National Alliance for Physician Competence Discovery Workshop

Context

Reframing the Mission, Purpose and Activities

Assignment

Context: Remember the concept of the playground. The last couple of rounds were mostly about play (playing can be hard work!). Now let’s bring some of the ideas back to ground.

Objective: First list any insights that you and your group members have had so far. Remember that the insights may have arisen from serendipity or combination. Or you may not have any, and that’s fine as well. Next, take a look at the purpose and activities of the National Alliance and apply the insights to see if anything should be changed. At this point we’re interested in outlining the major components of purpose and activities (output and key processes).

Process: It may be important to not jump the gun and reach too quickly to rewrite the purpose and activities. Take a few minutes individually to allow some insights to emerge in thought. Then have a brief conversation within your group about them and finally work on the core objective.

Exchange: Your group will be asked to report its work to the rest of the team when we reassemble in the plenary after this exercise.

Resources: Here is the stated purpose and activities from the National Alliance draft proposal for your reference. Also use for reference the Post-it Notes that were generated last night after dinner. Finally, you have access to the poster boards with the strategies that emerged in the previous rounds of work.

Purpose: The mission of the National Alliance for Physician Competence is to assure the public and the health care community that individual physicians are competent to provide safe medical care of the highest quality. Through partnership and collaboration, the Alliance will 1) advocate continuity in the definition, measurement and determination of physician competence across the continuum of education, training and practice; 2) support seamless collaboration among organizations that contributes to physicians pursuit of lifelong learning and improvement; and 3) seek ways to enable reformation of the system of physician self regulation so that it is efficient and effective.

Activities: Many benefits will derive from the creation of an Alliance. It will provide a forum through which the various groups composing medicine’s system of self regulation may identify and resolve current and future gaps in the continuum of education, training, licensing and certification. It will facilitate sharing of resources and knowledge, thus expediting the development and implementation of strategies to assist physicians in their lifelong professional development. Finally, and perhaps most importantly, it will be a visible demonstration of medicine’s accountability to the public for the competence of its members.

The National Alliance for Physician Competence will provide a mechanism for professional verification of physician competence. It will oversee the processes used to acquire and verify physician competence data, and inform the public about the quality of those processes and the relevance of the data acquired. The Alliance will convene physicians, other health professions experts and members of the public to develop recommendations for interpreting physician competence data.

A core function of the Alliance will be to establish and maintain a “Trusted Agent,” i.e., a data exchange infrastructure built upon business principles agreed to by members of the Alliance and owners of existing data repositories. Such an infrastructure will allow data owned by multiple sources to be aggregated and reformatted in ways tailored appropriately for use by individual physicians, by the public and by credentialing bodies.

Report Outs

 

Bryan

OK - let's get together. Let's here some brief reports. We'll give you six minutes for each group. We'll start with team one.

Group 1

We spent some time thinking about the insights. We've talked about not predicting the future but adapting and possibly influencing it instead.

The second insight has been developing and that is the growing sense of trust.

We've heard some stuff about the value of diversity and the value of simplifying the rules.

We've talked about the glaring absence of certain stakeholders - particularly the government.

One of the audio sessions talked about the wisdom of the crowds. Compete, collaborate and coordinate. What has been rewarding has been the experience of the passion and the tolerance for change.

I'd like to talk about the purpose of the Alliance. We had talked about this need for integrated systems and whether there should be a system that looked at and assessed the role of physician in teams.

We might want to consider whether we should work to reduce system impediments to quality care.

The sense is to assure the public that individual physicians are competent. It is impossible to express their competence without a system that enables them to be competent. We might want to consider whether we should work to reduce system impediments to quality care.

Are we prepared to take on this larger task? Even if we improve individual physician competence we have a gap in the absence of system level transformation. It's a question to consider whether it is worth pursuing. What are your thoughts?

I think you've hit on something very important. Physician competence doesn't exist in a vacuum. The way you said it implied that the system is outside the physician. Be careful not to imply that one of the competencies is to wait until the system is fixed.

There are things that the profession cannot do by themselves without creating an alliance with a larger group.

