17 August 2016

Health Practitioner Revalidation

The Medical Board of Australia has published a discussion paper and the interim report of its expert advisory group on on practitioner revalidation, concerned with what should be done "to make sure that medical practitioners in Australia maintain and enhance their professional skills and knowledge and remain fit to practise medicine".
Regulation is about keeping the public safe and managing risk to patients. Part of this involves making sure that medical practitioners keep their skills and knowledge up to date. ... We are committed to finding the most practical and effective way to do this that is tailored to the Australian healthcare environment. 
The interim report proposes a ‘two by two’ approach to revalidation
  •  Two parts: Strengthened CPD + proactive identification and assessment of ‘at-risk’ and poorly performing practitioners 
  • Two steps: Engage and collaborate in 2016 + recommend an approach to pilot in 2017. 
The Board states
This ‘two by two’ model represents evolution, not revolution, in the requirements for doctors to make sure they provide safe care to patients throughout their working lives, the report states. ‘An integrated approach will be most effective. CPD alone, however rigorous, may not identify the practitioner who may be putting the public at risk. A regulatory approach, however thorough, cannot reliably, single-handedly improve the quality of care provided by most competent doctors,’ 
In discussing Strengthened CPD the Board states
Evidence-based approaches to CPD best drive practice improvement and better patient healthcare outcomes. Strengthened CPD, developed in consultation with the profession and the community, is a recommended pillar for revalidation in Australia. 
Identifying and assessing at risk and poorly performing practitioners: A small proportion of doctors in all countries is not performing to expected standards at any one time, or over time. Another group of practitioners is at risk of poor performance. Developing accurate and reliable ways to identify practitioners at risk of poor performance and remediating them early is critical, with considerable transformative potential to improve patient safety. It is equally critical to identify, assess and ensure there is effective remediation for practitioners who are already performing poorly. 
The report recommends guiding principles should apply to all potential approaches:
 Smarter not harder: strengthened CPD should increase effectiveness but not require more time and resources 
Integration: all recommended approaches should be integrated with – and draw on – existing systems and avoid duplication of effort, and 
Relevant, practical and proportionate: all recommended improvements should be relevant to the Australian healthcare environment, feasible and practical to implement and proportionate to public risk.
The Interim Report comments
Part two: Identifying and assessing practitioners at risk of poor performance and poorly performing practitioners A small proportion of doctors in all countries is not performing to expected standards at any one time, or over time. Many practitioners found to be under-performing self-remediate or return to safe practice with local support. This is the preferred approach. Another group of practitioners, however, is at risk of continued poor performance. To improve patient safety, improve practitioner performance and reduce the adverse impacts of patient complaints on complainants and doctors, it is critical to develop accurate and reliable indicators to identify at-risk and poorly performing practitioners, and when necessary, to intervene early with improved remediation processes. It is equally critical to improve our ability to identify, assess and effectively remediate practitioners who are poorly performing, including those who are the subject of multiple complaints or notifications and are already at a high predicted risk of continued poor performance. We do not know enough about the extent of ‘at-risk’ and poorly performing medical practitioners among those undertaking different types of CPD programs in Australia. The EAG proposes that strategies to effectively identify and assess ‘at-risk’ and poorly performing practitioners should apply across all categories.
Practitioners at risk of poor performance
Identifying risk factors
Prevention is better than cure. Developing indicators to identify ‘at-risk’ practitioners and being clear about actions to effectively assess them is critical, so effective interventions can follow.
The strongest risk factors associated with an increasing regulatory risk profile that have been identified and replicated both nationally and internationally are: • age (from 35 years, increasing into middle and older age) • male gender • number of prior complaints, and • time since last prior complaint. 
Additional individual risk factors found in certain studies include: • primary medical qualification acquired in some countries of origin • specialty • lack of response to feedback • unrecognised cognitive impairment • practising in isolation from peers or outside an organisation’s structured clinical governance system • low levels of high-quality CPD activities, and • change in scope of practice. Based on available evidence, the EAG believes that the time has come to deepen our understanding of factors that most reliably and practicably indicate practitioners at risk of poor performance that are relevant to medical practice in Australia.
We propose that there is now enough evidence to trigger discussion and draw on insights available about how various risk factors might be used to proactively identify practitioners at risk of poor performance in the Australian healthcare environment. Doing this could enable early intervention to protect the public and individual doctors from ongoing risk and improve the performance of these doctors. Deepening the understanding of the risk profiles of doctors who are already the subject of complaints or notifications using existing regulatory databases will provide a more accurate picture of risk indicators, improve ways to predict risk, and suggest the optimal timing and avenues for intervention.
Assessing individuals
Having identified the cohorts, or groups of practitioners at most risk of poor performance, it is important to then assess the identified individuals to determine whether and how the individuals actually pose a risk to public safety. Not all individuals in at-risk groups will be underperforming. Some practitioners who are identified as underperforming will return to safe practice simply through the process of being assessed and receiving feedback.
Robust early detection and remediation processes are anticipatory and preventive. They should be non-punitive, individualised and educational, designed to return the doctor to safe practice as soon as possible. The level of assessment of at-risk practitioners should be proportionate to the level of risk, consistent with the guiding principles. Examination-style assessment will not be effective in this task.
Tiered assessment
The EAG supports a tiered approach to assessment of performance, scaled to match the level of potential risk. A tiered, multi-faceted assessment strategy could start with multi-source feedback for low-risk cases, escalating through peer review and feedback processes, to more thorough in-situ evaluation to fully determine the nature of serious underperformance in doctors as required by the regulator. Cost-effective, early interventions should escalate only as needed.
1. Specialty-specific multi-source feedback (MSF) is the recommended starting point to assess whether practitioners in at-risk groups are performing safely, or are underperforming, or are poorly performing. The available evidence indicates that it is an effective and practical performance appraisal tool. MSF gained from colleagues, co-workers, and patients may provide a practical, cost-effective and efficient pathway for the early detection of doctors at risk of poor performance. It is consistent with the guiding principles outlined on page seven. Used effectively in CPD programs, it has been shown to identify gaps in both clinical and professional performance, to trigger self-reflection and to improve practitioner performance. It has also been used to help identify doctors who are not performing to accepted standards. 2. The next level of assessment – for doctors who may pose more serious risk – involves more intensive peer-mediated processes. This could include peer review of medical records, peer review of performance in practice, and/or facilitated feedback based on practice or outcomes data. 3. The highest level of assessment would align with extensive performance assessment, as can be mandated by regulators. Comparing the results of MSF from ‘at-risk groups’ with results of MSF from practitioners not in at-risk categories will be important for benchmarking.
Poorly performing practitioners: identifying, assessing and remediating individuals
International research indicates that about six per cent of medical practitioners are poorly performing at any one time. No Australian research has yet reliably identified how many medical practitioners in Australia fall into this category. Future Australia-specific research should confirm this number. In the meantime, the EAG believes that action is required to identify, assess and where possible remediate all of these practitioners, in the public interest.
Responsibility for identifying and remediating under-performing and poorly performing practitioners in Australia needs further development and consensus.