Continuous quality improvement for the Australian medical profession

Continuous quality improvement for the Australian medical profession Continuous quality improvement for the Australian medical profession Avant s comments on revalidation in Australia May 2017

Position paper by Avant Continuous quality improvement for the Australian medical profession Avant s comments on revalidation in Australia Avant believes that: 1. The vast majority of doctors practising in Australia are competent, perform well and provide safe and effective health care. 2. Lifelong learning, the maintenance of high standards of practice and continuous improvement are key aspects of medical professionalism. 3. Programs which seek to encourage the of the medical profession as a whole should generally be supported. 4. The revalidation model proposed by the Medical Board of Australia does not demonstrate that it will improve performance of doctors or assist in identifying and remediating doctors at risk of poor performance. 5. Any model which seeks to encourage a culture of continuous improvement will only succeed if it is supported by the medical profession, and operates within an open and just culture where doctors feel supported. Avant recommends that: 1. The term revalidation not be used for any model which seeks to encourage the of the medical profession. 2. Before rolling out any continuous quality improvement program to the whole profession, the Medical Board of Australia undertakes one or more pilot programs. 3. Significant further research be undertaken to narrow the criteria used in identifying doctors at risk of poor performance within the medical profession. 2

Continuous quality improvement for the Australian medical profession Background Avant Mutual Group Limited ( Avant ) is Australia s leading medical defence organisation and medical indemnity insurance provider. It is a mutual organisation, owned by its members, and offers a range of insurance products and expert legal advice and assistance. Internationally there is an increasing focus on the importance of medical practitioners demonstrating their competence to practise throughout their working lives. Developing mechanisms to enable medical practitioners to achieve this has occupied medical regulators for some time. The United Kingdom introduced a process of revalidation in December 2012 amid much concern from the profession. Canada and New Zealand have also developed mechanisms aimed at ongoing review and improvement of medical practitioners. The Medical Board of Australia (MBA) has now proposed an Australian model for revalidation. It has two components: (1) strengthened continuing professional development (CPD) and (2) the identification and assessment of at-risk or poorly performing doctors. Avant supports the intentions of the MBA to encourage continuous improvement of doctors and proactively identify and remediate doctors at-risk of poor performance. However, Avant does not believe that the proposed model will achieve these aims. General principles Avant supports continuous quality improvement among the medical profession. Continuous quality improvement should be: focused on quality improvement and improving the competence and skills of the entire profession about improving and enhancing the professional practice of all doctors educative and not disciplinary or punitive supportive and collegial effective in achieving better health outcomes for patients applied across the profession with sufficient flexibility to take into account different scopes of practice within the profession and different specialties in the profession evidence-based simple, not over-engineered, and easily implemented within existing healthcare systems relevant to the field of practice and context procedurally fair, clear and transparent. Mechanisms for continuous quality improvement should encourage doctors to assess their skills against applicable standards and expectations for quality health care, and assist doctors to identify skills which require development or improvement. This position paper sets out the principles which Avant believes should underpin any model for continuous improvement and the identification of doctors at risk of poor performance, as well as outlining Avant s concerns about the revalidation model that has been proposed by the MBA. 1

Position paper by Avant Avant s comments on component 1 - Strengthened CPD Avant has a number of concerns about the MBA s CPD proposals outlined in the Expert Advisory Group interim report dated August 2016 ( the interim report ): 1. There is a lack of evidence to show that revalidation/strengthened CPD will lead to better patient care and safer medical practice. CPD is used as a proxy for competence without clear evidence that participation in CPD achieves competence or leads to better patient outcomes. In any model, the outcomes of strengthened CPD need to be identified and evaluated. 2. Any CPD system must be easy to implement and not take doctors away from their core business of treating patients. The model proposes that multisource feedback ( MSF ) will be a key component of strengthened CPD. However, it is not clear how MSF would be implemented in the context of private practice or out-ofhospital practice where doctors work in consulting rooms alone with the patient. In these contexts there will be limited opportunities for peers to judge a colleague s competence. 3. There is a lack of clarity around governance. Will governance rest with the colleges or the MBA or both? 4. There is an emphasis on peer review and practice visits as part of strengthened CPD but no suggestion about training programs for reviewers. To provide meaningful engagement, those undertaking peer review and practice visits, must be appropriately trained in assessing against agreed standards and providing effective feedback to doctors. 5. It is not clear how strengthened CPD will be funded. Doctors would be concerned if the proposal would lead to an increase in registration fees, which would contribute to pressure on healthcare costs. Responsibility for CPD The operation and implementation of CPD programs rests primarily with the colleges. Considerable work has been undertaken to date by many colleges to enhance their existing CPD programs with a view to improving the performance of their members. Avant believes that the colleges should continue to be actively involved in setting the standards and content for quality CPD programs. CPD programs need to be flexible enough to be applied in different practice settings and scenarios, but there is currently an absence of consistent profession-wide minimum standards/content for all CPD programs. Avant s experience suggests that the profession would benefit from CPD which extends beyond clinical skills and includes non-technical skills such as areas of risk, quality, safety and professionalism. Nontechnical skills could be the subject of a common curriculum across all colleges and we recommend that the colleges work collaboratively to enhance their CPD programs in this regard. 2

Continuous quality improvement for the Australian medical profession Avant s comments on component 2 - Identification and assessment of at-risk and poorly performing practitioners Avant has the following concerns about the second component of the revalidation proposal: 1. The risk matrix identified in the interim report is too broad and needs to be refined. The current research into doctors at most risk of poor performance does not provide a sufficient evidence base for regulator action. Any screening tool for high risk doctors needs to be more precise and should be focused on objective underlying risk factors (rather than broad-based proxy variables such as age and gender). More work needs to be done to better understand the factors that increase the risk of poor performance. This should be the subject of dedicated research in the Australian context. 2. The culture of blame that can exist in some healthcare settings is a barrier to identifying at-risk and poorly performing doctors and to effective education and remediation of poor performance. 3. The profession is wary of anything that suggests that they will be identified and blamed. For this approach to have the confidence of the profession, we believe that it needs to operate within an open and just culture where practitioners feel supported to raise concerns. 4. It is not clear how benchmarks and standards of care will be set to permit comparison between peers. The colleges and specialist societies should take the lead in setting the benchmarks for comparison. 5. The proposed approach focuses on the individual and does not appear to take into account that doctors often work in teams and within systems. Quality and safety and risk management literature recognises that system risk is a key cause of, or a contributor to, poor performance. This should be addressed in any model that is proposed. 6. A number of healthcare provider organisations are currently trialling a Vanderbilt approach to managing poor performance and behaviour. Avant supports the use of the tiered approach of the Vanderbilt model for dealing with unprofessional and inappropriate behaviour and practice within medicine. The aim of the Vanderbilt model is to provide the ability and opportunity to practitioners to self-correct. It would be useful for the MBA to understand the outcomes of these trials before implementing its tiered approach to identifying, assessing and remediating at-risk and poorly performing practitioners Relationship between components 1 and 2 of the revalidation model The relationship between strengthened CPD and identifying at-risk doctors is not clear. Component two of the proposed model notes that MSF will be the starting point to assess whether doctors are in at-risk groups. It is not clear precisely how this will work (particularly within an educative framework), who will have the obligation (if any) to report practitioners to the MBA if they fail MSF, and what the threshold will be. If the purpose of strengthened CPD is to identify and target at-risk or poorly performing doctors, Avant believes that the profession will be reluctant to fully participate in it for fear of being reported. Strengthened CPD should aim for quality improvement across the profession rather than be a process for targeting at-risk doctors. 3

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