Professional Regulatory Bodies
Deb Zelisko (student)
Partners and Collaborators:
Jan Kasperski - College of Family Physicians of Canada
College of Physicians and Surgeons of Canada
College of Nurses
Ontario College of Family Physicians
In Ontario, the Regulated Health Professions Act (RHPA, 1991) grants self-regulation to 25 health care professions and as such is a policy instrument used in the delivery of health care in Ontario. Self-regulation is based on the concept of professionalism under which the profession is responsible for the conduct of and services provided by its own (Bales, 1986; Freidson, 1994, 2001). Included in this concept of professionalism is the notion that the profession will put the needs of those that it is serving ahead of self-interests (Freidson, 1994, 2001; Cruess & Cruess, 1997). Each of the health professions’ colleges is responsible for ensuring all aspects of the RHPA are upheld. These self-regulated professions vary significantly in their scope of practice and resulting autonomy and workplace settings as well as how they are remunerated (RHPA, 1991, Ghandour et al, 2010). These variations in scope of practice and remuneration may result in the professional being exposed to different conflict of interest scenarios. Conflicts of interest may interfere with patient care, erode patient trust and undermine the effectiveness of self-regulation (Tonelli, 2007; Haine & Olver, 2008). The aim of this study is to understand how professionalism works in practice to address conflicts of interest. Specifically, a qualitative nested multiple case study approach will be used to examine how three self-regulated professions, physicians, nurse practitioners and audiologists, which vary significantly from each other in terms of autonomy, workplace settings and remuneration, compare in addressing conflicts of interest.
A nested multiple-case study will be the methodology used. The first part of the study will focus on an analysis of the regulated health professions across Canada, in order to gain an understanding of which health professions have been delegated self-regulation, the criteria used in the delegation process and how consistently the results were across the provinces.
The second part of the study will be a multiple-case study. The goal of part of the study is to understand how the regulatory colleges define and address conflict of interest. Each college will have its own context due to the differences in practice specific variables. Three practice-specific variables that will be a focus of this study include the type of work done by a profession, the impact of economic incentives and the work environment of the professional. Each will be discussed subsequently as they relate to conflict of interest and self-regulation.
Practice-specific variables of interest in this study
Profession-specific regulations exist for each of these 25 self-regulated health professionals based on their legislated scopes of practice and obligations (RHPA, 1991). Due to the diversity of these professions it is important to understand which variables impact the potential for conflicts of interest exist.
The first practice related variable, work performed by the profession, directly impacts the workplace scenarios in which a health care provider might be exposed. Regulated health professions vary in their authorization to perform controlled acts, ranging from no authorization over any controlled acts to authorization over all of the controlled acts. For example, physicians have the broadest scope of practice and are the only health profession authorized to perform all of the controlled acts outlined in the RHPA (1991), nurse practitioners have the second broadest scope of practice with a large number of controlled acts within their authority, while audiologists have a small scope of practice and are authorized only for the controlled act of hearing aid prescription (RHPA, 1991). As a result of these variations in scopes of practice, a health professional will likely be exposed to different practice scenarios and situations in which a conflict of interest might potentially occur. The regulatory colleges for each health profession are responsible for outlining the practice standards and expectations pertaining to their registrant’s scopes of practice and controlled acts, in addition to ensuring ethical conduct and accountability to the public (RHPA, 1991). As a result, the colleges are also responsible for defining and addressing potential conflict of interest scenarios. The first part of the study will attempt to identify what the key differences are in the type of work done by the various professions and how this might impact conflicts of interest.
The second practice-related variable that might influence the potential for conflict of interest is the impact of economic incentives. In Ontario, physicians may be reimbursed through one of the following structures: fee-for service (FFS), capitation, salary, or a blended model (Aggarwal, Choudry, Gan et al, in press). In the FFS structure compensation is based on a fixed amount per service (Aggarwal, Choudry, Gan et al, in press). In a capitation-based structure remuneration is based on a fixed value per patient roistered, while salary is based on a negotiated compensation for services provided over a defined time period (Aggarwal, Choudry, Gan et al, in press). A blended model consists of two or more of these structures combined. Other health professionals may be remunerated partially through a publicly or privately- funded FFS structure or may be remunerated through a salary-based model which may or may not include incentives. Nurse practitioners are typically remunerated through a salary-based model, while audiologists are remunerated predominantly through a privatized FFS structure or salary-based model with incentives.
