David Benton, current CEO of the National Council of State Boards of Nursing (NCSBN), has worked in high-level government positions around the world throughout his career, making efforts to move the health care professions forward since the early 1980s. In the final installment of our three-part Q&A series, Benton and Ascend Magazine Editor Paul Leavoy discuss resilience, risk, and the importance of communication across different jurisdictions and regulated professions.  

Knowing what AI and digital technology can offer, what does the future of health care regulation look like to you?

Part of our work is about getting nurses and other disciplines to do the things that only a physical person can do, and to use AI in a way that supports their practice. If you look at human development, as things like our diet have gotten better, and as information and education have been made more available, our intellectual capacity has increased over the centuries – but not at a phenomenal rate.

Artificial intelligence is increasing at an exponential rate, and we are now at the stage where, through data mining, patterns can be identified by artificial intelligence (with a very high degree of predictive ability) that are simply too complex for us as mere humans to understand. That’s one of the big risks. We’ve got to recognize that the technology is there to augment but not to take over. Sometimes, things that look okay at the start can take you down an unwanted path. It’s another form of risk that we’ve got to manage.

Some of the work that we’re doing now with colleagues in Ontario, British Columbia, New Zealand, Australia, Singapore, the U.K., Ireland, and Spain, where like-minded regulators are now coming together to tackle big problems to help us deliver services in the global arena, illustrates the challenges we now face. It shows that we need to feel comfortable working with different types of experts.

We’re not going to turn regulators into AI experts, but we need to be able to reach out and identify those experts and work with them. Just as we need to work with economists to understand the financial impact of an event, we need to work with social scientists to understand what people are looking for in their services. We must broaden our base of collaboration to address some of these issues.

Depending on who you talk to, risk-based regulation is either a novel or obvious approach. How would you describe what risk-based regulation is and how it can be used?

The thing about regulation is that it is a mechanism of control. Too much regulation denies the opportunity to innovate. Too little of it puts the recipient of the service at risk. So, finding the right level is important if we’re going to protect the public but continue to advance the services that the public needs.

For me, Right-touch regulation is a pragmatic approach to ensuring that regulation is fit for purpose in today’s world. The challenges that we faced back at the turn of the 19^th century, as we started to finally set up regulators, are completely different from the challenges we face today. You don’t have to look back that far to remember a time when regulation was a process where you could either put someone on a register or take them off. That was it.

Now, we have a whole range of other tools that enable us to titrate the intervention we need. We are not unnecessarily removing people from the register who could, with a bit of education or treatment, be able to function effectively and deliver safe services. Risk-based regulation is something that has evolved over time and will continue to evolve, because if it doesn’t, then regulation is not going to be fit for purpose.

Can you give an example of how we quantify risk in health care regulation?

Another piece of work I’m doing at the moment is about how we manage regulatory performance. There are certain characteristics that are potentially problematic. For example, individuals working in isolation are far riskier than those working as part of a team. On a team, I can give and receive feedback, but if I’m working on my own, and my practice is deteriorating for whatever reason, that is a much riskier scenario.

We’ve got to start to identify what some of these markers are and then use that as part of this discrete choice project to enable you to differentiate between levels of risk. Let’s take a silly example – is the intervention that I’m offering reversible or not? If I am cutting your hair, then that is a much lower risk than if I am cutting your abdomen, where the chances of you dying are much higher. If you wait a couple days, your hair grows back, and you say, “I’m never going to see that barber again.” If a surgeon does the wrong job, you’re not going to be coming back.

What does resilience in health systems mean for you in 2022? How has the pandemic changed or sharpened your thinking around resilience?

What I would say is that the pandemic has been a blessing and it’s been a curse. We were presented with a whole series of challenges, but because of the nature of the relationship that we had prior to the pandemic, we were able to assemble small groups of individuals to work intensely on these challenges and come up with solutions.

Even if they aren’t the best solutions, or the solutions that bring us into the right space, we continue to evaluate. Part of what I think is important in terms of resilience is being comfortable to say, “I don’t have the solution to this. I know that if you and I get in a room together and trade questions, the combined intellect between the two of us will create better solutions.”

We saw it working with other regulators across different disciplines, and we also saw it in some of the other collaborations NCSBN did with other members of the Tri-Council for Nursing. The Tri-Council organizations are interested in a few things: education, practice, and regulation. That’s three pillars. There are five organizations involved with that group – NCSBN, the American Organization for Nursing Leadership (AONL), and the American Association of Colleges of Nursing (AACN), as well as the American Nurses Association (ANA) and the National League for Nursing (NLN), which are both educational groups.

During the pandemic, many of the issues we faced were what I describe as interface issues. It’s the ability to get clinical practice or the ability to deliver a service. You cannot, as an educator or a regulator or an employer, fix that yourself. You’re going to have to get other parts of the team. Resilience was about recognizing the weaknesses of us as individuals and valuing the contribution that we could all make to coming up with a solution that is far more robust and enables us to move forward.

You co-wrote a systematic review of nurse-related social network analysis studies. Can you tell us a bit about the substance of this report?

It’s something I’ve used a couple of times. Regarding the way that we communicate, I’m going to give two examples – one from when I moved to be the director of the university teaching hospital in Aberdeen, and one from when I came here. Looking at an organizational chart doesn’t tell you anything. It gives you some information about who’s in these boxes, but it doesn’t tell you the way the organization communicates. What I did was ask two very simple questions: who do you give information to (and on what frequency), and who do you get information from (and on what frequency)? By mapping that information, you can identify the individuals in an organization who are central to either collecting or disseminating information.

I was able to identify, out of 8,500 nurses in the organization that I led in Aberdeen, the dozen top individuals who were responsible for gathering information. If, on the other hand, you want to communicate something, there is some overlap, but there’s a different set of people who are actually the great communicators who spread the message. Using science to inform the way we understand the issues in an organization and the way the organization communicates is what I did. I also did it when I came here. When you move into an organization at first, there’s a window of time where you can make a huge difference if you understand how the organization works.

The biggest thing I discovered coming here was that we had a group of experts, but those experts were not adequately communicating within the organization. For example, our exams team are world class, but they weren’t naturally communicating with our IT folks or with our regulatory people. Understanding that and showing it to people and saying, “we’ve got to build the way we do work differently and use that to come up with better solutions,” is just resiliency again. It’s about coming up with better solutions so that people are there, they know what’s going on, and they make their interventions at the right time, so you don’t need to redesign things. You design it right the first time.

If you haven’t already, be sure to check out the first and second parts of our Q&A series with David Benton. Want to hear more expert insight on international health policy? Listen to the latest episode of Ascend Radio, featuring Martin Fletcher, one of Australia’s leading health care regulators.