If the physicians are competent we would have made some progress but that is not enough.

Are there other comments on that discussion?

Maybe there is an unintended consequence of making it easier on doctors by sharing this information.

The point though is to make sense of licensure and to understand that doesn't happen without understanding the rest of the system.

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Group 2

We focused on the Alliance. Complex Adaptive Systems - what might be the barriers to the adaptability of the Alliance? Every stakeholder has to come in with their own way of doing things. Gaining the trust and the buy-in of the members is something we face. We discussed the need for communication and the portfolio and trusted agent (which hasn't been talked about much so far today).

The government and regulatory parts of the system need to be considered. When we make a change the system has to adapt to that and then we have to adapt to that change.

Collaborative relationships to non-physician providers in the system.

As we get together and decide who are the charter members what is the role of each of these stakeholders in the Alliance? What are the preferences and interests of the members as they walk in the door?

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Group 3

We started back in terms of what we thought the Alliance is supposed to do. We said the Alliance should: Insure the public of competence and continuity across organizational activity.

We talked about the continuum of the professional career. Our insights come down to talking about whether we should be an organization of organizations. We are a forum to have conversations about these things.

If you look at the Good Medical Practice document those things become the measuring stick. We would meet and address how we are using the GMP and assess things that are falling through the cracks.

The downsides to this definition might be that it is evolutionary rather than revolutionary. It probably needs a small organization and would have a small staff and salaries and a place to be. That small staff might be the machinery to be the owner of the GMP and send out communications to the Alliance.

Who is the keeper of one's credentials?

We didn't talk much about this but the whole hospital structure is not involved in these conversations.

We have to remind ourselves about the 800,000 or so physicians that are out there. A very small number of those people know about these discussions. They might be offended that we are talking about their competency. We don't have buy-in from the doctor on the street. We might need to focus on tightening up the GMP document and set the goal of getting exposure and buy-in from the constituency we are wanting to regulate. We should figure out that we are doing something that is meaningful to them.

I think we need credibility with doctors on the street and that should be the focus of the Alliance. I don't think most physicians think highly of the organizations other then the one they belong to. There are way too many organizations and there is way too much bureaucracy. They aren't looking for more complexity but they are interested in how you can help me be a better, safer doctor tomorrow.

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Group 4

We started out with thinking that diversity and transparency would be important. The second insight was to think about the shift from goals to options for ways to achieve the goals.

There are different approaches and different metaphors.

We got to the statement of purpose and we agreed with group 1.

Another insight is that agents themselves may not be organizations. What we came to is there are other ways to think about agents. They could be technologies or different parts of organizations.

Taking an ecological model approach. We think we have had a carved out turf and what has happened is we built a lot of houses on that turf. We might be at risk from other houses coming into that turf.

This really supports our efforts to work together to self-regulate.

Some of us came in with the idea we would come up with something very different. We might be come out with incremental and experimental changes and if the experiments are done correctly they will catch on.

Our discussion around the options included the idea that we don't have to get all organizations to sign on to a specific purpose or a specific goal. They already have purposes and goals that support what we are trying to do. We need some transparency about sharing what we are doing and that will help everyone.

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Group 5

Our group doesn't have a board. We are going to deny we are saying these things.

We had a wide range of discussions. Kirsten represented a different point of view in our group. We ended up with some questions about what the context was around state regulations and federal participation (medicine is state regulated but the payer is federal government). There are state versus federal regulations. Some examples include: insurance, education system and hospitals. With the trends calling for transparency and the exposure of a number of failures within the health care system there seems to be a need to focus on this.

Even with a number of positive examples have we under-performed in terms of self-regulation?

Do we need to partner and ask for help from the Federal Government? Should we expand our role to include community responsibility as part of the accountability of physicians? Should we position the Alliance to be the Physician voice in the event of nationalized or federalized healthcare?

What about in the absence of Federalized Healthcare System? Should the Alliance by the voice?

It gets back to where we discussed something about an organization of organizations. We have backed away from this as a unified voice. We need a place to talk about common problems.

