There’s a pretty big policy change on the horizon of the healthcare system in British Columbia. One that most patients are probably not remotely aware of, that is likely to have sizeable, and foreseeable, albeit unintended consequences that might well result in achieving the opposite of what was intended. One that might make our already access strained system, even more painful, one in which both patients and the providers being impacted may not have been adequately consulted, and one that is likely not as evidence driven as it should be.
In the wake of a health-system scandal in 2011 involving 4 radiologists in British Columbia, where 12 British Columbians had their treatment delayed or were misdiagnosed and three of those patients died, where thousands of diagnostic images were suspect, British Columbia sought to improve the system by which doctors are licensed, credentialed and given privileges in order to safeguard patients. The policy response included the Provincial Privileging Standards Project an overview of which can be found here. With a blog about the project being established here. The stated goal of the Provincial Privileging Project was to create discipline specific privileging dictionaries along with criteria required to apply for and maintain those privileges for all medical staff disciplines in the province. Not a goal I'd choose for a major policy project, but it is certainly attainable.
The dictionaries would establish the set of procedures and activities a doctor would be permitted to perform based on that physician’s credentials (degrees and post-graduate training already completed), currency (the level of current experience the practitioner has in the activity), and context (the ability of the facility in which the doctor practices to support the procedures and activities). My understanding of how the dictionaries have been developed is that 28 expert “panels” have been established for each specialty with each panel consisting of two or more senior practitioners in each specialty who have delineated all of the activities undertaken in each specialty and have established “core activities” and “non-core activities” for each specialty along with the amount of recent experience in the procedures and in general practice that the expert panel felt would be required to maintain competence in undertaking the services. The physician would be required to request and demonstrate that they meet the qualifications to acquire privileges, and if they were lacking in any area there would need to be a “conversation” about it.
Providers have publicly voiced concern over the pending policy change as illustrated by a recent article in the BC Medical Journal. Provider’s are concerned that the currency standards that have been established have not been shown to demonstrate competency or procedural safety based on sound evidence and that the new dictionaries will ultimately lead to a loss of access to medical services.
In response to the criticism raised the champions of the project replied in a subsequent article . The reply to the concern expressed is that providers are being unjustifiably fearful of the policy change, that failure to meet a standard in the dictionary will merely merit a “collegial” discussion, that they understand that there is a difference between currency and competency and that there was wide consultation with 56 expert panels being established along with collaboration with administrators, and that they recognize that the dictionaries will need to be updated on an ongoing basis.
This policy change is fueled by the best of intentions (to safeguard patients) – however, patients and providers are right to question whether or not the policy will safeguard patients (at all) and to consider the full impact the policy may have on the healthcare system. Was consultation broad enough? Are the standards evidence based or are they arbitrary? What will happen to access to medical services as a result? What is the cost of this new tool and its maintenance and are there other policy tools that are likely to be more effective and less costly? And perhaps most importantly, will quality of care that patients receive actually improve?
Disturbingly, it appears that patients have not been included in the development of this policy. Disturbingly, it appears that including a few members of the specialties involved is considered “broad consultation”. Disturbingly, it appears that the standards that have been set are arbitrary in that every practice and procedure is to be included in the dictionary, whether or not there is clear evidence that volume of service delivery or experience has any clear link to quality or safety. Disturbingly it appears as though concerns with the policy are being brushed off as merely fearing change.
This policy will not improve transparency or shared decision making between patients and care providers. This policy will not improve the recourse patients have when they experience medical error. This policy will not encourage innovation in the delivery of medical services. This policy will not identify providers that have patients that experience qualitatively or quantitatively bad care – it will not monitor clinical performance. By and large this policy appears as though it likely will reduce the number of providers that are available to provide services to the public and will increase the amount of bureaucracy in the system. It appears that patients might well be told they can’t have access to a medical service at all, rather than have access to the service provided by someone who is overwhelmingly likely to be able to provide the service safely.
Quality care and public confidence is critical to the system, but we’d be foolish to think that the “Provincial Privileging Program” is going to effectively advance quality in the British Columbia healthcare system. Policies that are implemented with patient safety and patient confidence being the goal should be robust and subject to scrutiny by providers and patients. Knee-jerk responses to critical lapses in the provision of quality care should be avoided as they may be very expensive responses that fail to meet the goals that matter. If you think access to care in British Columbia is bad now, just wait, things could get substantially worse.