Leadership accountability for quality: A regulator’s perspective

by admin admin | Mar 01, 2011

Dennis Kendel, Registrar of the College of Physicians and Surgeons of Saskatchewan

The regulatory bodies of all healthcare professions strive to improve the quality of patient care by optimizing the performance of their members. But there are a number of challenges, says Dennis Kendel. For example, regulatory bodies in different areas of medicine rarely work together. As Canada’s population ages and more patients seek care for complex, long-term conditions, healthcare is becoming increasingly team oriented. There are no existing structures for evaluating team performance, and creating those structures will be difficult if regulatory bodies remain separated in disciplinary silos.

“It’s like having a regulatory body for every player on a hockey team and nobody paying attention to how they all work together to get the puck in the net,” says Dr. Kendel.

Dr. Kendel has spent much of his career learning how to improve the quality of patient care. From 1972 to 1985, the years he practised family medicine, he would frequently attend quality improvement conferences in the United States. These trips weren’t mandatory. He simply wanted to get better at his job. Fortunately, says Dr. Kendel, the drive to improve is commonplace in the medical profession.

“I think most healthcare professionals enter their professions with the goal of being as effective as they can be in helping the people who come to them for help. Some become jaded along the way, but most remain committed to doing the best they can,” says Dr. Kendel. “Over the years, our sense of what our obligation is has gone beyond preventing harm to trying to make sure the outcomes for patients are as optimal as possible. In addition to just pure risk mitigation, physicians are now encouraged to use best practices, to be current in their medical knowledge, and to work with other healthcare professionals to achieve best outcomes.”

Since leaving active practice, Dr. Kendel has worked with several organizations to help create a safer and better healthcare system for Canadians. In addition to his duties for the College of Physicians and Surgeons of Saskatchewan, he serves on an advisory committee for the Canadian Patient Safety Institute. He is also on the board of directors of the Health Quality Council of Saskatchewan, an independent agency dedicated to measuring and improving the quality of healthcare.

It’s pretty hard to force people to really generate quality care. They have to have a commitment to it and, fortunately, most do.

As part of its mandate to promote quality improvement, the Health Quality Council of Saskatchewan has studied high-performing health systems around the world. One of those systems was Alaska’s Southcentral Foundation, which is owned and managed by Alaskan Native people. Southcentral Foundation is renowned for meeting the needs of its patients—or “customer/owners”—by directly engaging them in all quality improvement efforts. This model, says Dr. Kendel, is one worth emulating.

“Ultimately, accountability has to be to the people who require the services,” he says.

Regulatory bodies also have a role to play in keeping healthcare providers accountable for quality improvement, says Dr. Kendel. The College of Physicians and Surgeons of Saskatchewan does this in several ways, such as through its Diagnostic Imaging Quality Assurance Program and its Laboratory Quality Assurance Program. Several years ago, the college made it mandatory for Saskatchewan physicians to enroll and participate in national medical maintenance of competence programs.
Most of the province’s doctors complied, though 11 defied the mandate and lost their medical licences.

“They had to pay a $300 penalty to get back in the game, but after the first year, nobody did that again,” says Dr. Kendel. “In terms of creating accountability, that is one tangible way. But we have to be honest and say most of the improvement comes from a self-directed commitment to quality. It’s pretty hard to force people to really generate quality care. They have to have a commitment to it and, fortunately, most do.”

Though regulatory agencies play an important role in healthcare, they can only do so much to encourage providers to maintain or improve quality. Provincial governments, on the other hand, have the resources and influence to compel sub-par performers to make significant changes. Dr. Kendel points to an Ontario law that requires hospitals to publicly disclose metrics such as infection and mortality rates as a good example. Public embarrassment is a strong motivator for improvement. And let’s not forget, Dr. Kendel notes, that provincial governments control healthcare budgets.

“Money is always the strongest lever,” he says.

Of course, a government can also be held to account for its healthcare decisions by voters. The problem with this type of accountability, says Dr. Kendel, is that the public tends to focus too much on access to health services and not enough on appropriate use of health services. More care doesn’t mean better care. For example, about a quarter of the CT scans conducted in Canada aren’t necessary, says Dr. Kendel, and thousands of people are being exposed to potentially cancerous
radiation for no good reason.

“About 50 people a year in Saskatchewan die from having CT scans,” he says. “If you think about it from a safety perspective, we need to raise the awareness of the public and of healthcare professionals that doing more in the way of examinations and interventions is not always best.”

Just as teaching the public about appropriateness of care can lead to quality improvement, so too can encouraging the public to teach healthcare professionals about the care experience. In this area, says Dr. Kendel, the medical profession could learn something from the hotel industry, which relentlessly pursues feedback from its guests to learn how to serve them better.

“We still get relatively little feedback from people about their experiences in healthcare,” says Kendel. “Often we are so focused on pouring dollars into more widgets and more visits that we don’t step back to see if the widgets and services we are offering are of good quality.”