Think about this. The reality might make more sense to have one university system but the different Universities won't do it. We would argue we should have a common message and this entity should come up with that. Our multiple organizations would then have to deal with their multiple voices.

Where this went is we are doing this to fend off Federal Healthcare. What if there is Federal Healthcare? We shouldn't go away. We might want to position ourselves just in case that happens.

Blue Cross Blue Shield's consolidation might create a debate about a private payer.

There are organizations that position themselves as an impartial educator. The theory is we can educate legislators on ground breaking issues.

I thought the focus on competence was to be the voice of the patient? Actually insuring competence we aren't focused on the healthcare system. I thought it was to be the voice for the values of the Alliance which includes both the patient and the profession.

How do you suffer from the absence of the voice of the profession?

If you put something out and say, "this is your voice" that might raise some issues. If the GMP can be framed to make things easier or to empower people then it becomes the voice and it might inspire people to create other things in that spirit. It could be like mid-evil Scottish history if you try to become the voice - there could be a lot of fighting on the highlands.

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Discussion

What are some of the themes that are emerging?

The first thing is to look at the purpose statement and look at whether we should consider the system's accountability as well as physician accountability?

The first thing is to look at the purpose statement and look at whether we should consider the system's accountability as well as physician accountability?

You can do both and continue to move forward with learning about measuring physician competence while experimenting with understanding the system changes that need to occur.

I think it's interesting to look at what is in it for you. There needs to be some exploration of doing this in a positive way and doing this as an attractor.

I was taken by what you said yesterday. You have to create another box and to look back at your own box. The Alliance could be a new box and allows these other organizations to leap over and look at their own box.

There is a lot of discussion around physician competence and that is the issue d'jour right now. To think about creating processes that address the issue d'jour.

From a patient point of view we are interested in transparency. That quest to understand is driving us.

Any other themes?

We have reinforced the idea of the Good Medical Practice being a vehicle to continue the dialog.

Diversity, collaboration and the positive focus on improvement. These would be at the grass roots of what we build.

Simplification of rules in our own organizations is a theme we have been talking about. Tomorrow might be an opportunity to look about this more tactically?

I'm still struck that we are having a theme of creating a structure with a 501c3 versus a sandbox where we can all play.

Creating a 501c3 might allow you to do some things in the world because of the way the world is structured. You might want to co-design both - the pool and the 501c3 - because the pool might not get you access to some things that a 501c3 can.

In Florida a 501c3 can own a for-profit corporation. That allows them to have two mentalities at the same time. They can have a dialog between the two.

There are more options then that. The shell that you create could be an agent - the form isn't that important but it might allow you to do some things you couldn't do otherwise.

We're all thinking zen. The reality is there are 800,000 physicians that don't think zen. They are interested in surviving. There is the pie in the sky conversations and then there is the question about how much energy someone has and the practical issues about what we can accomplish. My sensitivity is having the feedback from one of our groups about not creating another structure on top of the existing structures.

If we're not really comfortable about where we are I'm uncomfortable about bringing the government in.

The way you are engaging people and organizations is different from what has been done before. The government will have to learn that it is safe to engage with you.

You will have to figure out a way to position the experiments you do so that it eases some pain that physicians are having. Positioning is important in this conversation.

There is an interesting historical perspective here. There isn't another industry that doesn't have a centralized organization regulating or overseeing you. You are a self-regulating system. There is a large portion of government that regulates most other industries. Maybe the regulatory organizations you have developed are too rigid to deal with change?

How does the medical council in Great Britain work? I've been working with some boards in Canada and there is a federal standard. There is no federal regulatory agency though.

We heard a presentation in Canada about the tension between the provincial and federal agencies.

The first Good Medical Document was begun in Britain about 10 years ago. The General Council in Britain is a function of the National Health System. They have a voice into the government. Not all doctors belong to this group but that is the negotiating arm for payment.

Bryan

We're going to move along now.

We're going to have two more presentations by Norman and Curt. In the draft proposal there was a work plan and we've split those activities among the small teams to look at. Then you will switch and hear the other presentation and then go back to work and finish the same assignment on the different activities of the Alliance. At the end of the day there will be a report.

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