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Date Updated: November 9, 2011

Health System Reform Policies


Policy: Continuing efforts at healthcare reform should support the creation of a system within the professions for defining a common framework for competence, articulating minimum standards, encouraging continuous improvement, and developing common tools for measuring competence and performance for all healthcare professionals caring for patients in the United States.

An effective system without capable clinicians will not deliver optimum quality; conversely, capable clinicians in an ineffective system are unlikely to deliver optimal quality care, nor can they be cost-effective. The recent debate on healthcare reform has focused primarily on access to care and the cost of delivering care; these are the dominant themes in the 2010 Patient Protection and Affordable Care Act. While these aspects are central, reforms that address only access and cost will fail to meet their potential if they do not concurrently emphasize quality of healthcare services and of healthcare practitioners. The provisions in the Act supporting improved quality are only a beginning; continuing reform in which quality is a central theme should remain a high national priority.

Currently, a number of competing definitions of competence are in use (described in the Appendix: Current Frameworks For Competence). Creating a mechanism for reaching consensus on the definition of clinician competence – the kind of care that we believe to be the threshold for acceptability in our country – is an essential part of health system reform. Defining standards for minimally acceptable practice within a health profession is an intrinsic responsibility of the profession itself. Health system reform should support the health professions, individually and collectively, in the task of developing uniform definitions, measures, and standards.

Widely accepted uniform standards will allow the system to utilize assessment and measurement as a means of assuring compliance and encouraging improvement. The minimum standards developed should be acceptable and familiar to both the public and healthcare practitioners so that a mobile workforce and population provide and receive excellent care irrespective of locale or setting. The NBME provides an example of a mechanism for developing consensus on uniform standards; an overview of the NBME as a model for establishing standards is provided in the Appendix: A Model For the Development of Standards .

Assessments of competence and measures of performance become feasible after standards have been defined. Assessment of competence assures that a clinician (or an institution) has the knowledge, skills, and behavioral characteristics that are believed to be essential to meeting practice standards. Assessment of performance is based on measures in relation to tasks in the workplace. Such measures are essential ingredients in any system intended to promote evidence-based quality improvement, but with our current state of knowledge they are sometimes difficult to acquire, difficult to interpret, and often costly. Measures of competence can be standardized and benchmarked more readily than performance measures. There are some indications that measures of competence correlate positively with performance; they will continue to be useful tools even as more effective performance measures develop. However, measures of performance are likely to become increasingly important, particularly in efforts to support continuous quality improvement among active clinicians. Further information on the tools for assessment of competence and performance is provided in the Appendix: Measures of Competence and Performance.

An overview of the current systems in place to prepare and assess physicians is provided in the Appendix: Current System Characteristics. The reform process must encourage the development of coherent systems to evaluate clinician competence and performance, provide for mechanisms to improve skills in those found to be proficient as well as mechanisms to remediate practitioners who fall below minimal acceptable levels. Likewise, mechanisms for evaluating healthcare processes and outcomes to identify areas for systems improvement will facilitate improvement in clinician performance and healthcare quality.

Enhancements of healthcare information systems arising from health system reform should support both patient care and clinician assessment needs, since effective clinician assessment translates into improved patient care.

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