Seizing the Health Human Resource Future:Changing the Culture, Positioning for Success

Presentation to the CAAHP Annual General Meeting

Ottawa, May 28, 2014

Steven LewisAccess Consulting Ltd.

Saskatoon SK(306) 343-1007

Steven.Lewis@sasktel.net

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What This Presentation Is About

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

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My Perspective

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

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Part 1

History Is Not Destiny:A Dose of Realism Tempers a

Century of Boundless Optimism

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The Century of Achievement and Optimism

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)

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And We Thought It Would Only Get Better

Science will solve every health problem – just a matter of time and effort

More is better:ImagingScreeningSurgical repairDrugs

Specialization is good; sub-specialization is better

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Then Reality Set In

To Err Is Human in US; Baker-Norton in Canada – the system isn’t very safe

The system fails at the basics:Hand-washingEvidence-based preventive care (McGlynn et al)

More can be worsePSA and mammography screeningPolypharmacyCT scanning

Specialization is a risk factor (complexity)

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But the Triumphalist Culture Persists

Sophisticated diagnostics Emergency interventions Surgery Drugs Big Science (genomics, proteomics)

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What If We Started Over and Designed the System to Meet Societal Needs?

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

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What Most People Need to Thrive

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

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Or Put Another Way…

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

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Part 2

Implications for Health Human Resources

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Why the Workforce Looks Like It Does

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

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Is the Contemporary HHR Approach Compatible With System Goals?

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

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The Revival of Generalism

The reorganization and renewal of primary health careInterdisciplinaryHolisticMore 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

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What Makes Effective Health Care Workers?

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

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The Policy Front: Will Frustrations Lead Governments to Insist on Change?

“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

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Part 3

Opportunities for Allied Health Professions:Needs, Roles, Strategies

REPLACEABLE WORK

IRREPLACEABLE WORK

Physiological measures Motivation

Diagnostics based on pattern recognition

Calming of fear and anxiety

Scheduling and reminders

Decisions under conditions of uncertainty

Reasoning based on algorithms

Communicating effectively

Solutions that are context-independent

Knowing when to deviate from standard procedure

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Lessons from US Manufacturing

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 Chronic disease focused

Fragmented Integrated

Autonomous Interdependent

OBSOLETE TRAITS

HIGH DEMAND TRAITS

Narrow set of skills that can be automated

Patient-centred skills

Non-transferable specialization

Versatility

Autonomous team members

Interdependent team members

Authoritarian personality Empathetic personality

High control needs Comfortable with interdependence

Need for order and stability

Ability to adapt and create

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The Evidence Is Already In

Most scope of practice expansion has been highly successful:Nurse anaesthesia, endoscopy, NPsLPNs in all settingsDental therapistsRehab therapists as diagnosticians

Main barriers are professional self-protection and obsolete standards and regulation

The workplace and experience are great teachers that expand capabilities

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Potential for Substitution

“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

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Cultural Changes on the Horizon

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

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Teamwork

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

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Skill Sets for a Better Future

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

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What Kind of People Are We Looking For?

Versatility and adaptability Emotional intelligence in workplace Empathy and culture of service toward clients Communication

Within teams and organizationsWith people served

Creative problem-solving

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Keep Education Short, Modular, and Experience-Based

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

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Match Program Design to Needs

Aging and frailty Working with families Coaching and self-management Recognizing mental health issues

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Expose Students to System Concepts

Accountability Value for Money Indicators Quality Improvement Patient-Centered Care

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Influence Regulation and Legislation

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

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Be Careful About Specialization

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

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Create A Service Culture

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