Analysing Data for Risk-Based RegulationIn Nursing & Midwifery and other Health Professions.

Introduction

• Who we are• Opportunities for new approaches• What we needed to learn• What we have put in place• How we apply it• What’s next?• Some advice…

Who we are

Australia

• 23 million people• Federal system of government• 9.3% of GDP on health • Joint government funders• 70% public – 30% private mix• Good health status overall• Major gap for indigenous health• Mal-distribution of heath workforce• Significant international workforce

Major Consolidation• Eight State & Territory

based arrangements

• More than 95 health profession boards

• 75 Acts of Parliament

• 38 regulatory operations

• 1.5 million data items from 94 sources

• One national scheme

• 14 health profession boards

• Nationally consistent legislation (largely)

• One national organisation (AHPRA)

• National on-line registers

What we doAHPRA works with the 14 National

Health Practitioner Boards to:• Set professional standards • Register practitioners

Maintain national registers• Manage notifications • Accreditation

Objectives of legislation

• Protection of the public• Workforce mobility within Australia • High quality education and training• Rigorous and responsive assessment of overseas

trained practitioners• Facilitate access to services in accordance with

the public interest• Enable a flexible, responsive and sustainable

health workforce and enable innovation

Harmonising Registration Standards

• Criminal history • English language requirements • Professional Indemnity

Insurance arrangements• Continuing Professional

Development • Recency of Practice

Codes and Guidelines• Advertising• Mandatory reporting• Conduct

The diverse nature of the professions

Profession Registrants (2014-15)

Proportion of total

registrants

Notifications (2014-15)

Proportion of total notifications

Medical 103,133 16% 4,541 54%

Nursing and Midwifery

370,303 58% 1,807 22%

Psychology 32,766 5% 432 5%

Pharmacy 29,014 5% 490 6%

Dentistry 21,209 3% 766 9%

- Other Boards 80,793 12% 390 4%

Patient safety and workforce: driving reform of

regulation

Opportunities for new approaches

Lessons from the UK Professional Standards

Authority

Harry Cayton, CEO UK Professional Standards Authority

• Be clear on the problem

• Quantify the risk

• Pay attention to unintended consequences

• Keep it simple

What we needed to learn

What would Malcolm say?

Prof Malcolm Sparrow

• Detect patterns• Understand the

problems• Develop regulatory

solutions• Implement solutions• Measure effectiveness• Tell people about it

Collect information on harm in a systematic manner,

and then identify hotspots of risk

that are amenable to a regulatory response.

Reducing rule-breaking vs Reducing harm

Compliance based

Harm based

The value of harm information

“Conclusion: Systematic reviews compound the poor reporting of harms data in primary studies by failing to report on harms or doing so inadequately.”

Liliane Zorzela, ‘Quality of reporting in systematic reviews of adverse events: a systematic review’ BMJ, 8 January 2014

“[Health] …complaints have considerable sentinel value: for every adverse event complained of, dozens more lie below the waterline.”

Marie M Bismark, David M Studdert, ‘Realising the research power of complaints data’, New Zealand Medical Journal, 2010

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What we have put in place

AHPRA’s Regulatory Principles

While we balance all the objectives of the National Registration and Accreditation Scheme, our primary consideration is to protect the public.

In all areas of our work we: • identify the risks that we are obliged to respond to • assess the likelihood and possible consequences of the risks, and • respond in ways that are proportionate and manage risks so we can

adequately protect the public

When we take action about practitioners, we use the minimum regulatory force to manage the risk posed by their practice, to protect the public. Our actions are designed to protect the public and not to punish practitioners.

NRAS Risk-based Regulation Unit

To reduce harm to the public and facilitate safe workforce reform by increasing the use

of data and research to inform policy and regulatory decision-making.

Moving from a reporting system to a learning system.

