Profession regulation and health services improvement: Issues in regulation design and its impact on health services

Transcription

1 Profession regulation and health services improvement: Issues in regulation design and its impact on health services Jane Allison, DCR, BSc, MBA School of Government Victoria University of Wellington New Zealand

2 Overview 19 th century main professions established 21 st century standardisation & scopes in profession regulation Last 20 years improvement - service redesign New framework informed by other ways of examining profession regulation

3 19 th Century Origins 1800 physicians, surgeons, midwives, nurses, chemists, few lab tests 1840s pharmaceutical society, 1 st nursing school, anaesthetics 1858 Medical Act - title & guarantee of education not proficiency 1880s asepsis in surgery, separation infectious cases, psychiatry 1890s hospital social workers, physiotherapy, X-ray, radium therapy 1900 all main hospital departments & scientific management Electricity, steam laundry, medical records Role design science & social factors no effective treatment until 20 th century

4 19 th Century Origins Occupational therapy Social Work Physiotherapy 1858 Medical Act s Advanced Practitioners 2000s Intensify Regulation Radiology Laboratory Science Main Profession Societies & Training 1990s Health Ombudsman Pharmacy Medicine Nursing (Abel-Smith 1964) (Berlant 1975) (Dingwall et al 1988)

5 21 st Century Profession Regulation Standardisation of laws & regulators E.g. U.K. Health Professions Council (NHS Executive, 2000) Four joint profession committees Training, complaints, conduct, sick practitioners Standardizes interfaces registration & complaints Shares resources Delegates self-regulation for scopes-of-practice Proliferates professions under regulation

6 21 st Century Profession Regulation Scopes-of-practice & reserved procedures frameworks for flexibility Ontario 1991, Netherlands 1997, New Zealand 2004 Ontario HPAC 2001, 2009 Regime obsolete if no improvements, now oversight regulator Dutch research (de Bie et al 2004, 2005) Confusion in determination of proficiency, Verbal, standing orders - not one-to-one as per regulation Nurses perform reserved procedures on own initiative Rhode Island dissertation (Judge Bertness 2009) Nurse Practitioners practice medicine without a license Over specification of standards at regulatory level

7 Service Improvement - Redesign Multidisciplinary Assessment teams Discharge Pull strategies, protected time, discharge protocols ICT dashboards Locock 2001, 2003 Fillingham 2007 O Conner et al 2008 McGrath et al 2008 Bate et al 2008 Equipment layout 6 Ss sort, scrub 7 wastes wait, inventory etc Wards & Clinics Trauma assessment unit Short stay ward ED holding ward Emergency & Admissions

8 Redesign Programmes - Hospital Patient Focussed Care Booz Allen Hamilton Pilot cost & quality improvement, but defeated by profession regulation & scaling issues (U.S. Watson 1991, U.K. Hurst 1996) CQI, TQM U.S. hospitals Discrete success not organization-wide e.g. CABG, prostate cancer pre & post operative, falls (Shortell et al 1998) Business Process Re-engineering Leicester Royal Infirmary, U.S. survey Discrete improvements at LRI, e.g. O&G preadmission clinics & early discharge but no organisation-wide improvement (McNulty & Ferlie 2002) Worse performance on cost following redesign TQM & BPR (Walton et al 2005, 2006) Institute for Health Improvement & Baldridge JonKoping Rapid improvement against performance national indicators but others overtook them within 2 years without re(ovretveit & Staines 2007) U.S. Hospitals - study of scope of quality improvement 1800 hospitals More hospital departments involved = worse performance on both quality & safety indicators (Weiner et al 2005, 2006)

9 Redesign Conflicting Standards Profession Regulation Scope-of-practice Ethics interprofession relations (Jost 1997) Referral between professions & profession departments Service Redesign Job design Policies Process improvement flow through & between departments Reductionist emphasis on scopes & process distracts from policy inconsistency

10 Conclusion More of the same? Another brand of redesign? More interventions to make profession regulators perform? Institutional, purchaser or government regulation? More advanced practitioner roles with assistants? Construct a fresh approach? Attention to: Multiple not single profession model Regulatory leverage in supply chains Incentives on professions Employer authority & HR capacity

11 Profession regulation and health services improvement: Issues in regulation design and its impact on health services Jane Allison, DCR, BSc, MBA School of Government Victoria University of Wellington New Zealand