An example of a publicly funded FFS model occurs when a physician directly bills the Ontario Health Insurance Plan (OHIP) for each insured procedure done in the course of treating a patient. An example of a privately funded FFS model occurs when an audiologist directly bills a patient for a hearing aid evaluation and also charges them for fitting services and purchase of a hearing aid. A nurse practitioner might not be compensated through a FFS model, but through a salary-based model they would receive the same remuneration regardless of the amount of work performed. The potential for a conflict to arise in all of these scenarios exists because the professionals in the first two examples have the potential to either increase his/her compensation by providing more services or providing services more efficiently to increase productivity (Carson, 1994). In the last example, where remuneration is based on flat salary the conflict of interest exists in that the professional can perform the minimal amount of work, or provide partial services for their patients and still receive the same compensation (Carson, 1994). Further, conflicts of interest may exist for any profession if industry partners offer incentives or training sponsorship. The concept of professionalism asserts that professionals will provide the appropriate services for their patient irrespective of any opportunities to maximize personal gains (Cruess & Cruess, 1997). The regulatory colleges are responsible for the ethical conduct of the membership and based in the type of workplace setting and subsequent remuneration scenario the profession works within, the colleges are mandated to have the appropriate mechanisms in place. This study attempts to understand and compare how the three colleges identify remuneration-based situations where there is the potential for conflict of interest to arise and how these situations are addressed.
The third practice related variable being investigated is workplace environment. A health care professional may practice independently and have complete autonomy over their daily work, they may work in a collaborative interprofessional team environment, or they may work in a setting where their work is directed by management or other professionals. Workplace environment is related to and impacted by the type of work done a profession undertakes as well as economic incentives, in that if a health care provider is working in a solo practice they are autonomous in their actions and this workplace scenario is somewhat determined by their remuneration structure. However, regardless of remuneration structure interprofessional teams and collaboration exist in which health care professionals with various backgrounds and scopes of practice work together. For example, workplace environment does have an impact on professionalism in that when nurses have access to resources, information and are properly supported they are likely to feel a high level of accountability (Baumann & Kolotylo, 2009). Evidence also suggests that workplace protocols or practice guidelines may not be adhered to for a number of reasons (Hanneman, 2003; Puffer & Rashidian, 2004), and that strong interprofessional relationships impact nursing autonomy overall (Kramer & Schmalenberg, 2004a, 2004b). However, there is very little written about how conflicts of interest in these scenarios are identified or addressed. This study will examine further how these three colleges address conflicts of interest in varied workplace environments, in particular when interprofessional collaboration occurs.
The first part of the study was designed to gain a better understanding of the regulated health professions in Canada. An environmental scan of public documents, including those issued by regulatory colleges and provincial governments was done in order to answer a number of questions which were designed to assist in understanding the various factors that might impact conflicts of interest. The first question to be addressed was which health professions are self-regulated within each province across Canada. After this was determined, the differences between the provinces will were analyzed. Areas of analysis included: which of the health professions have been granted self-regulation and how this varies across provinces, the nature of work performed by these professions, the scopes of practice for the professions, and which professions have controlled acts. In addition, workplace settings were analyzed; including whether a profession is self-directed or self-employed in their work or whether they primarily work in a team environment. Finally, the economic incentives that accompany these different workplace environments will be determined for a subset of health professions. The intent of the analysis was to confirm the selection of three self-regulated health professions that vary in their scope of practice or work performed, the degree of self-direction they have in their work and exposure to various economic incentives for the second part of the study.
A multiple-case study is designed to compare differences and similarities between cases (Yin, 2003; 2009; Baxter &Jack, 2008). The College of Physicians and Surgeons of Ontario (CPSO), the College of Nurses of Ontario (CNO) and the College of Audiologists and Speech Language Pathologists (CASLPO) were selected as the three cases in this study on the basis of theoretical replication. Theoretical replication allows for a comparison of different types of conditions and a comparison to the theory underlying the study (Yin, 2009). Using the concept of professionalism as the underlying theory, the multiple case design allows for a comparison within and across the different professions selected and their regulatory bodies in terms of how conflict of interest is addressed. Research questions and analyses will pertain to each case separately, and the subsequent analysis will look at the results within each and then compare across the cases to draw further conclusions and address the underlying theoretical questions pertaining to professionalism.