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Using analysis to inform risk-based regulation

1. Quantitative analysis to detect patterns

2. Semi-quantitative analysis

to identify issues and themes

3. Case reviews & qualitative methods to understand the problems

Which of the following should be the greatest influence on the regulatory actions of a risk-based regulator?a) The characteristics of high-risk practitioners?

b) The patients who are most at risk of harm?

c) Which health care settings create the greatest risk?

d) Which procedures create the greatest risk?

How we apply it

Key QuestionsDescriptive Can we create clear, comprehensive,

accurate and timely risk profiles for each health profession?

Consistent Are our regulatory responses consistent across jurisdictions, years and professions?

Predictive Can we predict which practitioners and situations are more likely to cause harm?

Responsive What are the best right touch responses to the hot spots of risks that we identify?

Effective Are our regulatory responses effective in reducing harm to the public?

Medical Radiation Practitioner

Midwife

Occupational Therapist

Nurse

Physiotherapist

Osteopath

Chinese Medicine Practitioner

Optometrist

Psychologist

Podiatrist

Pharmacist

ATSIH

Chiropractor

Medical Practitioner

Dental Practitioner

0 10 20 30 40 50 60

Notification Rates (2010-2014)(enquiries, formal notifications and offences)

Notifications per year per 1000 practitioners

Under 24

25 to 34

35 to 44

45 to 54

55 to 64

Over 65

Female

Male

0 20 40 60 80 100

Notification Rate for Dental Practi-tioners

by Age and Sex (2010-2014)

Notifications per year per thousand practitioners

Predicting Risk

0 1 2 3 4 5+0%

20%

40%

60%

80%

100%

Probability of practitioner receiving another noti-fication

in next 12 months

Number of Notifications Practitioner Received in prior 12 months

Taxonomies & Classifications

Examples from risk analysis• The proportion of nursing notifications

relating to Health Impairment is 4.9 times higher than for all other professions combined.

• Approximately 10% of all notifications about nurses and midwives result in immediate action.

• The likelihood of a practitioner originated notification resulting in a caution or reprimand is 1.5 times higher than for a patient initiated notification.

Qualitative analysis on boundaries

• Professional boundaries fall along a spectrum from under-involvement and neglect to over-involvement all the way to sexual assault.

• Our data systems seem to be better at capturing the over-involvement end, and these are easier to deal with.

• An analysis of ‘under-involvement’ cases suggests concerning potential for risk of harm to patients

• In some cases the regulator only became aware after a pattern of behaviour not dealt with in the workplace

• In some cases, regulatory action can be an effective tool to change behaviour

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What’s next?

Future Core Focus

• Frequently reported practitioners• Increased risk of notifications with

age• Identification of factors most

associated with patient harm • Risk associated with overseas trained

practitioners• Evaluating impact of practice

restrictions

Regulatory topics for NMBA• National Health Impairment: Referral, treatment &

rehabilitation services for health professionals• How continuing competence is/can be defined &

assessed• Exploring factors related to nursing & midwifery

medication management & prescribing• Review of code of conduct and guidelines on

professional boundaries• Development of new model of IQNM assessment• The role of accreditation in risk based regulation

http://ecommerce.dent.unimelb.edu.au/product.asp?pID=91&cID=36

Some advice…

Reporting → Learning → Action

...moving beyond traditional regulatory levers

RegulatorRegistration and

notification processes

Employers

Professionals

EducatorsAccreditation Authorities

Awareness raising and advice to employersRegistration Standards,

codes and guidelinesTools for educators and

studentsAccreditation Standards

and processes

Esca

latio

n of

pro

fess

iona

l res

pons

ibili

ty

Lessons Learnt• Be clear: are you a risk-based

regulator?• Set realistic expectations• Requires new/different skills• Partner with external researchers• Data classifications and taxonomy

essential• Will always need subjective, qualitative • Close the loop – response system is

more important than the reporting system

Contact Information

Australian Health Practitioner Regulation Agency

• Martin Fletcher, Chief Executive Officer• Michelle Thomas, Executive officer – dental

www.ahpra.gov.auNursing and Midwifery Board of Australia• Veronica Casey, Practitioner MemberDental Board of Australia• Dr John Lockwood (AM), Chair