutional certification/credentials, regressing outcomes on presence/absence of credential is feasible but Leaves the black box in place Selection undermines confidence in results Need to model who seeks certification/credential For analyses of value of individual certification/credential To the extent a unit/facility characteristic (e.g., percent staff credentialed), need data on percent credentialed Need to resolve how to deal with the multitude of credentials at individual level HR data? To the extent an issue of treatment by credentialed vs noncredentialed clinician, need: Who cared for patient? (EHR?) What credentials (link HR data to EHR data on who treated? Control matching and selection issues (e.g., patient at risk of skin breakdown gets nurse with 29

30 Conclusion Need to demonstrate value of certification to key audiences Business case Research can influence policy and behavior Key audiences for this research: Institutions first, payers & regulators second, individual clinicians third Current information is insufficient to make case Research must address limited data on individual credentialing and its impact, and provide more convincing information on the value of institutional credentialing Need to identify and expand data sources Three priorities for future research on credentialing: Assessment of the causal link between credentialing and patient, clinician, and institutional outcomes dealing with selection as confounder Evaluation of the value of individual clinician credentialing (e.g., benefits to patients and health care providers) Business case Development and dissemination of rigorous methods to be employed in credentialing research. Building constituency, finding funding, establishing effective dissemination mechanisms all critical to assuring reliable research is conducted and used. 30